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| A sign supporting Medicare on Capitol Hill in 2015. (Jacquelyn Martin/AP) |
The case is among the most severe of a dozen examples of patient suffering cited in a strongly worded inspector-general report
on the hospice industry released Tuesday. The report takes Medicare to
task for what it describes as weak oversight and enforcement of the
growing ranks of hospice providers and recommends stronger safeguards
“to protect Medicare hospice beneficiaries from harm.’’
The
report, by the Office of Inspector General for the Department of Health
and Human Services, withheld information about the individual hospice
providers and the states where the examples of harm occurred. Vitas
Healthcare, which did not comment on the case, is not named in the
inspector general’s report. The Washington Post identified the 2016
Missouri case by reviewing state inspection records and matching them to
the specific circumstances described by the inspector general.
According
to the Missouri inspection documents, the patient had been living at
home under hospice care for more than 18 months when the discovery of
“maggots around the opening of his wound” triggered an urgent call by
the family in the middle of the night.
The
patient was taken to a hospital for removal of the pests and stayed
there for two days. One reason the patient was in hospice care was to
avoid unnecessary pain and trauma associated with hospitalizations, the
Missouri report said. In a “plan of correction” included in the Missouri
documents, Vitas neither disputed nor agreed with the state inspector’s
findings. It outlined steps it would take to improve supervision and
assessment of patients.
Other dire cases listed by the inspector general included a
patient whose pressure ulcers developed gangrene, resulting in an
amputation; a patient whose injuries from an apparent sexual assault
were missed and discovered only at a hospital; and another who did not receive appropriate medication and died in pain.
Despite
the seriousness of the harm, the hospices in each of the dozen cases
did not face serious consequences — largely because Medicare has few
disciplinary tools at its disposal, the inspector general said.
“When
hospices do not fulfill their obligations, there can be real human
costs,” Nancy Harrison, deputy regional HHS inspector general, said in
an interview. Medicare, she said, “needs to hold hospices accountable.”
While
the report describes a poorly regulated hospice system, it also found
that Medicare gives consumers limited options to screen for quality on
their own or lodge complaints.
A Post investigation in 2014 documented patient hazards and industry financial abuses. Although improvements have been made since then
— including the national Hospice Compare consumer website launched in
2017 — the gaps in enforcement and quality appear large, according to
the report.
Medicare
pays for most hospice care in the United States, with billings reaching
$18 billion in 2017, double the amount a decade ago. The number of
hospices has risen to around 4,500.
But Medicare’s oversight of hospice is not as strong as its oversight of nursing homes.
The frequency of hospice inspections by state or private
accreditation agencies increased from once every six years to once every
three years in 2018. About 300 hospice providers, or nearly
20 percent of all hospices inspected in 2016, had a serious deficiency
or a substantiated severe complaint, making them “poor performers,’’ the report said.
There
are few requirements for hospice companies to alert Medicare when they
detect violations. And when problems are discovered, Medicare has
limited tools to discipline providers for neglecting or harming
patients, even in cases of “immediate jeopardy.”
Other
than removing them from the Medicare program, a step that is very
rarely taken, Medicare has no ability to levy fines or other sanctions
on poorly performing hospice providers, the report said.
It
also found fault with Medicare’s Web portal, Hospice Compare, which is
supposed to help patients and families shop for hospice providers based
on quality and other metrics. But Hospice Compare does not list hospice
provider deficiencies or state inspection results.
“We
live in a time when we don’t even think about going to a restaurant
without checking its reviews. Why do we demand less from hospices?’’
Harrison said. “The information is already collected. We just need
to make that extra step and make it publicly available in a way that
patients can understand.’’
The
Missouri case provides an example of the gap. A Post review showed that
someone checking Hospice Compare would see that the Vitas Healthcare
office in St. Louis responsible for the patient with a maggot
infestation has a 96.4 percent quality rating, 11 percentage points
above the national average. Nothing is mentioned about the “immediate
jeopardy” finding or other serious deficiencies cited by inspectors.
