CALIFORNIA AUDITOR’S REPORT SAYS STATE’S LACK OF CONTROLS HAS CREATED OPPORTUNITIES FOR “LARGE-SCALE FRAUD AND ABUSE”
- California’s Acting State Auditor, Michael S. Tilden, forwarded a letter and a complete report of the audit examining the State’s licensure and oversight of hospice provider agencies. The report cites lax oversight of hospices as leading to widespread fraud, especially within Los Angeles County. A moratorium was put on new hospice licenses that began on 1/1/22 and continues until one year after this report was made.
- The report, titled “California Hospice Licensure and Oversight, The State’s
Weak Oversight of Hospice Agencies Has Created Opportunities for Wide-Scale Fraud and Abuse,” was issued on 3/29/22. The report says the California Department of Public Health isn’t doing enough to oversee hospices, is not following up on complaints, and is missing many opportunities for offering better oversight. The report recognizes, as well, that legislative action is called for in order to adequately address the current problems and strengthen the State’s ability to move forward. The report also calls for greater collaboration between California Department of Public Health, the California Department of Health Care Services, DOJ and Social Services.
- Highlights of the findings include recognition of the tremendous growth of the number of hospices in Los Angeles county. Hospice agencies have increase by 1,500% since 2010. And, there are more than 6.5 times the average national number of hospices in Los Angeles County relative to the aged population in 2019. Another key indicator is the finding of “large-scale fraud,” likely due to “fraudulent billing to Medicare and Medi-Cal and the apparent use of stolen identities of medical personnel to obtain license.”
- The California Department of Public Health is inadequate in its oversight of hospice agencies, says the report. The “perfunctory hospice agency licensing process,” says the report, “does little to verify that personnel are qualified or prevent fraud.” Public Health doesn’t adequately monitor programs or protect patients. It fails to perform investigations in a timely manner. The report also says that Public Health, Health Care Services and the DOJ “have not comprehensively assessed fraud risks related to hospice agencies.”
- The report offers a comprehensive review of the “fraud indicators” found in Los Angeles County. These include a dramatic growth in the number of hospices, “excessive geographic clustering of hospices,” long hospice lengths-of stay, high numbers of live discharges, and hospices using “possibly stolen identities of medical professionals.”
- Overall, the report presents: A comprehensive overview of hospice; The broad scope of the issues related to fraud and abuse in California hospices; A through description of the problems in Los Angeles County; A review of the complaints that have been made to Public Health and DOJ in Los Angeles County; Key concerns, and a critique of the work of Public Health.
- After presenting an in-depth review of the problems, issues and concerns, the report turns to its conclusion and recommendations. Specific recommendation are made to the Legislature, and the DOJ. The report also addresses the role of Public Health. Recommendations to the Legislature are many, and they are focused on creating the environment where stricter standards can be created and enforced.
- Recommendations are clearly described and delineated within the report. The legislative recommendations include, specifically in Los Angeles County, the creation of a task force to immediately “identify, investigate, and prosecute fraud and abuse by hospices” in Los Angeles County. The work group, including the Legislature, Public Health, Health Care Services, DOJ, and Social Services, recommends the paper, should annually “conduct a risk assessment of the Medi-Cal hospice program statewide.”
- Legislative recommendations also include, among other items, that there be statutes that:
- Require fraud training for Public Health staff who license and certify hospice agencies.
- Require key individual hospice staff to submit electronic fingerprints and any criminal record to the DOJ.
- Name specific criminal convictions that may prohibit issuance of a hospice license.
- Require that future licensure of any hospice should require demonstrated need for hospice service within the area the hospice wants to serve.
- Require the gathering of financial information from any hospice within licensure application.
- Issue emergency regulations to guide Public Health while “maintaining the general moratorium on new hospice licenses.”
- Require Public Health to perform license renewal for each hospice within two years of the new regulations.
- Require ongoing licensure inspections every three years.
- Revise state law so that at least 5% of the deemed-status hospices are also audited annually. Create a “system of sanctions” and fines for hospice violations.
- Require that Public Health have to address complaints within a designated time, and train staff for skills in addressing complaints.
