A Washington Post investigative report on hospice care in America found huge disparities in care levels amongst facilities offering hospice care, perhaps because of the lack of regular inspections to ensure a baseline of care.  For instance, some hospices are not providing any continuous nursing care or inpatient care, usually considered a given by patients and their families.  The result is that family members find that the support they expected while a loved one is in the care of some hospice centers is sometimes missing.  The Washington Post also found that more than one in three patients in hundreds of facilities are dropping the service before dying suggesting that hospice care is inadequate or that hospice facilities are padding their profits by admitting patients who don’t fit the criteria for hospice care according to Medicare rules.  Families say that that care exposes patients to more powerful drugs than they would have otherwise had access to such as morphine and other painkillers.  There’s been a series of articles recently that have painted hospices in a bad light.  Consider this one and this one.  But these last two sites aren’t news sites but rather two organizations that have their own agenda.  And this one also has a bias. So in the interest of providing a more fair and equitable report, Elder Law Attorney Rajiv Nagaich asked Dr. Juan Iregui for his take.  Iregui has been practicing medicine for 21 years and currently works at Franciscan Hospice and Palliative in University Place.

Dr. Iregui: I think the part of the article that brings up a real issue is the number of patients enrolled in hospice who are eventually discharged or outlive or graduate from hospice. There are several reasons for this.

 1. Ten years ago more than 90% of patients enrolled in hospice were cancer patients. Now that number is less than 50%. The other 50% correspond with patients with advanced chronic illness that include Congestive Heart Failure, Advanced Lung Disease and Dementia. In the absence of a good support network for these patients that used to die at a younger age 20 years ago, hospice becomes the best alternative to provide logistic support that would otherwise be very costly to families. Accurately determining life expectancy for these patients is very difficult and some of these patients do get better with hospice support because of the services they receive. Unfortunately under Medicare Conditions of Participation rules, these patients have to be discharged from Hospice because they are no longer declining. The interesting thing is the moment hospice support is withdrawn, patients again enter in a decline pathway, end up back in the hospital in a crisis, and back to hospice once again. This has been our experience at Franciscan Hospice. Our length of stay and number of live discharges are below national average and significantly lower than for-profit hospices. Hospice utilization in Washington State is still below national average particularly in King County.

2. It is true that hospices around the country are trying to prolong their length of stay for patients because traditionally patients are referred very late. Unfortunately the way hospices go about doing so, seems to be associated with whether hospices are for profit or non-for profit. For profit hospices have been shown to be more aggressive at enrolling patients which correlate with more alive discharges. This is how they maximize profit because patients who are not declining rapidly require less services and therefore the hospice margins are higher. There is also a difference between states in how hospices are licensed. Unlike Washington State where a CON (certificate of need) is required to open a hospice, other states allow for anyone (including nursing homes) to create their own hospice program. This results in multiple smaller hospices that compete with one another for the same population and have much more variability in quality and number of services provided.

 3. The truth is that not all hospices are equal. If you know one hospice, you know one hospice. This is the unfortunate state of our healthcare system where the burden is on the consumer to find out if a hospital, a surgeon or a facility have the ability to deliver the care they claim in their marketing strategy.

In terms of the cases that were used to illustrate the point of the article, they all sound very unfortunate. Without being able to look at the medical records and talk to the families and clinicians I am uncomfortable commenting on them. When I have looked at similar cases, it usually boils down to the quality of the communication with patients and families particularly when there is difference of opinions among family members in what constitutes the best care for the patient. This is a big challenge with dementia patients. Smaller hospices tend to stop medications for diabetes, congestive heart failure and COPD at time of enrollment. We disagree because many of these medications in fact improve or at least maintain the patient’s quality of life at the rime of enrollment

One important financial point that the article excludes is that hospices get paid per day and only for as long as the patient is alive. For a few days after patient’s enrollment, due to the investment on equipment delivery and services that goes into place to stabilize the care of the patient in the first few days, for several days and sometimes weeks depending on the patient, hospice operates at a loss. They actually begin to operate on a margin after a few days or weeks. From that perspective, hospices do better financially when the patient lives longer after the initial investment. I think the article insinuates that there is some sort of benefit or intend on shortening the patient’s life. There is certainly not a financial benefit for hospices, the intent part of it is better left to the court of law.

All the cases used in the article treats allegations as facts. Due process is missing

While undoubtedly there are bad hospices out there, good ones exist as well. The important thing is to separate the chaff from the wheat.  The American Hospice Foundation offers a list of 16 questions to find the most appropriate care for your loved one.