Update on in home dialysis

G and I went back to the dialysis center for a appointment. G will go every week for the next few weeks, so they can draw blood to make sure the dialysis is working. Also, they watch him
do an exchange to make sure he is following procedures.

He did well on his following procedures, so that is good. We did find out that he should
not be using the fluid with the highest dextrose concentration all the time, which he has been using. It takes off more fluid, but we were informed overuse can damage the lining of the peritoneum, causing scaring, and therefore causing problems with the exchange, which happens through the peritoneum membrane.

G is still having some trouble getting enough fluid out. I'll write about that some more later.

The good news is he is looking less swollen, so think we are least pretty much back to where he was after starting hemodialysis.

Another article about Hospice

Here is another article from Bloomberg about Hospice care gone awry.

Very scary.

Hospice Turns Months-to-Live Patient Into Addict

Suffering from painful nerve damage in his feet, Charles Groomes was prescribed a daily dose of 205 milligrams of Oxycontin and oxycodone in 2007. His doctor wrote that it was the most he was comfortable prescribing -- more, he said, than anyone without cancer should take.

After he was admitted to hospice care 11 months later, his painkillers were eventually increased to 2,880 milligrams, 14 times the pre-hospice levels. The hospice doctor forecast he had six months to live at most. He was wrong.

Groomes was discharged from Horizons Hospice LLC in Pittsburgh last year after 32 months. The legacy of the stay was debilitating, according to his family and doctors who examined him. He was depressed, addicted to narcotics and desperate. He turned to four doctors and three hospices begging for more drugs.

“This is a hospice case that spiraled out of control,” said Aaron Smuckler, one of the doctors who saw him. Groomes, who had a history of drug abuse, “clearly wasn’t dying” when he was on hospice; he needed drug rehabilitation and cardiac care, not more narcotics, Smuckler said.

Mary Stewart, Horizons Hospice’s director of operations, declined to comment on Groomes’s care and didn’t respond to a list of detailed questions.

Groomes died in his sleep at the age of 52 last August, 10 months after Horizons released him. It was also more than five years after he was first told he had six months to live -- in an earlier hospice admission in 2006.

Surviving Hospice

His story shows how lax admissions practices combined with narcotics dispensing may add up to harmful side effects for hospice patients, especially among those who survive their stays. About 1.1 million people are enrolled in hospice care.

Although hospices are supposed to enroll only people who they believe will be dead within 180 days, they often miss the mark. About 21 percent of patients stay longer, the U.S. inspector general responsible for Medicare reported in July, and more than 200,000 are discharged alive each year. Some providers are boosting revenue by flouting eligibility rules, federal prosecutors say.

At the same time, the use of narcotics is central to the mission of hospice care, which is to ease the pain of dying patients.

“It’s the exceptional hospice patient who doesn’t see any opioids,” said Mark Sullivan, a psychiatrist at the University of Washington in Seattle, referring to the powerful class of narcotics that includes morphine, Oxycontin and oxycodone.

Hospice Drug Addiction

Drug addiction among those who leave hospices has become more common in recent years, according to Walter Ling, a professor of psychiatry and director of the substance abuse program at the University of California at Los Angeles. “Everybody who works in the drug rehabilitation field finds these hospice cases,” Ling said.

“Hospices over-prescribe narcotics to patients who aren’t in extreme pain,” said Jane Orient a physician and professor at the Oregon Institute of Science and Medicine in Cave Junction, Oregon. She said her family removed her father from an in- patient hospice when it gave him morphine he didn’t need.

The discharge of 200,000 hospice patients raises the question of whether they were really dying in the first place, said Robert Berenson, a fellow at the Urban Institute and the vice chairman of Medpac, an advisory commission to Congress on health-care policy.

Potential for Neglect

“The potential for hospices to neglect these people, and then abandon them when they don’t decline, is a major quality challenge,” Berenson said. Told of the details of Groomes’s case, he said it “may be the tip of a very big iceberg.”

It’s “wrong” to assume that everyone who survives hospice was inappropriately admitted, said Jon Radulovic, a spokesman for the National Hospice and Palliative Care Organization, an industry trade group.

Some patients are truly dying when they are enrolled, but “respond very favorably” to care and become “somewhat better,” Radulovic said. Other patients leave hospice because they move away or defy their doctors’ expectations. Opioids are “prevalent” in hospice care because they tend to be inexpensive and highly effective in treating pain, he said.

More than half of hospice patients receive their care at home, as Groomes did. Most others are at nursing homes or hospitals. Nurses and hospice staffers visit an average of once a day, research shows. Doctor visits are rarer -- once every 100 days or so, according to Medicare billing records.

‘Caged Up’

Groomes’s wife and two of their four daughters say they saw Oliver Herndon, his hospice doctor, fewer than five times in the almost three years Charles was last on hospice. Months would go by when they didn’t see a nurse or home-health aide, either, they said.

