OIn the latest episode of Last Week Tonight, John Oliver addressed the many problems facing hospice care in the United States. This was “an almost offensive parody of this show,” he admitted. “If anyone else did that, it would be really hurtful. But I promise it’s worth talking about.”
“Many dedicated people work in hospices and provide tremendous relief to dying patients and their families, especially those who wish to remain at home,” such as the 1.8 million Americans who received end-of-life care at home last year.
But like everything else, hospices are subject to fraud, mismanagement and abuse. One government report estimates that hospices cost Medicare hundreds of millions a year due to improper billing.
Oliver began by examining the origins of hospice care in the United States, which was imported from England in the mid-20th century. “I know the British exporting a new method of dying sounds like the perfect slogan for over 400 years of colonialism,” he joked, “but in this case it was actually a good thing.”
The first American hospice began caring for patients in 1974, and others followed, mostly run by charities staffed by volunteers. In the 1980s, Ronald Reagan authorized Medicare to cover the cost of hospice after advocates argued it was cheaper than the aggressive treatments so many patients received until they died.
Of the roughly 6,000 hospice providers in the U.S. today, 75 percent are for-profit. These companies charge a flat rate averaging $218.33 per day for the first 60 days and $172 for each additional day. “That can provide a clear incentive to get as many patients as possible,” Oliver explains, quoting a marketing professional who, according to a Georgia lawsuit, said, “How do you get patients? You see someone in a wheelchair on the porch and you hit the brakes.”
“You know our system is broken when a hospice provider’s target group is kidnapped grandmothers,” joked Oliver.
A recent survey found that more than one in five families felt their hospice service did not provide timely care. Oliver pointed to documented cases of fraud, such as a company that billed Medicare for 17 days of care for a 70-year-old it never visited and whose family only called to check on his well-being. “It’s hard to defend the quality of this company’s services when they literally provided them over the phone,” he said.
There are even worse examples, such as a hospice company that skipped home visits and failed to assess the pain of a patient who ended up being infested with maggots. “It’s appalling,” Oliver said. “Treating dying people should ideally not sound like a scene from a damn Saw movie.”
“It’s not just about overdoing the care patients receive,” Oliver added. “Hospices can also admit patients who shouldn’t be there.” Because although the requirement for admission to hospice is a life expectancy of six months or less, the majority of Medicare spending on hospice now goes to patients who stay longer than six months.
Oliver referred to such “live discharge rates” – that is, how many people leave hospice alive. Some live discharge is to be expected, such as when a patient chooses a different hospice or decides to seek curative treatment again. Experts say a live discharge rate of 30% is high, and anything over 50% is a serious indication of possible fraud. And yet an analysis of the 507 hospice providers in California last year found a live discharge rate of over 70%; 135 hospices had a rate of 100%. “That’s crazy!” Oliver exclaimed. “If 100% of the people in your care leave hospice alive, you’re not a hospice, you’re a hotel. And statistically, an incredibly safe one.”
Oliver gave the example of a company called Merida, where several nurses testified that the majority of patients were not terminally ill, including one who had a regular job at Walmart. The group also enrolled people with diseases such as Alzheimer’s and dementia in its programs, falsely telling them they had less than six months to live, and even sent clergy to lie to the patients. “This is horrific,” Oliver said. “Frankly, everyone who participated in this deserves to burn in hell.”
Other patients have been placed in hospice inadvertently or without their knowledge, which can have serious consequences because curative medical care is not available in hospice. There are documented cases of patients losing access to chemotherapy, kidney dialysis, mammograms and coverage for life-saving medications because they were placed in hospice without their consent. “These are just not things you want to lose without realizing it!” Oliver noted. “Chemotherapy is not like a set of keys or the wife of the head of the Church of Scientology – where’s Shelly, David? Where’s Shelly? It’s been 17 years and I’m starting to think something bad has happened.”
The government has some red lines, “but one of the main problems is that, aside from major fraud cases, there are shockingly few consequences for bad behavior,” Oliver summarizes. “And the hurdles to running a hospice can be much lower than you think.” A medical background is not required, for example, and Medicare only requires hospices to be inspected every three years.
Some states are trying to improve the situation, but these plans are facing resistance. At the federal level, the Centers for Medicare & Medicaid Services (CMS) has initiated unannounced visits to all Medicare-insured hospices and subsequently revoked the licenses of 48 errant facilities. California has imposed a moratorium on new hospice licenses. But “experts say we should be doing a lot more here,” says Oliver, such as subjecting hospices with particularly high discharge rates to special scrutiny.
“Hospice care, when done well, is of great benefit to dying people and their families. It is too important to simply hope that the free market will solve the problem,” Oliver concluded. “This industry is in desperate need of reform. That is clear.”
