Posted by: Robert Markette
October 04, 2006

There is a great article in todays Washington Post about hospice care. You can read the article here.

The article discusses the hospice experience of Art Buchwald. Mr. Buchwald is a famous humorist who, last February, was diagnosed with kidney failure and told by his physician that he only had a few weeks to live. Nevertheless, Mr. Buchwald recently checked out of the hospice and went home.

The article is interesting for a few reasons. First, it touches on what a patient who is diagnosed as terminal and then lives goes through. More importantly, it touches on the inherent inaccuracy of predicting how long a terminal patient may live and how this is a problem for the patients.

The article overlooked how this inaccuracy can be a problem for the hospice providers. As the hospice providers who read this know and as the article points out, eligibility for the hospice benefit requires a physician certify the patient has less than six months to live. If the patient lives past the six months, additional periods can be certified eventually, the patient passes or the patient is discharged.

While a patient being discharged, especially if they have gotten better, can be a source of joy to hospice workers, I have talked to numerous hospice workers around the country who have run into a problem related to the surviving patient auditors questioning the appropriateness of the admission in the first place. Unfortunately, some auditors and regulators find it problematic if an agency has multiple patients who live more than six months or who are ultimately discharged from hospice due to healing or just plain survival.

However, this article points out a number of statistics that lead to the conclusion that hospice patients surviving longer than six months or even being discharged should be expected. The author interviewed a doctor who has published several studies about the accuracy of doctors estimates of how long a patient has to live. According to one study he published in a medical journal in 2000, only 20% of the time does a doctors prognosis approximate how much time the patient actually has left. He also found that 67% percent of the time the patient had much less time to live than the physician had predicted. If my math is correct, that means approximately 13% of the time the patient had longer to live than predicted. Another person interviewed for the article pointed out that hospice patients suffer from a number of other diseases not that are harder to predict, whereas in the beginning hospice patients primarily suffered from cancer.

The physician sums it up as doctors suck at predicting the future. (A skill that lawyers are also notoriously bad at.) But if doctors are no more able to predict the future with certainty than any other person, hospices should not have to worry about what the regulators will say when they are discharging patients from hospice care. You could argue that from the study the physician performed, at least 1 out of 10 patients should survive longer than expected. Given the comments of the other hospice experts regarding the broader range of diseases leading to hospice, that number could be even higher.

The point is that, because of the inherent inaccuracy of predicting the future and the nature of some of the diseases, such as congestive hear failure, that result in a patient receiving hospice care, patient prognosis is inaccurate. Medicare and others should understand that even if we expect physicians to accurately predict how long a terminal condition will take to run its course, they are not able to do so. If the physicians cannot, Medicare and Medicaid should expect to see patients live longer than predicted and should expect a certain percentage of hospice admissions will end with a discharge from hospice. Hospice providers should not have to worry that because they are in fact discharging patients who are alive or having patients routinely live longer than six months that they will be investigated for fraudulent activity.

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