CQ TODAY ONLINE NEWS
Sept. 4, 2009 – 12:11 a.m.
Nuggets of Truth In ‘Death Panel’ Rhetoric
By John Edgell, CQ Guest Columnist
When former Alaska Gov. Sarah Palin introduced “death panels” to the health care overhaul debate vernacular via Facebook in early August, she showed herself to be a brilliant idiot.
Technically, Palin’s claim of a panel of “downright evil” government bureaucrats rationing health care based on Americans’ “level of productivity” is obviously idiotic. There is not, and never will be, some mythical jack-booted panel of government pinheads, rubber stamps in hand, deciding who shall live and who shall die. As such, Palin was deservedly roasted.
Tactically, however, Palin’s move was pure brilliance: in but a few keystrokes she synthesized the underlying suspicion at least half of Americans have about a government role in health care delivery and created a visual metaphor from which the Obama White House and congressional Democrats still haven’t fully recovered.
So would it surprise you that Palin has a legitimate point? Well, sort of.
There actually is a government-appointed panel, named MedPac, which is made up of health care experts — those pesky pinheads — who analyze and make policy decisions, including policies about death. MedPac oversees and evaluates Medicare’s costs, physician payments and quality controls. Its decisions affect health care coverage for 40 million American elderly and the medical institutions involved in end-of-life care — in this case, hospice care.
In other words, there is a government panel which makes decisions that affect when (but not how) a hospice can “pull the plug on Grandma.” So does Iowa Republican Sen. Charles E. Grassley have legitimate point too? Well, sort of.
It depends on whether you believe for-profit hospices should be tacitly encouraged to keep patients under their care for extended periods of time in order to bilk Medicare for more days of service to pad their profit margins, and at largely taxpayer expense.
While Palin’s baby son Trig, who has Down syndrome, would never be denied needed medical care and left to die by some mythical bogus death panel, there actually is some truth that changes in Medicare’s reimbursement methods for hospice care will affect how and for how long millions of senior citizens spend their final days.
First, some background on Medicare’s hospice benefit, which began in 1983 primarily for the near-death elderly, mostly cancer patients, through nonprofit hospice facilities affiliated with religious and community organizations. By 2005, hospices treated 1.2 million patients and one-third of Americans who died did so at a hospice facility. Hospice admissions continue to increase at roughly 10 percent per year.
Overall, Medicare hospice spending more than tripled between 2000 and 2007, to more than $10 billion. Total hospice care will cost roughly $46 billion by 2030.
The future in hospice is all about how to make a buck — make that big bucks — and increasingly at the expense of Medicare patients and taxpayers. In 1990, for-profit hospice treated 9 percent of total hospice patients; today, it’s now 35 percent of total patients. Nonprofit hospices still treat 56 percent of the total number of patients, but that figure is trending steadily downward.
What began with largely charity-based Medicare hospice providers has in the past decade or so morphed into a multibillion-dollar, profit-driven corporate enterprise. Between 1994 and 2004, Medicare saw a 400 percent growth in the total number of for-profit hospice facilities, which is six times the rate of increase of Medicare-participating non-profit hospices. In the past decade, nearly 1,000 new for-profit hospices joined Medicare.
Hospice is now a huge profit center. The Journal of Palliative Medicine cited a 2005 study that large publicly owned hospice chains generate profit margins nine times higher than those of large nonprofits and three times higher than privately owned for-profit hospices of similar size. The biggest for-profit, publicly-owned hospice is VITAS, which treats more than 11,000 patients in 16 states. Other large chains are the publicly owned Odyssey Healthcare and Vista care, and the private Heartland Hospice, a division of HCR Manor Care, which in 2007 was bought by the Carlyle Group, the mega-investment firm, for $6.3 billion.
In June 2008, MedPac reported that length of stay in a for-profit hospice is roughly 45 percent longer than the length of stay in a nonprofit facility. Of course hospices with longer lengths of stay are more profitable.
So, inversely, and cynically speaking, does a typical nonprofit hospice affiliated with the Catholic Church ruthlessly “pull the plug on Grandma” much sooner than necessary, at least as compared to the kinder, gentler for-profit Heartland Hospice facility?
Longer stays at for-profit hospices doesn’t assure better care either. A 2004 study looked at 2,080 patients in 422 hospices and determined for-profit hospices provided terminally ill patients in need of end-of-life care a “full range of services only half the time compared with patients treated by nonprofit hospice organizations.” That’s because for-profit hospices lower costs by cutting services, namely “non-core” services such as prescriptions and labor-intensive personal care such as bathing. Moreover, families of patients at a for-profit hospice received counseling services, including bereavement counseling, only 45% as often as those at a nonprofit hospice.
In other words, Medicare hospice patients stay significantly longer at for-profit hospices than at nonprofit hospices, yet receive far less personal attention and spiritual counseling. Medicare’s existing reimbursement system contains incentives that make very long stays in a for-profit hospice hugely profitable, especially if labor-intensive patient care is purposefully denied.
