and Dan Keating
Hospice patients are expected to die: The treatment comforts the terminally ill without trying to cure them. To enroll a patient, two doctors certify a life expectancy of six months or less.
But over the past decade, the number of "hospice survivors" has risen dramatically in the United States, in part because hospice companies profit more by recruiting patients who aren't actually dying, a Washington Post investigation has found. Healthier patients are more profitable because they require less care and stay enrolled longer.
California's well-documented experience with more than 1 million hospice patients between 2002 and 2012 paints a portrait of the industry nationwide:
This vast growth took place as the hospice movement, once led by religious and community organizations, evolved into a $17 billion industry dominated by for-profit companies -- with Medicare paying roughly $15 billion of industry revenue last year.
And extended care is at the root of the rising costs. At AseraCare, for example, one of the nation's largest for-profit chains, hospice patients kept on living. About 78 percent of patients at the Mobile, Ala., branch left the hospice's care alive, according to company figures. As many as 59 percent of patients left another Alabama AseraCare branch alive and 48 percent from a third.
"It was definitely good news," said Bessie Blount, who said her father received hospice care in Monroeville, Ala., for a about a year before ending it. About three years later, 91-year-old Chocolate Blount, is still alive.
The work that the hospice nurses, aides and counselors do, often in the most trying circumstances, is emotionally and physically demanding. It typically allows patients to die at home or other familiar surroundings, and it enormously relieves families of the dying.
But AseraCare's survival rates reveal Medicare's problem: It pays a hospice about $150 a day per patient for routine care, regardless of whether the company sends a nurse or any other worker out on that day. That means healthier patients, who need less care and live longer, yield more profits and that leads, watchdogs say, to for-profit companies aggressively recruiting healthier patients.
In 2011, nearly 60 percent of Medicare's hospice expenditure went toward patients who stayed on hospice care longer than six months, reported MedPAC, the Medicare watchdog group created by Congress.
Some of those patients outlived a legitimate prognosis of six months, but the data suggests a profit role.
Consider the difference between the nonprofit and for-profit hospices: While the average nonprofit serves a patient for 69 days, the average for-profit hospice serves one for an average of 102 days, according to MedPAC.
Moreover, many former hospice workers say that the businesses take in people who are not in declining health. Four of the 10 largest hospice companies in the United States, including AseraCare, have been sued by whistle-blowers alleging that patients were receiving unneeded care. The Justice Department has joined several of these lawsuits.
MedPAC has for five years recommended eliminating the financial incentive for longer care. A Medicare spokesman said it relies on the two-doctor verification-of-need system.
The industry itself opposes change. Tampering with the payment system could have unintended consequences, said Jonathan Keyserling, senior vice president of health policy at the National Hospice and Palliative Care Organization.
Keyserling and others in the industry attribute the rise in hospice survivors to changing patient demographics. A larger portion of patients today have diseases with harder-to-predict outcomes. That's because the portion of hospice cancer patients, a more predictably fatal disease, has shrunk, they say.
The lawsuits against the for-profit hospices vary in the details, but they depict an industry vigorously competing for new patients who receive services they're not eligible for.
In a whistle-blower lawsuit, employees of one company tell of urgent administrative messages to recruit more patients to meet monthly goals.
AseraCare advises its recruiters to close a deal with families "not ready yet" for hospice to stress the urgency, saying things like, "We only have 10 minutes left," according to a company presentation for Alabama employees.
"Effective communication is the transfer of emotion, not information," according to the presentation.
And at Angels of Hope hospice in LaGrange, Ga., audio recordings cited in a complaint describe how some salespeople find patients by cruising neighborhoods.
"How do you solicit patients?" a marketer is quoted as saying. "You see somebody sitting on the front porch in a wheelchair and you hit the brakes."
AseraCare and Angels of Hope denied the whistle-blowers' allegations.
The government benefit, while costly in itself, promised compensating savings for Medicare: Patients would be choosing less-expensive home care rather than high-cost end-of-life medical treatment. Patients with chronic illness in their last two years of life account for about a third of total Medicare spending, much of it for physician and hospital fees in repeated hospitalizations, according to the Dartmouth Atlas of Health Care.
The industry makes no secret of what it needs to do to run a hospice profitably. VistaCare's annual report in 2004 noted that its fortunes depended on its ability to manage costs and "maintain a patient base with a sufficiently long length of stay."
It warned that "cost pressures resulting from shorter patient lengths of stay ... could negatively impact our profitability."
Medicare has responded with measures that might make it more difficult for hospices to enroll ineligible patients.
Next year, the agency will limit the use of vague categories when describing the ailments of hospice patients, specifically prohibiting the use of "debility" and "adult failure to thrive" as primary diagnoses.
A spokesman for Medicare said the agency is considering hospice payment reform, but nothing will happen in fiscal 2014.
Read more about hospice care and how you can take more control of the emotional, financial and physical burdens at the end of life in this newspaper's award-winning Cost of Dying series at www.mercurynews.com/cost-of-dying