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When Does End Of Life Begin: Hospice Under Scrutiny

When Does End Of Life Begin: Hospice Under Scrutiny

With a growing number of people choosing to die at home, the federal government is questioning who's in hospice and for how long.

The story of how LC Sallis got his name is pretty simple, according to his wife Betty.

The initials L and C are short for Loreen and Cecile, the names of the two nurses in attendance at LC’s birth, nearly 90 years ago.

It’s a story that still makes LC chuckle, though he and his wife Betty have surely told it many times to new friends and curious visitors. But LC is running out of chances to tell the story of his birth.

He’s dying. He has stage four heart failure, the final stage in congestive heart disease, a malady so common it accounts for almost half of all deaths among elderly Americans.

“He can’t go much farther with much more fluid and his heart is going to fail, his pump is going to fail, his lungs are going to fill up with fluid. He’ll have an arrhythmia or heart attack and his body will die,” LC’s doctor, Daniel Hoefer, says.

Investigative Newsource

Eighty-nine year old LC Sallis has stage four congestive heart failure. He passes the time sitting on a recliner watching television in his San Diego home.

Aired 2/5/13 on KPBS News.

With a growing number of people choosing to die at home, the federal government is questioning who's in hospice and for how long.


People with LC’s condition account for the majority of hospitalizations of people over 65, but LC has not been to an ER in two years.

Instead, he’s chosen hospice care - a type of care for people with less than six months to live.

LC joins a growing number of people choosing to die at home, willing to forfeit conventional “curative” treatment in exchange for pain management and comfort care.

For the vast majority of patients, hospice is paid for by Medicare. In 2010, of all the people who died and received Medicare benefits, 44 percent chose hospice, double the number in the past decade. But while the number of hospice patients doubled, the cost quadrupled. That divergence has led the federal government to increase scrutiny of hospice providers -- most notably San Diego Hospice, the largest in the state -- by questioning the eligibility of those accepted into care.

At the heart of the spiraling cost is a group of patients outliving their six-month prognosis.

Under pressure to save money and find fraud, Medicare is now asking, are they really dying?


When the Sallises moved back to San Diego from Riverside County to be closer to their kids a couple years ago, they had to choose a new family doctor.

Betty, a tall, slim, no-nonsense kind of woman, describes their decision, Dr. Daniel Hoefer, as random.

Now, the Sallises look back and believe some act of divinity was at play, sending them a doctor who’s been nothing short of a lifesaver, or at least, life extender.

“How are you doing today LC?” Hoefer asks.

“Okay, doc and you,” LC says.

Dr. Hoefer, a family physician and Chief Medical Officer of Sharp Healthcare’s Outpatient Palliative Care Program, doesn’t usually make house visits, but on a day in January he’s made an exception, agreeing to meet with a reporter and speak openly about LC’s illness and prognosis.

He bends down to look at LC’s swollen ankles.

“I’m going to look at your sexy legs,” Hoefer says.

“Don’t whistle,” LC says. “They’re puffed up there pretty good.”

Puffy isn’t a good sign. Hoefer is concerned that LC’s heart is so weak it can’t keep up with the demands of his body, and fluid is accumulating.

“Gravity is keeping you alive, keeping that fluid out of your lungs,” Hoefer tells LC.

Investigative Newsource

LC Sallis shares a laugh with his doctor, Daniel Hoefer, at his home on Jan. 10, 2013. LC is in stage four heart failure, and has opted to spend his remaining days in hospice care.

LC no longer lies flat on his back. Ever. It could kill him. Most of his day is spent sitting upright on a recliner nestled in the corner of the living room, watching television, passing the time with Betty, his wife of 66 years.

At night, he sleeps in an elevated hospital bed three feet from Betty’s queen bed.

“That’s been the worst part of it, after 60 years of having someone in bed with you every night and all of sudden you’re in this queen size bed all by yourself. I miss that closeness of sleeping together at night,” Betty says.

Hoefer tells LC to take a deep breath and listens to his lungs with his stethoscope. The wheeze is audible to everyone in the room. But what Hoefer can hear that no one else can, is the crackling in LC lungs, another bad sign.

“Like I asked you once before, how long do you think I got and I know you don’t know,” LC says to Dr. Hoefer.

“I will tell you the same thing I said, ‘if I had a hundred people in your situation, some would be here many months and some would be here for just a few days.’ So we just got to be prepared,” Hoefer responds.

“Only one person has that answer,” Betty says, another nod to whomever might be controlling the Salises’ fate.