Given this evidence, in January 2009, MedPac recommended that beginning in 2013, Medicare alter its current payment system for hospice care providers serving terminally ill patients, the first such method change since 1983. Instead of its current predictable flat-rate per diem payment rate to hospices caring for the terminally ill, Medicare would pay relatively higher payments per day at the beginning of the episode, and relatively lower payments per day as the length of the episode increases — a fairly radical and provocative departure from current policy.
At a certain point though, any elderly patient could cost more to keep alive than Medicare’s daily reimbursement payment rate. Again — cynically speaking — the longer a Medicare patient’s hospice stay, the less incentive a hospice has to keep a near-death patient alive. Would Grandma’s plug be pulled then to protect a profit margin?
If so, to quote Palin, sort of, “such a system is downright evil.”
John Edgell is a former Democratic congressional staffer.
Comments
It would seem that if someone is going to comment oh hospice care and the difference between for and non rofits that they should do a little bit more digging. As someone who has worked for over 30 years in non-profit hospice I take great exception to the comment "dose a typical nonprofit hospice...ruthlessly pull the plug on Gramma." How misleading can you get? If the author had just bothered to look a little deeper they would have found that there is a difference in the patient mix in nonprofit vs for profit hospices. If a hospice admits more patients from a Long Term Care facility with diagnosis like dementia they end up with a longer length of stay and lower cost. If the same hospice, whether a for or nonprofit admitted a greater mix of cancer patients then their length of stay decreases and their costs escalate. Different hospice choose different markets and different patients to market to. Do your homework. The bottom line is that nonprofit hospices give twice the service that forprofits deliver. Our patients are our 'stockholders' and we strive to give the best care to everyone.
Joni, I'm the author of the piece, and just to clarify: of course non-profit hospices don't 'pull the plug' on patients. Read the sentence in its full context, especially the "cynically speaking," plus the paragraph before and after, please. You then see that the point is for-profit hospices have 50% longer patients stays and deliver 50% of patient services. The premise of the article is to raise legitimate questions about increasing patterns of behavior on the part of for-profit hospice providers that affect patient care and the taxpayer. Here's a more full context: "In June 2008, MedPac reported that length of stay in a for-profit hospice is roughly 45 percent longer than the length of stay in a nonprofit facility. Of course hospices with longer lengths of stay are more profitable. So, inversely, and cynically speaking, does a typical nonprofit hospice affiliated with the Catholic Church ruthlessly "pull the plug on Grandma" much sooner than necessary, at least as compared to the kinder, gentler for-profit Heartland Hospice facility? Longer stays at for-profit hospices doesn't assure better care either. A 2004 study looked at 2,080 patients in 422 hospices and determined for-profit hospices provided terminally ill patients in need of end-of-life care a "full range of services only half the time compared with patients treated by nonprofit hospice organizations." That's because for-profit hospices lower costs by cutting services, namely "non-core" services such as prescriptions and labor-intensive personal care such as bathing. Moreover, families of patients at a for-profit hospice received counseling services, including bereavement counseling, only 45% as often as those at a nonprofit hospice."
So the author begins by blasting Palin's remarks as bogus and "obviously idiotic"...right before he goes on to explain and confirm Palin's "idiotic" allegations by highlighting the existing panels under the bill responsible for deciding when to deny healthcare or treatment...as if Palin was referring to anything else.
Patrick, the reference to 'idiotic' is the implication by Governor Palin that some mythical government panel will decide which individuals gets access to health care, and Palin's flat wrong on that. I say so. Where there is legitimate discussion is a government panel, MedPac, does make policy recommendations which are often defacto decisions about Medicare. In this case, it's about how hospice providers are reimbursed, and then it's the HOSPICE PROVIDERS who make the individual decisions about patient treatment -- NOT the government. Palin implied that government panels would make individual health care decisions, and that's simply idiotic. Also, we have 'death panels' today -- they're called insurance companies. They deny necessary health care, often arbitrarily, ruthlessly, and immorally. My column raises questions about the practices of for-profit hospice providers. But don't just take my word, consider their own statements. From the June 2008 MedPac report, "Evaluating Medicare's Hospice Benefit.": In their filings with the Securities and Exchange Commission (SEC), publicly traded for-profit hospice chains also generally acknowledge the nonlinear cost function of resource use within hospice episodes. VistaCare notes that "our profitability is largely dependent on our ability to manage costs of providing services and to maintain a patient base with a sufficiently long length of stay to attain profitability," and that "cost pressures resulting from shorter patient lengths of stay ... could negatively impact our profitability" (HCSM 2004). Similarly, Odyssey HealthCare acknowledged in their 2004 annual SEC filing that "length of stay impacts our direct hospice care expenses as a percentage of net patient service revenue because, if lengths of stay decline, direct hospice care expenses, which are often highest during the earliest and latter days of care for a patient, are spread against fewer days of care" (Odyssey HealthCare 2004). Odyssey HealthCare's average length of stay increased from 79 days in 2004 to 86 days in 2006, with no apparent change in the mix of patients it treated (Odyssey HealthCare 2007).
