really-blog

These are a few of the headlines and articles generated by the most recent OIG report entitled: Hospices Should Improve Their Election Statements and Certifications of Terminal Illness published September 15, 2016. Beginning with the leader in negative hospice hysteria, the Washington Post’s Peter Whoriskey (yes, that guy again), the relatively benign and definitely limited findings of the OIG’s report are being used as a major “gotcha” to accuse the hospice industry as a whole of rampant fraud and abuse. There are so many things to say about these headlines and articles as well as the report.  Deep breath.

Let me begin with the OIG report.  For those of you who have not had the pleasure of reading it (for example, possibly the authors of the articles we will discuss later), this is not a groundbreaking, hospice-shattering report.  All OIG reports about hospice are important, but it is limited and, like the articles it generated, it needs to be read critically.

Here’s a brief overview:

What the OIG wanted to do

The overarching goal of the OIG with regard to this report is to make certain that Medicare beneficiaries are making an informed choice when they elect hospice care and that hospice physicians are appropriately involved in the certifying process. Previous OIG reports and investigations have raised concerns in these two areas.

What the OIG did

The OIG reviewed hospice election statements and certifications of terminal illness from a stratified random sample of 565 general inpatient (GIP) stays. The sample was taken from data for a previous OIG study on GIP that included 282,225 GIP stays in 2012 for 252,759 beneficiaries. A GIP stay was defined as one or more claims for GIP for the same beneficiary, in the same setting, from the same hospice.

What they found

With regard to election statements, 35% of GIP stays in the sample used election statements that were missing required information or had other vulnerabilities. Specifically:

Election form did not specify Medicare

19%

Required waiver information was missing or stated inaccurately

12%

Required information about palliative care was missing

9%

Revocation or discharge information was inaccurate or unclear

4%

With regard to certifications of terminal illness, the reviewers found that the physician narratives were insufficient in 14% of the reviewed 565 GIP stays.

What they recommend

From these findings the OIG made the following recommendations to CMS:

  1.  Develop and disseminate model text for election statements
  2.  Instruct surveyors to strengthen their review of election statements and certifications of terminal illness
  3. Educate hospices about election statements and certifications of terminal illness
  4. Provide guidance to hospices regarding the effects on beneficiaries when they revoke their election and when they are discharged from hospice care

CMS concurred with the first three recommendations and neither concurred nor nonconcurred with the fourth.

The following are my thoughts on what they did, what they found and their recommendations.

Methodology and Findings

When I first read the report it struck me that there might be problems with the methodology. It occurred to me that the review of election statements of the stratified random sample of GIP 565 claims from 2012 could include multiple statements from the same hospice or even the same beneficiary. That could skew the findings since hospices tend to use the same election form for all patients. In other words, if there were reviews of election statements for the same beneficiaries or from the same hospice they would obviously have the same deficiencies.

Not trusting my limited expertise in research methodology, I consulted Weatherbee’s Senior Research and Data Analyst, Joe Polubinski, PhD.  He concurred that it could be possible that the study reviewed election statements of GIP stays from the same hospice or beneficiary. Also, hospices with larger number of GIP stays would more likely appear in a claims-based sample; biasing the sample with respect to the “hospice universe.”  In addition, and perhaps more importantly, he pointed out that the findings of this report are limited to the universe of GIP stays in 2012. It would not be appropriate to project these findings beyond 2012 nor does the sampling of claims from the GIP stays allow for precise statements regarding the prevalence within the hospice universe, only the claims universe.

The OIG did not make claims that the findings from this report can be extrapolated to the entire hospice industry but nor did it explicitly state the limitations of the report in this area.

What I think about what they recommend

I agree with the title of the report – hospices must improve their election statements and certifications of terminal illness.  There is always room for improvement. Hospices need to review their current election statements and processes for physician narratives and attestations to ensure they meet requirements.