Betty Sallis

Betty Sallis describes having to sleep apart from her husband, LC, after 66 years of marriage because he now has to sleep in a hospital bed.


LC has been in hospice care for about 13 months. He’s lived longer than expected. Like an increasing number of patients.

Hospice services can include, nursing care; counseling, a home health aide, homemaker services, physical and speech therapy, home medical equipment and medication.

Dr. Hoefer is trying to palliate LC’s symptoms - that means he can’t reverse his terminal condition or make him better, but he can make him more comfortable as his heart grows weaker.

For example, LC has an electrical oxygen pump. It’s one of the first things you notice when walking into the Salis’ impeccably clean home. It makes a constant whirring sound, the white noise of illness.

Investigative Newsource

The whirring sound of the oxygen machine is a constant reminder in the Sallis home that LC is sick — the white noise of illness.

LC goes almost nowhere in his house without the clear plastic tubes inserted into his nostrils. His oxygen levels are low enough, along with the fluid on his lungs, to make him uncomfortable. But his levels aren’t low enough for Medicare to pay for the equipment if he weren’t in hospice, Hoefer says. That’s because for terminal patients, the oxygen is considered comforting, rather than life-saving.

A nurse visits LC at home at least once a week, but more often as needed. She tracks his fluid retention, will increase his diuretics (medication that increases urination) if needed, and will address any other concerns.

Investigative Newsource

"My patients don't ever see the inside of the hospital because we're bringing care to them," Dr. Daniel Hoefer, Chief Medical Officer of Sharp Healthcare's Outpatient Palliative Care Program

When LC fell on the floor not long ago and split his head, Betty didn’t call 911. She called hospice. A nurse was at their house within 10 minutes, assessed the situation and helped Betty get LC to urgent care for stitches.

“My patients don’t ever see the inside of the hospital because we’re bringing care to them,” Hoefer says.

Not going to the hospital saves money for the patient and for the healthcare system, decreases the risk of exposure to serious hospital based infections, and avoids the confusion and isolation of being surrounded by unfamiliar staff.

“The probability that LC would have been admitted for his heart condition had he gone to the ER would have been almost 100% even though he had gone in for his laceration only,” Hoefer says.


Dr. Daniele Hoefer

r. Daniel Hoefer, Chief Medical Officer, Sharp Palliative Care Hospice, describes the prognosis of a stage four congestive heart failure patient.

While, the majority of hospice patients die within the first month of care, there is evidence that -- ironically -- hospice can extend life.

A 2007 study published in Journal of Pain and Symptom Management concluded people in hospice lived on average, 29 days longer than patients who did not choose hospice at the end of life. People with congestive heart failure, LC’s condition, lived 81 days longer, according to the study.

An analysis by the San Diego nonprofit journalism organization Investigative Newsource found the number of people in county hospices who lived longer than six months increased from one in 13 in 2004, to one in nine in 2010.

San Diego Hospice Patients living longer.

The Medicare Payment Advisory Commission, (MedPAC), an independent Congressional agency, has published several reports outlining its concerns about hospice care.

The commission’s report to Congress in 2012, reiterated its past findings, “that the structure of Medicare’s hospice payment system makes very long stays in hospice more profitable for providers than shorter stays, which may have led to inappropriate use of the benefit among some hospices.”

Hospice providers are paid about $150 a day to care for each of their patients. They receive that per diem, regardless of whether they provide services daily or weekly. The cost of hospice tends to be higher at the beginning of service and at the end, making short-term patients the costliest, whereas long-term patients provide more room for profit.

Since 2009, the commission has made recommendations “to reform the hospice payment system, and ensure greater accountability in use of the hospice benefit.”

Hoefer describes Medicare’s crackdown on hospice providers as “misguided.” He agrees hospice providers shouldn’t accept “just anyone” because they want “their medications paid for or stuff like that,” he says. But the increased scrutiny is creating an economic paradox.

Medicare may in the shortrun find over-payments and inappropriate use, but in the long run it may discourage hospices from taking on qualified patients. Those patients will then turn to the hospital, which is many times more costly per day, for their end-of-life care.

Hoefer says Medicare is picking on the relatively small group of people who live longer than six months.

“They can pick on the tail all they want, that’s their privilege and responsibility. I can morally, medically, legally defend every one of the cases we’ve taken,” Hoefer says.

Hoefer’s assessment was recently verified - a Medicaid audit of Sharp Hospice did not find a single inappropriate admission.

