U.S. Targets Hospices if Patients Live Too Long

Government auditors are reviewing the nation’s hospice programs because they believe too many people are living past the six months of hospice benefits federal regulations provide, officials said Friday.

Washington is conducting special reviews of hospice records and calling for repayment of money spent under Medicare for patients who lived beyond the expected six months after they had enrolled for hospice care.

The get-tough policy is part of the government’s Operation Restore Trust, a special program designed to combat waste, fraud and abuse in Medicare.

A dozen hospice programs have been notified by the inspector general’s office of the Department of Health and Human Services that they improperly spent $83 million caring for people who lived more than 210 days after enrolling for hospice care. Officials of the programs fear that they could be forced to repay the money spent on care for the dying.

The basic benefit is available to persons who are certified--by the patient’s doctor and the hospice medical director--as having no more than six months to live. About 90% of hospice patients are cared for at home, with Medicare paying the cost of nurses, home health aides, social workers and other personnel to help with the physical and emotional needs of the dying person and members of the family.

The government is now challenging the diagnoses of a random sample of people who did not die within six months and saying that many of them should never have been admitted to hospice care.

“It is of grave concern to us--what do you do if people live too long?” said Mary J. Labyak, executive director of the Hospice of the Florida Suncoast, in Largo, which could get an $8-million bill from the government.

“We are concerned about the substantial growth in hospice payments and lengths of stay,” Michael F. Mangano, principal deputy inspector general at HHS, told a congressional hearing earlier this month. About 65% of the cases audited “did not qualify for the benefit,” Mangano said.

“What we are concerned about is patients whose medical conditions never did support a prognosis of death within six months,” Mangano told Congress. “For example, our audits found patients with “unspecified debility or with Alzheimer’s disease or other chronic or lingering conditions, which at the time of admission to the hospice program were not likely to be terminal within six months.”

Doctors and their dying patients may become afraid to use hospice services, said Labyak. One of her long-lived patients told Labyak’s staff: “I just feel terrible because I am one of these people who cause the hospice trouble. I would die if I could, but God just won’t take me.”

The $83 million in alleged incorrect charges has been identified in five states where Operation Restore Trust has been working: California, Illinois, Texas, Florida and New York.

The government has announced that it will expand Restore Trust to all 50 states. That prospect is creating consternation within the hospice business, which cares for 400,000 dying people each year. The median period of treatment is 36 days--half die within that period and half live longer.

At least 90% or more of persons enrolled in hospice programs die within six months, according to industry estimates. It is the handful who live longer than expected who are at the center of the dispute.

The hospice benefit covers costs during two consecutive 90-day periods and a subsequent benefit period of 30 days. There is theoretically a fourth, indefinite period of care but only a comparative handful of people survive beyond 210 days.

At the Hospice of the Florida Suncoast, which cared for 16,000 persons from 1991 to 1995, the government selected 360 cases for review. These were persons who lived more than 210 days. The government said that 170 of the 360 should not have been eligible for hospice services because it was uncertain whether they were terminally ill, Labyak indicated.

About half the disputed cases involved cancer and a smaller number of persons had AIDS.

The federal government recommended that insurance companies handling Medicare claims move to collect the money from hospices, but no action has been taken yet. Labyak, whose organization serves Pinellas County, with a huge concentration of retirees, said that she worries constantly about the threat of having to return $8 million already spent. Labyak said: “I could get a letter tomorrow. . . . This can have a mass chilling effect on the use of hospices.”

According to reports by the HHS, the inspector general also recommends recovering:

* $4 million from the Hospice of Lake & Sumter in Tavares, Fla.

* $1.2 million from the Visiting Nurse Assn. of Texas.

“There is great concern in the hospice industry. People are very nervous,” said Toni Tullys, vice president for community affairs of the Visiting Nurse Assn. and Hospice of Northern California, based in Emeryville. Federal officials at a hospice convention this week said that they are looking at 20 hospices in California, Tullys said.

“There is no exact science as to when somebody is going to die, but that is not the issue,” said Judy Holtz, spokeswoman for the inspector general at the HHS. “This issue is looking at people being put into hospice unnecessarily, people who are not truly eligible for the benefit.”

Some hospice patients are living as long as four years, said Holtz. “We realize this is a sensitive area and the issue needs to be dealt with compassionately,” she said.

The government reviewers have looked at medical records and, in the disputed cases, say that the patients were not terminally ill.

Doctors and hospice administrators say that the government is being unreasonable, that nobody this side of heaven can predict accurately the exact date of death.

“Doctors just don’t know,” said Dr. Joanne Lynn, director of the Center to Improve Care of the Dying at the George Washington University Medical Center. “Medicare wants to enforce a policy of ‘zero’ errors at six months. I think that is just wrong,” she said.

For the government, hospice care is an industry rife with potential fraud and abuse. Payments have multiplied more than 24 times since 1986, reaching $2 billion in 1995.