Profits up in California: The average profit per patient has grown steadily. The combination of more patients and far greater profit per patient has pushed overall inflation-adjusted profit up more than tenfold. (click to enlarge; from washingtonpost.com)
by Ken
In a moment I'm going to back up a bit to try to enable you to understand why I was so shocked, and found my gut so clenched, upon reading an online teaser Thursday night for an investigative report in the Washington Post's "Cost of Healing" series which appeared on Friday's front page, "Medicare rules create a booming business in hospice care for people who aren't dying."
The gist of the article was that a mutibillion-dolar industry has sprung up in "for profit" hospice care, taking advantage of the daily amount Medicare pays for hospice care -- $150, according to the article, whether or not any care has been provided on any particular day -- by bulking up the rolls with large numbers of clients who, to put it bluntly, aren't really sick enough to be in hospice care, and therefore: (1) cost much less to care for than the dying people hospice care is designed for, and (2) for the same reason live much longer, thereby continuing to bulk up the predator-hospice companies' already outsize profits.
We'll come back to the article, but first, as I said, I have to back up.
In the years when -- from long distance -- I watched over my mother's final decline and passing, one lesson I kept relearning was that every situation and stage I encountered was a first time for me, all the people I was dealing with dealt with this all the time. Nearly all those people knew I had no idea what I was doing, and many of them not only counted on it but took advantage of it. Some were a little more helpful.
Miraculously, a very few people along the way showed genuine humanity, making it their business to try to help me understand what was happening and what could or needed to be done. In my state of perpetual apprehension and befuddlement, I doubt that I thanked those blessed souls enough.
The highest concentration of them worked for the hospice that was recommended to me when my mother's doctor, who had known her for many years, told me there was nothing more that could be done for her medically and he was recommending hospice care. He was aided considerably by the copy of my mother's "living will" I showed him, in which she made it absolutely clear that she wanted no heroic measures to prolong her life when there was no quality of life left to be preserved. When my mother was still relatively healthy, she had made a point of showing this to me and making sure I understood her wishes.
My first assumption was that "hospice" meant she would be "going to" a hospice when she was released from the hospital. I suspect I wasn't the first person to make the mistaken assumption that it was a place rather than a form of care for the terminally ill. I still had to figure out how to arrange her living situation.
But since my mother now needed around-the-clock care, and I thought a nursing home was our only option, there was someone at the hospice who guided me through every step of the Medicaid application, something I can't imagine how I would have managed on my own. It certainly wouldn't have occurred to me that I needed to talk to the funeral home (with which my mother had taken the precaution and taken on the expense of prepaying her funeral arrangements so that I wouldn't have to do that) and have them make her plan nonrefundable so that it wouldn't be counted as an "asset"! (And I should add that throughout the remainder of the process the funeral-home people, both in Florida, where my mother lived, and in New York, where she was to be buried, were also angels, handling everything with kindness and efficiency.)
There was another person at the hospice who made no secret of the fact that she hated the nursing-home option, and made me aware that there were now small assisted-living facilities where residents received invididual attention, and which might well be covered by the long-term care policy my mother had providentially scrimped to pay for, which up to that point had made it possible for her to have a home-care aide for a healthy chunk of the day. She wouldn't have been able to recommend a facility, but one of the people she suggested I talk to to better understand the small-ALF option did have a suggestion, of a facility not that far from where my mother lived run by a young woman who gave her residents the best possible care. Ana indeed turned out to be a saint, and took care of my mother till the end as if she were her own mother.
When I told the woman at the hospice of the arrangement I had made, I could hear her relief and happiness at the change from my nursing-home plan. She knew the facility, and considered it an excellent choice. As it turned out, she also made regular home visits to my mother, and in her new residence was able to provide me with information to supplement what I got from Ana. I know there were also regular visits by hospice nurses, and medical care when needed from those nurses and a doctor. The hospice also regularly supplied a range of supplies. When my mother died, there were kind expressions of sympathy from her hospice "unit."