The federal government is also concerned about the proliferation of for-profit hospices in recent years. For example, in San Diego County, the number of for-profit hospices jumped from six in 2007 to 12 in 2011.


Medicare introduced the hospice benefit back in 1983 as an experimental project. It was designed to help mostly cancer patients cope with pain in their final months of life, and allow them to die at home. San Diego Hospice, a nonprofit, was among the first to provide the care as an official Medicare benefit.

Respected as a pioneer in hospice, it came as a shock to many in the industry when news hit that San Diego Hospice was under federal investigation.

“None of it is about patient care, its all about eligibility, “ says Kathleen Pacurar, President and Chief Executive Officer of San Diego Hospice.

The Medicare audit began in February, 2011, shortly after Pacurar took over as president.

She recalls getting a letter informing her of the audit, and a short time later, eight people descended upon the organization for five days, taking with them a sampling of patient documents.

As recently as December 2012, San Diego Hospice was still being asked by auditors to submit documentation on every patient admitted.

Pacurar says Medicare could demand repayment of “millions” of dollars once the audit is complete, if it finds patients accepted into the program were not eligible.

Already, San Diego Hospice shut down its 24-bed hospital, laid off nearly 300 people, and consolidated its offices from Mission Valley into one location in Hillcrest. The move came after a lawsuit was filed by the owners of the Mission Valley office building, claiming San Diego Hospice had missed its December rent payment.

The beleaguered organization filed for Chapter 11 bankruptcy protection on Monday, saying it would allow them “to continue our operations, while reorganizing our assets and exploring our structural options to adapt to the current circumstances.” In a statement on its website, the hospice provider said it had cut its patient census by 50 percent over the past three months, “creating additional severe financial challenges.”

In its statement and in a fact sheet to employees, obtained by the Investigations Desk, San Diego Hospice emphasized its continued priority on patient care.

Medicare’s inquiry focuses on whether San Diego hospice allowed patients to stay in the program even when their diagnosis changed, in other words, they weren’t necessarily dying in six months or less.

“Making sure that what we’re providing in hospice is beneficial to the patient and that the way Medicare refers to it, they haven’t become what we call custodial patients or patients that have plateaued out,” Pacurar says.

San Diego Hospice began discharging patients late last year and is now more strict about who it will admit into the program.

“We narrowed the window of patients we take on because we’re so specifically looking at it through a strong lens of compliance,” Pucurar says.


Kathleen Pacurar

San Diego Hospice President and CEO Kathleen Pacurar describes the gap in Medicare coverage at the end of life.

For its part, Medicare has said little about the hospice audits. But news of investigations is slowly trickling out.

The National Hospice and Palliative Care Organization (NHPCO) points to a hospice in Delaware also under federal review and forced to lay off staff.

“They’ve (Medicare) recently began to turn up focus of audits for longer stay patients,” says Jon Radulovic, an NHPCO spokesperson.

Radulovic says the industry wants to do the right thing, and isn’t opposed to regular surveying. But the audits have had unintended consequences, including staff layoffs and patient discharges.

“Our biggest concern, are patients getting care they need?”


LC spent most of his life working for a large commercial air conditioning and heating company in San Diego, but was forced to take early retirement at 52 because of his bad heart.

The Sallises learned to stretch their retirement income, selling their Mount Helix home and opting to live in a mobile home in Hemet. Before they returned to San Diego, they travelled the country in their RV, became campground hosts, and never thinking they might one day use the service, volunteered at their local hospice. Now, on the receiving end, they are grateful.

“When the nurses and the different people (come) out to see us we just feel blessed...I can get on that phone day or night and call if there’s any problem,” Betty says.

Betty has heard about the crackdown on hospice providers, and she worries just a little that every small improvement in LC’s condition might mean they are at risk of losing the service.

Investigative Newsource

LC and Betty are taught how to manage LC's symptoms at home, and adjust his medications as needed.

It’s a conundrum: surpass a six-month prognosis and risk losing the care that is likely keeping you out of the hospital and extending your life. Experts are asking whether it makes sense to limit hospice care for a growing number of elderly, chronically ill patients who would benefit from it in the last year, even two years of life.

It begs the question, when does end of life begin?

For Suzi Johnson, Vice President of SharpHopsice, its a question without a simple answer.

“Our society looks at death as an event, it’s not,” Johnson says. It’s a continuum.

People who chose the benefit in the early days had cancer. And cancer has a predictable course, which makes it easier for doctors to make a prognosis, Johnson says.