- DOJ recommendations call for the DOJ to provide guidance to Public Health “about the types of information Public Health should include when it refers complaints that allege fraud to DOJ.” Also, the report calls on DOJ to create a procedure for providing adequate information on follow up of complaints.
- The report includes written responses to these recommendations from the California DOJ, California Department of Health Care Services, and the California Department of Public Health. These letters of input are each then responded to, in writing, by the Acting State Auditor.
- The report concludes with a reminder of the responsibility of California “to ensure patient safety by ensuring that hospice agencies are qualified to provide services.” Because of Public Health’s
lax oversight,” says the report, hospices have too easily received licenses, and the conditions now call for immediate action. The Legislature should “require Public Health to issue emergency regulations that address key gaps in hospice licensing requirements, a much-needed step that Public Health has neglected to take for the past three decades.” Greater collaboration between Public Health, Health Care Services, DOJ, and Social Services, says the report, can enable better response to fraud and abuse, and better prevention ofc more of it.
The full report appears at the first link below in html and the second link in PDF. It includes the letters that state how agencies agree or disagree with the recommendations of the report. The third link includes a fact sheet with key findings and recommendations.(California Hospice Licensure and Oversight; 3/29, https://www.auditor.ca.gov/reports/2021-123/index.html#section1 (HTML), and https://www.auditor.ca.gov/pdfs/reports/2021-123.pdf (PDF); Fact Sheet, https://www.auditor.ca.gov/pdfs/factsheets/2021-123.pdf)
OREGON RESIDENCY NO LONGER A REQUIREMENT FOR MEDICALLY ASSISTED SUICIDE
- A lawsuit challenged Oregon’s medical assistance suicide law’s requirement that the assistance can only be given to Oregon residents. The settlement was filed in the U.S. District Court in Portland, where “the Oregon Health Authority and the Oregon Medical Board agreed to stop enforcing the residency requirement and to ask the Legislature to remove it from law.” All other components of the law, such as two requests from patients, with at least 15 days between the two requests, remain unchanged.
- The suit was filed by Compassion and Choices on behalf of a Portland physician, Dr. Nicholas Gideonse. Gideonse, who has patients in Oregon and also just across the Columbia River in Washington State, is a supporter of medical aid-in-dying. “The lawsuit argued that the residency requirement violated the U.S. Constitution’s Commerce Clause, which gives Congress the right to regulate interstate commerce, and the Privileges and Immunities Clause, which forbids states from discriminating against citizens from other states in favor of its own citizens.” Gideonse notes that no distinction is made for residency in all other areas of his medical practice, such as delivering babies.
- Those who supported the law hope the change in Oregon’s law will extend to the other states that offer medical aid in dying. Those states are California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Vermont, Washington state and Washington D.C. (NBC News, 3/28, https://www.nbcnews.com/news/us-news/oregon-ends-residency-rule-medically-assisted-suicide-rcna21932)
* CMS released the proposed 2023 hospice payment rule on March 30, proposing a 2.7% increase in the hospice per diem. The action “proposes a permanent, budget neutral approach to smooth year-to-year changes in the hospice wage index.” The update also shares the proposed cap amount for FY 2023 at $32.142.65. Hospice Outcome & Patient Evaluation (HOPE) receives an update as well. The HOPE tool will be replacing the Hospice Items Set (HIS) as a quality tool once the reporting system is ready. The proposal will be online in the Federal Register at the second link below. Comments are due by 5/31. (CMS, 3/30, https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2023-hospice-payment-rate-update-proposed-rule-cms-1773-p#:~:text=The%20hospice%20payment%20update%20includes,of%20%2431%2C297.61%20increased%20by%202.7%25; Federal Register, 4/4, https://www.federalregister.gov/documents/2022/04/04/2022-07030/medicare-program-fy-2023-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting)
