Bipartisan legislation, that increasingly rare phenomenon, will soon bring greater federal oversight to hospice programs across the country.
The Impact Act, signed into law today by President Obama, is chiefly concerned with how nursing homes, rehab centers and home health agencies assess and report data on quality and other measures. But tucked into the legislation are provisions increasing the frequency of hospice inspections and allowing Medicare to review programs in which a large proportion of patients receive care for six months or more, considered a long hospice stay.
That’s good news, said J. Donald Schumacher, president of the National Hospice and Palliative Care Organization. “A lot of things can go wrong when no one’s looking,” he told me.
Like nursing homes and home health agencies, which also rely heavily on Medicare and Medicaid, hospices undergo periodic state surveys in order to be recertified for reimbursement. But until now no federal law specified how often those surveys must take place.
Medicare aimed to conduct surveys every six years, but after budget cuts extended that to every eight years — compared with every three years for home health agencies and every 15 months for nursing homes. A lot of hospices don’t draw even that limited scrutiny.
Investigations by the Department of Health and Human Services inspector general found that in 2005, about 14 percent of hospice organizations had not been recertified in the previous six years. By 2013, that proportion had climbed to 17 percent.
“Depending on the state, you can get a hospice license in this country and not get surveyed for seven to 15 years,” Mr. Schumacher said. In Oklahoma, Idaho and California, for example, most hospices weren’t surveyed within six years.
For years, national hospice organizations have asked the Centers for Medicare and Medicaid for more frequent inspections. “The response has always been, ‘There are no funds,’ ” Mr. Schumacher said. The Impact Act requires inspections every three years and supplies $70 million over 10 years to make that happen.
It also calls for reviews of hospice programs with a high proportion of long-stay patients, those receiving care for 180 days or more. Medicare hasn’t yet set the threshold that would trigger a review, but administrators are talking about a 40 percent to 60 percent range, said Angie Truesdale, the National Hospice and Palliative Care Organization’s vice president for public policy.
The median length of stay for hospice patients in recent years has been fewer than 20 days — probably much too short, in many cases — so a hospice that provides six months’ care for half its patients is a true outlier. In 2012, only 11.5 percent of patients were in hospice for 180 days or longer.
“They want to ascertain what’s going on,” Ms. Truesdale said of Medicare officials. “Is there a geographic or cultural difference? Is it a diagnosis? Or is it a business strategy?”
Business strategies have always played a part in hospice policies; officials have to pay salaries and buy supplies, after all, and Medicare reimbursements have been shrinking. But they may have become more central as the industry expands and changes.
The number of hospices has grown rapidly in recent years, from 2,500 organizations caring for about 870,000 patients in 2005 to 3,600 caring for 1.2 million in 2011. In the process, what we could once refer to without irony as the “hospice movement” has morphed from a largely nonprofit local effort, with many volunteers, into an industry.
For-profit hospices now dominate the field, and many are attached to national chains. Perhaps growth required that transformation, but for-profit ownership is also linked to higher “disenrollment” — patients being discharged before they die — and to rising criticism.
If reviews of hospices who carry dying people on their rolls for months leads to patients getting bounced because they are not dying fast enough, this change won’t bring happy consequences for them or their families.
But national hospice leaders think the reviews will make hospices more accountable. “I think it will benefit everyone,” Mr. Schumacher said.
So back pats may be due Senator Ron Wyden, Democrat of Oregon, and Representative Tom Reed, Republican of New York, the major catalysts for this hospice-related legislation. “Death is nonpartisan,” Mr. Schumacher said.