Drilling down further:

  1. It will be good if CMS develops model text for election statements.  I have always wondered why they did not do this years ago – it would alleviate confusion and make sure everyone is providing the same, accurate information.
  2. CMS concurred that they will add training regarding election statements and certifications of terminal illness to their Basic Hospice Surveyor Trainings. Let’s be clear why this was not done before.  The specific, detailed requirements regarding election statements and certifications of terminal illness are found in Subpart B of the hospice regulations – not within the scope of hospice surveys which historically have only dealt with the Conditions of Participation, found in Subparts C and D. Interestingly, in the report (page 5, end of first paragraph) the OIG says  “Surveyors review a sample of beneficiaries’ records during this process, including the election statements and certifications of terminal illness. Surveyors must cite deficiencies when hospices fail to meet requirements.” Although that may now happen when CMS implements this recommendation in their training, it has not been true in the past.  Valid and sufficient elections and certifications have been under the purview of Medicare contractors and related to payment scrutiny, not survey and certification for health and safety.  I wonder if CMS will institute L-tags to cite deficiencies if these forms do not include the required components as outlined in Subpart B, 418.22 and 418.24.
  3. Educate hospices about election statements and certifications of terminal illness. Education is good.  The more the better.
  4. Provide guidance regarding the effects of revocation and discharge. CMS did not agree nor disagree with this OIG recommendation maybe because it is confusing.  Part of the confusion stems from the question of how to manage revocations and discharges with regard to remaining days left in a benefit period. For example, if a patient revokes or is discharged in the middle of a benefit period, what happens to the remaining days in the benefit period, especially if the patient is readmitted? Does the patient lose the remaining days and get readmitted into the next benefit period? The thing is, this really does not matter anymore because beneficiaries have an unlimited number of 60-day benefit periods into which they can be admitted.  It did matter 20 years ago when there were only four benefit periods and if a patient was discharged in the fourth benefit period, he or she lost the possibility of ever being re-admitted to hospice again. Thankfully, the Balanced Budget Act of 1997 eliminated the fourth benefit period and implemented unlimited 60 day periods instead.  Consequently, the issue of losing days remaining in a benefit period and what benefit period to be re-admitted into is really not a big deal.  I am not sure why it continues to be raised as one.

So there you have it.  I have far exceeded the bounds of acceptable length of blog posts and have not even gotten into my discussion about the headlines and articles generated by this OIG report. I don’t even really want to go there it feels so toxic.  If there is anything we have learned during this interminable primary and general presidential election, whether Republican or Democrat, we have to agree that there are very serious problems with journalistic standards, truth-telling, fact-sourcing and click-bait.  To various degrees, the articles generated by this recent OIG report are further evidence of that.

Let’s just look at a few:

Here is what Peter Whoriskey says in  How tens of thousands of patients who weren’t actually dying wound up on hospice care:

About one in three hospice patients were not given key information about what the choice of hospice entails at the time they enrolled, according to a report being released today by the Office of Inspector General of the Department of Health and Human Services.

Really?  No.  Approximately one in three election forms reviewed from GIP stays in 2012 were found to have deficiencies – one can’t draw conclusions about what the patients were told and/or given during the admission process.  I don’t even want to touch the hysteria-inducing headline of the article. To take from the limited sample and findings of this report to conclude that it somehow EXPLAINS how hospices recruit patients who aren’t actually dying is ridiculous. I don’t think this guy is ever going to go away.

Then we have an article by Eric Pianin in the Fiscal Times article with the misleading headline:  Report Uncovers Widespread Medicare Fraud in Hospice Care that further states:

Now, a disturbing new report by the Office of Inspector General of the Department of Health and Human Services claims some unscrupulous hospice operators, doctors and staff are aggressively recruiting patients for their programs in an effort to maximize profits – even when in some cases the patients shouldn’t be in hospice. The improper and fraudulent activities amount to hundreds of millions of dollars.

Really?  Uh. No.  The OIG refers to some notorious hospice fraud cases (clearly the exception rather than the rule) but this disturbing statement and the headline of the article makes it sounds as if that is what the report concluded.  It didn’t.

Not sure where Luke Gale got his headline:  OIG: Providers offer ‘limited’ proof patients need hospice care but his article then basically just regurgitates Whoriskey’s.

And finally we have this from Emily Rappleye ‘s article OIG backs Washington Post investigation that found ‘hospice survivor’ count has risen dramatically:

The OIG found many hospices had patients sign paperwork that did not make it clear the care provided would be palliative, or provide relief from pain, rather than curative. It also found physicians had limited involvement in determining if hospice care was appropriate for patients in 14 percent of hospice general inpatient stays.

Really? No, not really.  She makes it sound like the OIG and the Washington Post are working in tandem and the OIG report was about the hospice survivor count rising dramatically.  It wasn’t.

Doesn’t this whole situation seem just a little out of control?  The bottom line is that the OIG conducted a review of election forms and certifications of terminal illness.  The sample of the study imposes limitations on the applicability of the findings to all hospices. However, it is likely true that there is room for improvement in the quality of hospice election forms and the physician narrative and attestation components of certifications of terminal illness.  That is about it.  Really.