“They told him to stay in bed, relax,” said his daughter Ashley, 17. “They kept him caged up in his room like an animal, waiting for him to die.”

Herndon, through his lawyer, declined to comment or answer questions about Groomes’s care.

Based on average daily reimbursement rates, Groomes’s two- year stay at Horizons cost Medicare an estimated $100,000. Medicare also paid for eight months at the beginning of his stay at a now-defunct hospice where Herndon worked, which transferred him to Horizons.

What happens to hospice survivors like Groomes, after months or years of giving up curative care, has never been comprehensively studied, said Russell Portenoy, chief of pain medicine at Beth Israel Medical Center in New York. “This is a study that begs to be done,” he said.

For-Profit Discharges

The rate of live discharges is highest at for-profit hospices, whose rapid growth in the past decade quadrupled Medicare’s hospice bill between 2000 and 2010, to $13 billion a year. More than one in five patients at for-profits are discharged, compared with about one in eight at nonprofits, according to a Harvard University study published this year.

For-profits also keep hospice patients longer -- an average of 98 days versus 68 days at nonprofits. Under Medicare rules, people can stay on hospice indefinitely, as long as a hospice doctor recertifies, every 60 days, that they have a prognosis of six months or less to live.

“The long lengths of stay and high rates of live discharges suggest some hospices are signing up people who don’t belong in hospice,” said Nancy Kane, a professor of health policy at Harvard and a former member of Medpac. “Any time there is money to be made, and you have this nebulous, gray area around ‘who is terminal,’ you get manipulation by some providers.”

Boat Captain’s Story

Robert Spain Jr., an unemployed boat captain, said his 10- month stay in hospice care turned him into an addict. Spain was admitted to a Vitas Healthcare (CHE) hospice in Jupiter, Florida, at the age of 56 in 2008, and diagnosed with terminal cirrhosis, his medical records show. He acknowledges a prior history of drug abuse.

Vitas, a unit of Chemed Corp. that is the nation’s largest hospice operator, put Spain on 240 milligrams a day of morphine, according to the records. That was stronger stuff than he had ever been prescribed before, he said, and after a few months he was feeling better and was puzzled why anyone thought he was dying.

When he asked for tests, Vitas ordered a sonogram, “reversed” Spain’s diagnosis to gallstones, and discharged him in January 2009. Still jobless and living with his 86-year-old dad, Spain said Vitas did nothing to help him get off the narcotics. He still takes 180 milligrams a day of morphine prescribed by a pain doctor.

Bar Bouncer

Spain was admitted appropriately to hospice and discharged when he was no longer eligible, said Kal Mistry, Vitas’s spokeswoman. Vitas “referred him to an appropriate care intervention clinic” before discharge, she said.

Groomes met his wife, Donna, while he was working as a bouncer for a bar in their hometown, Penn Hills, Pennsylvania. He spent most of his career working for his father’s business, servicing fire extinguishers and indoor sprinkler systems, said his daughter Austi, who is 22.

When she was a child he’d leave at dawn and return after 8 in the evening. The kids went to summer camp and every year Charles would pack the family in the station wagon for a beach trip to the Jersey Shore or the Carolinas.

Groomes’s wife said she and her husband started using cocaine in 1996, when some childhood friends re-entered their lives and smoked crack with them. Both parents became abusers, according to Donna and Austi, and things got rough. There were arguments about drugs. At times, the daughters were placed in foster care, Austi said.

Heart Disease

In 2005, after years of heart disease, Groomes had a defibrillator implanted in his chest to prevent cardiac arrest. The next month an echocardiogram showed his heart’s ejection fraction was 15 percent, meaning it was pumping blood at a dangerously low rate. A normal ejection fraction exceeds 55 percent.

In a hospital in September that year, Groomes tested positive for cocaine, twice. He wasn’t a model patient. He was getting morphine “off the streets” and ignoring prescribed dosages, according to his cardiologist’s notes.

By February 2006, Groomes had enrolled in the now-defunct Trinity Hospice, where he became a patient of Herndon’s, said Leslie Custer, Groomes’s nurse there. He withdrew from the hospice in mid-2006 to explore a possible heart transplant.

Heart Strengthens

While doctors told Groomes he wasn’t a transplant candidate, his heart was strengthening on its own. A test in August 2006 revealed normal cardiac output, according to his records. An echocardiogram in December 2006 showed an ejection fraction of 35 percent to 40 percent, more than double the rate 15 months earlier.

Groomes also had severe pain in his feet, which doctors diagnosed as diabetic neuropathy, or nerve damage. By March 2007, he was receiving Oxycontin and oxycodone via Albert Carvelli, the doctor at the University of Pittsburgh Medical Center whose notes described the dosages as the maximum he felt comfortable with.

