The Trump Department of Health and Human Services’ Inspector General has released two scathing reports concerning the Hospice end-of-life-care industry, with the hope of cleaning up hospice abuse. These reports include stories of maggots in stomach feeding tubes; failing to clean wounds which ultimately became gangrened requiring leg amputations; ignoring pelvic injuries from sexual assault and giving wrong treatment that put patients in the hospital.
The reports specify “significant vulnerabilities” and “deficiencies” which put patients at risk and “jeopardize safety.” Patients were seriously harmed when hospices showed gross negligence or failed to report patient abuse.
Medicare, which pays for almost all hospice treatment, looks to state agencies and accrediting organizations to make sure hospices maintain quality of care for patients. Inspectors review clinical records, visit patients, investigate complaints, and report any deficiencies discovered.
The new government report includes both state and accrediting agencies’ findings. Nearly all hospices were surveyed.
Deficiencies included mismanagement, lack of quality control, improper vetting of staff, inadequate assessments, and poor care planning. As a result, patients suffered.
Horror stories abound. One woman was repeatedly abused by her caregiver/daughter, who literally chained her to her bed, and would “leave her mother in a wheelchair in the bathroom with the lights off and would spray her with water when she called out for help,” according to the government report. Hospice was told of the abuse, but did nothing --not even visit the patient for several weeks.
Another patient had an abusive neighbor, who frequently burst into his apartment “naked, high, and drunk” stealing the patient’s prescriptions. Hospice knew this was going on, yet did nothing to protect the patient, the government reported.
“These hospices did not face serious consequences,” the report says, because Medicare “cannot impose penalties, other than termination, to hold hospices accountable for harming beneficiaries.” Medicare’s only enforcement power is to take the offending hospice out of the Medicare program. It cannot levy fines, or issue sanctions, or close a facility.
One of the report’s recommendations is for Congress to give Medicare “enforcement tools” and “statutory authority...to effectively protect beneficiaries from harm.”
Medicare began dispersing tax dollars for hospice in 1982. As medicine advanced, hospice promised tax savings, with terminal patients cared for at home rather than in hospitals under ever-more-expensive and almost-always-futile medical procedures.
“At the first meetings of our national hospice organization, we were nearly all women, mostly volunteers working on making our communities better,’’ Dr. Joanne Lynn told the Washington Post.
As soon as government money for hospice was unleashed, for-profit companies began invading the industry. For-profit hospices have exploded twice as fast as non-profits.
The industry has quadrupled since 2000. That year, 70 percent of hospices were run by nonprofit organizations or government agencies; by 2012, the percentages were nearly reversed.
Today, hospice cares for more than 1.5 million patients.
“Once Medicare started paying for hospice, it was more men in suits, and the focus shifted to administration and sustainable financing,” Dr. Lynn lamented.
In other words, Big Business horned in, and with it came bottom-line-only concern and its inevitable corruption.
A Washington Post analysis found per-patient profit rose from $353 in 2002 to $1,975 in 2012. A Huffington Post investigation found for-profit hospices charged Medicare nearly 30 percent more per patient than nonprofits.
Medicare doled out $18 billion to hospices in 2017. A company’s profit is capped, on average, at $25,000 a patient.
With that kind of money at stake, sales became a top priority. Hospice salesmen, dubbed “Outreach Specialists,” aggressively sought customers from doctors, hospitals, nursing homes, assisted-living facilities and Meals on Wheels groups. “Community Education Representatives” went to “health fairs” at senior centers with blood pressure testers and pitched families caring for an elderly loved one.
Whistleblowers from leading hospices testified that recruiters were told to stress the urgency of committing to hospice. Bonuses were given to reps who met new patient goals.
It gets worse. Ben Hallman’s 2014 exposé, “How Dying Became A Multibillion-Dollar Industry,” found for-profit hospices pressured staff to illegally enroll unqualified patients, and falsified health records to get more tax dollars. Hospices also illegally-obtained hospital records, submitted insufficient documentation and did not adequately train caregivers.
Hospices even admitted patients who were not dying. The whole idea of hospice is to comfort the terminally ill --rules are two doctors have to certify the patient has only six months to live.
But healthier patients require fewer visits and stay longer, making for-profit companies more money.