The
Centers for Medicare and Medicaid Services (CMS), which is in charge of
Medicare, said it has taken steps to improve Hospice Compare, including
adding information from consumer surveys.
It
said it is prohibited by law from posting inspection reports by private
accreditation agencies and has told the inspector general previously
that it would be “misleading” to post state inspection reports alone.
CMS has asked Congress in its budget for authority to post accreditation
agency reports.
“CMS
has zero tolerance for abuse and mistreatment of any patient, and CMS
requires that every Medicare-certified hospice meet basic federal health
and safety standards to keep patients safe,” the agency said in
response to the inspector general’s report. It called the inspector
general’s individual findings of patient harm a “selective sample” of
cases found between 2012 and 2016.
In
the example of the maggots in the patient’s feeding tube, the local
Vitas Healthcare provider was put on a track to be terminated as a
Medicare provider, but it corrected its deficiencies before that step
was taken, CMS said.
“CMS
does not have the statutory authority to impose remedies, such as
fines, on hospices,” the agency said. “Additionally, CMS cannot close
any facility.”
The hospice industry trade group in Washington, the National Hospice and Palliative Care Organization, which had not seen the report as of Monday, said it supports accountability and transparency in hospice. It pointed out that it supportedincreasing
oversight, including raising in inspection frequency to once every
three years. “However, NHPCO continues to stress that outliers in the
field do not adequately reflect the vast majority of hospice care
provision in the U.S.,” Edo Banach, the organization’s president, said
in a statement.
Congress told Medicare to begin reimbursing for hospice in 1982. Since then, the practice ofhospice has steadily become mainstream, routinely serving patients with dementia and other ailments of the elderly, and has attracted for-profit investment and chain ownership.
“At
the first meetings of our national hospice organization, we were nearly
all women, mostly volunteers working on making our communities
better,’’ said Joanne Lynn, a hospice physician and director of the
program to improve elder care at Altarum, a nonprofit health-care
consulting organization. “Once Medicare started paying for hospice, it
was more men in suits, and the focus shifted to administration and
sustainable financing.’’
Most hospice care continues to be delivered at home or in a nursing home, with routine visits by nurses and aides, but companies also run inpatient hospice facilities. The focus remains the same: comfort and palliative care, including pain medications, in a patient’s final months of life.
To
qualify for hospice coverage under Medicare, a patient must be
terminally ill with a prognosis of living less than six months. But as
increased numbers of patients with Alzheimer’s disease and other forms
of dementia enter hospice, many are living far longer than six months. Their Medicare coverage continues.
“You
increasingly have diagnoses of dementia, patients who are dying at
home, but their life expectancy is extremely difficult to estimate,”
said Melissa D. Aldridge, a professor of geriatrics and palliative
medicine at the Icahn School of Medicine at Mount Sinai, in New York.
Meanwhile,
Medicare pays providers the same amount for each day a patient is in
hospice — around $200 each day for the first 60 days and about $150 each
day after 60 days — without regard to how much care is provided.
“They’re
paying for a day of hospice with no accountability for what was done on
that day. How is Medicare going to oversee that?’’ Aldridge said. She
estimated two-thirds of providers are now for-profit, “with a payment
mechanism that is completely opaque as to what is being done.’’
While
Hospice Compare does not list any documented problems at hospices,
Missouri and Alabama are examples of two states that list complaints and
link to full inspection reports.
“We
want to be as transparent as we can,” said Dean A. Linneman, director
of regulation and licensure for Missouri’s Department of Health and
Senior Services. “The intent is for families seeking a good place for
their relatives to view reports, and it’s not too far-fetched to believe
that is a good learning tool for others in the industry.’’
Full Article & Source:
Hospices go unpunished for reported maggots and uncontrolled pain, watchdog finds
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