Tuesday, January 7, 2014

Response to Misleading WaPo Hospice Article: Part the First

(Welcome Dr. Bruce Scott to Pallimed.  I met Bruce on Twitter and later at the New orleans AAHPM conference.  I really appreciate his direct insight and critical viewpoint in weekly #hpm Tweetchats. I'm so glad he picked this topic to contribute his first post. It was so good we had to split up into multiple parts! - Ed. Sinclair)

Right before New Year's Eve, there was a flurry of activity on the Twitter #hpm hashtag (and in my email box). A Washington Post article was being discussed. Many people were linking to the article. These included lawyers and investigative journalists, as well as many professionals from across the hospice disciplines. It also included physicians in various levels of training and subspecialty who do not normally use the #hpm tag. I knew what to expect from some of these Tweeters, who have shown a remarkable ability to get it wrong on anything to do with palliative medicine or pain management. Others were more surprising, however given the poor quality of the article. This article was very badly written. It is quite deceptive, the statistics are frequently wrong or cherry-picked, and the conclusion does not follow from the premises asserted. I was surprised that such a poor piece of journalism should fool so many people who should know better.

Let’s start with the headlines: “Hospice firms draining billions from Medicare” and “Medicare rules create a booming business in hospice care for people who aren’t dying”.

If they had instead chosen a headline of “Hospice firms save Medicare gobs and gobs of money while improving quality of life and honoring patient wishes, but some companies seem to be skimming a bit too much off the top for our liking (all while operating legitimately within the silly rules that we set up)”, then I’d have considerably less problem with the article. However, this would have been an honest headline, and it wouldn’t have generated much buzz. They went for inaccurate and misleading instead. A headline more worthy of the National Enquirer or Weekly World News than the Washington Post.

“Hospice firms” are “draining billions from Medicare”? Really? Draining suggests waste or fraud. According to the article itself, Medicare expenditure on hospice in 2011 was $13.8 billion. Even if we charitably allow that $2 billion is enough to make “billions” truthful, are they really suggesting that one-seventh of the Medicare hospice budget was “drained” away? Hospice saves Medicare money. A lot of it. Even if they don’t approve of the strategies used by some (for-profit) hospices, they presumably aren’t making the argument that Medicare paid more for hospice patients than they would for the same patients not enrolled in hospice. I’m assuming that they aren’t making that argument, because they did not state it explicitly in their article. Also, it would be uncharitable to saddle them with an argument with as much credibility as anthropomorphic global warming denialism.

Even if we were to accept the idea that long lengths of stays in hospice are inappropriate (which I’m not), these admissions are STILL saving money for Medicare. Saving money, not “draining” it. In one headline, they used the phrase “people who aren’t dying”. In the article itself, they say that hospice companies earn more by “recruiting patients who aren’t actually dying” and “some hospice patients prove not to be terminally ill”. The journalists only name one specific disease associated with longer length of stay: Alzheimer’s disease. Alzheimer’s disease is a progressive, terminal illness. It is 100% incurable. No currently available therapy available can prevent progression of the disease. Everyone with Alzheimer’s is “terminally ill”. Everyone with Alzheimer’s is “actually dying”. They will have significantly shorter lives than their age-matched neighbors without Alzheimer’s, and they will die FROM their Alzheimer’s in most cases. The death certificates unfortunately will sometimes not reflect this, since an intensivist or a primary care physician will often list cause of death as “Septic Shock, secondary to Pneumonia” rather than “Septic Shock, secondary to Pneumonia, secondary to Alzheimer’s Disease”. Alzheimer’s is a situation where hospice can make a great quality of life impact as well. Pain is routinely unrecognized and undertreated in Alzheimer’s patients. Hospice helps with this and other symptom management. It also provides a team to help families to understand the natural progression of disease and them through the heartbreaking experiences that they will face regarding loss of cognition, personality change, decreased eating and drinking, and likely infections, which goes a long way to make the situation less traumatic for families. The fact that hospices benefit from longer stays with these patients should be considered a win-win situation. It helps offset the financial losses associated with referrals made at the last minute.

The authors assert that “the hospice industry is opposed to fundamental changes to the payment system”. This is simply untrue. The NHCPO has been calling for changes for years. The AAHPM has as well. Individual hospice (and geriatrics) leaders have been arguing (begging) for rule changes for years as well.

Let’s turn now to the ideas that length of stay or percentage of non-death discharge should be measures by which we gauge appropriateness of hospice enrollment. Non-death discharges are presented as if they are very common. If I didn’t know better, just going by the article, it would appear that non-death discharges are extremely common. Authors cite individual subsets of hospice firms with very high non-death discharges. Note that the authors change in mid-article for some reason from talking about California to talking about Alabama. They give some examples of very high non-death discharges from a subset of one for-profit hospice. When I read these percentages, they struck me as very high, and very strange. These are nothing like any hospice I’ve ever been involved with (and I’ve had significant experience with more than ten if you include my fellowship training). This immediately brought to mind many questions:

1) What are the denominators here?

Small denominators can lead to strange results. If these are small hospice branches, then it is hard to draw any broad conclusions.

2) What was this company’s national average non-death discharge? Did the authors know this? Did they try to find out? If they did know the number, why didn’t they share it?

3) What is the non-death discharge for all hospices nationally?

This was not difficult for me to find. It took seconds to get the NHPCO data. This places the non-death discharges nationally at less than 16%. Why on earth didn’t they report this number for us? They did say “The proportion of patients who were discharged alive from hospice care rose about 50 percent between 2002 and 2012”, but they neglected to include the actual percentages. By failing to do so, they are encouraging us to think it is a much higher figure than it is. This strikes me as deceptive. The fact that national non-death discharge is less than 16% highlights the fact that the high non-death discharge hospices are anomalies. They couldn’t be a very large component without dragging the national rate up to much more than 16%

4) Is there anything particular about Alabama that can explain these figures?

Probably. I’ve got a political opinion about why this might be, but that falls outside the appropriate scope of this post. (Note that the four states named by MedPAC with the highest percentage of over-cap hospices were Alabama, Mississippi, South Carolina, and Arizona. Over-cap hospices were much more likely to have high non-death discharges.)

5) Did patients discharge from hospice because they were getting bad care?

This is an essential question from my perspective. MedPAC thinks it may be an indicator of a substandard hospice. They might be right. If so, then Medicare should absolutely consider altering the rules to address the problem. If the hospices are NOT breaking any current rules, however, then this is a problem with poorly written rules combined with companies who are pursuing profits in a capitalist system. Note that for the specific patient mentioned in the article, Chocolate Blount from Alabama,
“It was definitely good news,” said Bessie Blount, whose father received hospice care from the Monroeville outfit and left after about a year, she said. About three years later, her father, Chocolate Blount, 91, is still alive. “He has good days and bad days,” she said. The family “said they miss the help that hospice provided”. It doesn’t sound like he was getting bad care according to the family.
To be continued...Parts 2 and 3 of this rebuttal will be posted later this week.

Part 1 (Tue): Debunking the hyperbolic headlines
Part 2 (Wed): Did these hospices enroll patients inappropriately? Do for-profit and not-for profit hospices differ?
Part 3 (Thu): Digging into the statistics and the way forward
Bruce Scott (@skipbidder) is an academic physician in Ohio, fellowship-trained and board certified in Geriatrics and in Hospice and Palliative Medicine. His hobbies include boardgaming, cooking, and pedantry.
(1/8/2014 - Edit - Added back in links that were lost when initially published. Fixed acronym for NHPCO. - Ed. Sinclair)

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