The Washington Post published an extensive investigative story on hospice the other day. The take away: Hospices (mostly for-profits) are making big bucks by manipulating their case loads to maximize Medicare payments. In short, they are taking on many patients who are frail but not dying and thus staying on hospice care for a very long time.
But the Post article misses a bigger question: Why are growing numbers of people willing to enroll in hospice—and often forego traditional medical treatment-- long before they are dying? Part of the reason may be because they thrive on the care hospice provides—care they rarely can get anywhere else in our medical system.
For the vast majority of patients, hospice provides care where they live (at home or in a nursing facility) rather than in a hospital. Highly skilled nurses, social workers, chaplains, and volunteers—all attuned to the needs of their frail, mostly elderly patients—provide the kind of holistic care people desperately want. The real question for our medical system is why—with a few exceptions-- do you have to be dying in order to get it?
That’s not to say The Post didn’t identify a legitimate problem. The tactic it described works because Medicare pays hospice a fixed daily rate (called a capitated payment). For the most part, the amount doesn’t change but hospice’s own costs are quite variable.
They are highest in the first days after a patient is admitted and in the final days before she dies. But in the period in between, hospice may provide relatively little care, especially if a patient remains stable. Thus, if someone is on hospice for many months, the provider can pocket a greater share of the capitated payment during that long period of stability.
This problem is hardly a revelation. For years experts have been suggesting ways to adjust the Medicare rate to prevent abuse. The challenge is more complicated, however, because hospice has two simultaneous problems: Those who stay on for very long periods of time and those whose stay is too short for them and their families to get maximum benefit. About one-third of hospice patients are enrolled for less than a week—far too brief a time.
So let’s fix the payment system. But more importantly, let’s step back and think about what hospice does and how to replicate it elsewhere in the health system.
Hospitals are increasingly using palliative care programs where patients can receive pain management, spiritual and social support, and comfort care along with medical treatment. But many patients still have no access to this care or don’t even know it exists. And far too many doctors resist even requesting palliative care consults for their patients.
The PACE program provides fully integrated health and social care--mostly for those eligible for both Medicare and Medicaid. But only about 25,000 people are enrolled nationwide.
The current fee-for-service health care system discourages this kind of care. Today, for the most part, the more doctors do, the more they are paid. And comfort care is built on providing less high-cost care, not more.
In many states, Medicaid is opting for fully managed care for low-income patients including, increasingly, the frail elderly and younger people with disabilities. Like hospice and PACE, this care is paid through a fixed capitated rate. Tying medical care to supports and services is something of an experiment. We still know relative little about whether it can provide better care for less money. But it certainly has the potential to do so, especially if tied to specific measures of quality.
Lawmakers and regulators should take note: Hospice shows that people crave well-coordinated care that often focuses more on social needs rather than high-tech medical treatment. We should restructure the payment system so providers can deliver it—even if you are not dying.
Full disclosure: My wife is a chaplain at a non-profit hospice.