Even so, Groomes started running short of pain pills and began asking Carvelli for more before his prescriptions were due to run out, according to the doctor’s notes. After that happened five visits in a row, Carvelli’s notes from February 2008 say he told Groomes he needed to find another doctor or “we will start to slowly wean him off his opioid” habit.

Back on Hospice

The next day, Groomes was re-admitted to Trinity Hospice, with a terminal diagnosis of congestive heart failure. Herndon, acting as the hospice medical director and Groomes’s attending physician, tripled Groomes’s prescriptions for oxycodone and Oxycontin, to a maximum dose of 600 milligrams a day, according to Groomes’s medical records. Later, Herndon prescribed an additional 1,680 milligrams a day of liquid morphine and oxycodone for “breakthrough” pain, plus a 100-microgram patch of Fentanyl, a potent narcotic, every 72 hours.

When Trinity shut down in late 2008 -- after the U.S. Justice Department said it found evidence of “substantial” Medicare losses from ineligible hospice admissions -- Herndon took his patients to Horizons Hospice of Altoona, Pennsylvania, according to Susan Seman, who was director of operations for Trinity’s Pittsburgh office.

On Groomes’s hospice certification at Horizons, signed by Herndon, the doctor wrote Groomes had a cardiac ejection fraction of 10 percent, which hadn’t been the case since 2005, according to the echocardiogram results in Groomes’s medical records. An ejection fraction of less than 20 percent is a Medicare criterion for hospice eligibility.

Hospice Extensions

Herndon noted the 10 percent ejection fraction in re- certifications to extend Groomes’s stay that he signed as Horizons’ medical director in 2010, copies of the documents show. Herndon also cited other eligibility criteria, noting that Groomes was bedbound and had chest pains and shortness of breath after minimal exertion.

Groomes, 6-foot-6 (1.98 meters) and more than 300 pounds (140 kilograms), was virtually an invalid after his re-admission to hospice, deadened by drugs and terrified he’d keel over and die if he left his bedroom, according to Donna, Austi and Ashley. Groomes had gone on federal disability in 2004 for his heart and pain conditions, Donna said.

He felt “worthless” for lying there, but the hospice prognosis that he was dying destroyed his will to go on, she said. In a “good-bye” video the hospice encouraged Groomes to make, he sobbed uncontrollably and could hardly speak.

Donna didn’t leave her husband’s bedside, even as their daughters “ran wild,” she said. Boyfriends came and went, and the four girls had six babies in their teen years. Three were born when their mothers were 16.

Medicare Coverage Expires

Three of the daughters developed their own addictions, Donna said, and two have had scrapes with the law, including Autumn, 25, now in jail for drunk driving.

Groomes told a Horizons counselor that one of his biggest worries was that Donna would relapse and use cocaine again after his death. Donna said in an interview that she has been clean for seven years.

After more than two years waiting to die, Groomes received a letter from Horizons saying his hospice coverage from Medicare was ending. His hospice nurse said he was being discharged because he wasn’t declining, Donna said. The family was told to find a new doctor.

She and Austi begged Herndon’s office to keep Groomes as a patient so the doctor could keep prescribing. His dependence on drugs was so severe, they said, they feared a harmful withdrawal without them. When the doctor’s assistants hung up on them, Donna and Austi decamped to Herndon’s office to plead their case, only to be told the doctor wasn’t around, Austi said.

Search for Medicine

“He had my dad on all those things, then basically shut him off,” said Austi, who has an associate’s degree in criminal justice and is unemployed. “He helped kill him.”

As Groomes’s medications were running out, Donna scrambled on the Internet to find a doctor or hospice to take him on. Hope Hospice, a Pittsburgh nonprofit, referred her to Smuckler at the University of Pittsburgh Medical Center for an evaluation. Smuckler made an 80-minute house call.

Groomes’s bedside table was strewn with pill bottles, while his physical exam “was not consistent with someone who had such a terrible cardiomyopathy,” Smuckler said, referring to the heart muscle weakening. “He hadn’t had a primary-care physician in four years. I wanted proof he had the conditions he had.”

‘Not Terminal’

Blood tests showed his diabetes was well controlled and other functions appeared normal, Smuckler said, “certainly not the kinds of results you’d expect from a hospice patient.” Smuckler referred Groomes to a cardiologist for tests, lowered his narcotic dosage and recommended methadone to help taper off the opioids.

After examining Groomes, cardiologist Jeff Krackow wrote in a report that he may be bedbound “by his own choice” which has made him “severely deconditioned” yet had no “compelling indication for hospice,” and proposed re-evaluating him for a heart transplant.

The cardiologist also suggested reactivating Groomes’s defibrillator. Herndon and Horizon never had it turned back on after it malfunctioned and shocked Groomes 15 times on a single day in 2009, his hospice records show.

A workup in January this year confirmed what Smuckler and Krackow had surmised: Groomes’s heart was fine. The ejection fraction was 65 percent.

“He absolutely did not have a terminal diagnosis,” Smuckler said.