This, then, is the background to the feelings I experienced when I saw the Washington Post report, whose online version began:
Hospice firms draining billions from MedicareIt took me awhile to wrap my brain around this.
By Peter Whoriskey and Dan Keating
Hospice patients are expected to die: The treatment focuses on providing comfort to the terminally ill, not finding a cure. To enroll a patient, two doctors certify a life expectancy of six months or less.
But over the past decade, the number of "hospice survivors" in the United States has risen dramatically, in part because hospice companies earn more by recruiting patients who aren't actually dying, a Washington Post investigation has found. Healthier patients are more profitable because they require fewer visits and stay enrolled longer.
The proportion of patients who were discharged alive from hospice care rose about 50 percent between 2002 and 2012, according to a Post analysis of more than 1 million hospice patients' records over 11 years in California, a state that makes public detailed descriptions and that, by virtue of its size, offers a portrait of the industry.
The average length of a stay in hospice care also jumped substantially over that time, in California and nationally, according to the analysis. Profit per patient quintupled, to $1,975, California records show.
This vast growth took place as the hospice "movement," once led by religious and community organizations, was evolving into a $17 billion industry dominated by for-profit companies. Much of that is paid for by the U.S. government -- roughly $15 billion of industry revenue came from Medicare last year. . . .
First I had to grasp that no, they weren't talking about he kind of hospice that had watched over my mother -- though already it occurred to me that most readers of the article wouldn't know enough about the subject to make the distinction; the message would likely be: Hospice care is a scam.
Then I had to overcome my automatic resistance to the idea that there's an entrepreneurial class so vile as to make a business out of phony hospice predation. Alas, once I understood the nature of the scam, it wasn't difficult to overcome this resistance, knowing as I do that if there's money to be made, there's no shortage of entrepreneurs for whom no degree of vileness would be an obstacle, and if there's a lot of money to be made, then it's likely to be more like a gold rush.
Today the Post published several letters to the editor about the Friday article ("The business of hospice"). But the response that struck the most responsive chord for me appeared only online, at the above link, in a comment by a reader who identified herself (wait, am I just assuming it's a woman?) as "ProgressiveCatholic":
As a former longterm social worker at a non-profit hospice in this area, my heart hurt to see the article in the Post not differentiate between the amazing care that local and national nonprofit hospices provide, but simply identify all hospice care as a way to abuse Medicare. The hospice I worked at for more than 8 years agonized over decisions about whether to take a patient and family off of our program, or to leave them on, receiving badly needed care, when they had elected the Medicare Hospice Benefit and lived longer than 6 months to a year.Yes, please differentiate, and then take the masterminds of the for-profit hospice ripoff and give them fair trials -- I'm thinking 15 minutes apiece should do it -- in preparation for their executions.
Though I can easily imagine that for profit hospices have abused this benefit, the fact remains that many hospices who are in this field are here, and have been for decades, to provide care, not make a profit. PLEASE DIFFERENTIATE between hospices in this community, and in many, who have been providing care, many times at a financial loss, for those on the Medicare Hospice benefit, and those for-profit hospices who have moved in to the field in the last 20-30 years, and may be (?) abusing the Medicare benefit.
A long term joke among our workers was that Hospice care 'caused people to live,' in that when a patient and family have their stress relieved, when caregivers get respite and when patients get adequate pain management, they do indeed, get better for a time. This then leads to the difficult choice of taking that care away, because they no longer meet the Medicare Benefit criteria vs. leaving the care in place, but potentially misusing the benefit.
This is a drastically different issue than "making money" off of hospice care. Hospices face the dilemma of being sued for trying to take someone off of hospice care (it happened to our hospice) versus being sanctioned by Medicare if they leave someone on hospice care. Though I agree for profit hospices have created a number of problems, the way this article reads misleadingly indicates that all hospices out there are "making money off of" dying patients.
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