“A longer length of stay is going to be more lucrative,” one hospice marketer explained. “If they come in very sick and die right away, it’s difficult to run a business that way.”
Medicare pays by the day, not the visit. Hospice companies can charge the government nearly $200 a day per patient ($6000 a month) for the first 60 days, then about $150 a day --regardless of how much care the patient needs, or how often hospice visits.
“They’re paying for a day of hospice with no accountability for what was done on that day,’’ Icahn School of Medicine Professor Melissa D. Aldridge said, “with a payment mechanism that is completely opaque as to what is being done.’’
Not surprisingly, average length of stay at for-profits is far longer than at non-profits (105 days/69 days).
The number of patients who didn’t die in California hospices jumped 50 percent from 2002 to 2012. At one Mobile AL hospice, 78 percent of “terminal” patients left alive.
A 2014 study found one woman who refused to take her cancer medicine, yet she kept getting better. After a year of hospice, she was finally tested. It turns out she never had cancer.
Multiple allegations from former employees charge hospices with enrolling patients who weren’t terminal --wasting well over $1 billion in tax dollars. Lawsuits also allege that patients received expensive care they didn’t need. The Trump Justice Department has joined several of those lawsuits.
According to the rules as they are now, hospices help determine whether a patient is terminal. At the start, two doctors certify a patient’s diagnosis. But re-approvals are routinely done by hospice physicians.
And corruption is made easy by Medicare’s acceptance of overly vague diagnoses, such as “debility” and “failure to thrive.” Next year, Medicare will prohibit such generalization in primary diagnoses.
“It is important that an initial step toward payment reform be taken as soon as possible,” industry watchdog MedPAC understated to Congress.
Hallman’s six month investigation also revealed over a thousand hospices hadn’t been inspected for more than seven years. The legal minimum was six years, until Congress under the Trump administration increased inspections to every three years.
Additional problems include “rogue” and false front hospices stealing tax dollars. Over billing, patient referral kickbacks, unneeded treatment, charging for therapies never administered, underqualified (lower paid) staff, and other methods of theft plague the industry.
From 2006 to 2014, the U.S. government charged that nearly every major for-profit hospice company committed billing fraud.
And there are even more serious charges.
Deaths from lethal doses of morphine and sedatives while under hospice care were brought to light by Peter Whoriskey in the Washington Post. Patients who were not dying when they started hospice, died from excessive doses of painkillers.
In 2009, the New York Times ran a story about “terminal sedation.” The article explained that a strong sedative, typically lorazepam, and a strong pain killer, typically morphine, are administered by an IV drip until heart rate and breathing are slowed until the patient can no longer eat or drink.
Patient overdosing “can intentionally hasten death,” the NYT article stated. A national survey found 83 percent of doctors said this is ethically permissible.
It is not known how often slow murder under the guise of palliative care is perpetrated. No data is collected about such lethal abuses.
Sandra writes, about the death of her father:
“I am absolutely certain that my father died because of the medication he was administered by hospice ...particularly the various forms of morphine he was given... These opioids caused the respiratory failure he went into as soon as hospice administered them to him. He was eligible for hospice with the diagnosis, ‘Failure To Thrive’ and ‘Debility’ after breaking his hip... He was just as alert (after the hip injury) as he had always been until hospice ‘snowed’ him... I didn’t hire hospice to push along my father’s demise.”The new government report concluded with recommendations to begin righting the hospice industry. The Trump Inspector General urges
- tighter, more extensive oversight of hospices,
- changing laws to allow Medicare to enforce violations, and
- public posting of reports finding deficiencies and violations on Medicare’s website, “Hospice Compare.”
The Euthanasia Prevention Coalition believes good hospice care eliminates the falsely-perceived “need” for “mercy killing” (an oxymoron). “The principles and practice of good palliative hospice care already developed and utilized, makes it abundantly clear that there is no need to die in pain, loneliness and anxiety.”
We believe in caring, not killing
We applaud the Trump administration’s Inspector General for a thorough investigation, support its recommendations as a start, and urge the strictest compliance to ethical standards throughout the hospice industry.
The only way to effectively "save hospice" from abuse is to return it to its roots, as expressed by Cicily Saunders. Good caring people who care for the physical, psychological, social and spiritual needs of a person as they approach a natural death.
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