It happened on Twitter, so it’s not exactly like it’s a big secret or anything. It was horrible, needless, tragic, and most notable for how quickly it led to circling wagons and how desperately the elephant in the room was avoided. It was also a normal day in a normal week in the world of corporate hospice, where service failures are a guaranteed feature and not a bug for one simple reason - hospice doesn’t scale. Some aspects of the service failure are less important, like who specifically it happened to or what exactly happened. You can find the particulars easily enough if you really want to, but my interest is in the larger issue: the greed and ineptitude of for profit corporate hospice chains, and the inevitable results of same. Here’s what I saw happen, admittedly limited to following it unfold on Twitter.
The family member of a physician is admitted to the local branch of a national corporate hospice chain
Someone contacts the national corporate hospice chain to report increasing symptoms and suffering
Someone at the national corporate hospice chain tells them to call 911
Ambulance ride, extended emergency room visit, diagnosis (likely consistent with the patient’s reason for choosing hospice plan of care), some level of discomfort, disruption, frustration, confusion
Return to original setting, try to get get back on track with the original hospice plan of care
Physician family member cries WTF isn’t this what we were trying to avoid?
What’s the problem? An effective hospice plan of care leading to the optimal outcome of a peaceful death usually doesn’t just happen on its own. It’s most often the result of thoughtful collaboration and support from an interdisciplinary team anchored by proficient (expert) nurses, who themselves are actively supported by a mission-driven organization that values their work. It’s a setting where events can build slowly until they explode into avoidable crises, so understanding any potential ‘worst case’ is the first step to preventing it from happening, with developing a plan to address it coming in at number two. It’s not possible to determine what led to the service failure in question, but there are indications of what may have contributed to it, most notably the name of a large national corporate hospice chain in the physician’s Tweet. Follow back to the national corporate hospice chain website to learn: “A VITAS Telecare nurse or other patient care expert answers your call. They have access to patient files and the expertise to answer questions, provide medical advice, contact your physician or dispatch a team member to the bedside—whether it’s 5:45 on a Monday night or midnight on New Year’s Eve.”
I haven't posted in a few weeks, but have still been busy. Here's the title slide for a one hour continuing education program I recently developed and presented to hospice clinical staff as part of their annual dementia training.
My next step is to incorporate the slides and video I used in the live presentation into a format suited for online learning.
The new hospice nurse and her preceptor were just getting the day started when a call came in from their clinical manager. The preceptor listened intently for several minutes, then put her phone away.
"Change of plans," the preceptor said. "We need to get over to Alcott Hospital. We might have to screen a patient for GIP." (pdf) "This will be a good experience for you."
When they walked onto the unit designated for hospice intensive care, the charge nurse gestured to a small group huddled in a corner.
Somewhere down the hall, a man screamed loudly. He was the subject of the small group's conversation.
The small group consisted of:
the unit's nurse manager;
the vice president of nursing;
a nurse named 'Sheila' who had been at Alcott since anyone could remember, was variously estimated as being somewhere between her late 60's to early 80's, wore a lab coat over expensive clothes, and seemed to just randomly appear in small group discussions or larger meetings, but was never either consulted or challenged.
The new hospice nurse started walking towards the group, but the preceptor pulled her back.
"Not our patient yet," the preceptor said.
"But aren't we supposed to screen somebody for GIP?" the new hospice nurse asked.
"Not our patient yet," the preceptor repeated.
The new hospice nurse could still hear the small group's discussion from where she stood with the preceptor's hand on her elbow, holding her back.
Somewhere down the hall, a man kept screaming.
"We can't use propofol," the nurse manager said. "He needs to go to ICU if you want to use propofol."
"What's going on?" the new hospice nurse asked the preceptor. "What else do you know about this case?"
The preceptor replied, "The patient you hear screaming is someone who's been on hospice, but not our agency. He was with East Cupcake Home Care and Hospice."
The new hospice nurse had never heard of East Cupcake.
"They're a small outfit twenty miles away," the preceptor continued. "They mostly do home care visits - wounds, new babies, teaching people how to inject their insulin, that sort of thing. Every once and a while they admit someone for hospice, and the same nurses do those visits, too. Their census is usually less than five, and anything complicated really throws them for a loop."
