Like many Americans, I have a story about hospice care for a loved one. When my father was dying from complications of dementia and diabetes, hospice caregivers sat with him, provided pain relief, and helped him be comfortable. They also gave my mother peace of mind that her beloved husband was receiving kind attention in his final weeks. To this day, she refers to those hospice workers as angels.
Sadly, not every family’s story is a positive one.
Some patients experience days of pain or severe anxiety because their hospices fail to provide pain management and other needed services. Some are signed up for hospice without their knowledge, including some individuals who are not terminally ill.
The Department of Health and Human Services’ Office of Inspector General, for which I work, recently published a report examining hospice practices over a decade. It showed that hospices do not always provide the services that patients need and sometimes provide poor-quality care. We also found that patients and their families often do not receive crucial information to make informed decisions about hospice care.
We uncovered multiple abuses in our investigations:
Hospice recruiters inappropriately promised Medicare beneficiaries free housecleaning and other services that are not provided through hospice without telling them they would be signed up for the hospice benefit. That means they unknowingly gave up treatments that could cure, or at least manage, their conditions and instead received only palliative care.
In a North Texas case, nurses allegedly gave high doses of drugs such as morphine, regardless of whether patients needed it, to justify receiving the higher hospice payments. Some of these excessive dosages resulted in significant injury or death.
Or take the case of Larry Johnson’s 87-year-old mother, who had dementia. Two days before she died, he learned that she had been enrolled in hospice more than a year earlier, a decision that an individual with dementia shouldn’t make without assistance. “My mother needed basic care, but not hospice ― and especially not for a year and then some!” Johnson said in an interview with our staff.
Our investigation in her case yielded results: The owner of that hospice company received a 6-1/2-year federal prison sentence for running an elaborate, $20 million hospice scheme that signed up patients who were not dying. The hospice is permanently closed.
The idea that hospice care could abuse and neglect patients when they are at their most vulnerable, or exploit them for unjust enrichment, is repellent.
Because taxpayers bankroll poor care and fraud through the Medicare hospice benefit, policymakers need to take immediate action to implement safeguards against fraud, waste, and abuse of this important benefit.
Growth in the use of hospice makes it even more important to take action now. The latest Medicare data show that hospice use has grown over the past decade: In 2006, Medicare paid $9.2 billion for fewer than 1 million beneficiaries in hospice care. Ten years later, it paid $16.7 billion for more than 1.4 million beneficiaries.
Quality hospice care can provide significant comfort and support to terminally ill patients and their families and caregivers. But we must take steps to prevent both the very human toll and the economic toll that hospice fraud takes.
The Inspector General’s office made recommendations to the Centers for Medicare and Medicaid Services, which runs Medicare, in seven key areas. Although CMS did not agree with a number of them, we believe they are essential for weeding out poorly performing and unscrupulous hospice providers:
- Congress should give CMS the authority to hold poor performing hospices accountable and take swift action when warranted.
- CMS should take steps to tie payments to patient care needs and quality of care, rather than the current approach of paying a flat rate regardless of how many services a hospice provides, which can create incentives to minimize services and seek patients with uncomplicated needs.
- CMS should provide more information to the public, especially Medicare beneficiaries, about hospice performance so consumers can effectively compare hospice providers. CMS now provides such information for nursing homes on its Nursing Home Compare website; a similar offering for hospice on Hospice Compare would help consumers make informed choices.
Patients and their family members can help guard against fraud by carefully reviewing the summary notices they receive from Medicare detailing the services for which Medicare has been billed on their behalf and report those that were not authorized or received.
Medicare beneficiaries who elect hospice care should receive high-quality services, and hospices should act with integrity when billing government health programs. Most already do that, and assist dying patients with dignity and compassion.
We strongly urge CMS and Congress to implement our longstanding recommendations to protect patients and their families from hospice providers that are exploiting this vital service.
Joanne M. Chiedi is the principal deputy inspector general for the Department of Health and Human Services.