The most common conditions of people in hospice today, are those that make predicting death difficult. Diseases such as Alzheimer's, Parkinson's, and heart failure.

And then, there is old age.

Debility and decline is the number one diagnosis of those in SharpHospice, and the number one diagnosis in 2009 across the country.

It’s a complex diagnosis because it’s multiple ailments that together make someone frail and close to death. But just how close?

“It’s a slope that takes time,” Johnson says. “The crystal ball doesn’t always exist.”


Suzi Johnson

Suzi Johnson, Vice-President of Sharp Hospice, describes how difficult it is to predict death in aging patients.

Johnson, together with Hoefer, has created a pre-hospice service for their patients, called Transitions. Sharp provides a nurse and social worker to patients to teach them how to manage their symptoms. For example, heart patients are taught how to adjust their medication if they’re feeling short of breath.

“What we’re looking at, is how we design a care continuum so we hand off patients (to hospice) at the right time in their disease.”

But there’s a catch. Medicare doesn’t have a benefit called “pre-hospice care.” Sharp is able to offer Transitions by treating patients for a set amount of money rather than billing procedure-by-procedure. This way they can stretch Medicare dollars. Transitions also is supplemented by patients who have private insurance.

Johnson said there’s a whole in Medicare’s payment plan for late stage illness. “That’s the broken part of of our system,” she said.

Johnson, Pacurar, and national hospice advocates would all like to see Medicare allow the chronically ill to access hospice or palliative care, before the final six months of life.

“How do you take care of patients with advanced illness who may be close to end of life but maybe not terminally, who may not fit into that eligibility perfectly?” Pacurar asks.

Other hospices across the country are experimenting with pre-hospice programs as well, according to the NHPCO.

“We know hospice works. How do we capitalize on that success and make it (more widely) available,” Radulovic asks.


The Sallises look at an old photo album, spanning 66 years of marriage and the birth of their children and grandchildren.

“That was back when I had curly, curly hair ,” Betty says, looking at the couple’s wedding photo.

“I remember you had curly hair.”

Investigative Newsource

LC and Betty Sallis were married in a small chapel in Hillcrest in September 1946.

After just a three-month courtship, the two married at the Wedding Bell chapel in Hillcrest.

“I knew the first time I danced with her she was going to be my wife,” LC says.

They raised two kids, a boy and a girl. They were the family LC, who lost his mother at 12, had always dreamed of.

“LC needed to be loved and to be special and that’s what I tried to give him,” Betty says. “With seven kids, he didn’t get that individual special love that I’ve been able to give him over the years. Pat myself on the back, I think it worked.”

Talk to a hospice doctor about end of life, and they immediately bring up “goals of care.” In other words, they ask their patients for their bucket list; what milestone do they want to reach before they die?

For LC, it was his 66th wedding anniversary last September, followed by his son’s 65th birthday in October, and his daughter’s 60th birthday last month.

And then there’s the couple’s great, great grandson in Montana, born last August. LC pines for the chance to meet him in person, although he will never be well enough to fly.

“I can’t complain about nothing, if I did I’d be a fool,” LC says.

Investigative Newsource

LC Sallis says he's had a good life, and he'd "be a fool" to complain about anything. He still hopes to one day meet his great-great-grandson in person.

His doctor says he’s getting every last breath his heart will give him, but when do you ever feel you’ve lived long enough?

“I think he’s waiting to turn 90 years old the second of April,” Betty says.

“I don’t think I’ll be here,” LC says.

“Well, we don’t know, you’ve surprised us so far.”

LC Sallis passed away peacefully, at home with his wife Betty at his side, Feb. 17th. Investigative Newsource Data Analyst Ryann Grochowski contributed to this report.

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Avatar for user 'theatreluvr'

theatreluvr | February 5, 2013 at 11:44 a.m. ― 4 years, 1 month ago

So sad about San Diego Hospice! They are incredible.

