Securing Hospice Care: An Interview With Dr. Kathleen Unroe

Securing Hospice Care: An Interview With Dr. Kathleen Unroe

Posted on Thursday, December 18th, 2014 at 9:55 am by lifemediamatters

Nursing home patients have longer hospice stays when compared to similar individuals receiving care at home or in their local community, according to a new study published in the Journal of General Internal Medicine. Nursing home patients also tend to be older, less financially secure and female.

Researchers, led by Dr. Kathleen Unroe, a Regenstrief Institute investigator and Indiana University Center for Aging Research scientist, determined that nursing home hospice patients are more likely to receive aid from both Medicare and Medicaid and suffer from dementia. Nearly 3,800 patients were surveyed.

The study, which also details how hospice patients move-in-and-out of care settings, aims to provide policymakers with guidance for best practices. One-third of U.S. hospice patients live in nursing homes.

Unroe spoke with Life Matters Media about the benefits of hospice care, the importance of advance health care planning and Medicare spending.

What inspired you to study hospice care in nursing homes?

I’m a nursing home physician, and I care for patients in a facility that specializes in dementia. I’m interested in understanding more about who in nursing homes uses hospice, who doesn’t and how it impacts the quality of end of life care.

I’m also interested in health policy, and there are also some tricky things about how the hospice benefit is structured. For example, if a patient is hospitalized and clearly near the end of life and hospice eligible, often he or she will still go to a nursing home on a skilled nursing benefit, because of the way that benefit is paid.

In this particular data set, I have linked Medicare and Medicaid claims, as well as minimum data set assessments on nursing home patients. It’s a nice, rich data set to follow the experience of patients.

Why are nursing home hospice patients older and less financially secure?

Nursing home hospice patients are reflective of the overall nursing home population, which tends to be a very elderly population, which also tends to be female. Nursing home days are predominately paid for by Medicaid.

Being in a nursing home is so expensive that most people will become impoverished to the point where they become eligible for Medicaid in order to pay for their care. Medicare does not pay for long-term care, so a person has to pay for nursing home expenses out-of-pocket or have long-term care insurance pay until Medicaid eligibility. Many people exhaust their resources to pay for 24-hour custodial care.

Dr. Kathleen Unroe

Dr. Kathleen Unroe

Nationally, 40 percent of Medicare patients die with hospice care. Your thoughts?

Hospice is only a few decades old, and it is now reaching 40 percent of all people. I think that when you consider how many people have short lengths of stay – in my study, 27 percent had hospice for a week or less – then yes, the benefit is underutilized.

Late referrals are especially problematic, because people are not getting enough time to truly benefit from the services hospice provides. Why is it only 40 percent, and why are so many people of that 40 percent on hospice for such a short time? I think there are a number of reasons.

In the nursing home population, prognosis is especially difficult. There are a lot of people with advanced dementia as a primary cause of death or suffer from a number of medical problems. It is not as clear-cut a trajectory as terminal cancer.

So, it is difficult to know how much time someone has left, and it complicates referral to hospice, because the hospice benefit has the six-month eligibility criteria. Two physicians need to confirm that your prognosis is six months or less. People wait.

There are also some people who will never accept hospice as it is currently structured. Hospice replaces your Medicare Part A benefit, so you have to forego curative therapy. Some people will never seek it.

How can physicians and nurses encourage more seriously ill patients to opt for hospice care earlier?

I think the heart of it is advance care planning. In Indiana, we just launched a POST program, Physician Orders for Scope of Treatment, which is based on the national POLST model.

I think POST makes a big difference, because if nursing homes build into their policies and procedures- or even just their culture- a goal of addressing these issues in a proactive way, they can better identify people whose goals-of-care are comfort focused.

Advance care planning helps get end of life conversations started earlier, and even helps build relationships between hospices and nursing homes. But advance care planning is so often missed. Every nursing home patient deserves an hour-long conversation about prognosis, about goals-of-care, about expected symptoms and complications from disease.

Medicare declined to reimburse physicians for end of life conversations in 2015, would that have helped to encourage advance care planning?

Time and reimbursement are issues, but I have also come to the belief that it doesn’t have to be the physician to lead these conversations. Yes, physicians must be involved, and I don’t want to absolve us of our incredibly important role in these conversations, but don’t leave it all up to us.

I think that social workers and nurses that have received additional training in having these conversations can lead, and then a physician can be involved to answer specific questions and sign orders. We need to encourage our partners to create time and space to have these conversations that should not be rushed. I don’t know if doctors can ever have these conversations with every patient, or at least not be the only person involved.

Yes, providers should be reimbursed for doing this important part of our job.