* “Strategic Restructuring for the Future, Insights on Building a Hospice Network From the Ground Up: A Conversation with Mike Milward, CEO of the California Hospice Network,” is a podcast by Husch Blackwell as part of their Hospice Insights series. The podcast features attorney Meg Pekarske talking with Mike Milward, who shares from his own experience about creating and being a part of “an innovative network model in California.” The podcast is online at the link below. (Husch Blackwell, 3/30, https://www.huschblackwell.com/newsandinsights/strategic-restructuring-for-the-future-insights-on-building-a-hospice-network-from-the-ground-up-a-conversation-with-mike-milward-ceo-of-the-california-hospice-network)
* In ‘New York hospice providers hope for funding to offset costs of “Fair Pay for Home Care bill,” Spectrum New 1 shares about a bill before the Legislature in New York. The bill, if passed, would insure that home care workers would be paid at least 150% of the regional medium wage. “An unintended consequence,” says Jeanne Chirico, president and CEO of the Hospice and Palliative Care Association (HPCANYS), is that hospice workers are included in the bill, but not covered in provisions to reimburse hospice providers for these increases in staff pay if “Fair Pay” passes. Chirico has worked tirelessly to help legislators understand the situation. Assembly Health Committee Chairman Richard Gottfried said, in a written statement, “‘I have long supported expanding access to hospice. I support providing state funds to enable hospices to meet the Fair Pay level until Medicare adjusts its rate. As we work towards a budget agreement, I’m hopeful we can address this issue in any Fair Pay budget language.’” And this change is important, says Chirico, because, as is, “the costs to hospice providers would be about $40 million a year.” And while that cost is offset for other home health providers, it is not for hospice care. What HPCANYS is asking for is that funds be “put aside” to “help the hospice providers cover that expense.” Though there seems to be an understanding of the problem, Chirico warns that without action, the financial hit could put some smaller hospices out of business.” (Spectrum New 1, 4/2, https://spectrumlocalnews.com/nys/rochester/politics/2022/03/30/new-york-hospice-providers-hope-for-funding-to-offset-the-costs-of–fair-pay-for-home-care–bill)
PALLIATIVE CARE NOTE
* Though palliative care teams are numerous in cancer centers, these teams typically “see more hospitalized patients rather than clinic outpatients.” Several studies have shown that “early integrated palliative care delivered alongside curative care helps people live better and longer,” says Jonathan C. Yeh, researcher at Beth Deaconess Medical Center and Harvard Medical School. Yeh is an author of a study reported in the Journal of Clinical Oncology (JC)). Healio spoke with Yeh, who shared some of the insights of the study. Those patients who received outpatient palliative care had both shorter lengths of hospital stays and longer lengths of hospice stay. Patients receiving outpatient palliative care were found to have hospice stays of 46.5 days, and only 6% received intensive care at the end of life. Patients who received inpatient palliative care were found to have hospice stays of 27.1 days, and only 15% received intensive care at the end of life. Yeh says, “Despite all of these research studies, palliative care clinics and home-based programs remain severely underfunded in the United States.” (JCO, https://ascopubs.org/doi/full/10.1200/OP.21.00546; Healio, 3/29,
* “Spirituality in heart patients” appears in the Journal of American College of Cardiology: Heart Failure (JACC: Heart Failure). Numerous studies have explored the role of spirituality in cancer patients, but there has been “a relative paucity of studies” in heart failure. Studies “suggest that spirituality serves as a target to improve quality of life and patient outcomes in heart failure.” Clinical outcomes for addressing spirituality include a greater quality of life, improved medication adherence, and lowering of anxiety, depression, and rehospitalization. (JACC: Heart Failure, April 2022, https://www.jacc.org/doi/10.1016/j.jchf.2022.01.014
* “Preparing for your first end-of-life conversation as a resident” appears in MDLinx. The article offers tips and takeaways for physicians and residents who are new in having end of life conversations with patients. They call for planning and preparation before the conversation. Consider, they advise, what goals you have, who to include in the conversation, when and where to have the conversation, and a structure of the interaction. More experienced practitioners, says the article, include four elements: prepare, have “a conversational entry point,” adapt for the individual patient, and invite the family. The article elaborates on each of these points. (MDLinx, 3/23, https://www.mdlinx.com/article/preparing-for-your-first-end-of-life-conversation-as-a-resident/6kdyWXYcSaGuNchawyCHpf)
