Hospice abuse undermines opposition to assisted suicide.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

An article by Ava Kofman that was published by Propublica on January 20, 2023 reports on the need for Hospice Reform.

For more than 20 years I have opposed assisted suicide and supported good end-of-life care. I do not view hospice as an alternative to assisted suicide but I agree that good end-of-life care reduces the demand for assisted suicide.

I also recognize that hospice abuse undermines opposition to assisted suicide.

Kofman's article - Pressure Mounts for Hospice Reform, focuses on the financial abuse in the hospice industry.

Last week, the four largest hospice trade associations jointly sent a detailed memo of policy proposals to the Centers for Medicare and Medicaid Services, which regulates the end-of-life care benefit. Their 34 recommendations, which span eight pages, directly address the alarming business practices outlined by a recent ProPublica-New Yorker investigation.

Dr. Diane Meier

Kofman quotes Diane Meier, a long-time palliative care leader who stated:

“The New Yorker-ProPublica investigation shook the industry to its foundation,” said Dr. Diane Meier, a geriatrician at New York’s Mount Sinai hospital and a leading authority on palliative care. “You have four major industry groups coming together, as they don’t always do, on a series of significant policy and regulatory changes for hospice. This suggests — contrary to public messages about this being just a few bad actors — that it’s not just a few bad actors. There are systemic problems with the lack of oversight and the profit motive.”

Kofman then reports:

Industry leaders are not the only bloc pressuring CMS for greater hospice oversight. Senators and government watchdog agencies are also pushing the agency for concrete changes. Last week, the Government Accountability Office released a report asking that hospices be required to report observations of abuse and neglect, regardless of whether the alleged perpetrator works at the hospice. MedPAC, the congressional advisory panel on Medicare spending, has again endorsed modifying the hospice payment structure to reduce part of the financial incentive for enrolling ineligible patients. And in late December, the inspector general’s office at the Department of Health and Human Services announced that curbing the abuse of hospice patients was among its top unimplemented recommendations.

Let's be clear. Everyone deserves excellent end-of-life care but unless the hospice industry is cleaned up, there will be a greater push for assisted suicide. Kofman reports:

Among its proposals, the memo discusses the need to rein in predatory marketing schemes. ProPublica’s reporting found that profit-seeking providers can take advantage of the fact that many people don’t know what hospice is to recruit new patients who are not dying. Some hospice marketers — known in the industry as “community liaisons” or “community educators” — aggressively solicit new patients with promises of free housekeeping and trips to the beach and casino. Others treat physicians to cash bounties and bottle service at Las Vegas nightclubs to gin up referrals. The groups ask that CMS update its regulations to require hospices to develop policies on “ethical marketing practices.” (Such policies, they note, must prohibit kickbacks, disclose bonuses to marketers and mandate that hospices clearly explain the benefit to patients.)

ProPublica’s investigation pointed out that practically anyone can open a hospice. I came across hospices owned by vacation-rental superhosts, a man convicted of drug distribution and a criminal-defense attorney (who once represented a hospice employee convicted of fraud and was later investigated for hospice fraud himself). The trade associations have asked CMS to prohibit individuals with convictions for certain crimes from operating hospices and to require training and background checks for hospice administrators, noting that “unqualified or risky hospice leadership” could lead to fraud or poor quality of care.

Kofman reports that hospices are being bought up by private equity firms.

It’s hard to require that hospice owners have appropriate qualifications, however, if the identity of those owners remains unknown. As private equity firms acquire an ever-greater share of the hospice market, many families have no way of untangling who actually operates their provider. This lack of transparency, the trade groups write, “makes accountability for poor performance difficult and makes it harder for patients and families to choose quality providers.” At the moment, it’s easier to research a hotel for your honeymoon than it is to research the hospice that will care for your loved one. But it doesn’t have to be this way: CMS could make hospices disclose their owners and major investors, the groups say. It could also revamp its Care Compare website — a sort of TripAdvisor for end-of-life care consumers — to prioritize quality metrics and make its data more accessible. In response to questions from a groundswell of readers in the wake of its reporting, ProPublica published a guide to help families research their provider and spot common signs of fraud. The trade groups propose that similar information be incorporated into the official Medicare handbook for hospice consumers.

The article concludes by stating that Centers for Medicare and Medicaid Services (CMS) already have the power and the suggestions for reforming the hospice industry.

EPC - USA opposed the Palliative Care and Hospice Education and Training Act (PCHETA) for several reasons. The first was related to this article, the abuse of hospice. The second reason was that the definitions in the act did not prevent assisted suicide groups from accessing the money.

The Euthanasia Prevention Coalition's interest in this area stems from the fact that people who seek death by assisted suicide are often trying to avoid a bad death. When someone experience hospice abuse, as they approach life's end, it undermines our opposition to assisted suicide.