For-Profit Hospices See More Live Discharges than Nonprofits

Live discharges from hospice, which often attract the attention of regulators, are more common among for-profit hospices than nonprofits, the Government Accountability Office (GAO) has found.

For-profits were also less likely to visit patients during the last three days of life.

GAO reported that in 2017 more than 22% of Medicare beneficiaries who enrolled in hospice were discharged alive, compared to 12% among nonprofit providers. More than 460 for-profit providers discharged half of their patients or more prior to death, compared to only 10 nonprofits that had similar rates.

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“Given the various reasons for live discharges, we expect that hospices will have some live discharges, but interpret a high rate of live discharges as potentially suggestive of quality of care issues,” the report indicated. “A high live discharge rate could in some cases be an indicator of poor quality of care provided or of provider misuse of the benefit, in that they may be enrolling beneficiaries who are not eligible for hospice.”

Live discharges can occur for a number of reasons, including the patient or family changing their minds about receiving hospice care, or the patient improves and no longer need hospice care. A patient may choose to resume curative treatment or move out of the hospice’s service area. In some cases, a frightened patient or a patient in crisis may call an ambulance or visit and emergency room, prompting revocation of the Medicare Hospice Benefit in order to receive hospital care.

Live discharges are not necessarily an indicator of malfeasance, but they do attract the attention of regulators such as the U.S. Centers for Medicare & Medicaid Services (CMS) or the U.S. Department of Health & Human Services Office of the Inspector General (OIG). Live discharges are a frequent trigger for CMS audits.

For-profit and nonprofit hospices cared for roughly the same proportion of Medicare hospice patients during 2017, according to GAO, 50% and 48% respectively.

One contributing factor may be that for-profit hospices tend to treat a higher percentage of patients who have a non-cancer diagnosis; 77% of their patients in 2017 had an illness other than cancer, compared to 69% among nonprofit hospice patients. Conditions such as dementia, congestive heart failure and chronic obstructive pulmonary disease have less predictable trajectories than many cancers, complicating physician’s ability to make an accurate six-month terminal prognosis.

GAO also found issues related to a quality measure that assesses the percentage of patients receiving at least one visit from a registered nurse, physician, nurse practitioner, or physician assistant in the last three days of life. This is among the publicly reported quality measures for which CMS requires hospices to submit annual data.

“Provider visits near the end of a hospice beneficiary’s life are critical to providing quality care, including for emotional support and for training the beneficiary’s family members or other caregivers on the signs and process of dying, GAO reported. “Assessing the number of visits near the end of life may provide insight into the quality of a hospice provider’s care; fewer Medicare hospice care visits in that time period could indicate poor quality of hospice care.”

GAO reported that 80 for-profits and three nonprofit hospioces provided no visits in 2017 from registered nurses, physicians, or nurse practitioners during the patient’s final three days.

In the 1980s and 90s nonprofits provided virtually all hospice care in the United States, but the balance has shifted. In 2016, 67 percent of Medicare-certified hospices were for-profit, and only 20 percent were nonprofits, according to the National Hospice and Palliative Care Organization.For-profit hospices accounted for 100 percent of new providers established during 2017, the Medicare Payment Advisory Commission (MEDPAC) reported in March.

GAO called for CMS to include more details on hospice providers’ performance on quality measures in public reports and recommended penalties for organizations with a history of poor quality that range from monetary fines to revocation of its Medicare certification.

“Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements,” the GAO report said.