A new report by Time Magazine shines a harsh light on the hospice care industry in America – reporting that 21 percent of hospices, accounting for more than 84,000 patients, failed to provide critical care to patients in 2015. The report, which includes vivid and heartbreaking stories, points towards a largely unregulated industry that received almost $16 billion in federal Medicare dollars last year.
Hospice is provided to Medicaid patients if they are expected to pass away within six months. Starting in the 1970s, hospice care focuses on relieving the symptoms of a patient and providing “comfort care.” The use of hospice care has become increasingly popular in the last couple decades. According to the National Hospice and Palliative Care Organization, enrollment in hospice care has more than doubled since 2000.
While most Americans think of hospice as a location, the reality is that most Americans utilize hospice care so they can pass away in their own home. With 86 percent of Americans saying they want to die at home, the trend is unlikely to reverse anytime soon, either.
Unfortunately, the report by Time Magazine details some disturbing problems with hospice care. Unlike nursing homes, hospice facilities or organizations do not face a yearly inspection to maintain certification. Instead, the facilities are supposed to be inspected every three years, but it is unlikely that even these infrequent inspections occur. The rule only came into effect in 2014 and only applies if there is “available funding,” – a perpetual problem for the cash-strapped government agency.
When a violation does occur, the Centers for Medicare and Medicaid Services (CMS) has very few options short of termination, which is disruptive to the near-death patients the agency is providing care for at the time. For this reason, despite CMS identifying serious problems in more than half of the 4,500 hospices inspected between 2012 and 2017 – only 17 hospice agencies were terminated by CMS. According to Time’s report, this is not because more hospices are not deserving.
The report by Time Magazine, in conjunction with the Kaiser Health News, painted a dire portrait of hospice care in America. A full 12.3 percent of patients received no medical professional visit during their last days of life, usually the time when palliative care is the most necessary. Sadly, this is better than the average response rate. According to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey, one in five respondents said that hospice care did not show up when called.
Part of the problem involves the flat-fee schedule for hospice care. Hospices are paid a flat daily fee by Medicaid – $191 for the first 60 days that a patient is enrolled, $150 after that. There are some requirements for receiving this fee, including establishing an end-of-life care plan that ensures all symptoms of a terminal illness will be treated and a requirement that the hospice must be available 24/7 – a particular problem in rural parts of the country such as Alaska, Appalachia, and upstate New York. However, because each person’s care is individualized in hospice, there is no requirement that hospice care visit a certain number of times. This leads to a problem where hospice agencies have no incentive to visit patients in the last days, and as a consequence, many are simply ignored.