Thursday, January 9, 2014

Response to Misleading WaPo Hospice Article: Part the Third

(If you missed Part 1 or Part 2, click on the links. If you don’t have time, here is the quick summary. The Washington Post published 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. Today Dr. Scott tackles some statistics and the way forward - Ed. Sinclair)

One of the consistent errors made by people commenting on this story, either in the comments sections or on social media, is the failure to understand the difference between estimated marginal life expectancy and actual marginal life span. The hospice regulations require two physicians to certify that the patient’s life expectancy is less than or equal to six months if the disease/illness runs its normal course, given their current condition and taking into account any decisions made by the patient/family to forego potential treatments. Many are erroneously confusing life span and life expectancy.

If the regulations instead required two physicians to certify that the patient’s actual marginal life span will be six months or less, then these commenters would be right. In that case, patients who lived longer than six months would be evidence of error. You would probably allow a few of them, as an acceptable error rate. One commenter argued that patients who lived longer than six months should be considered analogous to the patients with suspected appendicitis, had surgery, yet turned out to have a normal appendix. You accept a percentage of surgeries for normal appendixes in order to minimize the risk for missing abnormal appendixes. (This was a more common idea prior to the more extensive use of imaging to guide the surgery decision.) This is an inappropriate analogy. Starting an appendectomy for someone with a normal appendix is a mistake. No benefit accrues to the patient. A patient who lives for seven months after being admitted to hospice is not necessarily a mistake. It does not follow that the original certification was wrong. In fact, it was probably right. At worst it was likely to be borderline. Half the patients in a group with a median life expectancy of six months will live longer than six months. Those who do still received a benefit from being on hospice. And Medicare saved money because they were on hospice.

Since the regulations stipulate life expectancy, it would be useful to think about what a frequency distribution curve would look like for a set of patients with a median life expectancy of less than six months. It would be a positively-skewed distribution. It bunches up at the left side, since it is bounded at zero days. Patients cannot die sooner than right now. It tails off to the right, with what are called outliers. The flatter the curve, the further out that tail will go. For non-cancer diagnoses that are harder to prognosticate, the curve is flatter, with more outliers and more extreme values for outliers. This is not indicative of fraud. Claiming it is represents a misunderstanding of the mathematics involved.


Hospices have traditionally enrolled patients with life expectancies considerably less than six months. It has been a concerted effort to try to enroll patients sooner. This has been encouraged (even by MedPAC) as a way to save Medicare a great deal of (more) money. Consider the “ideal” situation, where most patients were enrolled when they reached a median life-expectancy of six months. In this case, half of the patients would have a life-expectancy greater than six months. There would (for most diagnoses) be outliers that stretched into years. A hospice that succeeds in enrolling patients earlier in the process—closer to the six month estimate – will end up with more patients who live 7+ months. This is simply the mathematical consequence of a positively-skewed distribution, which is what a life-expectancy distribution for hospice patients looks like. (The stats geeks reading this, who are already seething about my over-simplifications here, may be thinking that the distribution is actually bi-modal. I hear you. I feel your pain. But I’m not going to try to go into that idea now.)

Currently, when you see differences in the MEAN length of stay for for-profit hospices compared to not-for-profit hospices, it is because of differences in the mix between cancer and non-cancer diagnoses. The MEDIAN length of stay shows no difference. Cancer has a more predictable course. Its life-expectancy distribution curves are narrower. Non-cancer diagnoses have flatter curves, with more skew to the right. The outliers are further away from the median. The more of these patients enrolled, the more extreme outliers you expect, and the further you pull the mean away from the median. The authors admitted that NHPCO had explained this to them, but then ignored that explanation (or didn’t understand it) when they asserted that “the growth in the average duration of hospice care stems less from the decline in the proportion of cancer patients than from another trend. Patients who are suffering from a non-cancer ailment began staying longer on hospice: Their average stay in hospice care grew from six weeks to almost 11 weeks on average between 2002 and 2012.“ Do note that the authors are using an increase in average length of stay to 11 weeks as part of their argument. 11 weeks is less than three months. The Medicare Hospice benefit asks us to certify patients with an expected life expectancy of six months or less, more than twice that average. Any argument that seriously uses an 11 week mean length of stay as an argument that an unacceptably high proportion of these patients really had a life expectancy of greater than six months is prima facie a bad argument.

Others commented that non-death discharges should be viewed as errors as well. While I agree that the very high percentage of non-death discharges is worth looking into further, I vehemently disagree with the idea that non-death discharges should in general be considered failures, wastes of money, or fraud. There are many reasons for non-death discharges. Those of us who are hospice providers consider many of these reasons to be successes rather than failures.

Take the cancer patient who would have wanted to try chemotherapy but whose oncologist feels that performance status is too poor and burden outweighs benefit. This patient can enroll in hospice. Patients often feel better, improve, after enrolling in hospice. The extra help at home. The excellent symptom management. The optimization of medication regimen (which often includes discontinuing cholesterol, blood pressure, and diabetes medications that don’t have a net benefit vs burden). All of these things can contribute to a patient improving. Some of these patients will improve sufficiently that they are candidates for chemotherapy. We happily discharge these patients, knowing that we helped them and that they are not getting the treatment that is consistent with their goals. We call these patients “hospice graduates”.

