Arguably, the American Dream has morphed from 2.7 kids and a house with a white picket fence, to get rich quick without doing any work.
This diary is begins about a recently uncovered and addresssed scheme to get paid for no work which hopefully has been sufficiently corrected by actions taken by Medicare's Office of Inspector General (OIG).
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The concept of hospice is a relatively recent idea, having been established in England by Dame Cecily Saunders:
Dame Cicely founded St Christopher's Hospice in 1967 as the first hospice linking expert pain and symptom control, compassionate care, teaching and clinical research. St Christopher's has been a pioneer in the field of palliative medicine, which is now established worldwide.
Through her single-minded vision, and the clinical practice and dissemination of her work through St Christopher's teaching and outreach, Dame Cicely revolutionised the way in which society cares for the ill, the dying and the bereaved.
The current overview of St. Christopher's Hospice begins thusly:
Our vision is of a world in which all dying people and those close to them have access to appropriate care and support, when they need it, wherever they need it and whoever they are.
Sounds kinda like Shangri-La, no? If you're coming to the close of your life (or supporting someone who is), g'head and focus on that, 'cause, it's like, kinda big. (Edit: The original diary draft had a lot more about my several near-death experiences and struggling back from them, so 'Shangri-La' might have made more sense in that context - the 'end of life' part of hospice is not lost on me.)
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Earlier this year, MSN ran a story The High Cost of Dying, quoting Dartmouth's Dr. David Goodman of Dartmouth's Center for Health Policy Research:
"About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease."
So the lofty concept of Hospice jumped the pond (arguably losing some of that loftiness in most cases with the leap), and lo and behold, people started noticing that allowing patients and their families input into how they wanted to complete their days often included more time at home and less time in hospitals and fewer expensive procedures. In short, studies began showing that patients who had access to palliative care had lower bills than those who spent their final days or weeks in and out of hospitals.
As an example, a 2007 study (funded by the Health Care Financing Organization (HCFO) of the Robert Wood Johnson Foundation) at Duke’s Sanford Institute of Public Policy showed an average savings of $2,309 per hospice beneficiary.
But this is America, and if can make one buck, why not make six?
The basic concept of hospice is that a person can be accepted in a program when their physician believes they have six months or less to live. Joining a hospice program means that a patient accepts that in this stage, they are beyond seeking curative care and are asking for palliative or comfort care. A hospice has physicians and other health staff who will create a plan to reduce pain/increase comfort for that patient and to support the family in providing care, generally at home. Some hospices have inpatient facilities, but some use them primarily for short term admissions to address acute pain or other issues. The general philosophy is in supporting patients and families to come to closure and say their goodbyes with dignity and comfort. In the early on, hospices were pretty much nonprofit, focusing on human services.
The logistics coordinated by hospices will often incude getting hospital-type beds into the home, certainly cover delivery of prescriptions, may include IV supplies and delivery of meds, and respite assistance for home care-givers (generally through trained volunteers). This coordination and these services are what hospices get paid to do.
So all of this is great, or whatever, and makes sense.
But given that in this country there are always people who want something for nothing, apparently there have been a number of for-profit hospices created in the last few years who want something for nuttin, and they seem to have gotten away with it, but hopefully have been stopped. Apparently, these new fangled hospices began recruiting patients who were living in nursing homes where they already have staff managing pain and medication, and where respite care for family members wasn't necessary because there was paid staff link.
A recent OIG report (Medicare Hospices That Focus on Nursing Facility Residents, OEI-02-10-00070) found that hundreds of hospices had more than two-thirds of their beneficiaries residing in nursing facilities in 2009. These "high-percentage hospices" typically served beneficiaries who required less complex care than other beneficiaries but required hospice care for longer periods. By serving beneficiaries for longer periods, these hospices billed Medicare more per beneficiary, on average, which can mean larger profits. The numbers reflect this; compared to the overall pool of hospices, high-percentage hospices are more likely to be for-profit.
and
Eighty-two percent of hospice claims for beneficiaries residing in nursing facilities did not meet Medicare coverage requirements in 2009, totaling $1.8 billion.
I'm afraid this diary is less than I had hoped to produce on the subject - my head has been very fuzzy and, disappointingly, this is the best I can do for today. The upshot is that OIG is having to reduce hospice payments for patients who are in nursing homes and also to keep an eye on hospices with a majority of patients who are in institutions. Because of my own (very limited but significant to me) experience with amazing hospices, I am saddened by the cynicism of making a buck off the dying. Good news is that there should be less of it.