caring article part ii

Friday, January 18, 2008

Caring Article part II

I wrote a post about an article in Caring Magazine a couple of weeks ago, and want to continue working through the article today. (You should go back to post number one to understand what the article is about and who wrote it.)

As promised, today I want to discuss Mr. Hoyer’s thoughts on the “gaming” that is currently going on in the Medicare Hospice world. First, none of these things are new to this blog. In fact, they are a big part of why I started this blog in the first place. There are hospices across the nation who are “gaming” the system, cherry picking patients, and focused on finding ways to increase profits while paying as little attention as possible to patient care. Gaming, as Mr. Hoyer calls it, is the basis of my argument that non-profit hospices are focusing on the wrong thing when they say that for-profit hospices are evil. For-profit hospices are not the problem. The gaming practices that are used by hospices, both profit and non-profit, are the cause of many of the issues in the industry. If we are going to fix the problems within the hospice industry, the subject of gaming must be faced head on. According to Mr. Hoyer, Medicare may do that for us.

In the article he identifies three different types of gaming that are real issues and that will, “evoke a strong response from the legislative or executive branches”.

The first is what he titles “the Alzheimer’s ploy”. In this example of gaming, a hospice searches specifically for patients with long-term conditions like Alzheimer’s or dementia and tries to get these people admitted to hospice as early as possible. Clearly, someone with Alzheimer’s who is not in the final stages isn’t all that expensive to care for, so finding as many of these patients as possible will really help your profit margins. He also rightly notes, “In its more shameful manifestations, it may mean subsequently re-determining the prognosis and discharging these patients before they show up as long-stay patients or need significant services.” Just to make sure that everyone understands that last sentence, he is saying that some of the companies that focus on admitting patients very early on may discharge those patients from hospice before they get sick enough to actually need a lot of help or before they have been on hospice long enough to attract Medicare’s attention. In either of those cases, you are clearly dealing with companies that are focused totally on money with no regard at all for the wellbeing of the patient. I don’t really think there are very many companies that take their “gaming” to that extent, but I’m sure it does happen more than I want to believe.

The second “gaming” issue is “the continuing focus on recruiting nursing home patients”. Mr. Hoyer rightly points out that hospice care in a nursing home is not a bad thing, and that there is evidence that it is good for the patient. Unfortunately, it seems that hospice in a nursing home is often better for the nursing home and the hospice than it is for the patient. I really can’t say it better than Mr. Hoyer here:

“When hospices abuse this option, the result is a slight improvement in the lives of their nursing home patients, accompanied by an increase in revenue for both the nursing home and the hospice. In some cases, the agreements between hospices and nursing homes relating to these patients are reputed to include agreements in which hospices supply full-time staff to the nursing homes in return for a certain level of referrals. This is a practice that is likely to pique the interest of the Inspector General again, and may well lead to recommendations to reduce payments for patients in nursing homes, or even to eliminate the current option of caring for Medicaid patients who live in these facilities.”

I can tell you that I have been approached by a nursing home administrator before with the proposition of, “if I give you X number of patients, will you guarantee me that you will keep an aide in the building eight hours a day Monday-Friday”. That is exactly what Mr. Hoyer is talking about in the paragraph above, and I think it happens quite a bit. If a nursing home has enough patients on one hospice to keep the hospice’s aide in the building for a full shift, then the nursing home can reduce their aide staff by one during that shift. Clearly, this kind of incentive is a win/win for the hospice and the nursing home. Clearly, it is also illegal. There is so much room for shady dealings between hospices and nursing homes that many hospices have lost sight of where the line even stands. This says nothing about the growing trend of nursing homes companies that start their own hospices. If you think it is easy for a hospice and nursing home to get a little too cozy, just think what they can do when they share ownership and management! The nursing home/hospice relationship is, in my mind, the biggest issue in the hospice world today and may well cause the entire industry quite a bit of pain in the not too distant future. That sure seems to be Mr. Hoyer’s message.