Does A Just Society Use the “R” Word?

Posted on Saturday, December 13th, 2014 at 10:24 am by lifemediamatters

Courtesy WikiMedia Commons

Courtesy WikiMedia Commons

U.S. healthcare spending is poised to grow at an average of 5.7 percent annually over the next decade, stretching government budgets with an upswing in the economy, an aging population and expanded coverage under the Affordable Care Act. By 2023, healthcare spending will account for nearly a fifth of annual GDP, up from 17 percent in 2012.

Justice requires a percentage of GDP be spent on healthcare and a clear designation of covered basic services. This approach invokes the “R” word, the third rail of all discussions about the future of health spending. The principle of distributive justice, one of the four tenets of medical ethics, requires equal treatment of all patients and equal allocation of resources. Fairness not only permits, but requires, a health system to ration -not exclude- effective medical services that some may need if it is to serve all.

We are a collective moral society. There is no reason to exclude certain members of this society from access to basic medical services due to one’s ability to pay. The cardinal merit of rationing is that it guarantees that spending for all members of society will remain within the limit justice prescribes. The trajectory for cradle-to-grave healthcare places an unsustainable burden on this country’s fiscal health. Since healthcare is not the only factor determining the health of an individual or a population, it is our moral responsibility to set limits and allow other determinants of health to be funded.

Social contract theorist John Rawls argues the principles of justice are made in agreement with those entering into a contract with us to form a society. He further argues there must be “fair equality of opportunity” for its members. Rawls’ definition of what constitutes a just society is reached under a “veil of ignorance.” This veil pre-supposes that “no one knows his place in society, his class position or social status; nor does he know his fortune in the distribution of natural assets and abilities, his intelligence and strength, and the like.” Those responsible for establishing the framework for medical services would do so not knowing their ultimate personal impact, allowing difficult and equitable policies to be formulated.

Even though Rawls was not specifically considering healthcare, his theory fits. Without good health, fair equality of opportunity is compromised. If we consider ourselves a just society, we cannot exclude individuals from basic health services that strip their chances for productive lives. Without a system of rationing care, members will be excluded. And, yes, the elephant in the room is the scarcity of money.

The Independent Payment Advisory Board (IPAB), the fifteen-member panel established by the ACA to address per capita growth in Medicare spending, has deteriorated into a conversation instead of a working body. This Board became the “death panel” of healthcare reform, slipping into a coma due to the outcry from medical organizations and Congress alike.

But, realistically, “all talk and no action” must be replaced by readiness to act. We must come to grips with the competing needs for a larger slice of the fiscal pie. It cannot  be all about healthcare. Overt rationing is inevitable. However, the question remains: how do we best implement the process?

To provide basic healthcare services to everyone, a shift in the allocation of financial resources is necessary. Consensus regarding what constitutes basic care and how that cost fits within a fixed budget is required. A few examples illustrate how difficult the rationing discussion becomes when we consider where our healthcare dollars are spent and what changes may be assigned to free up resources for all.

  • In 2011, Medicare spending reached close to $554 billion, amounting to 21 percent of total health expenditures. Of that $554 billion, Medicare spent 28 percent -or about $170 billion- on patients’ last six months of life.
  • Dialysis, once a short-term bridge to transplant, has become chronic treatment for end stage renal disease and comes with an annual price tag of $50 billion, funded by Medicare and Medicaid. More than 100,000 candidates await kidney transplants on what has been called the “waiting list to die.”
  • Nearly 13% of all babies in the U.S. are born prematurely, a 20% increase since 1990. A 2006 National Academy of Sciences report found that the 550,000 preemies born each year run up about $26 billion in annual costs, primarily related to NICU care. Factor in the cost of treating the possible lifelong disabilities and the years of lost productivity among caregivers, and the real tab may top $50 billion each year.
  • Obesity in 2006 was responsible for close to 10 percent of medical costs, nearly $86 billion a year. Spending on obesity-related conditions accounted for an estimated 8.5 percent of Medicare spending, 11.8 percent of Medicaid spending and 12.9 percent of private-payer spending. By one estimate, the U.S. spent $190 billion on obesity-related health care expenses in 2005.

The list is endless, and our appetite is insatiable. From what bucket do we start to re-allocate funds to open the spigot for basic healthcare for all? The price of life matters, and how that bill is paid along the full continuum is open for debate.

Healthcare spending is not a bottomless pit. Where will the sacrifices be made for the good of society? If we adopt the veil of ignorance in setting public policy, we should arrive at a fair, albeit difficult, policy for rationing health services in a just society. Or is that just too hard for a country that repeatedly asks physicians to “do everything?”

