Deeper than the Headlines: Are Hospices Broken?

In July of 2019, the OIG published a report on their recent review of hospice caregivers. The report, “Hospice Deficiencies Pose Risks to Medicare Beneficiaries” provides a first-time look into national hospice deficiencies, including both hospices that were surveyed by State agencies and those surveyed by accrediting organizations. This report is the first in a two-part series. The second part addresses beneficiary harm in depth.

Background

Hospice care can provide great comfort to beneficiaries, their families, and other caregivers at the end of a person’s life. To promote compliance and quality of care, CMS relies on State agencies and accrediting organizations to survey hospices. As part of this process, surveyors review clinical records, visit patients, and cite hospices with deficiencies when they don’t meet Medicare requirements. Every hospice is required to be surveyed at least once every 3 years. These surveys are key to ensuring quality of care to the individual and comfort to their families and loved ones.

OIG Findings

From 2012 through 2016, nearly every hospice that provided care to Medicare beneficiaries were surveyed. Over 80 percent of these hospices had at least one deficiency. The most common types of deficiencies involve poor care planning, mismanagement of aide services, and inadequate assessments of beneficiaries. In addition to these, hospices had other deficiencies that also posed risks to beneficiaries. These failings, such as improperly vetting staff and inadequate quality control, can lead to poor care,  jeopardizing beneficiaries’ safety.

Over 300 hospices had at least one serious deficiency, or at least one substantiated severe complaint in 2016. These hospices, considered to be poor performers, represent 18 percent of all hospices surveyed nationwide. Most poor performers had other deficiencies or substantiated complaints during that 5-year period. Unsurprisingly, many of the poor performers had a history of serious deficiencies.

The OIG has been involved in a number of hospice fraud and abuse cases, which they estimate to have cost Medicare millions of dollars. In many of these cases, hospices enrolled beneficiaries who were not terminally ill, altered patient records, falsified documentation, and billed for services not provided. In one recent example, a Mississippi doctor admitted to receiving payments in return for referrals, and was given a lengthy prison sentence and ordered to pay nearly $2 million to Medicare.

Most hospices that were cited with a deficiency in 2016 were found to have had multiple deficiencies during the review spanning 2012 through 2016. And many of them had multiple deficiencies within the same year. Specifically, more than half–70 percent to be exact–of hospices that had a deficiency in 2016 also had at least one other deficiency in that 5-year period. Hospices surveyed by State agencies had an average of four deficiencies in 2016. Another twenty-nine percent of these hospices had at least five deficiencies that year.

Serious deficiencies–which occur when a hospice’s capacity to furnish adequate care is substantially limited, or the health and safety of beneficiaries is in jeopardy–were also not rare. Twenty percent (903 of 4,563) of hospices surveyed from 2012 through 2016 had at least one serious deficiency. The number of hospices with these deficiencies nearly quadrupled from 2012 to 2015, going from 74 to 292.

Per the report’s findings, many hospices have failed to coordinate and inform staff regarding beneficiaries' conditions and needs of service. This failure puts beneficiaries at risk of not receiving appropriate and timely care. In one such example, nurses did not notify physicians of their failed attempts over a 2-day period to perform an intravenous insertion. At another hospice, a nurse failed to notify a physician of the beneficiary’s escalating pain and the patient’s subsequent use of a higher amount of pain medication. The beneficiary was taking double the dose of fentanyl originally ordered.

The OIG Recommendations

Based on their review, the OIG recommended that CMS:

• Expand the deficiency data that accrediting organizations report to CMS and start using the data to strengthen its oversight of hospices
• Take the steps necessary to seek statutory authority to include information from accrediting organizations on Hospice Compare
• Include on Hospice Compare the survey reports from State agencies
• Include on Hospice Compare the survey reports from accrediting organizations, once authority is obtained
• Educate hospices about common deficiencies and those that pose particular risks to beneficiaries
• Increase oversight of hospices with a history of serious deficiencies

After reading some of the alarming findings in the report on the institutions that provide important care and comfort to our loved ones, implementing these recommendations would be a welcome start.