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Nearly 1 In 5 Hospice Patients Discharged While Still Alive

Aug 11, 2017
Originally published on August 11, 2017 12:41 pm

Hospice care is for the dying. It helps patients manage pain so they can focus on spending their remaining time with loved ones. But in recent years, nearly 1 in 5 patients has been discharged from hospice before he or she dies, according to government reports.

A study published last month in the journal Health Affairs finds that hospices with the highest rate of so-called live discharges also have the highest profits. The lead author is Rachel Dolin, a David A. Winston fellow researching health policy. Her paper found an association between high live discharge rates and high profit margins, but it didn't determine the cause.

"It's important to continue to study this area to get a better sense as to whether profits are driving the decision to discharge patients from hospice, rather than patient preferences and needs," says Dolin.

To qualify for hospice care, two doctors must certify that a patient is expected to live no more than six months. But patient James B. Nelson discovered that sometimes the doctors are wrong.

"It was decided that I was not dying fast enough," he told Arizona Public Media in 2015. "And so, to put it most succinctly, I flunked the hospice program."

Nelson died a few months after giving that interview, but his situation isn't all that unusual.

Government reports show that the median rate of hospice patients discharged before death has climbed steadily since at least 2000, peaking in 2012 and 2013 at almost 1 patient in 5, though more recently the percentage has declined somewhat. But the rate actually varies widely from one care organization to another. Some hospices discharge fewer than 2 percent of their patients prior to death, while others discharge more than 80 percent. Nonprofits have lower rates of live discharge than for-profit hospices. Regionally, live discharge rates are highest in the South.

It's important to understand, though, that when patients are discharged from hospice, they don't necessarily go anywhere. Hospice agencies, whether they are independent or affiliated with an institution like a hospital, usually deliver services to patients in their homes.

Medicare pays the bills for the vast majority of patients receiving hospice care, at a cost to the government of at least $15 billion a year. Federal regulators have questioned whether high rates of live discharge mean that hospices are making money by admitting patients who aren't actually dying.

But these decisions aren't that clear-cut, says Dr. Joe Rotella, chief medical officer for the American Academy of Hospice and Palliative Medicine. "We see more and more patients that have conditions like Alzheimer's disease or Parkinson's disease that don't always follow a predictable course," says Rotella.

Some who study aging are concerned that certain hospices are gaming the system. That's a worry of Susan Enguidanos, an associate professor in the Leonard Davis School of Gerontology at the University of Southern California. For example, she says that some hospices may be trying to avoid paying for costly treatments by discharging patients temporarily when they need to go to the hospital.

"Individuals that are going in for these very brief health issues are coming out and then, they're being readmitted to those [same] hospices," says Enguidanos.

That's not a good reason to discharge someone, says John Keyserling, senior vice president for communications and policy at the National Hospice and Palliative Care Organization, the trade association for hospice providers.

"Any association between profit margins and clinical decision-making is inappropriate and not something that the hospice community supports," Keyserling says.

That hospice community has nearly doubled in size since 2000. Enguidanos says it has also changed a lot.

"Hospice organizations started as grass-root efforts and were largely nonprofit for a long time," she says. "Now we've had a huge increase in for-profit hospices." There's a concern, says Enguidanos, that by discharging patients early, some hospices may be "trying to avoid costs that they should be responsible for."

Whatever the shortcomings of some hospices may be, Keyserling says that his biggest worry is that people who could be helped by hospice aren't taking advantage of it in time. He says about half of patients die within 17 days of being admitted. And that turns hospice into "crisis care" instead of the comfort care it's intended to be.

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AILSA CHANG, HOST:

Hospice care is for the dying. It helps patients manage pain, comforts them, perhaps even allows them to focus on spending a last bit of quality time with their loved ones. But in recent years, nearly 1 in 5 patients have been discharged from hospice before death. And a new study finds that hospices with the highest rates of these so-called live discharges also make more money. NPR's Ina Jaffe reports.

INA JAFFE, BYLINE: To qualify for hospice care, two doctors must certify that a patient is expected to live no more than six months. But patient James B. Nelson said he defied the expectations.

(SOUNDBITE OF DOCUMENTARY, "PASSING ON")

JAMES B. NELSON: It was decided that I was not dying fast enough. And to put it most succinctly, I flunked the hospice program.

JAFFE: This is from an Arizona Public Media documentary "Passing On," which notes that Nelson died several months after this 2015 interview. But his situation is not that unusual. Government reports show that the median rate of hospice patients discharged before death has increased, peaking in 2012 and 2013 at about one patient in five. Now there's a new study in the journal Health Affairs that finds that hospices with the highest live discharge rates also have higher profits. The lead author is Rachel Dolin, a Winston health policy fellow.

RACHEL DOLIN: It's important to continue to study this area to get a better sense as to whether profits are driving the decision to discharge patients from hospice, rather than patient preferences and needs.

JAFFE: When a patient is discharged from hospice, they don't necessarily go anywhere. Hospice services are usually delivered where the patient lives. And those services cost Medicare more than $15 billion a year. Federal regulators have questioned whether high rates of live discharge mean that hospices are admitting patients who aren't actually dying. But those decisions aren't that clear cut, says Dr. Joe Rotella, chief medical officer for the American Academy of Hospice and Palliative Medicine.

JOE ROTELLA: We see more and more patients that have conditions, like Alzheimer's disease or Parkinson's disease, that don't always follow a predictable course.

JAFFE: But some experts who study aging think that hospices may be trying to avoid costs that should be their responsibility. Susan Enguidanos, an associate professor of gerontology at the University of Southern California, gives the example of hospices temporarily discharging patients who need a trip to the hospital.

SUSAN ENGUIDANOS: Individuals that are going in for these very brief health issues are coming out, and then they're being readmitted to those hospices.

JAFFE: Which could be a bad thing, says Jon Keyserling, senior vice president for communications and policy at the National Hospice and Palliative Care Organization, the trade association for hospice providers.

JON KEYSERLING: Any association between profit margins and clinical decision-making is inappropriate and not something that the hospice community supports.

JAFFE: That hospice community has nearly doubled in size since 2000. And Susan Enguidanos says it's changed a lot.

ENGUIDANOS: Hospice organizations started as grass-root efforts and were largely nonprofit for a long time. And now we've had a huge increase in for-profit hospices.

JAFFE: James Keyserling says his biggest worry is that people who could be helped by hospice aren't taking advantage of it in time so that instead of comfort care...

KEYSERLING: Much of hospice is crisis care.

JAFFE: ...With about half of patients dying within just 17 days of entering hospice.

Ina Jaffe, NPR News.

(SOUNDBITE OF OLAFUR ARNALDS & NILS FRAHM'S "01:41") Transcript provided by NPR, Copyright NPR.