Medicare Declines To Reimburse Physicians For End Of Life Discussions In 2015

Posted on Tuesday, December 9th, 2014 at 9:07 am by lifemediamatters

Courtesy WikiMedia Commons

Courtesy WikiMedia Commons

The Centers for Medicare & Medicaid Services has tabled plans to reimburse medical practitioners for end of life conversations with seriously ill and elderly patients, despite broad support within the medical community. CMS is accepting public comment on the decision through December 31.

The 2015 Medicare Physicians Fee Schedule, an 1,100 page document, incorporates billing codes that serve as a guide to how Medicare will reimburse various services. Two billing codes for advance care planning services submitted by the American Medical Association were acknowledged but not approved for payments.

For example, billing code 99497 would have reimbursed practitioners for 30-minute advance care planning sessions with patients and families, during which advance health care directives would be explained, and even completed. The 2015 code does not authorize payment for the discussion. CMS declined to comment.

Similar proposals were removed from the Affordable Care Act in 2010 after political opponents associated advance care planning sessions with “death panels,” a widely discredited accusation.

Advance care planning codes

Advance care planning codes

The decision to delay reimbursement was met with disappointment from end of life care advocates and some medical organizations. The American Academy of Hospice and Palliative Medicine is circulating a petition and urging practitioners to voice support for end of life conversation reimbursement.

“It seems like a short-sighted omission on the part of CMS,” said Dr. Porter Storey, executive vice president of the AAHPM. “It seems to me that there are a lot of important discussions that need to take place as people get sicker to help them get the care they want. I have every intention of submitting a comment personally.”

The AMA delayed commenting on the matter, as future coverage remains under consideration by CMS.

Thaddeus Pope, director of the Hamline University Health Law Institute, said the CMS delay could be due to implementation issues or politics.

“They are seeking comments and are planning to roll it out – presumably now in 2016,” he said. “After decades of inadequate reimbursement, we can wait one more year. Fortunately, many private insurers are already reimbursing well for advance care planning.”

The hope among supporters is that doctors will encourage more seriously ill patients to complete advance health care directives and identify “goals of care” if they are reimbursed for their time. As millions of baby boomers age, interest in advance care planning has grown. However, according to the Institute of Medicine’s newly released Dying in America, most Americans lack basic understanding about end of life care choices.

“We know a lot of things about how physicians behave, and they respond to incentives,” said Dr. Ziad Obermeyer, an emergency medicine physician at Brigham & Women’s Hospital in Massachusetts. “Currently, physicians are discouraged against having these discussions, because they have to take time from things that are reimbursed, and these conversations are also really difficult to have.”


Hospice Leads To Better Care, Lower Costs At End Of Life: JAMA

Posted on Sunday, December 7th, 2014 at 10:14 am by lifemediamatters

Clinicians in ICU. Courtesy WikiMedia Commons.

Clinicians in ICU. Courtesy WikiMedia Commons.

Terminally ill patients enrolled in hospice care have lower rates of hospitalization, intensive care unit admission and invasive procedures at the end of life, according to an extensive new study published in the Journal of the American Medical Association. Hospice patients also incur significantly lower medical costs than non-hospice patients.

Researchers, led by Dr. Ziad Obermeyer, an emergency medicine physician at Brigham & Women’s Hospital, studied hospice and non-hospice patients using a nationally representative sampling of Medicare fee-for-service beneficiaries who died in 2011. Some 18,000 patients with poor-prognosis cancers (brain, pancreatic, metastatic malignancies) enrolled in hospice care before death were matched to an equal number of similar patients who died without hospice support. Median hospice stay was 11 days.

The average costs of care for patients in their last year of life in the non-hospice group was $71,517, compared to $62,819 for those enrolled in hospice; savings totaled close to $9,000. The study also revealed a huge disparity: 74 percent of patients in the non-hospice group died in a hospital or nursing home, compared to just 14 percent of hospice patients. Recent studies indicate the vast majority of Americans wish to die at home, but rarely do.

Dr. Ziad Obermeyer

Dr. Ziad Obermeyer, lead researcher

“While enrolled in hospice, beneficiaries were hospitalized less, received less intensive care, underwent fewer procedures and were less likely to die in hospitals and skilled nursing facilities,” researchers write. “Over similar periods before death, most non-hospice beneficiaries were admitted to hospitals and ICUs for acute conditions not directly related to their poor-prognosis cancer. Such care is unlikely to fit with the preferences of most patients.”

Hospice care is designed to help comfort the seriously ill near the end of life, and it has become increasingly popular in recent years – reaching nearly $14 billion in payments during 2011. The Medicare hospice benefit, established in 1982 to help patients pay for care, is usually provided only to those with a life expectancy of six months or less.