"Yikes," was all the new hospice nurse could say.
The preceptor went on, "This guy came into the ER this morning. His wife brought him in. He has metastatic cancer and lots of pain. He was on a CADD pump with morphine but it didn't relieve his pain, so the nurses from East Cupcake kept calling the oncologist, who kept increasing the basal rate and the breakthrough dose, and on it went until the wife brought him to the ER. Now here we are."
"But shouldn't we step forward?" asked the new hospice nurse. "Don't you think we can help?"
"Not our patient yet," the preceptor replied. "His wife revoked hospice and he's been admitted here. He's an oncology patient, and they haven't asked us to join them, and we'd have to get the wife's consent to admit him back to hospice first, so we just have to wait."
"Then why are we here?" asked the new hospice nurse.
"The settlement... is the final chapter of a seven-year legal battle that also saw Amedisys pay $150 million in 2014 to the U.S. Justice Department ...The shareholders said in the class-action that their investment in the Baton Rouge-based company had been damaged by the Medicare fraud scheme."
"... neither the company nor any individual defendant concedes or admits liability... Amedisys noted in its filing."
Amedisys reported net income of $37.3 million in 2016 on revenue of $1.44 billion.
Thanks for reading, see you next time, let's keep 'em honest!
I spent fifteen (15) minutes on Google to come up with this rogue's gallery that includes some of the largest and loudest for-profit corporate hospice players in the game. It's not a definitive list, but compiling one would be a worthwhile endeavor.
For now - the first draft of the Death Nurse Hospice Fraud Wall of Shame, based on my brief, superficial, but nonetheless informative research, here presented in chronological order.
These 12 settlements add up to over $337.54 Million. The September bust in San Francisco is one to watch.
For a sense of the money at stake, Medicare paid about $19 Billion in claims for hospice care in 2017.
robot brains for rolling robot talking doctor heads
From the investment site SeekingAlpha (audio for SeekingAlpha subscribers only) Transcripts | Healthcare Humana's (HUM) CEO Bruce Broussard on Q3 2019 Results - Earnings Call Transcript Nov. 6, 2019 5:21 PM ET | About: Humana Inc. (HUM) Q3: 11-06-19 Earnings Summary Press Release 10-Q EPS of $5.03 beats by $0.47 Revenue of $16.24B (14.32% Y/Y) beats by $89.34M. Here's how it looks from the ground as reported by friend and critical observer Anonymous at Strange Tony's Generic Hospice Blog: Big Picture for Kindred at Home "Two web meetings addressed Kindred at Home's future under the ownership of Humana and two financial rapscallions, TPG and Welsh, Carson, Anderson and Stowe (WCAS). The first occurred on November 5th when KAH President David Causby and Hospice President/Curo Health Services founder Larry Graham held a fireside web meeting for employees. ...Causby wants Kindred to be know for stellar clinical care and being innovative. Management's priorities are to provide enhanced benefits and show appreciation. The Curo way at our hospice has been the opposite of everything he stressed. Humana et al delivered poor clinical care, rigidity under bad systems, benefit cuts and zero acknowledgement of hard work and high performance by dedicated staff (most of whom are now gone). The dastardly duo ended with a dark future under Humana with artificial intelligence determining the level of care and what day that should be delivered. The goal is to decrease hospitalizations for Humana's Medicare Advantage enrollees and decrease the live discharge rate for hospice. That might mean only admitting patients who actually qualify for hospice. The pressure to meet targets for admissions and average daily census had patients sneaking onto service that clearly did not qualify. That pressure grew after Humana, TPG and WCAS bought us in July 2018." Read the whole thing
Blast from the past - NYT When a Health Insurer Also Wants to Be a Hospice Company By Reed Abelson June 22, 2018 "Humana is teaming up with two investment firms to become the nation’s largest provider of hospice care, dominating a rapidly growing — and controversial — business."
