The Washington PostDemocracy Dies in Darkness

How tens of thousands of patients who weren’t actually dying wound up on hospice care

Kim Davis kisses her husband Mark Davis at a hospice care facility in Virginia Beach, Va. (Jay Westcott/For The Washington Post)

Hospice patients are expected to die. The service, after all, is intended for the terminally ill.

But over the past decade, as a 2014 Washington Post investigation found, the number of patients who outlived hospice care in the United States has risen dramatically, in part because hospice companies earn more by recruiting patients who aren’t actually dying.

Now government inspectors have turned up information about how that happens.

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.

In their investigation, government inspectors reviewed a random sample of the documentation that patients sign to indicate they want hospice care. In many cases, the patient was not informed that electing hospice meant that they intended to forgo a cure for their terminal illness — a critical distinction between hospice care and other health services. Hospices instead provide "palliative care"- that is,  care focused on the prevention and alleviation of suffering.

"When people elect hospice care they are forgoing curative care - and it's important for them to know that," Nancy Harrison, one of the investigators, said in a interview.

Moreover, in about 14 percent of cases reviewed, the physician who is supposed to approve the enrollment of a patient in hospice care paid only cursory attention to the matter. They provided scant information about the patient's prognosis, and "appeared to have limited involvement  in determining that the [patient] was appropriate for hospice care," according to the report.

The trend is "alarming" said Jodi Nudelman, who also worked on the report.

Medicare, the government insurer, pays for the vast majority of hospice care in the U.S. In 2013, it paid $15.1 billion for hospice services covering 1.3 million people. The federal government in recent years has sought to recover more than $1 billion from hospices that, according to attorneys, illegally billed Medicare for patients who weren’t near death.

Patients who aren't near death are more profitable because they typically require fewer services. Hospices are paid a flat daily rate for hospice patients.

The Office of Inspector General at HHS "has investigated and is investigating hundreds of hospice fraud schemes,” a spokesman said.

The report follows a 2014 series in The Post, "Business of Dying," that examined how hospice care, which had begun as service provided by nonprofit groups, had changed as businesses began to provide the service.

The series reported that at hundreds of U.S. hospices, more than one in three patients are dropping the service before dying, a sign of trouble in an industry supposed to care for patients until death.

When that many patients are leaving a hospice alive, experts said, the hospices are likely to be either driving them away with inadequate care or enrolling patients who aren’t really dying in order to pad their profits.

It is normal for a hospice to release a small portion of patients before death — about 15 percent has been typical, often because a patient’s health unexpectedly improves. But research showed that at some hospices, and particularly at new, for-profit companies, the rate of patients leaving hospice care alive is double that level or more.

The number of “hospice survivors” was especially high in two states: in Mississippi, where 41 percent of hospice patients were discharged alive, and Alabama, where 35 percent were.

The new findings by the government inspectors are part of a larger body of work by the government that, in the inspectors words, reveals "numerous vulnerabilities" and raises serious questions "as to whether Medicare is paying appropriately for hospice."