The findings also highlight the importance of frank, honest discussion between doctors and patients about goals of care. The Centers for Medicare and Medicaid Services is debating the risks and benefits of reimbursing physicians for end of life discussions, proposals removed from President Obama’s Affordable Care Act.

Dr. Joan Teno, associate director of the Center for Gerontology and Health Care Research at Brown University Medical School, says that the cost savings associated with hospice care are much less important than the health benefits it provides seriously ill patients.

“A key policy concern is if hospice saves money, should health care policy promote increased hospice access? Perhaps an even larger policy issue involves the role of costs and not quality in driving U.S. health policy in care of the seriously ill and those at the close of life,” she writes in an accompanying editorial. “The general expectation is that persons who choose to enroll in hospice should not die in an acute care hospital, and their hospital expenditures should be less than if they were not enrolled in hospice.”

A recent study led by Teno suggests some newer for-profit hospice programs have accepted patients too early and discharged others when the costs of caring for them rose. Nearly 20 percent of U.S. hospice patients are discharged before death, and not-for-profit and government-run hospices have lower rates of discharge than newer for-profit programs, according to the findings published in the Journal of Palliative Medicine.

“Dying patients are a vulnerable population and often are impoverished, frail, older, and cognitively impaired,” she adds. “As both private insurers and Medicare change the financial incentives in health care from doing ‘more’ to ‘less,’ there is an increased need for transparency and accountability.”

Trial Date Set For Passages Hospice Fraud Case

Posted on Wednesday, October 8th, 2014 at 3:26 pm by lifemediamatters

Passages owner Seth Gillman. (Credit:

Passages owner Seth Gillman via

The health fraud trial date involving Lisle, Illinois-based Passages Hospice has been set for July 6, 2015, an official with the Department of Justice told Life Matters Media.

Seth Gillman, 45, a partial owner who founded the company in 2005, was first charged in January with health care fraud and conspiracy to defraud the government. According to prosecutors, Passages knowingly over-billed the government by millions of dollars for unnecessary hospice care for seniors.

In May, fraud charges were brought against Gwen Hilsabeck, who served as a co-administrator; Carmen Velez, who served as director of clinical services and director of nurses for the Chicago region; and Angela Armenta, who served as director of certified nursing assistants for the Chicago region.

The four defendants, all released on bond, appeared before U.S. Judge Thomas M. Durkin in June and pleaded not guilty. Passages, a corporation, has also pleaded not guilty.

According to prosecutors, Gillman, Hilsabeck, Velez and Armenta participated in an elaborate scheme “to cause Passages Hospice LLC to submit false claims to Medicare and Medicaid for medically unnecessary hospice care, namely, hospice care for patients who were not terminally ill and hospice care that did not qualify for general inpatient care.”

Between August 2008 and January 2012, Medicare paid the for-profit hospice company more than $90 million for hospice services, including more than $20 million for general inpatient services. From 2006 to late 2011, Passages submitted claims for about 4,700 patients to Medicare and Medicaid.

Gillman, Hilsabeck, and Passages allegedly paid bonuses to nursing directors and certified nursing assistant directors employed at the company in order to increase the number of patients receiving general inpatient care. In 2012, Medicare’s daily reimbursement for general inpatient care was $671.84; the daily payment for routine care was much lower, $151.23.

One former employee told LMM she quit after realizing that something felt wrong.

“I left the company a few months before the indictment, after I couldn’t ignore my gut,” she said, asking not to be named as she continues to work in a similar industry. “I was in the dark about the fraud, but I knew deep down I couldn’t be a part of that company anymore. I was appalled to find out how many people were involved in the deceit. I was lucky enough to leave on my own for another job, but my coworkers and friends weren’t. They’re still fighting for pay, vacation time and 401K contributions owed to them.”

In February, Passages closed in light of the allegations. The hospice operated in four states, yet the majority of services were provided to Illinois seniors. Earlier that month, employees told LMM that they vowed to continue operating for patients’ sake.

According to the FBI, federal agents have interviewed patients, family members and more than 30 former and current Passages employees. Several reported the allegedly fraudulent billing and marketing practices to Medicare and law enforcement.

Hospice is generally care provided in a patient’s home, but it can also be provided in a center, hospital, nursing home or other long-term care facility for people facing illness near the end of life. The number of hospice patients served has risen more than 25 percent during the last five years from 1.25 million in 2008, according to figures published by the National Hospice and Palliative Care Organization.

Passages did not operate an inpatient facility, instead deploying nurses to visit hospice patients in nursing homes and private residences. The next status hearing is set for Dec. 8.