Is Hospice Losing Its Way: A Podcast with Ira Byock and Joseph Shega

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: GeriPal, Alex.

Eric: Half of this podcast has to be in French per law in Quebec because we are at the AAHPM annual meeting.

Alex: Yes, at the [Alex speaking French]

Eric: Alex took five years of French, and that’s all he can say, unfortunately. [laughter]

Lauren: Nice accent, Alex.

Eric: Alex, we have some great guests with us today.

Alex: We have some wonderful guests. Holding the microphone for me is Lauren Hunt, who’s a frequent guest on GeriPal. She’s a hospice and palliative care nurse practitioner and Assistant Professor in the School of Nursing at UCSF. Welcome back to GeriPal, Lauren.

Lauren: Thanks for having me.

Alex: And she’s going to be a guest host today. We also have Joe Shega, who is a hospice physician, and he is a Chief Medical Officer and Vice President at VITAS Healthcare. Welcome to the GeriPal podcast, Joe. I think this first time we’ve had you on.

Joseph: Yes, This is the first time. I’m excited.

Alex: Welcome. And welcome back to the GeriPal podcast, Ira Byock, who is a author and well-known, has written several books about hospice, inspired many to go into the field, and is the founder of-

Ira: The Institute for Human-

Alex: The Institute for Human Caring. I don’t have my notes in front of me. Thank you, Ira, and welcome back to GeriPal podcast.

Ira: [Ira speaking French]

Alex: And we also have filming us Anne Kelly, who’s a frequent host on GeriPal and guest host. She’s filming us today. Thank you, Anne.

Eric: We have an exciting podcast episode that stemmed initially from…we were thinking about this from a New Yorker article that came out around the hospice hustle and thinking about, where are we with hospice? And the big question, is hospice losing its way? And what does the future hold as we think forward for hospice? Before we go into that very deep topic, I think somebody has a song request. Is it you, Ira?

Ira: It was, I believe, me.

Eric: Well, what is the song?

Ira: Money from Pink Floyd.

Alex: Great choice. I think it’s self-explanatory. Here it goes a little bit.

(singing)

Ira: So good.

Eric: Ira, we start off all of these podcasts with a question of, why did you pick that song?

Ira: Oh, I think one of the themes I think runs through the topic that we’re going to talk about today is follow the money. And it is probably the key to explaining how we’ve gotten to where we are today.

Eric: Great. So I’m going to put a little background. Usually I don’t put a lot of background on this podcast, but I got to … in November of 2022, Ava Kofman, along with ProPublica, published … well I won’t want to say great, published an article in The New Yorker that I think it was divisive in the hospice and palliative care community. I think some individuals thought there was cherry-picking of stories that made it seem like hospice is this bad thing, that it’s taking advantage of vulnerable individuals and it didn’t talk enough about the good things that hospice does.

On the other side, there’s another group that thinks, you know what? It gave voice to what a lot of people have been feeling over the last 10 years as things have shifted with hospice. I’d love to hear from each of you because this story really started a question is, is hospice losing its way? I’m going to turn to you, Joe. Thinking about that question, first of all, what’d you think of the piece and what do you think? Is hospice losing its way?

Joseph: I think the piece itself reflected a lot of cherry-picking and a lot of one-sided stories. There was really no balance to the good stories that hospices do, whether your tax status doesn’t really matter about that. And we’ll talk about that when we talk about the research. I’m very proud of the work that we do every day and we take care of patients and families no matter where they live or who they are to help them meet their end of life goals. I think that’s the part that’s still the fundamental foundation of hospice, individualized care plans focusing on patients, families, wants, needs and goals.

Eric: Great. Lauren, what do you think about you? When you read that piece, were you in either of those camps?

Lauren: Yeah, I think I can definitely see Joe’s point of view. Full disclosure, I talked with Ava Kofman a bunch while she was preparing that article, and I thought based on my professional experience working in hospice, things that I had seen, that she raised a lot of issues that I had personally encountered in my clinical experience. So I think she was somewhat purposefully inflammatory in some of the stories that she told, but I also think that those things are certainly happening on the ground.

Eric: Ira, when you read that story, what was going through your head?

Ira: I like the article. I thought it was well reported. I think it’s being mischaracterized. There was no attempt to balance anything. This was an investigative report about fraud and healthcare, pure fraud, pure victimization of vulnerable people. She happened to focus on some specific for-profit hospice providers. They were all actually publicly traded or private equity owned for-profit hospice providers. And I didn’t read it as damning of all for-profit providers, but I think it needed to happen.