Pattern Repeats

The next problem was returning Groomes to the living. Groomes and his wife resisted Smuckler’s suggestions to try physical and occupational therapy. They demanded more narcotics, and after Groomes twice ran short of pills ahead of schedule, Smuckler told the couple they’d have to see a pain clinic for more.

“She infantilized him,” Smuckler said. “Every time he twitched, she would medicate it.”

The pattern kept repeating in the next eight months. Groomes went to a pain doctor, a neurologist, several emergency rooms and two more hospices, seeking narcotics that he said he needed for intractable pain. The question all of them asked, Donna said, was how such a young man ever got to this point.

“No one qualified in palliative care should have ever allowed Mr. Groomes to come back on hospice in 2008,” said Cristen Krebs, executive director of the Catholic Hospice of Pittsburgh, who evaluated Groomes for hospice and reviewed his medical records. “If he had terminal heart failure in 2006, what was he doing standing there in front of them in 2008? His cardiac status had improved, but they neglected to find out.”

Hope Runs Out

By August, Groomes lost hope, said his wife and daughters. None of the doctors or hospices they’d seen would refill the prescriptions Herndon wrote during 32 months in hospice. Groomes prayed on the side of his bed to die, Ashley said. He told Donna to “let him go,” she said. She urged him to hold on for a group of specialists due at the house Aug. 16 for a patient evaluation.

The team from Family Hospice & Palliative Care, led by physician MaryBeth Salama, spent 90 minutes examining Groomes and reviewing his health history. They told Groomes he wasn’t dying, so he couldn’t go back on hospice, according to Donna. The bad news was he needed to learn to live with his pain.

Groomes died that night in his sleep. While his death certificate says heart failure, Donna said she believes he may have swallowed a bottle of 80-milligram Oxycontin pills that went missing. There was no autopsy.

“The doctors failed us something terrible,” she said. “This family went down in a whirlwind.”

To contact the reporter responsible for this story: Peter Waldman in San Francisco at pwaldman@bloomberg.net

To contact the editor responsible for this story: Gary Putka at gputka@bloomberg.net

Learning Home Dialysis

G is at this moment doing his 3rd exchange at home.

This morning he forgot to put a clamp on the line to the bag which collects the fluid (from
his stomach), and as there is a "Y" which allows fluid to go from the full bag to the empty
bag, one must put a clamp on the line.

He forgot, and all the new fluid went straight to the empty collection bag, instead of
into his abdomen. But, he just had to get a new bag and try it again.
There is a check list of about 30 steps for the entire procedure, and it's easy to get
confused. Of course like anything, practice, practice, practice.

We think in a few weeks he will be able to go on what is called "the cycler".
It is a machine which pumps the fluid in and out at night while you sleep.
It needs to run about 10 hours, so that will be perfect. G might have
to do 1 exchange during the day, but that would be all. It would give him
much more freedom, and be less work.

Good news...finally

Well, we finally caught a break today.

After a slow start, with some "gunk" coming through the line, the catheter started
flowing well, and the nurse was able to put in and get out a lot of the fluid for
dialysis.

While waiting for the fluid to work (min. 2 hours) we went through training.

G, being G, got 100% on all the quizzes. So even though yesterday was a slow
start, we made up for it today.

Tomorrow we will take some supplies home, so by Sat. G will be doing the dialysis
at home himself. He has been able to do everything for the dialysis, which entails
a lot of very specific steps to avoid contamination. It is SO important to keep
the catheter from getting infected, and G is taking this very seriously, which
I really appreciate.

The majority of the supplies will be delivered directly to our house, or if we are
traveling for more than a few days, we can get them delivered to wherever we
will be.

So, looks like we finally caught a break.

G will go to the dialysis center 2 times a month so they can run tests to see if
he is getting proper dialysis, and also give him Epogen shots which he will need
for production of hemoglobin.

PD catheter exposed - not working well

Yesterday after dialysis G went to have the PD catheter "exposed".

The resident had a little difficulty as it didn't want to come out. Of course, it has been buried
for 2 months, so it probably got a little "attached" (lol).

The Dr. asked us "will they flush out the catheter tomorrow?", and we replied "we don't know...".
It always amazes me that we get asked questions like this...but then it makes me mad that I DON'T know.....because usually I am quite prepared.

So today we went for the PD training. The catheter wouldn't run, so she put some saline in it as there was blood in the catheter line (you could see it), then she tried it some more.

To do the PD dialysis you put fluid into the stomach cavity through the catheter, leave it for a while, and then drain it out. The tech managed to get about 50 cc's in, some drained out, then it stopped.

There are a few possibilities for this problem. In my opinion the most likely one mentioned is that the end of the catheter in the abdomen got twisted and is pointed upward. This would explain why some of the fluid drained out but not all.

