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Dying To Get Rich....A Hospice Story!

     This week the Department of Health and Human Services (DHSS) Office of Inspector General (OIG) issued two reports regarding problems facing the multi-billion dollar proprietary Hospice Industry.  The reports focused, as liberal agencies do, on the industries response to patients.  Specifically the reports concluded:

"Following up on earlier work analyzing the Medicare hospice benefit, the Department of Health and Human Services (DHSS) Office of Inspector General (OIG) “found that from 2012 through 2016, the majority of U.S. hospices that participated in Medicare had one or more deficiencies in the quality of care they provided to their patients. Some Medicare beneficiaries were seriously harmed when hospices provided poor care or failed to take action in cases of abuse."

     This is not surprising given the minimal regulatory supervision and virtually non-existent financial penalties policies that constrain this "in your home/who knows what really happens" industry.  The report did, at least, suggest that DHSS, whose leadership is perpetually terrified by Trump invasions, try to do something to mitigate the "serious harm" to America's "overlooked" most vunerable.

    Of course any rational American will likely agree with the findings in this report.  (online at Meciare.gov/Government Watchdog Agency Issues Report Highlighting “Significant Vulnerabilities” in Medicare’s Hospice Benefit).....but what the Report did not address is that in recent years the Medicare Cost for Hospice Services has escalated at a far higher rate than the rate of increase for other Long Term Care Medicare Services.  (From 2014 to 2016 Hospice Payments increased from $15.2b to 17.2b, while Medicare Home Care Payments increased only from 18.2b to 18.6b, and Medicare Skilled Nursing Home payments actually decreased from 27.9b to 27.4b).......and sadly, there is serious concern as to whether these Services, when, as, and if actually delivered were of meaningful benefit to Hospice Patients.

    So what is Hospice Services?  Ask any Baby-Boomer and they will tell you the "heard on the street" answer is that for terminally ill patients, Medicare will pay for nursing, aide, therapy, social work, and chaplain services provided by a for-profit-agency that is licensed by the State and employs such licensed and certified personnel prepared to provide these services. Well, this is all fine and good, but other than Chapalin Services, most families faced with terminal condition situations presume that nursing services and aide services involve diredt, hands on, care.  Actually, this is not entirely the case. Chapter 9 of the Medicare Benefits Policy Manual explicitly identifies all forms of Medicare Covered Nursing Services to be restricted to engagements related only to assessment of a Hospice Patients changing condition.  Specifically 40.1.1 - Nursing Care (Rev. 188, Issued: 05-01-14; Effective: 08-04-14; Implementation: 08-04-14) sets forth the purpose as  "Assessment of pain and or symptoms to determine the need for medications, other treatments, continuous home care, general inpatient care etc.  In the absence of an NP, an RN is authorized to assess the patient, but not do engage in direct care services.   Policy provision 40.1.7 does provide for Certified Aides to actually provide Hospice Patients direct "personal care", but not as a consequence of a patient certified by a Doctor to be eligible for Hospice Services, but only to the extent that such aide services are assessed to be necessary by the Hospice Nurse. Medicare statistics show that historically the number of aide visits is only about 30% of the Nurse Assessment visits.  This is perhaps not surprising considering that the participating For-Profit-Agencies are paid on a per-diem basis regardless of the number of Nurse Assessment, Aide Visits, or Chaplain Visits that the Agency makes during an episode period. 

     Given the above clarification that Hospice Agencies get a Congressionally Defined Fixed Per-Diem Payment from Medicare for having a nurse assess a patient's condition as frequently as the nurse deems necessary and to, when, as, and if the nurse decides, have an aide provide some scope of personal care services at whatever frequency the nurse decides, and to, if the patient explicitly asks to see a Chaplain whose theological identity is unknown to the "near death patient"....then surely the obvious follow-up questions are: 

  •     How much is the per-diem
  •     How long does an episode last
  •     How frequent do Hospice Nurses actually make assessments visits
  •     How often do Assessment Nurses authorize Aide Visits
  •     How often do assessment nurses recommend Continuous Care Services
  •     How frequent do patients request Chaplain visits

