Hospices: Delayed Death and Payment Consequences

“Doing this for 40-something years. Every time I think someone is going to die tomorrow, damned if they don’t live for a year and a half.”


Sumpter Blackmon, MD, Camden, Alabama
Medical Director, Hometown Hospice, a hospice Medicare is dunning because its patients live too long


On November 25 a New York Times front page article, “In Hospice Care, Longer Lives Mean Money Lost,” reported,


“Over the last eight years, the refusal of patients to die according to actuarial schedules has led the federal government to demand that hospices exceeding reimbursement limits repay hundreds of millions of dollars to Medicare.”


Sometimes, in its desperation to save money, Medicare does something silly. No one, not even the most esteemed among us, knows with certainty how long it will take patients to die. It depends on the underlying disease, on what organ will shut down first and the organ failure cascade that follows, on the will to live, on the desire to die, and maybe even on something or some one greater than one’s self.


The only thing we know with certainty is that Medicare hospice care, started in 1983, is growing more expensive. Medicare payments tripled from 2000 to 2005, to $8.2 billion, and 40% of Medicare recipients now use the service, often for routine care in the home, where Medicare pays $135 a day. Duke University researchers say hospice care saves money, if one takes into account alternative forms of care in other settings, such as hospitals, nursing homes, or Medicaid home care.


Hospice care was originally designed for cancer patients, who are assumed to run a predictable course at a certain point in their illness. But in recent years, patients with Alzeimer’s , amyotrophic lateral sclerosis, strokes, and Parkinson’s disease are being admitted to hospice. The average stays for these patients is 86 days versus 44 days for cancer. To be admitted, two doctors must certify that the patient has less than 6 months to live.


Medicare and others have determined that 1 of 13 hospices, some 220 to 250 of them, are somehow gaming the system – mismanaging the disease or misestimating the time to die – to the tune of $166 million to $200 million a year. According to Congress, a hospice’s total annual reimbursement can’t exceed the product of the number of patients it serves and the per patient allowance set by Congress ($21, 410 in 2007). If a hospice has exceeded its reimbursement limit over the last five years, it must structure a plan to pay back Medicare a high interest rate, 12.5% in the case of the Camden, Alabama hospice.


Somehow this all seems wrong. Has Medicare seriously considered the cost of alternative forms of care, which often involve continuing chemotherapy or other fruitless pursuits for cure? Has Medicare polled its constituents, whom they serve, to ask their level of satisfaction with hospice care? What will be the human consequences of putting out of business hospices in rural areas, where no alternative care for the dying is available? Has Medicare considered patients die individually, rather than statistically?