There are a couple more possibilities. Anyway, we were sent home with instructions for G to take laxatives, as one of the other possibilities is there is too much pressure on the catheter from the intestines being full. I doubt this is the problem, but it's the easiest one to try and fix.

We will go back tomorrow morning. If it's still not working then they will X-ray it to see if the catheter is in the wrong position.

I am not really surprised by all this. With G, nothing ever goes as it should.

At least the good news is we didn't get the snow and sleet they predicted, so driving around
wasn't that bad.

Quick Update

G's catheter was coming out yesterday morning when they started to hook him up for dialysis.

So he had to go to the "access center". We had to wait because they had to work him in,
so we were there from about 11:30 until 2:30. They managed to put another catheter
in the same spot, then he went back for dialysis from 3:00 until 6:30.

G will go Monday to have the PD catheter "exposed", and start classes on Tuesday, so he can do home dialysis. Classes are Tuesday through Friday, and hopefully he will be good to go.
The dialysis company called back and said they would figure out some way to work
him in to the classes next week.

G's hearing in his right ear is better. He went to the Ear Nose and Throat Dr. last week, they
said it might only be temporary, and to come back in 3 months. They had given him steroids,
which appeared to do the trick, but I don't really understand why it might only be temporary.

His eyesight is so much better. He can now read things on the computer.

They released him from Occupational Therapy, but he will continue Physical Therapy. He is set up for 4 weeks, 2 days a week , in Jan. for P/T.

Because of the change in his dialysis catheter, he is not suppose to get up and down much, so he will have to again take it easy. He had been getting up and down to get things for himself from the kitchen, but I guess I get to play waitress again for a while.

Classes for home dialysis

I guess I have mentioned before that G has never been happy with his renal Dr. at the dialysis center.

It started when he had all his tests and paperwork done to get on the kidney transplant list. He had an appointment
with her and thought she would review everything and refer him to get on the list. Instead, her reply was "I don't have time to look at all of that now".....

And then, 3 months later he had his stroke, and well, she continued to show her ineptitude
since then.

Anyway, he has wanted to change Drs., but has not yet managed to do so. I suspect it will be difficult to
do staying with the same dialysis company, because you know how Drs. are, they don't like to step on
each other's toes.

But, the dialysis place phoned last week and said they wouldn't have any classes available for G to start training
for home dialysis until Jan. I whined and complained, and said how high risk he was because his catheter doesn't always run well. She said "let me see what I can do", but so far no good ideas.

This gave me a good reason to check out the other dialysis company in town. G will have to get an appointment with a Dr. at that company before they can write the order, and the office was closed Friday afternoon.

So Monday morning we shall see if he can get an appointment with this other group, and they can do training
the week of Christmas. It's not as early as we would like, but I think it is just a good time to move to this other company.


End result is G won't be able to start home dialysis until after Christmas.
We will also have to reschedule a couple of Drs. appointments. G has so many it's difficult to work around
sometimes.

Such is life.

Article on Hospice Care

I just happened to read this article on Bloomberg News, and it reinforced what I had learned about too many of the hospice agencies. Not all of course.

Also, the hospital bill for the 2 1/2 weeks G was in the hospital was $130,000.00.

No wonder Medicare costs are so high.


From Bloomberg News

By Peter Waldman - Dec 5, 2011 11:01 PM CT

Janet Stubbs was grateful when the nursing home recommended hospice care for her aunt Midge. Although Stubbs knew her aunt wasn’t dying, the offer of free, Medicare-paid hospice visits from a nurse and chaplain, plus an extra weekly bath, was too good to pass up.

Stubbs didn’t know that her aunt, Doris Midge Appling, was admitted to Hospice Care of Kansas during the company’s “Summer Sizzle” promotion drive, which paid employees as much as $100 a head for referrals, according to the U.S. Department of Justice. Stubbs also said she had no clue that the nursing home doctor who referred her aunt for hospice moonlighted as medical director for the hospice company.

“It doesn’t seem right,” said Stubbs, who had Appling’s power of attorney to make medical decisions. “What incentive did the doctor have to put my aunt on hospice? How much was she being paid?”

Harden Healthcare LLC, the hospice’s current owner, said medical directors received no incentive pay. Appling’s doctor, Donna Ewy, didn’t return four calls seeking comment.

Hospice care, once chiefly a charitable cause, has become a growth industry, with $14 billion in revenues, 1,800 for-profit providers and a base of Medicare-covered patients that doubled to 1.1 million from 2000 to 2009.

Compensation based on enrollment numbers, pay to nursing- home doctors who double as hospice medical directors, and gifts to the nursing facilities have helped fuel the boom, according to an examination of 1,000 pages of court documents and interviews with more than 45 current and former hospice employees, patients and family members.

KKR Buys In

“They wanted us to admit, admit, admit,” said Joyce White, a former marketer for Vitas Healthcare, a Chemed Corp. (CHE) unit that is the nation’s largest hospice chain. “All of us competed against each other to make our numbers. You lived or died by your numbers.”

