When Does End Of Life Begin: Hospice Under Scrutiny
February 5, 2013 9:51 a.m.
With a growing number of people choosing to die at home, the federal government is questioning who's in hospice and for how long.
Related Story: When Does End Of Life Begin: Hospice Under Scrutiny
CAVANAUGH: Our top story on Midday Edition, we learned on Monday that San Diego hospice is filing for Chapter 11 bankruptcy. That announcement follows months of headlines that this largest and oldest hospice care facility in San Diego is the subject of a federal audit. Joanne Faryon, I-newssource producer, you've been familiar with this continuing story.
FARYON: That's right, Maureen, we first started telling you about this story several months ago when it was learned that San Diego hospice was under this Medicare audit. It's ongoing. It began in February, 2011. What's happened since it began, Medicare is questioning the eligibility of several of its hospice patients. San Diego hospice started discharging several patients. They went from 1,000 to 500. So yesterday they filed a chapter 11 bankruptcy, basically said we now have about half the number of patients in care, which means they're getting half the amount of money from Medicare, because that's who pays for hospice, and they're reorganizing.
CAVANAUGH: So the problems have led to this reorganization filing?
FARYON: Exactly. And we also obtained an internal document that had gone up to employees, and the head of the hospice did want to make it clear that patient care was still the No. 1 priority. They still do have patients in care, and that basically to let their clients know that they were going to do the utmost to make sure that care continues.
CAVANAUGH: Now, the troubles at San Diego hospice prompted some questions at the I-newssource investigations desk here at KPBS. In a series of reports, the investigation finds that as Americans continue to live longer, both the cost and the definition of hospice are expanding. I want to reintroduce what you've been hearing right now, Joanne Faryon. She is working on that series. It's called when does end of life begin, and welcome.
FARYON: Thanks, Maureen.
CAVANAUGH: Suzie K. Johnson is also here, be vice president of sharp hospice. Welcome.
JOHNSON: Thank you.
CAVANAUGH: And doctor Daniel Hoefer is joining us, welcome to the show.
HOEFER: Thank you very much.
CAVANAUGH: Let's start out with why you wanted to work on this series.
FARYON: Well, what we really wanted to do at KPBS was look at our growing ageing population. We know the baby boomers are turning 65. When you turn 65, you can access Medicare, so we wanted to look at what's going to happen to all these people with regard to healthcare? Our focus became more narrow when we learned more about hospice and decided now, this is a great lens by which to tell this story.
CAVANAUGH: Now -- and what have you found out so far as you've begun to tell this story?
FARYON: Well, there's a lot going on with hospice care that this is something more and more people choosing. 44% of the people enrolled in Medicare who died in 2010 chose hospice at the end of life. So it's something that more people are turning to, but as a result, it's costing the federal government more money. Ten years ago, it cost about $2 billion, $3 billion a year. Now it's up to $13 billion. The other thing Medicare is looking at, we've got twice as many people choosing hospice, but it's costing us quadruple the amount. So what's going on? So they're asking the question, what's going on with hospice? And they have launched these audits, which we just heard San Diego hospice is sort of undergoing one of these, but it's happening across the country, not just here.
CAVANAUGH: We have CEO of San Diego hospice on the line. Kathleen, welcome to the program. Are you with us?
NEW SPEAKER: I am, can you hear me?
CAVANAUGH: Yes, I certainly can. Thank you for joining us. I just have a couple of quick questions for you because Joanne Faryon gave us a good background of what may have led up to this Chapter 11 bankruptcy filing. What happens to patients currently in care at San Diego Hospice?
NEW SPEAKER: Oh, our patients won't feel any difference. We'll still be providing the amazing care that we've been delivering to patients for the past 35 years. This really is about us looking at restructuring and addressing our financial issues. Our staff is remarkable and still out there caring for patients tremendously.
CAVANAUGH: But you have had to cut staff, and you've moved your facilities of the will you still be accepting new patients?
CAVANAUGH: Today, yes, we will still be accepting new patients. Of and the reason for the staff cuts, as our census has decreased, we needed to outline the staff to more appropriately fit our census needs.
CAVANAUGH: How will this reorganization change San Diego hospice, this reorganization that is required by a Chapter 11 bankruptcy filing?
NEW SPEAKER: For us right now, going into chapter 11, it really is to allow us to continue our operations while we're reorganizing our liabilities and assets. Overall patient care should not be impacted. It really is why people go into Chapter 11, to reorganize financially.