Before I offer facts and insights responding to the above questions, I should acknowledge that I have a close business connection to an Independent Living Facility (ILF) that for a decade has provided "Senior Services" to 100's of Seniors.  Although I don't know the exact number, perhaps as many as 5% to 10% have received Hospice Services, almost always because their families have encouraged this choice.  Beyond this general experential knowledge, I  have read much about the Hospice Industry, something that I find that very few Hospice personnel have, I suspect,  done.  For instance, I have asked, over many years, Hospice Staff at many levels, how much Medicare pays for their services.  Again I can't substantiate, but I am about 0 for 50+, although its on Google's Hospice first page.  Anyway!

Cost  There is no cost to the patient.  For the US Treasury the answer for FY2019 is $196.25 for each routine (non-inpatient) patient day from 1 through 60.  For days 61 forward the payment rate is $154.21. For Continuous Home Care (24 hour support) the  FY2019 payment rate is $997.38 per day.

Duration  Essentially for so long as a MD or DO, will sign the orders, each order stipulated to provide for a 60 day episode.

Frequency  Nurse visit frequency is not mandated by Medicare, in that the single reason for Nurse Visits is for assessments purposes for the purpose of authorizing available services early listed in Paragraph 4 above, the frequency of such authorized non-nursing services are available at the discression of and for a time period determined by the assessment nurse. In a recent Hospice Services Event in which an area Hospice Agency commenced services for a 95+ aged woman who was a long term resident at the ILF, in the summer of 2018 and subsequently completed multiple Service Episodes up through the Summer of 2019, detail for a 118 day continuous service period revealed that 83 visits occured, 36 of which were Nurse Assessment visits (10 RN & 26 LVN) and 47 were Aide visits.

Aide Visits  The average number of "Aide Visits" completed for Patient Activities of Daily Living per Episode is as reported for most recent statistical year between 12 and 16.  Ovviously this may vary depending on the patient's profile, or the assessment bias of the authorizing nurse.  Although again, I do not have date to support, but guest sign-in logs at the ILF earlier mentioned would, on average, agree.

Continuous Care Services  In 2019 Hospice Agencies were authorized to provide 24 hour "in residence"  continuous care services to Hospice Patients, when, as, and if authorized by an Assessment Nurse employeed by a Licensed Agency.  Medicare when authorized would increase the per-diem payment to the Agency from the $196 to $997.  No ILF residents resident at the property at which I have direct knowledge,  during the last 10 years have been assessed to need this service.

Chaplain & Other Visits  Again, without supporting data, the experience at the ILF has been that there has never been  a visit from other than a Nurse, or Aide, or Chaplain, and that Chaplain visits have averaged about 3 per episode.

Story Summary

    Perhaps more than any previous culture, Americans are disconnected from mortality.  Indeed many who have not had a close encounter with 21st Century Hospice still think it is a charitable program provided by churches. My personal  "closer than I would like"  exposure, having worked within the Long Term Care Industry for 3 plus decades,  is that Hospice Visits are valuable for all the obvious reasons.  My experience has been that the Nurses and Aides are almost always caring and responsible persons.....but the structural/payment attributes of the Industry are somewhere between ridiculous and a travesty.  Yes, without public funding, reasonably conduited through Medicare, there would be little if any end-of-life support for the 95% of the population that cannot afford $5000 a month for Private ILF/ALF/SNF care....but, is there any justifiable value in sending an RN/LVN to apatients home for a 15 minutes evaluation every 4 or 5 days when they do nothing besides assess and yet virtually never change the "services protocol"  (excepting medication changes).  The aide visits are helpful, both as to needed ADL support as well as the compassion benefit of caring contact, but not if they are not authorized.  And therefore.....it does not take a rocket scientist or Mother Teresa to figure out that terminal patients need ADL/Compassion care, and not just clinical assessments of their declining physiology.... and "further" the most egregious of all the Hospice's structural flaws: 

Does it make any sense that everytime a $20 per hour LPN or a $15 per hour CNA walks through a Hospice Patients Door, that the American Government is going to pay a For-Profit Agency about $250 per visit (($500 per hour).  Are we stupid, or greedy, or both!




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