Publicly traded companies like Chemed and Gentiva Health Services Inc. (GTIV) have created hospice chains through serial takeovers in the last decade. Hospice buyouts and investments by private-equity firms have also led to boosted enrollments.

Funding from Kohlberg Kravis Roberts & Co. enabled closely- held Harden’s acquisition of Hospice Care of Kansas’s parent last year. The seller: private-equity investor Apax Partners, of London and New York.

“There was always pressure to get the patient census up, any way we could, to sell the company,” said Rae Ann Angelo, a Wichita salesperson for the Kansas hospice between 2003 and 2009, including most of the time when Apax owned it. “You can’t sell unless you show big growth.”

‘Make a Buck’

Other private equity concerns that have been active in the hospice trade include Denver-based KRG Capital Partners LLC. KRG sold Dallas-based Trinity Hospice for $75 million in 2006. The company was liquidated by the buyer, nursing-home operator Sunrise Senior Living Inc., (SRZ) two years later, after $67 million in writeoffs and government allegations of ineligible patient enrollments prior to the takeover.

“After KRG came in, it was clear their philosophy was, ‘Put everyone on hospice, don’t ask questions and build!” said Catherine Covington, who worked as a Trinity compliance officer from 2000 to 2004. “They were there to make a buck.”

KRG members on Trinity’s board ordered “immediate disciplinary action” when they learned of compliance violations, which led to terminations, according to KRG spokesman Topper Ray.

Diapers, Wheelchairs

Hospice Care of Kansas, or HCK, gave salespeople a budget of $500 a month to buy lunches and gifts for doctors and nursing-facility managers and staff, said Angelo, who now works for another hospice. Nursing homes have been offered diapers, wheelchairs, nutritional supplements and other supplies in return for patient referrals, other former hospice workers said.

Vitas paid salespeople bonuses based on patients’ length of stay, according to White, who worked for the company in Cathedral City, California, from 1998 to 2004. Medicare, which foots 90 percent of the national hospice bill, compensates providers on a per-diem basis, and lengthier stays increase profitability, federal data show.

Vitas “compensates some marketing and management representatives based on overall growth,” according to spokeswoman Kal Mistry. She said Vitas does not link compensation to length of stay or pay bonuses to employees involved in admissions decisions.

Pizza Parties

VistaCare Hospice, a unit of Atlanta-based Gentiva, paid enrollment bonuses to doctors, admissions directors and branch managers, according to Misty Wall, a former social worker for the company and now an assistant professor at Boise State University in Idaho. VistaCare also gave pizza parties, gift cards and other extras to its registered nurses and social workers for meeting admission targets, Wall said.

Wall has filed a lawsuit against VistaCare in U.S. District Court in Dallas under the U.S. False Claims Act, seeking repayment to the government for admissions of ineligible hospice patients. The law lets plaintiffs share in any recoveries. The Justice Department, which has not joined Wall’s suit, is opposing VistaCare’s motion to dismiss the claim.

The allegations predated Gentiva’s ownership of VistaCare, according to spokesman Scott Cianciulli, who said the company is committed to complying with all Medicare rules.

The inspector general of the U.S. Health and Human Services Department is probing hospice marketing practices and financial relationships with nursing facilities. The inquiry was spawned by a 2009 report by the Medpac commission, a congressional advisory body, that found hospices “aggressively marketed” to nursing-home patients, and paid incentives to medical directors for “inappropriate” referrals and enrollments.

Complicated Laws

Under various federal statutes, paying for patient referrals or compensating employees based on the number of Medicare patients recruited may be illegal. But the laws are “painfully complicated” and loaded with exceptions, said Ryan Stumphauzer, a former federal prosecutor in Miami who helped launch South Florida’s Medicare Fraud Strike Force.

Stumphauzer said he and other “cautious” lawyers believe the health care laws bar all employees and contractors from earning bonuses based on Medicare enrollment goals, including salesmen and managers.

Nursing-home physicians referring patients to hospices that also pay the doctors, especially in cases when the compensation includes enrollment bonuses, may violate a federal statute known as the Stark Law, according to Stumphauzer. The law is designed to ensure that doctors refer patients based on who provides the best care, not based on who is paying them.

Patient 11

Seven pending or settled lawsuits against hospice companies say that enrollment-based incentives led to admitting patients who didn’t qualify for hospice care. Appling, Stubbs’s aunt, is identified as “Patient 11” in one of these cases, a U.S. Justice Department civil fraud complaint against HCK and its owner, the Voyager HospiceCare unit of Harden. Prosecutors say the company bilked Medicare by paying bonuses to employees and doctors to sign up patients who weren’t dying.

HCK in court filings denied it billed Medicare for ineligible patients. Those the government identified were eligible because “a medical director and/or an attending physician certified” they were terminally ill, HCK said.