I will say that, and I want to get out there for any of our listeners that a few weeks later I published an op-ed in STAT called Hospice Needs Saving, where I focused on a different, and I think even more serious problem, which is variability in hospice care and the specific lapses that have happened progressively over the last 25 years in hospice care that we’ve all known about for a long time.

I don’t want Ava Kofman’s article to draw all our attention because the issues that she brought out had been brought out before. In fact, as we sit here a year ago in March, 2022, the California Auditor’s office published a very excellent monograph of abuses of hospice care in California. Anybody listening, please Google this. California Auditor’s Hospice Licensure Report March, 2022. It’s a devastating report that should have had our whole industry, our whole field’s hair on fire then. And it’s interesting we didn’t talk about any of this until the ProPublica New Yorker article, which made it impossible to deny, but we had been effectively denying it as a field for nine months or more.

Eric: Why do you think that’s the case? Because there has been a sea change in hospice. So part of this is the profit status. So initially hospice grew as a non-profit, charity based, community based organization. 30% of hospices were for-profit in 2000. Now it’s 70%. So there it’s shifting more towards potentially more of a profit model of care. But more importantly, I think most of us are seeing a large amount of variability independent of profit status.

Ira: For one thing, I want to be very clear. I am not against for-profit hospice care. I’m not against even publicly traded or private equity owned for-profit hospice care. I am passionately against bad care and there is a lot of bad hospice care that preys on highly vulnerable patients and is unnecessary. There is a path to the future.

I want the for-profit, including the private equity owned hospice programs to succeed. I want them to succeed by delivering reliably excellent care. And while we’re here, and just let me push to the future of the conversation, that our own associations … the academy is my home. My professional home. I’m literally a founder. I’m a past president of blah, blah, blah. Our heads have been in the sand. We have not been doing enough to address the progressive prevalence of bad hospice care.

Joseph: Again, the issue is what IRA just said. When you talk about hospice care, it needs to be about mission. What is the mission? It’s also very clear that how long a hospice has been in practice is highly associated with the quality and the type of care. So hospices have been around for decades, generally provide higher level care. And to Ira point, we need to focus on those newer hospices to try to get the quality of care where it needs to be. NHAC NHPCO, when the California report came out have been very focused with the legislature to try to come up with common sense ways to try to eliminate hospices that don’t really provide consistent quality care.

One simple solution is to focus on hospices that really don’t take care of a sufficient number of patients to really meet the quality threshold. So if you think about 100 patients per year, that you need to have some benchmark after going into business to care for so many terminally ill patients. If you can’t meet that benchmark, it’s probably not going to contribute to the overall quality of care to the community. And it’s an easy way to try to ensure quality hospice programs. And that’s an ADC of two to three patients a day.

Eric: Which is really interesting because it seems like there’s a lot of … especially in California and Texas. California, I think they put a-

Alex: Moratorium.

Eric: Moratorium, I can’t even speak anymore, on new hospices because there were a lot. It felt like every single day there was a new hospice that somebody was referred to. And the hard part is, as a provider in palliative care, I actually have very little say of which hospice the individuals we consult to go to. It feels somewhat random in some ways. And then it’s even harder because we’re talking about quality. How do you actually assess for the quality of these hospices? Ira, you’re giving me a sigh.

Ira: Well I mean, I’m sorry, but I have been for 30 years saying to when it was NHO and NHPCO and the academy, we could put in place some clear parameters for quality. It’s not rocket science. Everybody says there’s, “Oh, Ira. It’s very complex.” It’s not that complex. Are you going to see a doctor are? What happens after hours if you have an emergency in your home? Who sees you? How is that done? How many patients is my hospice nurse case manager responsible for on any given day? How many doctors are there and how many patients are they responsible for? Does the hospice offer general inpatient care? Does the hospice offer continuous home care?

All of these things we could create data for today. I’m sorry, we don’t need any other studies to do that. And you hear the agitation of advice because I’ve been trying to, and you signed, Eric, a statement called Core Roles and Responsibilities of Physicians in Hospice Care. It’s going to be published as a special report in JPM I hope in May with as of today, 279, I think HPM physician colleagues, signatures including 21 of the living past presidents of the academy. For 30 years nobody from our field, from our discipline has created any sort of seal of approval or any sort of clear, transparent parameters for referring physicians or for discharge planners to refer to. We could have done this for decades and we today still haven’t done it.