The same sort of improvement can be seen in non-cancer patients as well. Dementia patients are a prime example of this. We see improvements for the same reasons: more care at home, better symptom management, optimization of medication regimens. Now these patients improve enough that they no longer fit the category of “life-expectancy less than six months”. We discharge these patients, but LESS happily. We are happy that they improved, but we’d like to keep them, since we think our interventions led to the improvements. For Alzheimer’s disease, these patients are STILL DYING. They still have a terminal illness. They just have a life expectancy estimate that exceeds six months. Most of us wish we didn’t have to discharge these patients. We discharge them because we play by the rules. A rational, well-designed Medicare hospice policy wouldn’t require us to do so. Note that the scrutiny placed on hospices for these patients has actually led to more patients being discharged (as hospices fear they will be challenged on these admits). If you are more interested in scoring rhetorical points than you are in having an honest discussion, then you can use this “increase in live discharges” to claim this proves that hospices were doing something wrong all along.

The authors inappropriately used mean as the measure of central tendency when discussing length of stay. Hospice length of stay data graphs out as a positively-skewed distribution. The honest measure of central tendency to use with such a distribution is the median. Use of the mean instead is considered to be deceptive. It will be listed in any handbook of “How to Lie with Statistics”. This is basic, intro-level stuff. There are only two possibilities. Either the authors knew that mean was inappropriate or they didn’t. If they didn’t know that using the mean is inappropriate, then they are not qualified to be incorporating such statistics into their articles without seeking help. (Their editor should have caught this. If neither the editor nor the authors were sufficiently familiar with intro-level statistics, they should have asked a starving adjunct professor teaching at the local community college to help them out.) If they DID know that mean was inappropriate and chose to use it anyway, then they are guilty of deception, of believing that their narrative was so important that the means justified the ends when trying to convince others. Including both mean and median would be acceptable reporting (and is what both NHPCO and MedPAC do).

The mean length of stay did increase between 2000 and 2011, but didn’t substantially between 2009, 2010, and 2011. Between 2009 and 2010, both the mean and median length of stay DECREASED. The median (50th percentile) length of service in 2010 was 19.7 days, a decrease from 21.1 days in 2009. The average length of service dropped to 67.4 days in 2010 from 69 days in 2009. Comparing 2000 to 2011, the average length of stay increased from 54 to 86, but the median stayed the same at 17 days. Between 2000 and 2011, total number of hospice patients increased from 534,000 to 1,219,000.

For access to the primary data:
http://www.medpac.gov/chapters/Mar13_Ch12.pdf
http://www.nhpco.org/press-room/press-releases/research-published-jama
http://www.nhpco.org/press-room/press-releases/hospice-facts-figures
And for annual stats back to 2006 see this Pallimed post.

Thus the same number of short stay and long stay patients are being added. Long stay patients defray the costs of taking care of short stay patients. And long stay patients enrolled in hospice still save Medicare money, even the outliers.

The authors used flawed MedPAC data when discussing profit margin. MedPAC itself admits that their data is inaccurate and incomplete. It fails to include costs for federally mandated volunteer (for at least 5% of patient care hours) and bereavement services (for at least 13 months after patient death). These are real costs to hospices, and the data ignores them.

From this NHPCO press release:
“The discrepancy in the numbers is an indication of a change in the calculation methodology, by excluding the costs of delivering statutorily mandated services, rather than pointing to the fact that hospice margins are actually shrinking. For MedPAC to recommend countering an erroneous growth in hospice margins by reducing the annual inflationary adjustment is absurd and potentially devastating to the hospice community”.
Finally, let me reiterate that I actually agree that there is some fraud by hospice firms. There is some fraud in all situations involving companies with a profit motive. The authors did not make their case that it is widespread. They didn’t come close to making their case that hospice firms are costing Medicare any money at all, much less “draining billions”. They pointed out that some lawsuits are pending. I’d point out that these represent potential problems and not yet proven ones. Judges have ruled against Medicare and for hospice organziations in the past in hospice CAP payment cases.

Despite having grossly exaggerated the cost to Medicare, falsely suggested that discharged patients weren’t actually dying, and deceptively used statistics to advance their narrative, the authors did raise some important points as well. They described some fairly unpleasant recruitment tactics. I consider some of these tactics to be unethical. I would not want to be involved with a hospice that used them. The recruitment bonuses are particularly galling. Note that the NHPCO actually considers these to be unethical as well. They are not, however, against the current rules, nor are they illegal. And they are the same sorts of things that happen at businesses around the country. I want hospices to be better than businesses around the country. My gut feeling is that hospices ARE in general better than businesses around the country. (I think that this stems partly from the fact that hospice team members, current blogger excepted, in general are very nice people.) But we can’t expect all hospice firms to be better than other corporations just because it’s the nice thing to do. With money involved, it isn’t a surprise that some companies aren’t. If Medicare would like to write some better rules, I’d be among those cheering.

Other posts in this series:
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.

Thursday, January 9, 2014 by Bruce Scott ·

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.

Wednesday, January 8, 2014 by Bruce Scott ·

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)

Tuesday, January 7, 2014 by Bruce Scott ·