With a heavy heart I read the latest Washington Post article lambasting the hospice industry for not providing the higher levels of care: continuous care and general inpatient (GIP) when patients need it. Citing numerous examples, and naming specific hospices at fault, this latest investigative reporting by the Washington Post continues its general thesis from a previous article last December: the hospice industry, dominated by for profit providers, is doing a lousy job.
Hospices just can't seem to win these days. At the risk of oversimplification, the higher levels of care issue is a damned when you do, damned when you don't situation. Let's talk amongst ourselves...
Continuous care and the GIP are two of the four levels of care to which patients are entitled when they elect the Medicare Hospice Benefit. They are referred to as "higher levels of care" because the reimbursement for these levels of care is higher than the other two (routine home care and inpatient respite) and the needs of the patient at either of these levels of care are greater.
Hospices are required to offer these levels of care - it is not optional. There are eligibility criteria for these levels of care and if a patient meets them, he or she should receive either continuous care or GIP. If the patient meets the eligibility criteria, he or she needs the higher level of care and, as demonstrated in the Washington Post article, likely suffers if it is not provided. That is not only heartbreaking, it is wrong. But it is a complicated issue and hospices have been damned when they don't provide enough of these higher levels of care (as is the case in the Washington Post article) and damned when they provide too much of it (for example, by the Office of the Inspector General). It can seem like a no win situation and the middle ground hard to find. Looking at it from the damned when you do, damned when you don't framework, the issues come into sharper focus.
Damned when you don't
The Washington Post article focused on those hospices that don't provide enough (or any) continuous care or GIP. The statistics cited are troubling and even appalling in some cases. It is hard to believe that a hospice (unless it is super tiny) could go for a whole year without any patients qualifying for and/or needing continuous care or GIP. I also find it hard to believe, as one person was quoted as saying, that the reason no continuous care was provided was because the hospice was providing such good care that their patients didn't need it. Perhaps the hospice was providing fabulous care, but I don't think that could entirely mitigate the need a patient might have, at some point, for the intervention of one of the higher levels of care.
It is not that hospices do not want to provide the levels of care to which patients are entitled and which they might need. On the contrary, I am sure hospices, for the most part, want to and wish they could. There are two main reasons, in my view, why hospices don't provide these levels of care (when they don't):
- Hospice regulations prohibit hospices from contracting for nursing services which makes the provision of continuous care a financial and logistical nightmare; and
- In some locations in the country it is virtually impossible to obtain contracts for the provision of GIP either because potential facilities refuse to contract with the hospice or there just are not any inpatient facilities available in the area.
Hospice regulations require that more than 50% of the continuous care provided in a 24 hour period be nursing care, yet regulations prohibit hospices from contracting for nursing services except in exceptional circumstances (and CMS has made it clear that providing continuous care is not an exceptional circumstance). Consequently, to provide continuous care a hospice has to provide the nursing portion of the care with its own nurse employees who are likely already carrying heavy caseloads and maxed out. Alternatively, some hospices hire nurses specifically for the possibility of needing to provide continuous care. If they hire dedicated continuous care nurses they have to hope there is enough work to keep the hired nurses busy and resist the temptation to use them to provide continuous care when it is not necessary. This then leads to the damned when you do scenario discussed below.
With regard to GIP, It can be impossible to find an inpatient provider willing or able to negotiate a contract with a hospice to provide GIP. That is just a fact. Or the only place a hospice can get a GIP contract is a skilled nursing facility and patients / caregivers are unwilling to go to a SNF for care. Some hospices have been able to build their own facility to provide GIP, but most can not and, depending on the needs of the community, probably should not build a facility. Hospices that are able to solve the GIP problem by building their own facility may solve the damned when you don't problem but then may be vulnerable to the damned when you do problem.
Damned when you do
Hospices that solve the underutilization problems with continuous care (by hiring more nurses) and GIP (by building their own facility) sometimes tilt more towards over-utilization problems, the damned when you do scenario. The Office of the Inspector General (OIG) cited both underutilization and over-utilization (billing for a higher level of service than was necessary) as hospice risk areas in its Compliance Program, Guidance for Hospices published in 1999. More recently, the May 2013 OIG report entitled Medicare Hospice: Use of General Inpatient Care addressed both the too much GIP and the lack of GIP issues. Its findings for 2011 included:
- Medicare paid $1.1 billion for GIP mostly provided in hospice inpatient units (rather than hospitals or SNFs);
- 23% of Medicare beneficiaries received GIP during 2011;
- One-third of GIP stays exceeded 5 days, with 11 percent exceeding 10 days or more;
- Hospices with their own inpatient units provided GIP to more of their patients and for longer periods of time that hospices that used other settings; and
- 953 hospices, or 27% of all hospices did not provide any GIP in 2011 and 439 of these hospices did not provide continuous care either.
Hospices have already faced increased payment-related scrutiny for providing too much GIP or continuous care in their efforts to keep the nurses it has hired to provide continuous care busy or fill the beds of the facility it has built to provide GIP. This is likely to increase, as will increased scrutiny of providers who do not provide continuous care or GIP.
My musings on the Washington Post article may be an oversimplification of the complex problem of providing continuous care and GIP. But the Washington Post article was an oversimplification as well.
I don't know what the answers are. I do know that something seems to be happening in terms of the perception (and perhaps the reality?) of the hospice industry and it is not good. As distressing as the article was, what was worse was the nearly 150 comments generated by the article, mostly describing horrible experiences people have had with hospice. Clearly this Washington Post article and the previous one last December help to inflame negative reactions to hospice. What gets lost in the shuffle of this negative publicity are the hundreds and hundreds of hospices that are doing amazing things everyday taking care of patients and their families (shout out to Hospice Care Network in New York for the wonderful care, including GIP, they provided to my Dad and my family).
Nevertheless, perception is (or can rapidly become) reality. If there is a paradigm shift going on where the reputation of hospice care is changing from the "gold standard of end-of-life care," and "angels of mercy" to one of money grubbing death profiteers, we have a major problem. (My colleague Kathy Brandt explores the role of the "sales mentality" in changing the public perception of hospice in response to the Post article.) A much bigger issue than levels of care that we must address is questioning if the quality of care provided by hospices has deteriorated to such a degree that, as many commenters stated, people are thinking twice about using hospice for themselves or for a loved one. Where and how does one even begin to think about this?
Posted by: Heather P. Wilson, Ph.D. CEO, Weatherbee Resources