For individuals in the last stages of life and their families, hospice care can promise welcome comfort and relief from pain and greater quality of life during those final months. By focusing holistically on patient and family needs, hospice care is designed to reduce stress, increase comfort, and limit disruptive (and costly) hospital stays. The truth, however, is that the realities of hospice care too-often fall far short of the promised benefits and can actually harm patients. Two recent Office of Inspector General reports from the U.S. Department of Health and Human Services underscore major vulnerabilities with the hospice program that directly impact quality of care for beneficiaries.
Hospice care covers palliative as well as a broad range of related services for the patient and his/her family including nursing care, physician services, counseling, home health aide and homemaker services, drugs for symptom relief, therapy, equipment, and bereavement support for families. Hospice care, however, is not automatic. Medicare beneficiaries must elect to receive the hospice benefit. By doing so, they are also agreeing to forgo Medicare coverage for treatment of their terminal illness and any related conditions (Medicare continues to cover treatment for unrelated conditions).
As our population ages, use of hospice care is increasing. In 2016 alone, Medicare paid $16.7 billion for hospice care impacting 1.4 million beneficiaries. Services are provided by Medicare-certified hospices. These hospices may be for-profit, nonprofit, or government-owned agencies. Payment is made on a per-day basis, regardless of the quality or scope of care provided. According to the Office of the Inspector General (OIG), for profit hospices accounted for 64% of total Medicare dollars in 2016.
The findings in the OIG reports are sobering. Here are just a few from the 2018 and 2019 reports:
- Over 80 percent of hospices had at least one care deficiency; 20 percent were deemed serious deficiencies (directly impacting quality of care). Most hospices with one deficiency in 2016 had multiple deficiencies from 2012 to 2016.
- One-third of hospices had complaints filed against them; almost half of those complaints were severe.
- More than 300 hospices were poor performers.
- More than 40 percent of hospices surveyed assessed beneficiaries inadequately, directly impacting care they could access.
- Most beneficiaries (about 75 percent) do not see a hospice physician, including those with complex medical needs.
- Hospices did not always provide needed services, including adequate pain management or wound treatment.
- Hospices often failed to adequately coordinate care or keep physicians informed of emerging medical issues.
Compounding the problem for beneficiaries, the OIG stated CMS is not providing the information beneficiaries and families need to make informed hospice care decisions. The Hospice Compare site CMS launched in 2017 was criticized for relying on self-reporting and lacking critical objective information about quality of care and complaints. Hospices were found to have a similar issue by often not fully informing beneficiaries and families of their benefits.
The reports contain a number of recommendations for improvement. As it stands, hospices participating in Medicare must be surveyed at least once every three years (as of 2015). Surveyors may cite a hospice with a deficiency. Unlike their broader enforcement powers with providers such as nursing homes and home health agencies, the most severe penalty the Centers for Medicare and Medicaid Services (CMS) can initiate is termination from Medicare. Hopefully that will change.
When provided as intended, hospice care can be very beneficial to individuals facing end of life and their families. Therefore, care should be exercised in choosing a hospice provider.