Thanks for reading. See you next time. Happy Hospice Month! *not a solicitation or financial advice, for education purposes only
Hospice in America is a $19B+ industry. We're talking about real money from a customer everyone knows can pay the bill - the federal government. Almost two-thirds of the players are corporate for-profit regional and national hospice chains, and they're selling hard.
They're also well-organized, including with an industry trade group and paid flaks lobbying Congress and churning out press releases.
Hospice is also probably the least transparent industry operating today - even compared to others that have long been notorious for their secrecy, like the funeral business. I haven't met anyone who's selected a hospice based on the kind of detailed comparison shopping they've done for a new car or vacation destination.
I can understand why - looking for hospice sounds like a grim task, so it's easy to avoid.
But the bigger reason is simple - there's very little useful information available that can help a patient, family, referring provider, or even just a curious, highly motivated, death-positive individual looking to check out their options, just in case.
I'm working on a longer piece that explores this conundrum in greater detail, and it's taking more time and has gotten more detailed than I first anticipated.
So in the meantime, I thought it would be helpful to revisit the suggestion of my friend, colleague, and data wonk Boo Boo, who made the argument here two years ago that it's possible for us to get a good sense of a hospice based on one important number.
Here's my own "bottom line" about evaluating a potential hospice, in an environment where that term "bottom line" has assumed greater importance over the past 20 years: if they don't have enough staff, they can't even begin do the work reliably, consistently, safely, or with any expectation of decent quality.
What if a hospice can't clearly satisfy you with an answer to, "Do you have enough staff?"
I find most of the questions unhelpful, because they don't lead to the kind of information that could differentiate one hospice from another in any meaningful way. The third question prospective patients and families are instructed to ask is blatantly self-serving - Is the hospice you're considering part of our hospice industry trade group?
That statement reminds me of a speech Jimmy Carter made in 1974 as Governor of Georgia. It's called his "Law Day Address" because it took place at a luncheon event on that day - May 4. Someone there also made a low-quality audio recording, perhaps on a portable cassette tape player. Here's the relevant passage:
"The regulatory agencies in Washington are made up, not of people to regulate industries, but of representatives of the industries that are regulated. Is that fair and right an equitable? I don't think so.
I'm only going to serve 4 years as governor, as you know. I think that's enough. I enjoy it, but I think I've done all I can in the governor's office. I see the lobbyists in the state capital filling the halls on occasions. Good people, competent people, the most pleasant, personable, extroverted citizens of Georgia. Those are the characteristics that are required for a lobbyist. They represent good folks, But I can tell you that when a lobbyist goes to represent the Peanut Warehouseman's Association of the Southeast, which I belong to, they go there to represent the peanut warehouseman. They don't go there to represent the customers of the peanut warehouseman.
When the Chamber of Commerce lobbyists go there, they go there to represent the businessman of Georgia. They don't go there to represent the customers of the businessman of Georgia.
When your own organization is interested in some legislation there in the capitol, they're interested in the welfare or prerogatives or authority of the lawyers. They are not there to represent in any sort of exclusive way the client of the lawyers.
The American Medical Association and its Georgia equivalent - they represent the doctors, who are fine people. But they certainly don't represent the patients of a doctor."
To their credit, towards the end of the one-page cheat sheet the hospice industry trade group includes a muddled indirect version of the single most important question to ask any hospice:
Do you have enough staff?
But this weak sauce is still too strong for some members of the hospice industry trade group, because the long-form glossy adds in this great example of weaselspeak - hemming, hawing, dodging, and obfuscating:
Gotta read the fine print weaselspeak
This weaselspeak begs another question - why wouldn't a hospice be willing to share that information?
The most obvious reason is simple - because the answer isn't a favorable one, and the hospice would rather keep the public in the dark about its unsafe staffing.
Unsafe staffing should eliminate any hospice from consideration. A hospice with unsafe staffing is a hospice that abuses its staff with unreasonable demands, subjects its patients and families to risky poor quality care, and makes you wonder what else they're trying to hide.
One of my favorite online and social media pastimes is asking hospices about their staffing:
The biggest hospice in Massachusetts has never responded
Two years ago Medicare rolled out HospiceCompare, their early attempt to support the first of the four admonitions of the Death Nurse Manifesto: Patients and families need to know more and demand better.
