Medicare Hospice Patients by Primary Diagnosis, 1992 and 1998
From 1992 to 1998, 58 to 67% of all hospice patients were also Medicare recipients. In 1992, 75.6% of Medicare hospice patients had a primary diagnosis of cancer. In 1998, 57.4% did. As more patients and doctors became aware of hospice services, more patients with non-cancer illnesses chose to take advantage of these services. But, as more patients took advantage of these services the average length of stay in hospice care for Medicare beneficiaries declined (from 74 days in 1992 to 59 days in 1998). Those diagnosed with illnesses other than cancer stay longer in hospice care than those with cancer. But, from 1992 to 1998, the average number of days used by non-cancer patients declined by 38%. The average number of days for cancer patients declined by 14%.
Medicare pays for hospice care when the beneficiary is expected to live 6 months or less. Once cancer patients choose hospice care over curative measures, the disease follows a progression that's fairly easy for the physician to predict. Progression of non-cancer illnesses may be less easy to predict. Those with Alzheimer's disease, for example, may be able to live for many years before the illness finally takes their lives, while others will die after a shorter period of time. The patient, his family, and his physician may postpone the decision to enter hospice care until the patient's heart is weakened or a secondary illness brings him closer to death. And by the time the patient is in that weakened condition, he may have days to live rather than months.
But there are always exceptions to the rule and some patients live longer in hospice care than what their doctor predicted — longer than the 6 months allowed by Medicare. What do hospices do then?
In 1993, the Health Care Financing Administration (HCFA) warned hospices about "questionable certifications and recertifications of terminal illnesses."17 If they didn't improve their documentation and certification procedures, they would be denied payments.18 Audits in Puerto Rico in the early 1990s found that hospices there were billing Medicare to take care of patients with illnesses such as obesity and arthritis. In the United States, the government found that Medicare paid out more than $83 million in fraudulent claims. As a result, in the latter part of the 1990s, the HCFA turned to United Government Services (UGS, a subsidiary of Blue Cross & Blue Shield of Wisconsin) to root out fraud.
In 1997, UGS focused its attention on Plattsburgh, N.Y. Some patients of Hospice of North County received letters informing them that they may owe the government thousands of dollars for unneeded hospice care. All the recipients of the letters were diagnosed as terminally ill, in their 80s and 90s, and had outlived the federal guidelines for the Medicare Hospice Benefit.
One woman who received the letter was Rosie DesParois, an 87-year old woman diagnosed with advanced breast and endometrial cancer when she entered hospice. Doctors thought the cancer had spread to her liver, but she was still alive four years later. The hospice was getting $88 a day from Medicare for those four years.
"Mrs. DesParois, a retired nurse…hated taking medicine and was terrified of needles. She loved the idea of spending her final days in her old house that she adored, tinkering in her flower garden, continuing her 70-year cigarette habit. Alice Ballard…[a hospice nurse] visited several times a week and, with the rest of the hospice staff, worked miracles, recalls Mrs. DesParois's granddaughter…. She remembers how hospice nurses brought coffee and doughnuts, gently coaxed her grandmother into taking pills, even hand-washed her collection of antique teacups. [After the hospice dropped Mrs. DesParois, she] couldn't remain at home, and she slid downhill…. She was sent to a hospital, then to a nursing home where she became almost unrecognizable…. She stopped eating almost completely…. Cancer spread to her pancreas and her stomach." She died on September 16, 1998, "away from her home and the hospice staff." The government's cost-saving move to stop paying for her hospice care (because "the auditor was dubious that she was that sick") ended up costing Medicare nearly twice what it was paying hospice in nursing home reimbursements.19
In May 1998, UGS started to seize the hospice's Medicare reimbursements. A court hearing was held in September 1998 and the hospice won. The judge determined that there had been no fraud. "The fact that some patients 'exceeded those expectations does not indicate that a fraud was perpetrated,' he wrote.20 Rather he said, 'it suggests that health and illness, life and death, are subject to factors and influences beyond the science of medicine.'" The government appealed and lost. In March 1999, UGS returned $85,000 to the hospice. (Unfortunately, the hospice's court fees were $80,000.)
Now, fear of audits (and litigation, presumably) has changed the way the hospice does business. The hospice is more selective in admitting patients. Patients' records have to be written in such a way as to allow for the least amount of interpretation. No longer are nurses allowed to write: "The patient is stable." Instead, something similar to: "The patient is experiencing improved quality of life with hospice pain and symptom control and supportive services." And, adherence to the "six-month rule" is stricter. Mary Lou Kingsley, a North County hospice nurse, wondered if the hospice, in an attempt to comply with Medicare law, abandoned a patient with heart and lung disease. Nine months after he came to hospice (3 months longer than the 6 months allowed by Medicare) he was doing better, so the hospice discharged him. Two weeks later he was found dead. Did this hospice abandon the original hospice care concept envisioned by Dr. Cicely Saunders (see previous panel)? Are others doing the same in an attempt to ward off the auditors?
Sources: The National Hospice and Palliative Care Organization. "More Patients and Families Choose Hospital Care Each Year." Retrieved September 11, 2002 from http://www.nhpco.org. William J. Scanlon. Health, Education, and Human Services Division. United States General Accounting Office. "Medicare: More Beneficiaries Use Hospice; Many Factors Contribute to Shorter Periods of Use," September 18, 2000. Retrieved September 11, 2002 from http://www.gao.gov/new.items/he00201t.pdf. "The History of Hospice." Retrieved September 11, 2002 from http://www.cp-tel.net/pamnorth/history.htm. Lucette Lagnado. "Rules are Rules: Hospice's Patients Beat the Odds, So Medicare Decides to Crack Down-Terminally Ill Who Don't Die Within a 6-Month Period Risk Losing Coverage-Al Ouimet's 9-Year Survival." The Wall Street Journal, June 5, 2000. Retrieved September 11, 2002 from http://www.nhpco.org/public/articles/c025.doc.
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