Appling was discharged after 20 months in HCK, and lived four more years before her death in April at age 106. Medicare paid nearly $80,000 for her hospice care.

Imminent Death

Harden’s purchase of HCK’s parent was part of a flurry of buyouts in the sector. A record 17 hospices were acquired in the first six months of 2011, according to Dexter Braff of the Braff Group, a Pittsburgh-based merger-advisory firm. Prices for mid- sized and larger hospice chains have risen “significantly” in the past two years, from about one times annual revenue to as much as 1.5-times, said investment banker Burk Lindsey of Raymond James & Associates in Nashville.

The rise of for-profit hospice care since 2000 has helped drive a 60 percent increase in the average time patients spend in hospice, to 86 days in 2009, according to Medpac. The average stay of the 10 percent of patients who remained in hospice the longest soared 71 percent to 240 days.

That means at least 110,000 patients weren’t facing imminent death when they were admitted -- although doctors said they were. To qualify for Medicare hospice coverage, patients must have a prognosis of six months or less to live, certified by two doctors.

‘Christmas Cash Blitz’

Profit margins on healthier patients who survive for years with minimal care can exceed 20 percent, according to Medpac. Medicare patients can stay on hospice indefinitely, as long as a hospice physician recertifies that they are terminally ill every 60 days.

Besides the “Summer Sizzle” promotion, the push for patients at HCK included “Christmas Cash Blitz” and “Fall Frenzy” admission drives. Those eligible for cash incentives in these and other programs included managers and admissions and medical staff, according to a dozen former employees.

A former company nurse said employees were warned that disclosing the incentive arrangements outside the company was a fireable offense, according to summary of her interview with the Federal Bureau of Investigation.

The nurse, Yolanda Anderson, was dismissed for revealing the bonus program to a social worker at a nursing home, according to a Justice Department court filing. Harden couldn’t comment on the reason Anderson left because her departure pre- dated its acquisition, said spokeswoman Meg Meo.

Free Vacations

Hospice salespeople would vie with drug marketers to provide lunches for doctors, since free food was often the only way to buttonhole them, Angelo said. She’d let physicians’ offices order off the menu from Scotch & Sirloin, a Wichita steak house, and then pick up and deliver the order.

Doctors and nursing homes that Angelo looked to for referrals were given baskets of bread, candy and other goodies at holidays, plus pens, mouse pads, calendars and hand sanitizer emblazoned with the hospice logo, she said. Medical directors -- many of whom also worked for nursing homes -- took a company- paid annual “retreat” to locales including San Diego, and free family vacations at Great Wolf Lodge in Kansas City, Kansas, according to Angelo.

Angelo said her base salary was about $45,000 a year, plus $8,000 to $10,000 in bonuses that were hers to keep whether or not admitted patients turned out to be ineligible.

Rising Patient Stays

HCK was founded in 1998 by Wichita social worker Mark Rowe. Rowe sold the company in 2004 for $11.9 million to Voyager HospiceCare, a startup launched that year by a firm later acquired by Apax. Rowe stayed on as chief executive officer until 2006, garnering at least $2.1 million in additional pay from Voyager, according to HCK court filings.

Under Voyager’s control, HCK increased the average patient stay at its main Wichita branch 45 percent to 109 days, according to Healthcare Market Resources, a medical researcher in Thresher, Pennsylvania. During the same 2004 to 2009 period, the average length of stay at all Kansas hospices rose 30 percent to 86 days, the firm said.

Apax sold Voyager in 2010 to Harden for roughly $80 million, or about four times Apax’s investment, said Thomas Combs, Voyager’s co-founder. The purchase was funded with $90 million in loans and equity from Kohlberg Kravis, which now owns a minority stake in Harden, according to KKR spokeswoman Kristi Huller. She declined to comment on the government’s allegations and referred further questions to Harden.

‘Patients Aren’t Widgets’

Apax wasn’t named in the U.S. suit against Voyager and HCK, which is pending. Lew Little, Harden’s CEO, declined to answer questions about the federal allegations against Voyager and HCK.

“It is not an unusual practice” for doctors to be medical directors at nursing homes and hospices simultaneously, and some patients “take comfort” from continuing into hospice with the same doctor, Little said in an email. No HCK medical directors, including Ewy, received compensation based on referrals or enrollment size, Little said.

“The hospice industry is not about financial incentives but about providing quality of life and dignity to patients,” he said.

HCK taught salespeople to visit nursing facilities to identify hospice prospects, get to know their families and strike up “friendly games of dominoes,” said another former marketer, Vickie Hardiman. When Rowe pushed her to accept commissions for patient admits, Hardiman said she refused because “dying patients aren’t widgets.”

Admissions ‘Pressure’

Rowe, who now owns an HCK rival, Rivercross Hospice in Kansas and Oklahoma, said his hospices have always complied with federal rules and regulations and receive high marks from government overseers.