November is the month to be aware of hospice, and that means it's time to look at hospice's biggest and fastest growing sector, the privately-held and publicly-traded companies trying mightily to get their hands on as much as they can of the *$19,000,000,000.00 +/- Medicare paid out for hospice in 2017.
*That's nineteen billion dollars, give or take.
There are lots of players bouncing around the for-profit hospice space, but here's one that caught my attention and continues to educate me about corporate hospice, Caris Healthcare.
First, take off any rose-colored glasses that may obscure the proper understanding about the true nature of our work in hospice.
I'm not kidding
This also explains something I've been hearing since I first started digging more deeply into for-profit corporate hospice, namely the term, "same store sales."
My nursing colleagues, physicians, and other clinicians often describe our knowledge and practice as the skillful combination of art and science. In the world of corporate for-profit hospice, the main difference between a hospice nurse and the kid who hands over a bag of fries is that the hospice nurse's boss needs to watch them more closely.
Being on the Board of Directors of a industry's national trade group is a valuable platform. Very valuable.
Spoiler alert - pills fell on the floor
The corporate website is one way to learn more about a company. I also like to assess the company's approach to its website and other materials, because I think it provides useful insight into their mindset and culture. Here, for example, Caris has chosen to put their own people front and center instead of using stock photos.
Absolutely positively perfect
Of course they're tooting their own horn in this blog post, and who wouldn't? It's a compelling story and deserves telling. Then I clicked on the photo...
Is this somebody's idea of a joke?
Or, maybe their hosting platform has a technical requirement that all pictures must be uploaded sideways.
Is this somebody's idea of a joke?
I didn't know much about Caris before their CEO shared his vision for the best hospice earlier this year in the online version of The Hill, a popular news outlet covering politics, policy, business, and international relations.
I think this might be the same Nashville location that was practically perfect in every other way.
Maybe it's because burdensome regulations create needless and time-consuming administrative work?
“We have significant expertise in investigating hospice fraud, as this part of the country unfortunately has seen more than its share of these schemes,” said Special Agent in Charge Derrick L. Jackson for the Office of Inspector General for the region including Tennessee. “When hospices increase their bottom lines by billing taxpayers for unneeded services, they are diverting money from vulnerable, terminally-ill individuals.” United States Department of Justice
Kicking Irony's corpse
Part of the cost of doing for-profit corporate hospice business.
I wanted to see what else the company had to say about itself, especially coming straight from the founder. So, click on 'About,' then click, 'Message from our founder.'
Founder says null?
In the words of Norman MacRae, Founder and CEO of Caris Healthcare: "N;"
Mission, vision, and values null?
Leadership team null?
There's not much else to say, so let's have the final slide, please...
Pulp Fiction: "The path of the righteous man is beset on all sides by the inequities of the selfish and the tyranny of evil men. Blessed is he who, in the name of charity and good will, shepherds the weak through the valley of the darkness. For he is truly his brother's keeper and the finder of lost children. And I will strike down upon thee with great vengeance and furious anger those who attempt to poison and destroy my brothers. And you will know I am the Lord when I lay my vengeance upon you."
King James Version (25:15-17): "Thus saith the Lord GOD; Because the Philistines have dealt by revenge, and have taken vengeance with a despiteful heart, to destroy it for the old hatred; Therefore thus saith the Lord GOD; Behold, I will stretch out mine hand upon the Philistines, and I will cut off the Cherethims, and destroy the remnant of the sea coast. And I will execute great vengeance upon them with furious rebukes; and they shall know that I am the LORD, when I shall lay my vengeance upon them."
Young's Literal Translation (25:15-17): "Thus said the Lord Jehovah: Because of the doings of the Philistines in vengeance, And they take vengeance with despite in soul, To destroy — the enmity age-during! Therefore, thus said the Lord Jehovah: Lo, I am stretching out My hand against the Philistines, And I have cut off the Cherethim, And destroyed the remnant of the haven of the sea, And done upon them great vengeance with furious reproofs, And they have known that I [am] Jehovah, In My giving out My vengeance on them!"