* Massachusetts is engaged in exploring physician-assisted dying. On March 31, Massachusetts’s Attorney General Healey said she believed the Legislature should set the rules around the topic, and felt this is a better approach than letting the court make the decision. The state Supreme Judicial Court did just hear a case that involved two Massachusetts’s physicians asking to be allowed to ”assist terminally ill patients who wanted to take lethal medication.” Healey says she believes she is ready to join other states in legalizing physician-assisted dying, and is open to working with other key stakeholders to consider changes. (WGBH, Boston Public Radio, 3/31, https://www.wgbh.org/news/politics/2022/03/31/healey-now-supports-a-terminally-ill-patients-right-to-die)
* Washington State Hospital Association is offering a free live webinar, “Recognizing Inequities in Serious Illness and End-of-Life Care.” The event is scheduled for 4/29. Registration and more details are online at the link below. (WSHA, 3/31, https://www.wsha.org/articles/webinar-recognizing-inequities-in-serious-illness-and-end-of-life-care/)
* A research study published in JAMA Health Forum reports significant growth in the number of older Americans dying with Alzheimer’s disease and related dementias (ADRD). The study explored a sample of 20% of the “fee-for-service decedents ”67 years or older from 2004 and 2017. “An ADRD diagnosis within the last 2 years of life was identified using diagnosis codes from inpatient, professional service, home health, or hospice claims, requiring the standard claims algorithm that required at least 1 claim and a more stringent algorithm that required at least 2 claims.” The research shows that, in 2004, 34.7% of these patients died with an ADRD diagnosis. But 2017, the number grew to 47.2%. Several factors that impacted this growth are shared in the study. (JAMA Health Forum, 4/1, https://jamanetwork.com/journals/jama-health-forum/fullarticle/2790757?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=040122)
* “Humor, Serious Illness, and End of Life: Using humor to lessen a person’s suffering” appears in Psychology Today. With “proper tact and timing” in using humor, says the article, it can relieve suffering of very ill patients. Humor is an important coping method, says the article. Author of the article, physician Kaja Perina, says humor can help create connection. “What humor allows,” says Perina, “is the reconnection of one’s suffering with their humanity and brings just a bit of temporary joy back into view It’s not a panacea, but it makes its mark. It’s a therapy that only we humans can share with other humans without needing any technology.” And for palliative care and hospice professionals, she adds, “Perhaps the one main ingredient that we bring to the table is connection.” (Psychology Today, 3/30, https://www.psychologytoday.com/us/blog/end-life-matters/202203/humor-serious-illness-and-end-life)
GRIEF AND ADVANCE CARE PLANNING NOTES
* In response to the American Psychiatric Association’s recently naming prolonged grief (longer than one year) as a mental health disorder, Devyn Greenberg wrote an article decrying that move. The opinion article, “Grief is love, not a mental disorder, published in Washington Post, shares Greenberg’s continuing grief over the loss of family members. She believes many of the symptoms the psychiatric association named for the new “disorder” are common experiences of grief. “If grief is love,” she asks, “why set expectations on its pace or texture? Why pathologize love?” (Washington Post, 4/1, https://www.washingtonpost.com/opinions/2022/04/01/grief-is-not-mental-disorder/)
* New York Times shares some of the responses it has received in response to the American Psychiatric Association’s recent announcement naming prolonged grief (longer than one year) as a mental health disorder. “Prolonged Grief: A Mental Disorder, or a Natural Process?” is a compilation of some of these letters, and most writers are “opposed to declaring it a disorder, arguing that it is stigmatizing.” The selected letters are online at the link below. The original article, “How Long Should It Take To Grieve? Psychiatry Has Come Up With an Answer,” has received over 1300 responses. The second link is to that article, and readers can link to the responses at the bottom of that article. (New York Times, 4/2, https://www.nytimes.com/2022/04/02/opinion/letters/grief-mental-disorder.html; https://www.nytimes.com/2022/03/18/health/prolonged-grief-disorder.html )
* End of Life University offers a podcast titled “Tools for Caregivers To Manage Stress and Increase Joy.” Roger Moore, a certified hypnotherapist and author, is the featured guest. The podcast is online at the link below. (End of Life University, 3/28, https://eolupodcast.com/2022/03/28/ep-344-tools-for-caregivers-to-manage-stress-and-increase-joy-with-roger-moore/?mc_cid=5b684133d7&mc_eid=d0771da91c)