WSJ shines spotlight on hospice eligibility
Fraud investigators focus on terminal diagnosis
In 1997, United Government Services (UGS), a Milwaukee-based Medicare carrier, sent a half-dozen letters to patients under the care of Hospice of the North Country Inc. in Plattsburgh, NY. The message: "You are no longer eligible for the hospice benefit." Additionally, patients were told their cases were under scrutiny for Medicare fraud. Those who had received letters had well exceeded six months of care, with one remaining under hospice care for four years.
More than three years later, the hospice’s ordeal in trying to convince fraud investigators that their obvious outliers were not incidents of fraud, but rather the result of dividends brought about by the compassionate care that is the hallmark of hospice, was recounted in a feature article in the June 5 issue of the Wall Street Journal.
The pressure of six months
While the story is no surprise to those in the industry, it does shine a spotlight on what industry leaders have long argued: The six-month terminal diagnosis is an ineffective way to determine hospice eligibility.
"It’s just not a failsafe way to determine eligibility," says Angela Thimis, director of communications for the National Hospice & Palliative Care Organization (NHPO) in Arlington, VA. "What has happened is that hospices feel pressure to discharge patients and not admit some patients because they aren’t sure."
Thimis says the article sparked a number of phone calls to the NHPO from families of former hospice patients who said their loved ones were also discharged from hospice because they had outlived their terminal diagnosis.
Hospice of the North Country’s problems centered around a few cases, most notably the story of 87-year-old Rosie DesParois, who was suffering from advanced breast cancer and endometrial cancer when she was admitted to hospice.
Doctors had said her cancers had spread to her liver, but despite the metastasis, she was still alive four years later, when investigators questioned why the hospice was still being paid $88 per day.
UGS asked for the $450,000 it paid the hospice for care of the patients they deemed ineligible for hospice care. The hospice’s executive director, Sarah Anderson, says she had no choice but to fight; paying back the money would have meant bankruptcy for the hospice that treats 25-28 patients each day.
Because DesParois was no longer eligible for hospice care, she was eventually placed in a nursing home, away from the comfort of the home she had thrived in, where she spent hours tending to her garden. More important, DesParois lost the care of hospice workers who had managed to coax the woman to take her medicine and overcome her fear of needles.
In the nursing home, DesParois’ health declined precipitously. Her cancer spread to her pancreas, leaving her in agony. She developed gaping bedsores, and by the fall of 1998, she was dead. Ironically, Medicare paid $150 per day for nursing home care.
Rather than look upon the experience bitterly, Anderson chooses to be philosophical. But she still laments the direction she has seen her hospice and other hospices move as a result of increased efforts to root out abuse based on the six-month terminal illness diagnosis.
"Hospices are now seen as professional health care providers that have to be regulated in a regimented and bureaucratic way," Anderson says. "It’s altering the soul of hospice. I believe the whole concept of hospice is an art masterpiece, but we are now being forced to have to paint by the numbers."
The tale of Hospice of the North Country is an exaggerated example of what many hospices face, says Karen Woods, executive director of the Washington, DC-based Hospice Association of America.
"It shows how difficult it is to make terminal prognosis and how difficult it is to stop providing care," Woods says.
Woods also says that the story shows how a changing health care industry can’t exist under the same conditions that govern it. "They are trying to focus on making hospice a structured benefit, when the reality is that it’s difficult. They need to find a balance, but I don’t have the answer."
Still, Woods is pragmatic about hospice’s plight. While some cases may exceed the six-month terminal illness, hospice providers, she says, must understand the benefit was not designed to be given for a long period. Caring for someone who is dying for more than six months wouldn’t seem like a bad thing, she says. "But you have to focus on the rules."
Taking greater care
Both Woods and Thimis remind hospices that they must take greater care in reviewing patients’ length of service. Woods says local medical review policies should be used to determine eligibility, along with the appropriate documentation to show that patients meet admissions and recertification guidelines.
Hospice of the North Country did not come away from their experience unaffected. While its leader believed they were right, the hospice still adopted changes to ensure it could justify each admission and recertification.
For one, admissions are tougher at the Hospice of the North Country. "Our medical directors are much more picky," says Anderson. "We are more cautious with our admissions and recertifications."
It has been three years since the Hospice of the North Country was faced with an investigation that could have driven them into bankruptcy. According to experts, there is still a great deal of government attention being paid to hospice.
"In some respects, we are victims of our own success," says Jay Mahoney, president of Summit Business Group in Annandale, VA. "As we have gotten bigger and there has become more money, there has been more attention, and that attention is breeding more attention and more regulatory scrutiny."
At the same time, the federal government is no longer singling out hospices. "It certainly felt that way a few years ago when we felt like the entire weight of the government was falling down on our shoulders," Mahoney says. "The fact of the matter is that they are looking very hard at all providers. There is simply a general environment of mistrust out there."
Public sentiment may be fueling the charged atmosphere of mistrust and increased federal oversight of health care programs across the board. As a result, hospices face a complex regulatory environment that is becoming even more complex as interpretations evolve over time, Mahoney says.
Since hospices began sprouting up two decades ago, changes in health care have prompted hospices themselves to evolve too, including Hospice of the North Country. In the early 1980s when Hospice of the North Country was in its infancy, its motto and message to patients was: "We won’t leave you; we’ll be here to the end." Bygone days, says Anderson. "We don’t say that anymore."
(For more information on government regulation of the hospice industry, see Hospice Management Advisor, July 2000, pp. 77-79.)
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content