Admissions directors at the Kansas hospice were eligible to earn bonuses of up to 15 percent of their salary for meeting enrollment targets, and medical directors were eligible for “ad hoc ‘spiff’ bonuses” based, in part, on enrollment, according to the government complaint, filed last year in U.S. District Court in Kansas City, Kansas.

Nurses evaluating patients for hospice admissions reported to the marketing department, and felt “pressure” to admit patients whom the marketers identified, whether eligible for hospice or not, according to Pat Perkins, a former HCK nursing supervisor.

Hospice ‘Doorkeepers’

HCK paid nursing-home doctors up to $4,000 a month to consult for a day or so per week on patients’ conditions and to sign treatment orders, said Roger Megli, a former HCK chaplain and marketer. The nursing-home physicians served as the hospice’s “doorkeepers,” according to Megli.

“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,” said Megli.

The company used its network of nursing-home doctors to provide a ready supply of patients, according to family physician Larry Anderson of Wellington, Kansas, a former president of the Kansas Medical Society. Several times 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.

Hershey’s Kisses

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 that goes to the nursing facility from Medicaid, which covers the indigent elderly.

“Hospice should not be in nursing homes at all,” said Anderson. “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,” according to documents filed in the court case.

Ewy signed two separate hospice admission orders -- one as Appling’s attending physician at the nursing home and another one 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, Kansas. 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 said she worries her aunt’s hospice stay may have deprived Appling of medical treatments that might have helped her. Patients who enroll in hospice agree to accept pain management instead of aggressive, or “curative,” treatment.

Resisting Discharges

Stubbs said no one explained that when she enrolled Appling. Stubbs wonders if 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 asks.

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, Kansas, 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.

To contact the reporter responsible for this story: Peter Waldman in San Francisco at pwaldman@bloomberg.net

To contact the editor responsible for this story: Gary Putka at gputka@bloomberg.net

Home Dialysis delayed

G went to the surgeon yesterday to have the PD catheter (the one in his stomach) "exposed", so he could start
training for PD dialysis, which he can do at home.

The letter from the PD dialysis training group said the appointment was at 11:00.
I wrote on the calendar the appointment was at 12:30, so called to check, and I was correct.

We got there at 12:15, and was told the Dr. would be 45 minutes late as he was still in surgery.

Finally, at 3:00 he shows up. They don't have it marked down that he is suppose to expose the PD catheter, and
he says that G should not start PD dialysis as long as the wound on his arm is not healed.

Long story short, another 2 weeks before the surgeon will expose the PD catheter, so G has to continue hemodialysis.

I had already cancelled VA transport for dialysis, so took G myself, and will for the next couple of weeks. I think one of the reasons G really dislikes going out for dialysis is sometimes he has to wait an hour before they pick him up.
Also, he has to sit in a recliner, basically on his back, for almost 4 hours. The reason he must lie down is
because he is still getting hemodialysis through a catheter in his groin, and it doesn't run well unless he is flat.

He told me that yesterday his blood pressure hit over 400 for just a bit, as there wasn't any blood coming out of the catheter. The nurse had him cough, and that was enough to start the blood flow. Good thing. I guess that
is one of the reasons he could die during hemodialysis. Or, have a major stroke.

On a good note, the wound on his arm, at the fistula site, is healing up nicely.

Cataract surgery was successful

G had the cataract surgery on Tuesday. We had to cancel o/t and p/t for that day, as the meds
they gave him made him dizzy. And, because he insisted on walking with the walker instead of using
the wheelchair when we came home, he fell about 3 feet from the car.

Luckily he fell on wood chips, and didn't appear to hurt anything.

The next day he had to go back to the Eye surgeon, who checked the eye, and said everything looks good.
G could take the eye patch off that morning, so he already knew he could see better.

Yesterday G went to the Ear Nose Throat Dr., to see why his voice is hoarse, and why he can't hear
out of his right ear.

The cause of the hoarse voice is due to nerves being damaged during the Carotid Artery surgery. They said
to give it 3 months, and if it isn't better, they can do surgery.

As for the right ear, apparently G had a stroke when he was in the hospital, and the busted blood vessels
were on the right side which caused his hearing loss. G said "don't you remember when I was in the
hospital I said I thought I had had a stroke?". I do remember this, and I remember us discussing it, and
realizing that unless it was a "bleeder", there is nothing which can be done. The day I thought he might be
having a stroke they took him for a CT scan, which would show a bleeder, and they said there wasn't one.

Anyway, they gave him steroids which said might help his hearing to come back. He is to take them for
5 days (I think). Problem is it could make his blood sugar go up, so he will have to check his blood sugar
That's not the worse thing in the world, as he never checks his blood sugar. Of course, he is very
careful about what he eats, and his A1c is always excellent.

Well, gotta run. Time to get G up to go to dialysis. This will be his 2nd to last time he has to go out for hemodialysis, assuming the PD works.

Later.