Former President Jimmy Carter entered hospice care at his home in Plains Georgia last week. Hospice care is a form of palliative care for Medicare beneficiaries who are terminally ill with less than six months to live. People on hospice care agree to forgo all further treatments and are made as comfortable as possible until their deaths.
Since it was announced that former President Carter has entered hospice care well-wishes have flooded in from around the world. The logical question many people have is how much time does Jimmy Carter have left? I have heard no specifics but I suspect this move was done as his end is near. That’s how it’s supposed to work. My father-inlaw was on hospice care for only two months before his death. Other relatives have had similar experiences. That’s not always how it works though. What is less known is that Medicare hospice care has become yet another scam for unscrupulous providers. It is increasingly common for hospice patients to outlive Medicare’s six-month limit. That’s because too many patients are fraudulently recruited who don’t really qualify for hospice care.
“It’s an open secret that hospice is one of the poster children for fraud and abuse in Medicare,” said David Grabowski, a health policy professor at Harvard who serves on MedPac, the federal advisory panel on Medicare spending.
This is a report from the Department of Health and Human Services, Office of Inspector General (HHS OIG) from 1998. It outlined how the cost of the Medicare hospice care program had skyrocketed in only a few short years.
Medicare’s hospice benefit provides palliative care to individuals who are
terminally ill. Palliative care focuses on pain control, symptom management, and
counseling for both the patient and family. Medicare hospice payments increased
from about $958 million for Fiscal Year 1993 to over $1.8 billion for Fiscal Year
1995. Although the hospice benefit is still a relatively small portion of total
Medicare Part A expenditures (about 1.5 percent), it has grown considerably over
the past several years.
Here’s an HHS OIG report from 2019, 20 years later. It outlines the areas of abuse in the hospice care program. It found that in 2016, the last year of data in the report, Medicare hospice care cost taxpayers nearly $17 billion. That is nearly 10 times the amount in 1995, which was a steep enough increase to raise concerns back in 1995. The report also found some vulnerabilities in hospice care. There is an incentive to recruit uncomplicated patients and underprovide for their needs. There is also an incentive to recruit nursing home patients who may not need hospice care. However, that’s not all.
According to Stat News many patients are duped and recruited without even knowing what they’re signing up for:
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.
The hospice owner in Larry Johnson’s case (above) was jailed for 80 months for running a $20 million scheme that signed up patients who were not dying. Of course, patients not at risk of imminent death are cheaper to treat. The problem for patients not yet needing hospice care is that they are deprived of therapeutic care that could extend their lives. Also, what happens in six months if they’re still alive?
The nonprofit news outlet Pro Publica wrote about the ongoing fraud in the hospice program. Some of the bad actors aren’t just individuals operating on a small scale. One person interviewed was Marsha Farmer. As a “community educator” (i.e. marketing) she had high quotas to fill of people she was supposed to sign up for her employer’s hospice. Her employer didn’t seem to care who she signed up as long as they were getting paid.
Farmer was selling hospice, which, strictly speaking, is for the dying. To qualify, patients must agree to forgo curative care and be certified by doctors as having less than six months to live. But at AseraCare, a national chain where Farmer worked, she solicited recruits regardless of whether they were near death.
Farmer’s bigger problem was that her patients weren’t dying fast enough. Some fished, drove tractors and babysat grandchildren. Their longevity prompted concern around the office because of a complicated formula that governs the Medicare benefit. The federal government, recognizing that an individual patient might not die within the predicted six months, effectively demands repayment from hospices when the average length of stay of all patients exceeds six months.
Of course, there are ways to game the system.
But Farmer’s company, like many of its competitors, had found ways to game the system and keep its money. One tactic was to “dump,” or discharge, patients with overly long stays. The industry euphemism is “graduated” from hospice, though the patient experience is often more akin to getting expelled: losing diapers, pain medications, wheelchairs, nursing care and a hospital-grade bed that a person might not otherwise be able to afford. In 2007, according to Farmer’s calculations around the time, 70% of the patients served by her Mobile office left hospice alive.
Hospice care is a great idea that is being abused for profit. Let’s hope President Carter’s experience shines some light on the program and results in HHS cleaning it up.