With coronavirus infections and deaths rising anew in worrisome fashion from coast to coast, matters could not get worse with the nation’s long-term care, right? Guess again. Profit-mongering and “audacious, widespread fraud” apparently has run amok in hospice care in the Golden State.
Because California, alas, too often serves as a trend-setting locale, patients, their loved ones, clinicians, regulators, and politicians may wish to take heed of an investigation published by the Los Angeles Times. The newspaper reported that too many older, sick, and injured patients have been gulled into signing up for unneeded and undelivered services meant for folks at the end of their lives:
“[M]any [hospice patients] are unwitting recruits [of] unscrupulous providers who bill Medicare for hospice services and equipment for ‘terminally ill’ patients who aren’t dying. Intense competition for new patients — who generate $154 to $1,432 a day each in Medicare payments — has spawned a cottage industry of illegal practices, including kickbacks to crooked doctors and recruiters who zero in on prospective patients at retirement homes and other venues … The exponential boom in providers has transformed end-of-life care that was once the realm of charities and religious groups into a multibillion-dollar business dominated by profit-driven operators. Nowhere has that growth been more explosive, and its harmful side effects more evident, than in Los Angeles County. The county’s hospices have multiplied sixfold in the last decade and now account for more than half of the state’s roughly 1,200 Medicare-certified providers, according to a Times analysis of federal health care data.”
Running a scam with huge harms
The harms can be huge to individuals sucked wrongly into this specialized care, the newspaper reported:
“Some patients who unknowingly enrolled in hospice later discovered they had signed away their rights to lifesaving emergency medical treatment, state inspection records show. Others endured excruciating pain in their final days when providers failed to deliver the comforting care they desperately needed. Still others suffered the consequences of neglected, festering sores that developed maggots or resulted in hospitalizations. Privacy laws and government reports that keep the names of patients, doctors, and hospice administrators confidential make it difficult to quantify and humanize many of the cases. But The Times found that since 2008, regulators have cited hospices in California more often than anywhere else in the country for the most serious types of violations, four times as many as states such as Texas and Georgia, which also have large numbers of providers.”
Here is how the newspaper found the scam gets run on vulnerable and gullible people throughout the state, quoting Sandy Morales. She oversees a federally funded, statewide hotline that aims to help Medicare beneficiaries prevent, detect, and report fraud:
“Fraudsters stick to a familiar script, enticing or duping Medicare recipients into signing up for services they don’t need … They send recruiters door to door and to churches, food banks, senior centers and apartment complexes, often misrepresenting hospice as an ‘extra’ Medicare benefit that pays for nursing visits, hospital beds, or other needs. The pandemic has spun off new schemes … with unscrupulous recruiters now enticing prospects with hand sanitizer, gloves and promises of other Covid-19 ‘freebies.’ Many who sign up don’t even realize they are in hospice care. ‘They’ll say, “No, I’m not dying. I wanted help with housekeeping and cooking, and that’s what I signed up for,”’ Morales said.”
Problems with safety and quality of care
The newspaper said that for-profit companies, with generally lax regulatory oversight, have shoved charities and religious groups out of their pioneering, well-intentioned, end-of-life care programs. Instead, with few credentials and the prospect of reaping profits from undelivered services, the money-seeking now exploit hospice care, causing significant problems, especially for those in dire need of care:
“With the explosive growth have come serious quality-of-care issues. The Times’ review of more than 800 state licensing and inspection reports revealed instance after instance in which patients were deprived of comforting care because of the actions — or inaction — of hospice providers. Mismanaged pain medications, neglected infections, missed nursing visits, incompetent or dishonest home health aides — all were cited among hundreds of violations that required hospices to draw up plans to correct the problems but resulted in little or no disciplinary action. Patients suffered for lack of pain medication or had maggots crawling out of festering foot sores and head wounds, state inspection records show. Others died alone because no one from the hospice showed up when needed.”
Sketchy operators know that state inspectors are outmanned and under-resourced, so they take advantage of time delays between reported complaints, official visits, and potential consequences — mostly slaps on the wrist. State inspectors also see too many situations where crooks get help from health workers, either in assisting in wrongful classification of patients as terminally ill and needing hospice services, or in referring individuals who prove to be easy marks in frauds.
In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them by abuse and neglect in nursing homes and in other long-term care facilities. It is unacceptable that hospice, an important aspect of dignified end-of-life treatment, often in institutions, of those with grave illness or injury, would be corrupted by sketchy operators seeking a fast buck.
Prosecutors, at the state and local level, may need to build more criminal cases against the shady. But the coronavirus pandemic has revealed canyon-sized shortcomings in the way the nation deals with the aged, ill, and injured requiring institutionalization. Federal regulators and prosecutors also may need to step up their scrutiny of Medicare and Medicaid spending on hospice.
Deadly nursing home problems persist
In nursing homes, it is unacceptable that the same factors that figured in waves of deaths and illness have not gotten addressed to avert a winter repeat, as reported on Dec. 12 by the Atlantic Magazine and the Covid Tracking Project:
“A new Covid-19 spike in America’s long-term-care facilities emerged in the West and Northeast last week, with both regions reporting their highest numbers of new cases in the past six months. The Midwest and South saw a small downturn in new cases, which is promising, yet the week still saw the nation’s highest number of newly reported cases — 51,574 — in long-term-care facilities since we started collecting these data in May. Nationally, deaths increased by 27% from the previous week … the Northeast is beginning to see Covid-19 case increases reminiscent of that region’s devastating outbreaks at the beginning of the pandemic. The 838 deaths the region reported in the week from Nov. 26 to Dec. 3 is the largest increase since early June, and 38% of these deaths came from Pennsylvania. That state last week hit a six-month high in the number of recorded cases, with 4,970. That represented more long-term-care-facility cases than any state in the nation except California, which reported 5,075.”
We’ve got a lot of work to do to ensure that our rapidly graying population has sound options for care, in institutions and at the end-of-life. We need places for the vulnerable to go, not to die — and badly. We need care givers and facilities that can offer them, no matter how frail or declining, a place for a decent life and a death with dignity.