CAVANAUGH: Last question to you, Kathleen, any idea when the federal audit is going to be completed?
FARYON: That has been one of the great mysteries out there. We've been anticipating it for about two years now and have had very little information coming from Medicare, and we just have no idea.
CAVANAUGH: Okay. Thank you for joining us.
NEW SPEAKER: Can I clarify one more thing?
CAVANAUGH: Go ahead.
NEW SPEAKER: The great stories that are coming out in the paper, I just really wanted to clarify that although we have filed for bankruptcy and we're hoping we can work through our current financial difficulties, the process is uncertain. So I want the community to know that we actually encourage Scripps to enter the hospice business, to help us meet the community's needs for high-quality hospice care. I know there's a lot of publicity around there about Scripps going into hospice business. And we have a longstanding positive relationship. And I truly believe as we're working through our issues, Scripps opening hospice will be a great outcome for our community.
CAVANAUGH: Duly noted, Kathleen. Thank you for joining us. Joanne, you were explain to us why you have decided to start on this series of reports. I think that maybe since we've done so much talking about it, just remind us, what's different about hospice care than just going to the hospital for treatment?
FARYON: Right. So people are choosing hospice, I think, primarily they're saying we want to die at home. We don't want to have the end of life hospital experience. And it's really a kind of homecare, as an outsider looking in, and spending time with some people in hospice, this is it a service where you have nurses on call, and nurses will visit your home once a week, twice, three times. She'll find out, are you taking your medication, what's happening day to day, how are you living, how are you managing your care? The person in the hospice knows that there isn't a treatment or an operation or a therapy out there that's going to reverse the disease, that's going to stop or make them better. Buff they want to be made comfortable and get quality of life at the end. So they pick this kind of care instead.
CAVANAUGH: And it's our vernacular to say that someone has gone into hospice care. Do people actually go anywhere?
FARYON: Most of the care, one statistic I read was 95% of the care happens in the home.
CAVANAUGH: Now, I want to bring Suzie Johnson in, you're vice president of sharp hospice. You've been in the hospice industry for a number of years. What's accounting for this trend? More people in hospice, and more of them living more than six months?
JOHNSON: Well, when the hospice care benefits started in 1982, most patients who came into hospice care had a diagnosis of cancer. Over time, that's changed. People live longer now with medical diseases, heart failure, COPD, etc, and because they are living longer with advanced illness, it's appropriate that there comes a time where patients are really focusing on pailiation of symptoms versus trying to reverse or cure a disease.
CAVANAUGH: But that six month limit --
JOHNSON: That comes from Medicare. Medicare says you're terminal if your disease progresses as predicted, you will die in six months or les. So that's where this whole notion of living the six months doesn't mean you're still terminal. And I will clarify, Medicare says if you're reevaluated, and you have less than six months to live, your hospice benefits can be extended. But there are a growing number of these people who are in hospice and receiving care past the six months. So Medicare is saying, wait a minute, are you still eligible?
CAVANAUGH: Doctor Hoefer, you treat people in hospice care. If people are being cared for at home, why does that have to be designated hospice care?
HOEFER: That's a great question. And ironically, in many cases, it is the same care I would provide as a family physician as I would as a hospice palliative provider. The management of symptoms is simply to take the care and to be sure those patients are managing their condition as efficiently and effectively as possible. That's the most aggressive way to effective symptom management. And I don't always see a defense between traditional medicine and hospice and palliative medicine. What I do see is a lot of people don't understand hospice and palliative medicine. The current system we have in America doesn't provide for us to stay and maintain a presence to continue that high level of aggressive symptom management unless you're on hospice.
CAVANAUGH: Considering that explanation, I'm going to throw this out for the panel here. Considering the costs increase in hospice care, it's almost double the number of people who are in it, are it's increasing at quadruple the rate, why is it so expensive?
JOHNSON: Well, it's not more expensive than traditional care.
FARYON: And I think you can pick up on how much money you're paid when you take hospice clients.
JOHNSON: Right. Hospice is paid a per diem rate. When you look at the total cost of care over a period of time, hospice care is less expensive for almost every single disease type. I think the point is at what point are patients are appropriate for this level of care? And that is the puzzle that is very difficult to actually answer.
CAVANAUGH: And part of that puzzle is the fact that hospice care is shown to actually in some cases extend the life expectancy of some patients; isn't that right?