Eric: Yeah, even in our own organization it’s something that we’ve always talked about doing, but the complexity of even trying to figure out what quality metrics are we going to use. The star rating has not been incredibly helpful for us when it comes to hospice. Joe, what are your thoughts?

Joseph: Well, I think again, from my perspective, quality is what matters. And trying to figure out what those quality measures should be. Reading Ira’s article, it essentially was the VITAS Medical Director job description. He quotes Joel [inaudible 00:14:50], who was a founder of the hospice movement and the role of the physician in hospice with many other great leaders. But I agree with you that focusing just on star ratings doesn’t tell the whole picture. That’s also been shown in the literature because I don’t believe there’s adequate risk adjustment for the types of patients people care for.

For example, we often are the second, third, or fourth choice for hospice where other hospice providers turn down patients. It might be complexity, it might be acuity, it might be the psychosocial situation or social determinants of health.

Eric: Lack of a caregiver.

Joseph: Lack of the caregiver. And yet they’re dying. And so we try to meet them where they are. And even if you look at the most recent studies that have been published, there’s a differential in the ethnicity of patients served. For-profit hospices serve about twice the number of black and brown patients than non-for-profit hospices. And I can tell you for VITAS, a lot of times that’s because other hospices turn away their needs. But it shouldn’t be about that. It should be about the quality of care. What is the mission? What patient populations do you want to serve?

Ira: Can I just say two things? One is be wary when every anybody says, “Oh, it’s so complex, we really don’t know what to do.” That’s become a dodge. I practiced emergency medicine for a lot of years and a lot of people come in, if they’re in extremis it may be complex, but you find a way to take action. I would suggest that given what we know and what’s come out in the data recently about quality and hospice care, we should act as if we’re in extremis. And there are some things that we can put in place, frankly tomorrow to give discharge planners some parameters to look at, but also to provide some guidance as the field to the auditors, the accountability community, the legislators and others. We could do this right now.

I would only suggest that star ratings, everybody keeps looking for something for CMS to do or for Congress to do. Let me tell you that when anybody comes with bad problem and says, “We need to get Congress involved,” my heart sinks. An angel dies somewhere. What we’ve done in the last few months is the economy and NHAC and NHPCO and all that have written strong policy proposals to CMS and to Congress, to Earl Blumenauer and others, which are all great. They really are. Absolutely everyone is great. None of them obviate the field clearly stating what quality looks like and when we should all be concerned that the hospice programs cannot deliver quality. We could do that tomorrow.

Eric: Lauren, I’m going to turn to you. Your thoughts on that?

Lauren: I mean, I think the fundamental tension that we’re seeing and the reason that I’m concerned about the hospice industry right now is that there really, there’s this tension right now between what the mission of hospice is and the profit motivations that are in the field right now. I also just wanted to respond to Joe’s point about for-profit hospices and the care that they provide, which I think is a really interesting issue. I would say on average what the research shows is that for-profit hospices tend to have higher margins, they tend to provide fewer visits. And this is on average.

But I think what we’re missing a lot of information on what Joe is talking about is just how much variation there is in that within both non-profit and for-profit, and I think these issues are coming up in non-profit hospices as well, and we just don’t have the data because the information is not reported to anybody. The nuances around the types of ownership, the practices of that organization-

Eric: Who actually owns the hospice is opaque.

Lauren: And looking in the Medicare data, you cannot figure out when a hospice changed ownership. So I think that understanding that variation is incredibly important. I think that there are for-profit hospices like VITAS that have been around for a long time that really have the resources to support people whose goals of care are less aligned with the traditional hospice philosophy. And then I have one more point.

Eric: Go ahead.

Lauren: In terms of the quality ratings, so if you come to my talk tomorrow, I have a talk on hospice quality. One of the really interesting things that we found in our study was just how many hospices do not have a quality rating because they’re too small or too new. It was one third of all hospices in this category. And I just think there’s all these small new hospices that are flying under the radar and we just have no idea what’s going on with them.

Eric: And I think that feels like-

Joseph: Our analysis showed 40% did not have a quality rating.

Eric: Which feels like a fundamental issue right now is, and we’re going to be talking about this more, variability and then potentially what our role is in this field around that issue. A couple things I’d like to tease out before we get into what’s our role, because I promise we’ll get there, is going to Lauren’s first point. We’re talking about mission, the important of mission, but there’s also another mission that has entered into the field strongly. There is a reason private equity is buying up hospices, including nonprofit hospices. And private equity generally isn’t in there for the long haul, 30 years. They’re in there three to five year turnarounds to make a profit. We’re seeing dramatic increases in private equity fund or buyouts of hospices. And again, there is this potential secondary mission of profit.

