Is Hospice a Drain?

Recently, The Washington Post ran a story investigating the increased use of hospice care. Its investigation found that the number of “hospice survivors” has increased greatly in the last few years. That is, people are put on hospice. Then they get better, and come off hospice. The Post’s story suggested that one reason this happens is that hospice firms have gotten better at recruiting patients, and that they have a motivation to recruit patients who aren’t quite dying yet. These sorts of patients need less care and stay on hospice longer. As the story’s headline put it, “Hospice firms draining billions from Medicare.” Of course, as a geriatrician doing house calls in the San Francisco Bay Area, I completely agree that it’s best when families can care for elders at the end of life. But I know from experience that this is just not possible for many families. Sometimes, adult children live far away. Other times, relatives simply do not have the resources—whether of money, of time, of expertise or of all three—to provide hospice care to their loved one.

Hospice care can be a great boon at the end of life. The popular perception is that “hospice” means “giving up.” Actually, patients on hospice—care that emphasizes alleviating symptoms rather than a cure—tend to live a bit longer than similar patients who don’t get hospice care.

While the Post’s investigation found an increase in patients enrolling in hospice too early, many patients enroll in hospice care too late, or not at all. For instance, only one-third of Medicare patients with a dementia diagnosis currently receive hospice care. And according to 2013 figures, the median number of days in hospice care was about 18.7 days.

What worries me is that our “fee-for-service” model of health care emphasizes profit incentives, there are just too many angles to squeeze. This hospice situation is just the latest.

A few years ago, it was nursing homes that were maximizing the number of Medicare dollars they could grab. Then the requirements tightened, and now almost none of my patients qualify for Medicare-paid nursing home care. I even had a patient who was refused nursing home care after a hip replacement, a situation in which a month or two of nursing home care would seem to be an obvious choice.

So now it’s hospice care that appears to be the profit center: The medical groups and hospitals have an incentive to release patients into hospice care. If a patient is put on hospice, they will not “bounce back” to the hospital for 30 days. In our current system, hospitals and medical groups make money from doing procedures, i.e. “fees for services.” They don’t make money taking care of patients in need of chronic care or recovery care, so they push those patients into hospice. And, apparently, many of these patients don’t die and “graduate” from hospice care.

I believe that the problem is not Obamacare, and it’s not Medicare. The problem is that we still seem to be too wedded to this “fee for service” model. It would make so much more sense if doctors, hospitals and medical groups were free to consider the need of the patient foremost. Everyone will tell you that that’s the case now, but the economic pressures in medicine are intense. Of course, hospitals and doctors want to care for patients but they also need to keep the lights on.

There are no great answers here, but it seems to me that a single payer medical system would avoid the kind of distortions like this spike in patients referred to hospice too early. In the meantime, I worry for the patients.

Elizabeth Landsverk, MD Specialist in Geriatrics

Board Certified in Geriatrics, Internal and Palliative Care Medicines. House calls throughout the San Francisco Bay Area


Right to Folly? Dealing with realities of suspected dementia

“If someone who is alert and aware makes a conscious choice to live in unclean, potentially dangerous conditions, as long as it doesn't affect others, they have the right to refuse help." That is correct. However, the devil is in the details. We, as a society, including doctors, lawyers, judges, and other professionals in elder care, often miss early dementia (the loss of executive function) where someone superficially sounds fine, or has a MMSE (Mini Mental State Examination) of 25 or knows time, place and self. They are too quickly judged competent and left to their own devices. I would STRONGLY advise that if elders sound fine but are acting in very concerning ways such as letting strangers into the house, giving money away and other unusual behaviors out of context of their usual behavior for the last many years, get Neuropsychological testing. That is the only way to see who really has “the right to folly" and who has early dementia with loss of judgment before loss of orientation or social skills.

Senior Scam Stopper Seminar September 29th

This is an event for seniors, their family members, and caregivers to attend a free fraud-prevention seminar on Monday, September 29, 2014, from 9-11 a.m. in South San Francisco. The event is being co-sponsored by the California Public Utilities Commission, in partnership with Assembly member Kevin Mullin and the Contractors State License Board. And, actually, as scam artists do not discriminate, all ages are welcome! Please pass on to any of your clients, patients, family members or families who may be interested. Be informed, be aware.Address: South San Francisco Municipal Services Building (Social Hall) 33 Arroyo Drive, South San Francisco. For more information and to RSVP please contact Assembly-member Mullin's office at 650-349-2200.



When things get plugged up

Woman with pillsOne of the most common problems I encounter doing my rounds of geriatric house calls is that elders’ bowels do not always move regularly. This may not sound very serious, but it is. Constipation may lead to an impacted bowel, a condition in which everything is so plugged up that it must be removed manually. If left too long, constipation may even lead to hospitalization. Many, many things may interfere with normal bowel function. But there’s one that consistently surprised clients in my practice: medication.

Here is a list of drugs and supplements that can cause constipation: • All narcotics: Codeine, Vicodin, Morphine. • Verapamil, a drug that treats high blood pressure, angina, and irregular heartbeat. • Diltiazem, used to treat high blood pressure and angina. • Anticholinergic drugs. These may be used to help breathing in patients who have “chronic obstructive pulmonary disease,” (COPD). They may also treat the tremors caused by Parkinson’s disease, or to treat muscle spasms, stomach cramps, or ulcers. They come under dozens of brand names. Ask your doctor if you’re unsure if your elder takes anticholinergics. • Detrol, Ditropan, Sanctura – medicines used for overactive bladder.

You can’t be healthy if your bowels don’t move. Don’t wait three to five days before taking action. If an elder has not had a bowel movement in two days, it’s time to start investigating, time to take action.

If an elder is not drinking enough fluids, a very common situation, Metamucil will just turn to concrete in the bowls. Try to get more fluids into your elder. Sugar-free candies, those made with sorbitol, have a laxative effect, and elders usually love them. You may also try Milk of Magnesia. If none of these approaches work, call your doctor.

Elizabeth Landsverk, M.D

ElderConsult Geriatric Medicine