Wednesday, January 8, 2014

Response to Misleading WaPo Hospice Article: Part the Second

(If you missed Part 1, you can read it here. If you don’t have time, here is the quick summary. The Washington Post wrote an article December 26th, 2013 claiming hospice care was taking billions from Medicare presumably in waste and fraud. This series offers a critical review debunking the claims and offering a more insightful view of the challenges hospices face. - Ed. Sinclair)

6) Did these hospices enroll patients inappropriately?

This is the element that most needs to be addressed. The only real way to assess this is by checking the documentation for the individual hospices in question. If there had been a report of widespread denials for inappropriate hospice admissions, it would have done much more to support the assertion that hospice firms were draining money from Medicare. That would mean that they were doing so outside of the current rules rather than within them. The lawsuits mentioned will help bring clarity here. Do I doubt that there is fraud involved in some hospices? Not in the slightest bit. One could expect some le
vel of fraud, since there is a significant amount of money involved. If these hospices were clearly admitting patients outside of the regulations, then they should be punished. If the situation is widespread enough, then steps need to be put in place to prevent it. This does not come close to justifying the “draining billions” headline, though. It also doesn’t come close to being a few rotten apples that spoil the bunch. If the cases go against them, it will be a few rotten apples that got caught and punished. And even then, these rotten apples saved Medicare money along the way for the appropriate care they delivered to eligible patients.

If these hospices WERE NOT habitually admitting patients illegitimately, but we are still unhappy with their practices (while following the rules), then we need to change the rules. Any set of rules that allow for “gaming” WILL BE gamed when corporations are concerned. This is simply an expected consequence of how companies work in our capitalist system. Would a system that only had government hospices and charity hospices work better than the one we have now? Maybe. Probably. It seems to work well in the UK. But it would take a fundamental change in the way we as a country handle this part of healthcare. And it is very clear that we are nowhere near this being politically feasible. So if we are going to have for-profit companies delivering hospice care, then Medicare should write better rules. You cannot punish a company for maximizing their profits if they are following the rules and breaking no laws. So the parts of the article that refer to gaming the system to avoid running over cap are moot. They are NOT the fault of the companies doing the gaming but of poor rules construction. (Note that I’m using “gaming” here because I don’t like some of the practices described either. The companies probably won’t agree that gaming is a fair description, of course.) The decisions to game the system are not made by hospice docs. They are made by administrators and the financial folks. Nobody is knocking down MY door to ask me to make the decisions about what to do when the hospice has some extra money left over. There are good reasons for this, one of them being that I’d spent it differently than the bean counters would. The social worker would get a raise. Or we’d get the chaplain an electric plug-in menorah that doesn’t violate fire codes at the nursing home. Or we’d get one of those snazzy one-cup coffee makers for the family area in the inpatient unit. Or we’d hire some other staff, like a pharmacist or a psychologist or even a music thanatologist. But I’m a hospice doc, and a true believer. They don’t let me make these calls.

7) Do for-profit and not-for-profit hospices differ in the quality of care they provide for patients?

I personally used to suspect this to be the case. I ached for this to be the case. I would have to take extra care to make sure I fairly evaluated the evidence, since I had so much personally invested in the idea that not-for-profit hospices were better. I’ve had personal experience with many hospices that I’ve worked or trained at (and more still that I’ve referred patients to), including for-profit, not-for-profit, and government (VA). The VA was different, since they operated under what was essentially an open-access model. Apart from that and the one open-access for-profit hospice I worked at in training, the hospices were pretty similar in terms of the patients enrolled and the certification processes. The quality of care was fairly similar as well. I do personally think some hospices do a better job, and I could rank them in mind, but these preferences do not break on profit vs non-profit lines. These are all anecdotal experiences, however, and don’t really provide much ground for generalization. (Any more than the strangely high Alabama non-death discharge hospices do.) Luckily, the NHPCO has done surveys on families to gauge satisfaction, so we have data instead of anecdote. Their comprehensive Family Evaluation of Hospice Care survey shows no differences in family caregivers’ evaluation of quality of care. (This information appears to be available only to members, so I can’t link to it here.) Christian Sinclair reviewed this issue in 2011 on Pallimed and since then there have not been any ground breaking journal articles exposing a huge gap in the quality of hospice care based on profit status.

To be continued...Part 3 of this rebuttal will be posted Thursday
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.

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