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raeanderson | February 5, 2013 at 12:23 p.m. ― 4 years, 1 month ago

This article points to a more fundamental, systemic problem, one that is likely to overwhelm us as millions of Americans come to the last part of life. Thanks to advances in modern medicine and public health, more of us will survive the diseases that once killed us swiftly and predictably—cancer and heart disease—and will instead live out our final years plagued by multiple chronic conditions of aging. Half of us who make it to 85—and there will be many—will suffer from dementia, an array of illnesses that will make it hard for us to live on our own, and harder still for our families to provide the hands-on care that is needed. Hospice provides a good model of care for the cancer patients it was originally designed to serve, and for whom prognosis was more predictable. But it does not serve efficiently or comprehensively what the majority of us will need and Medicare doesn't cover. In terms of our changing healthcare patterns, those near the end of life can be viewed as sentinels - the veritable "canary in the coal mine" - sensing and signaling the quality of our healthcare system and the way in which we treat those who are seriously ill and dying.
What, exactly, do we need? More than anything, we need programs that support family caregivers, those individuals who provide an estimated $450 billion dollars worth of care for older adults. We need hospice-like wraparound services that would help people from the time they are seriously ill or disabled, and that offer home care services, respite for our caregivers, and supports for what we can no longer manage or cope with on our own. We need social structures and public policies that support families as they live through years in which they simply cannot piece it together on their own.
As a country, we’ve done a remarkable job of creating a health care system that does well at treating acute problems and curing much of what ails us. But that system, with all its fragmentation and problems, is simply not one that is going to be able to serve our aging population. At the Altarum Institute Center for Elder Care and Advanced Illness, we aim to do just that. You can learn more about our work—and join in!—on our blog at

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Avatar for user 'jdrinca'

jdrinca | February 5, 2013 at 12:41 p.m. ― 4 years, 1 month ago

This makes me so mad! San Diego Hospice is being investigated for fraud because 1 out of 9 of their patients exceeds the 6 months of care allowed by Medicare! Now they are turning people away because they don't want to risk taking on people too early. If those people had hospice support, they could avoid many trips to the emergency room! Most families call in hospice too late, not too soon. Because of our miserable, broken system, more patients and families will suffer more at the ends of their lives.

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grannyjml | February 6, 2013 at 2:03 p.m. ― 4 years, 1 month ago

San Diego Hospice saved my sanity when my daughter was dying of cancer. Her two sisters , her Father and I were in shock She was in her late fortys but could not survive.The care she received relieving the awful pain was tender and careing.
The rest of us could not have survived without the Hospice and the understanding help and support we received. My husband and I are 80 yrs old and living on a very fixed income but we still contribute what we can to the San Diego Hospice. The care they provide is incalcuable.

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Avatar for user 'Jim'

Jim | February 9, 2013 at 12:13 p.m. ― 4 years, 1 month ago

This excellent series points out in a clear way the issues surrounding end-of-life care and how these issues affect our health care system, and I appreciate KPBS's great reporting. The tragedy of this story is that while bureaucrats and health care managers dither and score political points with a "crackdown" on waste, real health care from a respected San Diego institution suffers. A question I have is about the response from our Democratic legislators which, so far as I can see from phone calls I have made and news sources I have researched, is zero. Is San Diego Hospice going to be the first victim of Obamacare? Is this demise supported by Rep. Susan Davis and Scott Peters and if not, what is their response?

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Avatar for user 'mapfel'

mapfel | February 11, 2013 at 7:35 p.m. ― 4 years, 1 month ago

Excellent article and points out how are system is failing many patients who can greatly benefit from both Hospice and Palliative Care for these chronic conditions. LC has CHF, the number 1 reason for hospital admissions in the US, but thru excellent care , has avoided this for the past 2 years. How much money has this saved Medicare ?? Good palliative and hospice care save the system a lot of money and provide coordinated, patient centered care (One of the Triple Aims). I would rather see patients on hospice for longer than 6 months rather than less than 10 days, which is the current norm in many places. This is another reason we need to have payment reform which can address these issues, rather than disaster time and money auditing excellent docs such as Daniel Hoefer and organizations like San Diego Hospice

Mark Apfel, MD

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Joanne Faryon, KPBS Staff | February 11, 2013 at 8:54 p.m. ― 4 years, 1 month ago

Hello Everyone,

Thank you for your thoughtful comments. Many of you raise some excellent points and I wanted to let you know we are continuing to report on this issue. We expect to have another installment in the coming weeks. We also appreciate many of you sharing your personal stories about hospice. We have an email address />if you would like to share your experience. We read all of the emails - your stories truly help in our reporting.
Joanne Faryon
Investigations Producer

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Joanne Faryon, KPBS Staff | May 3, 2013 at 3:58 p.m. ― 3 years, 10 months ago

Another hospice accused of filing false claims - This time against VITAS - the largest for-profit hospice chain in the country.
The federal government alleges VITAS billed Medicare for ineligible patients and inflated the level of care they received.

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