(singing)

Ira: Thank you very much. I was an early proponent of for-profit hospice care. As somebody who has been part of literally more non-profits than I can remember, non-profit governance structures is a pain in the ass. And it’s very hard to go through a board of directors when you want to build something or invest something and it’s just hard to raise capital and it’s just hard. Management, it’s hard.

So I was encouraged by the early for-profits. They were mostly wholly owned by people passionate about the field and passionate about the mission of caring for people who were approaching the end of life. They were highly efficient, their staffing ratios, the physician involvement, their responses to emergencies, all the things that I care passionately about were actually quite good. What happened, and I was directly a part of, not in an ownership or employed way, but in a consultant and supporter way of a number of the early for-profits.

What happened was that they went through initial public offerings, they went through IPOs and they began being traded on Wall Street and they became investor owned. And as soon as they became investor owned, there were two missions. One was to deliver excellent care to dying people and their families. And the other was to return a reasonable return on investment to their shareholders. They are legitimate. That’s an illegitimate mission of a investor owned program. But it balances and is in tension sometimes with giving the best care possible.

What we’ve seen now is that now private equity has gotten in and now the founders, people who own those programs drift away. They get bought out or they retire or something and things change. It’s not that the investor owned or private equity owned programs are immoral, they’re more amoral. They have to balance these two missions. Again, I want them all to succeed, but they must succeed by delivering consistently, reliably excellent care. I’m not about to be paralyzed by allegations of complexity. Our field has a role to play in that.

Eric: Yeah, we care for a lot of complex patients. Complexity is our thing. Joe, from your standpoint, thinking about this, do you feel a tension as part of a for-profit hospice? That’s his first question. And the second question is, a lot of people also, we hear a lot of poo-pooing of for-profit hospices. But I got to say, there have been times where we have turned to, I’m going to say VITAS, as our third line. For example, one case that we had not too long ago, one of the hardest cases, nobody was willing to touch him, no caregiver. And Carla Perissinotto, one of the MDs there was in his house every single day helping to clean up the house too. Something I’ve never seen hospice do. And this was from a for-profit. So thoughts on either of those?

Joseph: Well, as you know, my background was 15 years at University of Chicago, 3 years at Northwestern. I came to work for VITAS because I needed to move to Florida because my dad had a serious illness, metastatic colon cancer. What I love about VITAS is I report to the CEO. So I’m held to my metrics, my standards, but it’s always about what’s best for patients and families. How do we make this work for patients and families?

I’ll give you a perfect example. Working with Abe Brody at NYU to do a randomized control trial of an intervention for education, for psychotropic use in end stage dementia patients. We are now just transitioning to an EMR, so the whole study was done when we were on paper. What he said to me was, “Of all the hospices we worked with, yours was the only one that reliably, consistently can provide us with all the pharmacy data we need at any time for any patient.” But we’re still on paper.

So it’s about knowing the processes, it’s about understanding the processes, it’s about creating the infrastructure to create efficiencies to make it work so that you can meet the needs of patients and families. For me, my goal every day when I wake up is how many terminally ill patients can we provide the best care for? When I talk to our doctors, that’s what it’s about. When I talk to our nurses, that’s what it’s about. When a patient doesn’t get admitted and it gets escalated to me, we try to figure out what can we do to help support them. ‘Cause we don’t want people dying in the ICU. We don’t want people dying in the hospital if their goal is to be at home. Most of the time it works out. Sometimes we can’t meet their needs. But the mission is what drives it. If you do good quality patient care, I believe the other naturally follows.

Eric: All right, so I got another question. Joan Tino’s Group a month ago published a great study looking at care or caregiver, primary caregiver survey data. And in that survey data, what they found was that nonprofits consistently scored both in summary scores and individual scores better than for-profits. With that said, there was great variability in both groups, but generally for-profits had greater variability where you had some for-profits that did much better than national average and some for-profits that did much worse than national average, more so than we saw in non-for-profits. So we’re talking about variability for hospices. It seems like, and it feels right to me like that the variability that I see in for-profits seems bigger in my own daily practice than the variability I see in non-profits. Thoughts on that? Ira? You’re shaking your head, maybe not.

