“If I’m getting $3,000 or $4,000 a month from a hospice to work one day a week, I’m going to refer my patients to hospice, too,” Megli said.
The company used its network of nursing-home doctors to provide a ready supply of patients, according to family physician Larry Anderson of Wellington, Kan., a former president of the Kansas Medical Society. When he declined to approve his patients for hospice because they weren’t dying, one of the nursing-home doctors certified them instead, Anderson said. He called it ”a win-win for everybody but the taxpayer.”
More than half of Voyager’s patients resided in nursing homes, according to Combs, the company’s co-founder and former senior vice president. That compares to about one-third of Medicare hospice patients nationally.
The government often pays twice for hospice patients in nursing homes — about $137 a day to the hospice provider from Medicare, and about $200 a day to the nursing facility from Medicaid, which covers the indigent elderly.
“Hospice should not be in nursing homes at all,” Anderson said. “It’s redundant, and it’s an expense we cannot afford and don’t need.” In July, the inspector general of HHS recommended reducing payments to hospices in nursing home.
Stubbs, Appling’s niece, said she got a call one day from the nursing home where her aunt lived offering extra care if she were enrolled in hospice. HCK admitted Appling with a terminal diagnosis of cardiovascular accident, or stroke. It was changed later to “general debility.”
Ewy signed two hospice admission orders — one as Appling’s attending physician at the nursing home and another as the Kansas hospice’s medical director, copies of the documents show.
Not that Appling was dying, Stubbs said. She and her husband continued visiting her aunt twice a month at the home, Wheat State Manor in Whitewater, Kan. Stubbs’s son and his children often joined them. Aunt Midge in her wheelchair would eat Hershey’s Kisses and play ball with the children in the garden, or Uno indoors when it was cold.
‘Inappropriate for hospice’
A year after Appling went on hospice, the medical staff noted in her chart that she’d gained weight, was “doing well” and was “inappropriate for hospice,” according to documents submitted as evidence in the federal fraud case. Yet Appling remained on hospice eight more months before the company discharged her, according to Stubbs.
Medicare paid HCK $3,980 a month to care for Appling, according to the government’s complaint. On top of that, Stubbs paid the nursing home $4,000 to $5,000 a month for room and board. “I feel really dumb,” Stubbs said.
Stubbs wonders whether her aunt, who had several strokes, might have benefited from drugs or rehabilitation unavailable to most hospice patients.
“Could we have made her remaining years more comfortable?” Stubbs says.
In 2005, the year Appling went on hospice, about 25 percent of HCK’s patients did not meet eligibility requirements and an additional 25 percent were questionable and needed to be reviewed, according to Diana Alvarez, the company’s former director of program integrity.
When members of the medical staff wanted to discharge a patient for good health, hospice managers — whose pay was tied to enrollment — resisted, according to Brian Billings, a physician in McPherson, Kan., who worked for HCK from 2003 until 2007. Billings said he quit because the hospice wouldn’t discharge patients who “obviously” didn’t qualify. “There was a definite shift toward the bottom line,” he said.
Gerald Stout spent about a year in HCK hospice care ending in 2006, and is still alive more than five years later, said his daughter, Brenda Chastain. No one “ever said anything about dying” when he was admitted, Chastain said.
Eight months after Stout was admitted by HCK for Parkinson’s disease, medical reviewers noted in his chart that he’d gained weight, got around well with a walker and “was not appropriate” for hospice. He was discharged three months later. Medicare paid more than $34,000 for his hospice care.