Hospice enrolling well patients to kill them?

The online headline of the WaPo’s latest on the Medicare hospice benefit (in fairness to the author, they typically don’t have control over headlines; but the article itself has such competing themes, it would be hard to figure out the headline):

Lethal doses: the dangers of hospice care

The hospice industry is booming, but concerns are rising about treatments for patients who aren’t near death.

If you stopped at the headline, and sub-headline you would get several ideas:

  • Hospice is enrolling patients who aren’t dying
  • Lethal doses of medicines are being given, meaning either euthanasia or homicide is occurring (depending upon the state there is no legal difference between the two)
  • Hospice is booming, presumably due to enrolling and then killing patients who aren’t dying

Not sure where to start, so I will just make a few points.

  • There are legitimate worries about long hospice stays, particularly that go beyond the presumptive period of 180 eligibility for hospice. But, the business model for hospices getting rich by enrolling non dying patients into hospice is not to kill them, but to bill Medicare for their care for a long time. Hospice is reimbursed on a per diem payment schedule. The financial maximization incentive is to serve patients for a longer, not shorter, period. Long hospice stays are a problem, but this article’s mashup of enrolling patients who aren’t dying to get rich and then killing them via overdose makes no logical sense together.
  • There are some very bad stories in this article. At least one of them is essentially an accusation of homicide. If I talked to a reporter about the care described, I would definitely take the next step and talk to the district attorney in the county in question.
  • There is a story of a patient getting better, but the hospice continuing to provide care without acknowledging this reality and continuing to provide hospice. This is one example of the traditional long stay hospice concern. Purposefully giving your patients fatal overdoses is directly contra to the financial motive of wanting to bill Medicare for a long time for patients who don’t need hospice.

To say that this article went for the sensational is a bit of an understatement. However, it bizarrely throws together different types of sensational narratives in a way that makes little sense. They are bilking Medicare via long stays! They are killing their patients with overdose! Logically, there could of course be examples of both, but this story does not do a good job of setting these cases against the general context of hospice care. And given that this is a part of a series on hospice which implies some knowledge of the context of hospice, I would expect better in a newspaper of this stature.

cross posted at freeforall

Author: Don Taylor

Don Taylor is an Associate Professor of Public Policy at Duke University, where his teaching and research focuses on health policy, with a focus on Medicare generally, and on hospice and palliative care, specifically. He increasingly works at the intersection of health policy and the federal budget. Past research topics have included health workforce and the economics of smoking. He began blogging in June 2009 and wrote columns on health reform for the Raleigh, (N.C.) News and Observer. He blogged at The Incidental Economist from March 2011 to March 2012. He is the author of a book, Balancing the Budget is a Progressive Priority that will be published by Springer in May 2012.

10 thoughts on “Hospice enrolling well patients to kill them?”

  1. The people at hospice were so kind to us last summer as my dad struggled to die.

    I don’t doubt for a minute that lethal doses of morphine, fentanyl, et al are administered in some hospices; I’d hope out of sheer human compassion and mercy.

    I’d have given any thing for an accidental overdose for my father.

  2. If people are living longer in hospice, does that say something about the appropriateness of non-hospice care?

  3. It is not entirely possible to know the cost of care until you have signed the patient up. Lethal overdoses is a form of adverse selection. It happens especially for dementia patients who can be healthy AND expensive.

  4. Dame (in my view Saint) Cicely Saunders, the founder of the modern hospice movement, opposed the legalization of euthanasia in the UK, partly because proper palliative care makes it unnecessary in almost all cases. As I understand it, if the doses of morphine needed to control pain shorten life, and that’s what the patient wants, it’s just good Hippocratic medicine.

  5. I don't think you get the points here:
    Clinard Coffey was referred to hospice for pain management caused by an aortic hernia and chronic back pain. They felt the hernia would rupture causing a sudden death. 2 1/2 years ago they said the hernia would kill him within 6 months but that did not happen. Two hours after he was assigned to hospice his chart was changed to kidney cancer without an examination, test, etc. 6 days after being assigned to hospice you can see him on youtube "Pop and son Jeff" 6 videos. Now imagine that this is the same man that 9 days later was dead from what they said was stage 4 kidney cancer. He was killed day to day with drug increases daily despite pain levels from 2-4 on a 1-10 scale and he had NO cancer.

    1. I think you're the one that missed the point. Don never said that there weren't problems, even in some cases serious ones. He even stated that there was one case that sounded like a homicide.

      He said that the overarching claim of the article was wrong, not a specific case.

  6. The family this week convinced the City Police Captain to file a criminal report. It has now been assigned to a detective for investigation. If you search Clinard Elliott Coffey you'll see this story has gone world wide. Its a murder. The only difference in this and Dr. Kevorkian is that Bud Coffey didn't want to die!

    1. The question, it seems to me, is what all that has to do with hospices. There's a long and dishonorable history of medical personnel messing with patient records and killing patients in non-hospice settings, but we don't usually assume that that's what hospitals are about.

  7. But that is what hospice is about. Unfortunately, when the quality and dignity of life is too hard to focus on, the hospice caregivers work towards pallative relief, but they have no balance in their approach. Any pushback is treated by the hospice caregivers as a failure of the family to accept the truth. Also, hospice medical care is incredibly careless and lazy. The feeling is that the patient is terminal so "whatever" is the attitude when better medical care is asked for. This attitude is true of each hospice environment that I have witnessed (4 to date). The caregivers ARE compassionate. They make a real effort to alleviate pain, but refraining from unnecessary prolongation of life too often translates into needlessly or carelessly hastening it.

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