HOEFER: That's absolutely true.
CAVANAUGH: Why is that?
HOEFER: The answer would be because when you put a patient on hospice early enough, as I pointed out, we don't just start morphine and oxygen, but we take that care and use it more effectively. We keep those patients from decompensating, meaning they have to call 911 and go to the emergency room. What's the most costly tool we use at the end of life? The hospital. 25% of charges for Medicare per year go to the last year of life, and of those charges, most of them are hospital-based charges. That's not part of the picture anymore when they're on hospice. So you always have to balance the cost saves versus the cost you lose, and the irony is by being more aggressive with that in-home traditional care layered on top with hospice and pailiative care, the patient lives longer.
CAVANAUGH: I see. So you have more people who are being extended beyond that six months that was originally envisioned by Medicare.
JOHNSON: That's right. And it's a multiplier effect, right? Nationally it's about 150, you times that by 30 days, and someone might be getting $1,000 to have them in hospice care. San Diego hospice, they're an $83 million business as one hospice, and most of that money is coming from Medicare.
CAVANAUGH: I see. You've been spending time with one of doctor Hoefer's patients and his wife.
FARYON: He's same is al C. Solace. Basically his heart is giving up. He's been in hospice care 13 months. So he is the poster child for this sort of patient that's really in the minority. Even though there's a growing number, there's still fewer of them who is living past his 6-month diagnosis. For all of these reasons that doctor Hoefer mentioned, he's managing his care at home. He hasn't been to the hospital in two years, and I want to play some tape. This is a great example of how hospice care is different. To set this up, I'll let you know that his wife, Betty, starts telling the story, she tells me she's at home and suddenly she hears him call out for her.
NEW SPEAKER: And I said where are you, and he says laying in the kitchen floor, and I mean, he was in a pool of blood like that. He had split his eyebrow open. So I just said lay there till I can get this blood cleaned up, then I got a pillow and covered him with a blanket and called hospice. And I said should I call 911, and she said no, your nurse is on her way. She was here within five or ten minute, and she looked at him and she said you're going to be taking him to urgent care. He needs some stitches.
CAVANAUGH: And so why call hospice before you call -- or instead of calling 911, Suzie?
JOHNSON: Better care court coordination. There wasn't a reason for him to go to the emergency room. Had he gone, the likelihood he would have been assessed for his heart failure and other symptoms was very, very high. His wife and he have the skill set to manage at home with supportive care. And I think this is where hospice is so absolutely critical. Why do people live longer? Care coordination, care management, aware of symptoms, this is what we're going to do, this is how we'll help manage you. So we did L. C. And his wife a big favor by managing him at home where care is safer and the environment is more familiar and avoiding a hospitalization all together.
FARYON: This is a couple, they have been married for 66 years, and Betty says the worst thing about all of this that's happening is they can't sleep in the same bed because L. C. Has to sleep in the hospital bed. So imagine L. C. Having to be hospitalized. So Betty wouldn't even be in the same building with him. How that would have -- you know, played out for both of them because they're a unit together. And that's what you see. He has this powerful caretaker at home with him, and it's making a big difference in his life.
CAVANAUGH: Many people have basically said that hospice is a tremendous idea, so many people choose it. We've heard that more people are choosing it. Again, there's this rigid -- these rigid rules that are being used. Is there any movement to sort of change that and to widen out the definition. Hospice?
HOEFER: The answer is absolutely. And it's not just widening the definition of hospice, but it's palliative care, and palliative care is prioritizing comfort without abandoning traditional care but prioritizing what patients ask for. It's not about one person or the other, it's about everybody. But people should have the choice about where they want to be at the end of life, what type of care they would want, and if they want the hospital, that's fine. But we're offering them an alternative that the vast majority of patients are looking for. How you would expand hospice is to redefine admission criteria and understand what hospice is because it's a different declined structure for every diagnosis. People with cancer die differently than people with dementia, and the needs of people along the end of life functional decline pattern is dramatically different. So six months is an arbitrary time that only fits an economic model, not a practical medical model.
CAVANAUGH: Joanne, what's next?
FARYON: What we're working on now is part 2. As a result of this increased scrutiny, hospitals are discharging patients. So patients are getting letters saying you are no longer terminal or you no longer qualify. So we're going to follow up on these patients and find out where do you go? Do you end up in the hospital, what happens to you?