On the latest Last Week Tonight, John Oliver delved into the many issues with hospice care in the US. Doing so is “an almost offensive parody of this show”, he acknowledged. “If somebody else did that, it would genuinely be hurtful. But I promise this is worth talking about.”
There are “lots of dedicated people work with hospices, providing huge relief for dying patients and their families, particularly those who want to remain at home”, such as the 1.8 million Americans who received end-of-life care at home last year.
But like anything, hospice is subject to fraud, mismanagement and abuse. One government report estimated that hospice’s inappropriate billing costs Medicare hundreds of millions per year.
Oliver first looked into the origins of hospice care in the US, which was imported from England in the mid-20th century. “I know the British exporting a new way to die sounds like the perfect slogan for over 400 years of colonialism,” he joked, “but in this case it was genuinely a good thing.”
The first American hospice began caring for patients in 1974, and more followed, mostly composed of charities staffed by volunteers. In the 1980s, Ronald Reagan authorized Medicare to cover the costs of hospice after advocates argued that it would be cheaper than paying for the aggressive treatments that so many patients received up until they died.
Now, of the roughly 6,000 hospice providers in the US, 75% are for profit. Such companies charge a flat fee of, on average, $218.33 per day for the first 60 days and $172 for every day after that. “That can create a clear incentive to sign up as many patients as possible,” Oliver explained, quoting one marketer who, according to a Georgia court case, said: “How do you solicit patients? You see somebody on the front porch in a wheelchair and hit the brakes.”
“You know our system is broken when a hospice provider’s target demo is kidnapped porch grandmas,” Oliver quipped.
According to a recent survey, over one in five families did not think their hospice service provided timely help. Oliver pointed to documented cases of fraud, such as a company who billed Medicare for 17 days of care for a 70-year-old they never visited, and just called his family to inquire on how he was doing. “It’s hard to defend the quality of that company’s service when they were quite literally phoning it in,” he said.
There are even worse examples, such as a hospice company that skipped home visits and failed to assess the amount of pain for one patient who ended up with a maggot infestation. “Which is horrifying,” said Oliver. “Treatment for dying people ideally should not sound like a scene from a fucking Saw movie.”
“It’s not just exaggerating the care that patients are getting,” Oliver added. “Hospices can also enroll patients who shouldn’t even be there in the first place.” Because while there’s a requirement that patients should have a life expectancy of six months or less for entering hospice care, most of the Medicare spending on hospice is now for patients who stay longer than six months.
Oliver pointed to such “live discharge rates” – how many people leave hospice alive. Some live discharge is to be expected, like when a patient chooses a different hospice or opts to pursue curative care again. According to experts, a live discharge rate of 30% is high and anything over 50% a serious indicator of possible fraud. And yet an analysis of the 507 hospice providers in California last year found a live discharge rate of over 70%; 135 hospices had a rate of 100%. “Which is wild!” Oliver exclaimed. “When 100% of the people in your care are leaving alive, you’re not a hospice, you’re a hotel. And statistically, an incredibly safe one.”
Oliver used the example of a company called Merida, where several nurses testified that the majority of the patients were not terminally ill, including one who had a regular job at Walmart. The group also enrolled people with illnesses like Alzheimer’s and dementia by falsely telling them they had less than six months to live, even sending chaplains to lie to the patients. “Which is horrendous,” said Oliver. “Frankly, anyone who took part in that deserves to rot in hell.”
Other patients have been accidentally enrolled in hospice or enrolled without their knowledge, which can have serious ramifications, given that hospice precludes curative medical care. There are documented cases of patients losing access to chemotherapy, kidney dialysis, mammograms and coverage for life-saving medications because of hospice enrollment without their consent. “Those just aren’t things you should be able to lose without realizing!” Oliver remarked. “Chemotherapy isn’t like a set of keys or the wife of the head of the church of Scientology – where’s Shelly, David? Where’s Shelly? It’s been 17 years, I’m starting to think something bad has happened.”
The government has some red lines at its disposal, “but one of the key issues is, outside of major fraud cases, there are shockingly few consequences for bad behavior,” Oliver summarized. “And the barriers to operating a hospice can be much lower than you think.” A medical background isn’t required, for one, and Medicare only requires that hospices be inspected once every three years.
Some states are trying to fix things, though those plans can meet opposition. At the federal level, the Centers for Medicare & Medicaid Services (CMS) has initiated unannounced site visits to every Medicare-enrolled hospice and, as a result, revoked the licenses of 48 offending practices. California has placed a moratorium on new hospice licenses. But “experts say there is so much more that we should be doing here”, said Oliver, such as targeting hospices with especially high live discharge rates for particular scrutiny.
“Hospice care, when done well, is hugely beneficial to those that are dying and their families. It is too important to just hope the free market fixes it,” Oliver concluded. “This industry badly needs reform. That’s clear.”
