Hospice in the Spotlight – Audits, PEPPER, and Patient Autonomy

Today I want to focus on hospice. Now, of course, talking about the end of life is not pleasant, but it is inevitable for all of us – and all of our patients. It is worth noting here that a CEO of a pharmaceutical company was quoted several years ago refuting that fact. The CEO stated that “Americans have a funny approach to this (referring to the option of forgoing chemotherapy at the end of life): we think death is optional.” He went on to suggest that our views on death are a positive in that it is actually an opportunity for pharmaceutical companies to sell more drugs.

But why talk hospice now? Because it seems to be hospice’s time to be in the spotlight.

If you have been reading the news, last week you likely heard about a big U.S. Department of Justice (DOJ) $6.5 billion fraud takedown. Included in that was another hospice fraud scheme that included a funeral home employee who sold information on recently deceased people to a fraudster who then submitted claims for hospice services that were never provided. These claims seemed appropriate at face value, since the patient did indeed die.

Then, as I mentioned last week, the Centers for Medicare & Medicaid Services (CMS) has released the Program for Evaluating Payment Patterns Electronic Report (PEPPER) for hospice organizations.

And to top it off, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released an audit of hospice claims finding that Medicare paid over $255 million for patients who were not eligible for hospice care.

I won’t address the fraud cases, other than to say it is incumbent on every one of us to say something if we see something, so let me talk first about the OIG audit by saying it was a disappointment. How did the OIG determine which cases to audit? They looked at patients who did not have an inpatient admission or ED visit within the 18 months prior to starting hospice. Really? Patients cannot develop a life-limiting condition without at least one visit to the hospital? That makes no sense. But it is actually better than one administrative contractor cited in the report, whose criteria for auditing hospice claims is if the patient remains enrolled in hospice for two years.

Now, the OIG reports that their auditor did review each patient’s medical records to determine if the patient had a terminal illness, but sadly they did not provide one single example. Those examples are so valuable, yet they chose not to provide even one case.

Doctors are not clairvoyant. We cannot look at a patient and know the course of that patient’s cancer or other disease. It was also interesting to note that over half of the improper claims were actually due to deficient paperwork, not ineligibility for hospice care.

And then there is the hospice PEPPER. The data there actually supports the uncertainty in predicting death, as nationally, about 15 to 20 percent of patients are discharged from hospice as no longer being terminally ill. There are obviously many more measures in the PEPPER, so hospices should review it carefully to see how they compare to others and ensure that their practices are compliant.

Finally, I want to end this with a recent Facebook discussion. A case manager described a 93-year-old patient with end-stage dementia who fell and broke her hip. She underwent surgery, and the case manager could not get her accepted to a skilled nursing facility (SNF), as she could not cooperate with therapy – and she asked for suggestions.  

I then posted about my similar patient. When I got that call from the ED about the hip fracture, my call was not to the orthopedist, but rather to the daughter, to offer the option of not performing surgery and instead managing her mother’s pain and consulting hospice. The daughter was relieved to have the option of avoiding surgery, even though it would likely hasten her mother’s death. To her, quality was more important than quantity. She could not imagine her mother wanting to undergo surgery and managing post-operatively with her dementia. She chose hospice for her mother, who died a few weeks later.

As I have said here in the past, just because we can do something does not mean we should do it. Patients have the right to have their goals of care and treatment preferences respected, but that means asking about them so we can honor them.