The final type of gaming is what I have heard Don Schumacher of NHPCO call “drive by hospice”. Mr. Hoyer calls it a “historical revival” since it is a problem that was identified not long before Medicare brought the hammer down on Home Health in the 1990s. Basically, the problem here is that there are quite a few new hospices that are being started across the nation for the sole reason that hospice is a profitable business that can be started with very little money or effort. Of course, if your desire to start a hospice is founded in the ease of entry into the industry and the lack of capital needed, then the much needed desire to care for sick people is missing from the equation. These companies are being started by people who often have no business being in the hospice business. Unfortunately, they see hospice as being just another business and treat it as such. According to the article, this was one of the things that caused the big crack down on Home Health and it was also one of the things that the crack down did a very good job of ending. I’m afraid that will be repeated in the hospice industry, and it will, no doubt, be painful.

That’s the end of the gaming discussion and also the end of section one of the article. Before we move to section two, we’ll talk about Mr. Hoyer’s thoughts about the cap. Hopefully, I’ll get to that next week.



It would be wonderful if blog readers could get a copy of the article being discussed, either via a web page or as a PDF.


It is distressing to hear about the abuses of hospices and nursing homes, but it is also, from my perspective, very distressing to hear that it may become a lot more difficult to get hospice care into nursing homes.

For one thing, if hospice is discouraged from working in that setting, then there is a greater likelihood that more people will receive inappropriate aggressive treatment, poorer symptom control, and families who are shocked at the death of a loved one who is clearly failing.


I am an internist and have watched 3 family members die of Alzheimers in nursing homes in the last 2 years. I see the abuse of the NH Hospice. My mother in law said-“Why discharge Hospice–she is entitled to it.” The extent of the Hospice care was a special mattress and an extra bath per week for a patient with the only remaining cognitive skill of being able to open her mouth and swallow. THere is so much education that needs to be done of the consuming public about limited resources vs benefit.


What can an individual do to protect themselves from “gaming” hospices? My father has been on hospice for the past year (adult failure to thrive). We are now on our second hospice provider and have suspected that they have been milking the system for all it is worth! Also (as a side note), where can one find clearly defined guidlelines detailing what services hospice must make available?


Interesting to me that you are so convinced that providers with CAP issues are cheating the system, and here poking at providers who largely DON’T have cap issues, because they are willing to play God and decide who get’s their services based NOT on medical eligibility, but on some model of “business practice”. You in ignorance again and again suggest that good hospice programs don’t have cap problems, but here you are moaning about one of the bad things companies do to avoid the cap.

You seem to be very interested in statistics. How about this one? In what you like to refer to as “rural” states like Oklahoma where there are significant cap issues and large cap demands ONE thing those stats indicate is that lots of people are getting hospice care, which if done correctly is one of the best things done with federal money.

The fact is, the CAP is going to put a lot of programs out of business, and there are lots of “educated” people like yourself who assume this is the industry taking care of itself. Maybe it isn’t. Maybe just because you haven’t yet received a cap demand doesn’t mean you are “doing it right” and someone who had received that letter is “cheating the system” or guilty of bad practice. MAYBE there is more to it than you understand.
I don’t pretend to understand the cap. I do work for a GOOD hospice program that believes in following ALL medicare guidelines and doing what’s right for patients, period.
Wouldn’t it be interesting to know if “more competetive” means more eligible people getting the service they deserve? And if that is the case, wouldn’t it be something to celebrate? Wouldn’t it seem reasonable to want to promote/support and champion that scenario?
The cap is likely to put many programs out of business. In some areas this will mean no hospice care. Who is that good for? Is it reasonable for a group like NHPCO to seemingly NOT care about those programs that cannot survive these cap demands? Are you comfortable asserting that they are all BAD programs that are getting what they deserve? That is what you SEEM to be suggesting.