This is a case of someone presenting statistics well but ignorant of the basics. The concluding question "Would Grandma's plug be pulled then to protect a profit margin?" is absurd. 'Pulling the plug' is murder. Secondly hospice patients have generally opted out of intensive care solutions where pulling the plug is even possible. Third, medications, one of 'skimped' services noted by the author, are generally a patient cost, assumed by insurance and not a direct hospice cost. The facility, even a for-profit, has little incentive to reduce med costs as a result. There may be some basis to the claim that for-profit Hospices could reduce costs by increasing patient/staff ratios (i.e. reduced baths, or exercise of patient) but the idea that any organization can 'pull the plug' and get away with it is misguided supposition. The reduction of non-patient services such as grief counseling is a reality and will continue as Medicare costs are reduced. But who else even offers these services? If a loved one dies at a hospital see who schedules you for grief counceling, unlikely. If you want to uncover a problem look at the care-home industry where patient/staff ratios are exploding. 8,12,16 patients per nursing assistant per shift. Lucky they get diapers changed. Ratios are much lower in a hospice. What Edgell does not tell you is that Hospice is a cost effective method of dealing with end of life care. Hospital care is not set up for caring for the dying and can make life miserable for terminal patients. Home care is often difficult on the family and the patient often suffers from serious lack of care or even abuse. (Grandma often flees her own home in fear of her decendents 'pulling the plug'. All Hospices are under financial attack at the moment. However the 'only plug' that may be pulled is the number of available beds in these worthwhile facilities. Edgell has obviously never spent any significant time in a Hospice. He speaks hypothetically and with some ignorance of the actuality. People turn to hospice not to die but to live out the remaining days they have in peace. Most gain that peace with the help of palliative care (pain treatment), good staff, and an environment that facilitates family participation in the last days, weeks or months of their lives. Edgell should volunteer at a hospice, go through the training and make friends with the patients. If he did I am sure his rather flip attitude toward the care provided would change radically. Come on John, take your fingers off the key board and hold hands with a few dozen dying people, listen to their stories, and experience their passing. Then tell us what it's all about.
Barack Obama to a daughter at healthcare townhall: No, I wouldn't give your 100 year old mother a pacemaker. I'd give her a pill instead for the pain. Gov't bureaucrat denying care because of cost!! From HIS own lips. Die old woman, DIE.
Typical Liberal hate spewing toward Gov. Palin prior to agreeing with 90% of her points.
I brought this article into one of our team meetings this past week, and told them that I wanted to respond, but my response was getting longer and longer (also because I was mad as a wet hen over these accusations). One of the points is that all businesses must make a profit or close their doors - having reimbursment for hospice makes it possible for more patients to be served. As passionate as I and other nurses, doctors, aides, social workers, etc. are about hospice care, I would not be able to volunteer to take on many patients if we went back to a purely volunteer system. The other point is that to compare tax exempt (the so-called not for profit) hospices vs the tax paying hospices, is that we are both paid the same per diem - about $120 a day (try getting into a nursing home for that!) is an apples to oranges comparison. The not for profits have a lot more money than the for profits - they can use their fund raising money for whatever they like - rennovating their buildings, having far more staff, marketing, etc. Many times the comparisons of not-for-profits offering more services are non-core servies per the Conditions of Participation. It's great that they have many programs to educate and help the community with bereavement issues (which also help market hospice to the community), but these extra services are just that - extra, not core services that directly benefit the patient. We do need to evaluate each hospice service individually. It's not appropriate or helpful to decide on one hand that healthcare is not a right for all citizens and we're at the mercy of the insurance companies that make billions in profits, but on the other hand, those of us providing the care should for some reason be "angels of mercy" who don't care about putting food on our own family's table. The bottom line from my team's input on this article was their committment to do their best to conform to the paperwork requirements that often make it look like a hospice isn't doing what they should. But they also wanted to invite the author of this article to come for a visit - to come out with our staff to the patient's homes to see what we really do. Statistics just can't tell the whole story, but seeing is believing, and I think you'd be pleasantly surprized and even touched by the work being done to comfort, support, and uplift each of our patients and their families.
El Paso, As with most of the frantic screaming on this subject, you avoid the truth. If a hundred year old woman was opened up to place a pace maker the odds of her dying of the operation or suffeing complications are likely so great as to make the risk not worth taking. Providing her with meds is likely a better course of action. (I have a 95 year old relative who has faced a similar situation, and we chose not to do the procedure because of the risk and the limited benefit.) By the way El Paso, how is your blood pressure?, do you smoke?, do you exercise regularly to get your heart rate up, do you eat properly?, Overweight?, Go to the doctor for regular checkups?, Take care of your teeth?, Have health insurance?. Most Americans are likely to do more to shorten their own lives than any government panel ever could. Most Americans are their own best Euthanasia Machine. Stop worrying about what the government is going to do to you and go out and learn how to run a marathon. It will relieve stress and make you healthier. YOU will live longer. Finally, if you are not taking care of yourself I am offended that MY health insurance, right now, without any government intervention, is higher because of you. Why is that right? What makes this solution so fair? Why do people who care for themselves have to pay for the lazy and the stupid? I'll take a plan that says ' If you take care of yourself, you get better care.' any day of the year. If that means a board must discriminate in offering services based on how well one takes care of oneself, then so be it.
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