The Office of the Inspector General (OIG), a division of the Department of Health and Human Services, has released a memo detailing the surge of Americans relying on hospice care in the 10 year period from 2006-2016. Some of the most notable findings include:
- The number of hospice providers has grown 43% (from 3,062 in 2006 to 4,374 in 2016)
- Medicare spending on hospice is up 81% (from $9.2 billion in 2006 to $16.7 billion in 2016)
- The number of those whom received hospice care increased 53%
- The number of Medicare beneficiaries who received hospice care rose 32%
The surge in those relying on hospice has led government officials to take a closer look at the quality of care provided to those receiving hospice services within their own home, in an assisted living facility, nursing home, or inpatient hospice facility. The OIG’s report publicly voices concern about the care that is actually given vs. the care that is promised, as well as the level of treatment being billed to Medicare. The report references The Centers for Medicare and Medicaid Services’ (CMS) citations against hospice providers and legal cases, including failure to follow simple pain management standards, an especially frustrating revelation given that the primary goal of hospice is to provide respite from physical and emotional pain during one’s final days.
Majority of Hospice Facilities Have Been Cited for Care Deficiencies
A 2015 Kaiser Health News/Time investigation found that hospice is a major provider of palliative care in this country, with 1/3 of Americans relying on these services at the end of their lives. That same investigation revealed that CMS found deficiencies in the care provided by half of all hospice organizations, but only 17 providers lost their Medicare certification.
Industry experts firmly believe that the payment model used by CMS is to blame for most hospice deficiencies, pushing hospice administrators to seek quantity over quality. CMS currently reimburses hospice providers per patient, per day. No matter the services provided to the patient, the hospice facility or provider is reimbursed the same. There are 4 levels of hospice care and CMS reimbursement rates correspond to the classification of care indicated as necessary by the hospice provider.
- Routine Home Care – At patient’s place of residence; Reimbursement per day is $190.55 per day.
- General Inpatient Care – At hospice center, hospital, or skilled nursing facility; Reimbursement is $734.94 per day.
- Continuous Home Care – Temporary in-home round-the-clock care; Reimbursement is $964.63 per day
- Inpatient Respite Care – Brief care within hospital or hospice facility, intended to give a break to patient’s primary caregiver; Reimbursement is $170.97 a day.
Hospice providers have been found to inflate the level of care required by patients, classifying a patient as in need of General Inpatient Care, when in reality they may only require Routine Home Care.
In 2017, Seth Gillman, founder and CEO of Passages LLC, the largest provider of hospice care in Illinois, was found guilty of elevating the level of care needed by patients at his hospice facilities and sentenced to 6.5 years in federal prison.
Gillman had repeatedly classified patients in his facilities as needing General Inpatient Care when lesser levels of care would have sufficed. With no need to show evidence that he was providing more frequent and complex services and care to his patients, he was able to scam $20 million from the Medicare program. His story is one of many such hospice Medicare fraud schemes, yet no change has been made to the per patient, per day payment model.
The hurt felt from hospice fraud is far beyond just the financial hit to taxpayers. Patients and their loved ones are often not receiving the care promised. The OIG found numerous cases in which patients were classified as needing care, but that care only involved a phone call to the family to see how the patient was doing. Patients were left to suffer for days with too low or altogether missing doses of pain medications and some were lured into hospice even when they didn’t require it.
OIG’s Recommendations for Improvement
The report included a list of areas of improvement, several of which CMS has agreed to. One major area that CMS says they are unable to change is the area of payment. The group says they have verified that the amount paid per patient, per day based on their classification is inclusive of the services and care required at that level.
The OIG’s recommendations that CMS have agreed to are:
- Increase the amount of potentially useful information provided to the public on Hospice Compare, CMS’ online tool that details hospice facilities. Currently the data is minimal and the OIG has recommended adding information based on claims.
- Develop tools that will notify beneficiaries, their families and caregivers of the possibility of hospice for palliative care.
- Strengthen analysis of claims from hospice providers that raise red flags.
- Take action against hospice providers that raise concern.
- Increase oversight of patients classified as General Inpatient Care in nursing homes and skilled nursing facilities, because this combination has a history of fraudulent billing.
- Strengthen analysis of claims in which patients have longer General Inpatient Care stays.
No one’s final months, days, and moments should be filled with pain, especially not when we have entrusted our loved ones to those who promise to ease their suffering.
The full 45-page OIG report can be found here.