A state inspector in Missouri documented the grim details: a deep, poorly treated pressure wound on the patient’s tailbone, apparent pain that caused grimacing and — in a crisis requiring a trip to the emergency room — a “maggot infestation’’ where the feeding tube entered his abdomen.
The official cited Vitas Healthcare, the nation’s largest hospice chain, for putting the patient in “immediate jeopardy,” the most severe category of violation. The inspector found that Vitas staffers had skipped home visits and failed to assess the amount of pain the patient endured.
The case is among the most severe of a dozen examples of patient suffering cited in a strongly worded inspector-general report on the hospice industry released Tuesday. The report takes Medicare to task for what it describes as weak oversight and enforcement of the growing ranks of hospice providers and recommends stronger safeguards “to protect Medicare hospice beneficiaries from harm.’’
The report, by the Office of Inspector General for the Department of Health and Human Services, withheld information about the individual hospice providers and the states where the examples of harm occurred. Vitas Healthcare, which did not comment on the case, is not named in the inspector general’s report. The Washington Post identified the 2016 Missouri case by reviewing state inspection records and matching them to the specific circumstances described by the inspector general.
According to the Missouri inspection documents, the patient had been living at home under hospice care for more than 18 months when the discovery of “maggots around the opening of his wound” triggered an urgent call by the family in the middle of the night.
The patient was taken to a hospital for removal of the pests and stayed there for two days. One reason the patient was in hospice care was to avoid unnecessary pain and trauma associated with hospitalizations, the Missouri report said. In a “plan of correction” included in the Missouri documents, Vitas neither disputed nor agreed with the state inspector’s findings. It outlined steps it would take to improve supervision and assessment of patients.
Other dire cases listed by the inspector general included a patient whose pressure ulcers developed gangrene, resulting in an amputation; a patient whose injuries from an apparent sexual assault were missed and discovered only at a hospital; and another who did not receive appropriate medication and died in pain.
Despite the seriousness of the harm, the hospices in each of the dozen cases did not face serious consequences — largely because Medicare has few disciplinary tools at its disposal, the inspector general said.
“When hospices do not fulfill their obligations, there can be real human costs,” Nancy Harrison, deputy regional HHS inspector general, said in an interview. Medicare, she said, “needs to hold hospices accountable.”
While the report describes a poorly regulated hospice system, it also found that Medicare gives consumers limited options to screen for quality on their own or lodge complaints.
A Post investigation in 2014 documented patient hazards and industry financial abuses. Although improvements have been made since then — including the national Hospice Compare consumer website launched in 2017 — the gaps in enforcement and quality appear large, according to the report.
Medicare pays for most hospice care in the United States, with billings reaching $18 billion in 2017, double the amount a decade ago. The number of hospices has risen to around 4,500.
But Medicare’s oversight of hospice is not as strong as its oversight of nursing homes.
The frequency of hospice inspections by state or private accreditation agencies increased from once every six years to once every three years in 2018. About 300 hospice providers, or nearly 20 percent of all hospices inspected in 2016, had a serious deficiency or a substantiated severe complaint, making them “poor performers,’’ the report said.
There are few requirements for hospice companies to alert Medicare when they detect violations. And when problems are discovered, Medicare has limited tools to discipline providers for neglecting or harming patients, even in cases of “immediate jeopardy.”
Other than removing them from the Medicare program, a step that is very rarely taken, Medicare has no ability to levy fines or other sanctions on poorly performing hospice providers, the report said.
It also found fault with Medicare’s Web portal, Hospice Compare, which is supposed to help patients and families shop for hospice providers based on quality and other metrics. But Hospice Compare does not list hospice provider deficiencies or state inspection results.
“We live in a time when we don’t even think about going to a restaurant without checking its reviews. Why do we demand less from hospices?’’ Harrison said. “The information is already collected. We just need to make that extra step and make it publicly available in a way that patients can understand.’’
The Missouri case provides an example of the gap. A Post review showed that someone checking Hospice Compare would see that the Vitas Healthcare office in St. Louis responsible for the patient with a maggot infestation has a 96.4 percent quality rating, 11 percentage points above the national average. Nothing is mentioned about the “immediate jeopardy” finding or other serious deficiencies cited by inspectors.
The Centers for Medicare and Medicaid Services (CMS), which is in charge of Medicare, said it has taken steps to improve Hospice Compare, including adding information from consumer surveys.
It said it is prohibited by law from posting inspection reports by private accreditation agencies and has told the inspector general previously that it would be “misleading” to post state inspection reports alone. CMS has asked Congress in its budget for authority to post accreditation agency reports.
“CMS has zero tolerance for abuse and mistreatment of any patient, and CMS requires that every Medicare-certified hospice meet basic federal health and safety standards to keep patients safe,” the agency said in response to the inspector general’s report. It called the inspector general’s individual findings of patient harm a “selective sample” of cases found between 2012 and 2016.
In the example of the maggots in the patient’s feeding tube, the local Vitas Healthcare provider was put on a track to be terminated as a Medicare provider, but it corrected its deficiencies before that step was taken, CMS said.
“CMS does not have the statutory authority to impose remedies, such as fines, on hospices,” the agency said. “Additionally, CMS cannot close any facility.”
The hospice industry trade group in Washington, the National Hospice and Palliative Care Organization, which had not seen the report as of Monday, said it supports accountability and transparency in hospice. It pointed out that it supportedincreasing oversight, including raising in inspection frequency to once every three years. “However, NHPCO continues to stress that outliers in the field do not adequately reflect the vast majority of hospice care provision in the U.S.,” Edo Banach, the organization’s president, said in a statement.
Congress told Medicare to begin reimbursing for hospice in 1982. Since then, the practice ofhospice has steadily become mainstream, routinely serving patients with dementia and other ailments of the elderly, and has attracted for-profit investment and chain ownership.
“At the first meetings of our national hospice organization, we were nearly all women, mostly volunteers working on making our communities better,’’ said Joanne Lynn, a hospice physician and director of the program to improve elder care at Altarum, a nonprofit health-care consulting organization. “Once Medicare started paying for hospice, it was more men in suits, and the focus shifted to administration and sustainable financing.’’
Most hospice care continues to be delivered at home or in a nursing home, with routine visits by nurses and aides, but companies also run inpatient hospice facilities. The focus remains the same: comfort and palliative care, including pain medications, in a patient’s final months of life.
To qualify for hospice coverage under Medicare, a patient must be terminally ill with a prognosis of living less than six months. But as increased numbers of patients with Alzheimer’s disease and other forms of dementia enter hospice, many are living far longer than six months. Their Medicare coverage continues.
“You increasingly have diagnoses of dementia, patients who are dying at home, but their life expectancy is extremely difficult to estimate,” said Melissa D. Aldridge, a professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai, in New York.
Meanwhile, Medicare pays providers the same amount for each day a patient is in hospice — around $200 each day for the first 60 days and about $150 each day after 60 days — without regard to how much care is provided.
“They’re paying for a day of hospice with no accountability for what was done on that day. How is Medicare going to oversee that?’’ Aldridge said. She estimated two-thirds of providers are now for-profit, “with a payment mechanism that is completely opaque as to what is being done.’’
While Hospice Compare does not list any documented problems at hospices, Missouri and Alabama are examples of two states that list complaints and link to full inspection reports.
“We want to be as transparent as we can,” said Dean A. Linneman, director of regulation and licensure for Missouri’s Department of Health and Senior Services. “The intent is for families seeking a good place for their relatives to view reports, and it’s not too far-fetched to believe that is a good learning tool for others in the industry.’’