Medicare rule could endanger hospices
BY SHANNON MUCHMORE World Staff Writer
Sunday, October 07, 2012
10/07/12 at 7:51 AM
Hospice services across the country could be forced to close because Medicare will soon resume requiring them to refund money that exceeds its payment cap, people in the industry say.
Medicare had stopped collecting the repayments for several years due to litigation over the issue.
Two Tulsa hospice managers have adopted stricter guidelines for accepting patients after they were forced to shut down their hospice company, Sojourn Care, a year ago to avoid paying millions of dollars the company would have owed to Medicare. They say other hospices in Oklahoma will be forced to do the same soon.
However, some people in the health-care industry and former employees of Sojourn Care allege that some of the company's patients were left without care and necessary medical equipment when the hospice shut down.
The owners, Lois Armstrong and David Daucher, said they did everything they could to make sure their patients continued to receive care.
Other former employees said the company operated within Medicare guidelines. No complaints were filed against Sojourn for discharging patients improperly, according to records from the Oklahoma State Health Department.
'Fundamental flaw'
Hospice is a federal benefit through the Medicare system that provides palliative care and support to dying patients instead of aggressive treatment. To be eligible, a patient must be certified by two doctors as having less than six months to live.
Patients can receive hospice services indefinitely as long as doctors continue to certify they have less than six months to live. Hospice care is usually delivered in a nursing home or the individual's home.
To ensure that hospice would be less expensive than conventional treatment at the end of life, Medicare set an annual cap on payment to hospices based on the number of beneficiaries each hospice has. Any payment a hospice receives beyond the cap is supposed to be repaid to Medicare.
The rate for hospice services is $135 a day per patient.
The number of hospices that exceeded the cap increased from 2.6 percent of all hospices in 2002 to 12.5 percent in 2009, according to Medpac, an independent agency that advises Congress on matters related to Medicare.
Armstrong and Daucher launched an organization, the National Alliance for Hospice Access, to speak out against the cap.
After years of litigation over the issue, including a lawsuit filed by Sojourn, the government recently made a small change in the way hospices calculate their cap payments. Daucher said that change will reduce the money owed.
Sojourn first owed a repayment because of the cap in 2005, and it paid the amount with interest on an extended payment plan, Daucher said. Medicare suspended or didn't issue repayment demands from 2006 to 2010, but Medicare reports suggest Sojourn would have owed about $27 million under the old calculation method.
Armstrong and Daucher said they knew that even under a different calculation they could not afford the repayment, so they made the difficult decision to close Sojourn.
They closed Oct. 14, 2011, and discharged their last patient two weeks later.
Now that the government has settled with the numerous hospices that sued because of the cap, it will begin issuing repayment demands again. That will force other hospices to make the same decision Armstrong and Daucher did, they said.
Daucher said the cap itself is wrong because it forces hospices to use stricter medical guidelines for accepting patients than required by law and thereby restricts access to hospice care.
"It is a fundamental flaw in the hospice benefit," he said.
The cap is not popular with providers but it exists to control costs by deterring companies from recruiting ineligible patients, said Bruce Stuart, a professor at the University of Maryland and a former Medpac commissioner.
There was a concern that companies would owe money on the cap but then declare bankruptcy and begin operations again under a new name, he said.
Patient transfer problems
Hospice patients cost the most in the initial days of getting service and in the final days before death. Hospices can save money by having patients with longer length of stays, he said.
The average length of stay varies by region but is particularly high in Oklahoma, he said.
The national average length of stay in 2010 was 86 days.
Figures on Oklahoma's average length of hospice stay were not available from state officials.
Daucher said if hospices offer consistent services, they do not necessarily spend less on patients with longer stays, and Sojourn did not.
Tulsa physician Dr. Sandra Dimmitt, who had several patients with Sojourn and who was their former medical director, said some of them had their equipment taken away before they were established with another hospice.
"They're in a time of hardship anyway and then you go and do this to them?" Dimmitt said.
Sojourn would also often certify patients who weren't eligible for hospice benefits, but determining eligibility is difficult and other hospices do the same thing, she said.
A former Sojourn case manager said she was called by a woman who was oxygen-dependent but whose oxygen was taken away when Sojourn shut down.
They also took her bed, the only one she had, said the former employee, who asked not to be named because she still works in the industry.
"She had nothing," the former case manager said.
When Sojourn closed, Merlin Upshaw's ventilator and wheelchair were taken away, along with a bed specially designed to prevent bed sores, said his daughter, Mary Hendricks. He had been with Sojourn for about five months over the period of a year.
Upshaw, 92, was turned down by two hospices that determined he had more than six months to live before being accepted by Life's Journey Hospice, Hendricks said.
He got a few pieces of equipment back before he died about a week later in a nursing home, she said.
"It just all kind of happened in a blur," Hendricks said.
Armstrong said some Sojourn patients who needed it retained their equipment even after they were discharged and until they could find a new provider. Nobody complained to the hospice about their equipment being taken away, and anyone in a nursing home should have had adequate equipment, including proper beds, she said.
The former employee said she was pressured by her bosses to help recertify patients she didn't think were still eligible for hospice care by showing no progress or good signs in her reports.
Another former Sojourn nurse, however, said the company stayed within Medicare guidelines for recertification.
Armstrong and Daucher deny they certified ineligible patients or pressured employees to do so.
"The idea that we kept patients on that program or pressured anybody is outrageous," Armstrong said.
Former Sojourn employee Karin Bailey said she never saw anyone pressured to make reports that would cause patients to be recertified when they shouldn't be. She said that she enjoyed her time at Sojourn.
'Complex decisions'
Bailey worked for Sojourn from October 2003 to January 2007 and again from October 2010 until it closed a year ago.
"It honestly was the best job that I've ever had," she said.
Bailey said she didn't know the hospice was closing until the day it was announced to the entire staff. She would have preferred to have more warning that the hospice was being forced to shut down, she said.
Sojourn employees did their best to find health-care providers for the patients, Bailey said.
Grace Hospice of Tulsa accepted about 15 Sojourn patients and determined a few others were not eligible for hospice benefits, said Ava Caughrean, executive director of Grace.
The patients they accepted had no funding, but she said Grace often works to take on such patients.
"We wanted to try to do the right thing and bring them on service," Caughrean said.
Sojourn did not provide adequate discharge planning for the patients it was no longer caring for, Caughrean said.
Medicare guidelines require a hospice to find another community resource for any service being taken away, she said.
"You don't just take care away from someone," she said. "Especially someone who is elderly and dependent."
Sojourn also admitted and kept on patients who no longer met the criteria for hospice services. They would pick up people immediately after they were rejected by Grace as not eligible, she said.
Armstrong and Daucher said they did take patients rejected by hospices from time to time because they wanted to make sure everyone eligible had service, even if they didn't have insurance, had difficult personal circumstances or had outlived a six-month prognosis.
"Sojourn Care may have deemed a patient eligible where another hospice concluded the patient was not," they wrote in an email.
"From time to time, another hospice may have admitted a patient that Sojourn Care did not deem eligible. These are complex decisions and competent clinicians may disagree."
Original Print Headline: Medicare rule could endanger hospices
Shannon Muchmore 918-581-8378
shannon.muchmore@tulsaworld.com