Ira: I don’t know. I’m not close enough to programs to know. I mean, in Los Angeles County, the for-profits are a disaster with some of the longer term, like VITAS, being exceptions to that rule. But it’s just a mess. But there are like 800 or 1,000.

Eric: We had a period of 10 years in California where every six months we increased our number of hospices dramatically.

Ira: But I will say, and I pointed this out in the op-ed in STAT in December.

Eric: We’re going to have a link to that op-ed in STAT in December

Ira: That last year, 53% of hospice programs provided no GIP care to any patient. This is a condition of participation. This is not a best practice. This is min specs, this is the floor, right? 61% of for-profits delivered no GIP care. So what happens if somebody’s in extremis in home, if they have just infarcted their bowel on home hospice or if they start seizing and they’re crescendo going into status epilepticus, what happens?

Either they go down continuous home care or somebody comes to the home, or they go into GIP, or they are a live discharge and get admitted to the acute care hospital. Again, and I keep bringing this back to the field and our academy and our associations. This is something that we should all kind of have our hair on fire about. And it’s happening. It’s been happening. With the data that we currently have it can be seen. We’ve all seen it and we’re not … well, you know it dominated the agenda of this meeting in Montreal. And no, it’s actually not there at all.

Eric: Yeah. We have one session.

Ira: One session tomorrow.

Eric: 5:00 PM. I see some of the folks at that session. Lauren, is your hair on fire?

Lauren: Yeah. Yes, my hair is definitely on fire. I was recently, I attended a stakeholder stakeholder session for people in California to comment, the California Department of Public Health is taking comments right now on how to better regulate hospice following the moratorium on new hospices opening in California. Yeah, I think it’s incredibly concerning. There’s absolutely no reason why there should be 1,000 hospices in LA County. Following one on-

Eric: 1,000 in LA County alone.

Lauren: Yeah. I think that’s about right.

Ira: North of 800.

Eric: And some of them are located in the same basement I’ve heard.

Joseph: The Van Nuys building. Yes.

Lauren: I think my question-

Eric: We got some inside details here.

Lauren: For both of you is, as we’re thinking about how to regulate hospice at the federal level and at the state level, how do we that in an effective way that actually improves quality and also doesn’t create burdensome and time-consuming tasks that take away from clinical care for nurses and for the-

Ira: Here I would refer you to the joint statement that NHPCO and NAHC and Leading Edge and NPHI, I think those were the four that came together and have issued to CMS and Congress. And in our own academy, Tara Friedman wrote two letters to Earl Blumenauer in January that actually articulates something like 30 different policy steps that could be taken. They’re really excellent, and if I have any complaint about them at all, it’s that they could have been issued in 2008, 2009. We knew enough then basically to say pretty much the same thing. Certainly in the last five years we could have done this. But setting aside the timing, they’re excellent and trying to get to just those issues.

Eric: Joe, I’m guessing from your standpoint, not from VITAS, but yours, you probably feel like you have a lot of regulations and oversight and that there’s probably, I’m guessing a lot of hospices that have been around feel like we know how to do a good job and Congress telling us to do more oversight, is that right? May not be the best thing?

Joseph: Well, I agree with Ira’s point, which is those recommendations that were submitted were very thoughtful in trying to improve quality. Again, if it’s going to improve quality and not come to cost of clinical care, we need to support it. Again, there should be more self-regulation than governmental regulation. We need to do the job and put in the work every day to try to make that happen. I completely agree with that, and I agree with Ira’s point. Do you provide four levels of care? That’s not a burdensome quality indicator.

And just one comment about the RAND study, I will say, the response rates to those surveys runs around what? 29%, which leaves 70% we have no clue how they report their experience. It’s the only survey CMS does that’s not based on patient’s experience. It’s based on somebody else’s. And it’s really important to point out that, as you said, there were for-profit hospices and non-for-profit hospices in the higher ends and the lower ends of quality. It was statistically significant, but not all of it was clinically meaningful.

Eric: The three point difference in this, what? 100 point scale, may be like amyloid drugs, but we won’t go there. So you said there was just an article published yesterday on cost of care with hospice, is that right?

Joseph: Yes. So NHPCO and NAHC worked with NORC at University of Chicago to do the first real … there’s been a lot of studies published about hospice quality for decades to show that it improves quality. There’s been some great studies that looked at cost, but this study actually looked at cost up to a year before death. So they looked at those that died in 2019, did a year back look at total cost of care that showed at six months, if somebody lives six months on average, those in hospice cost the Medicare trust fund 11% less than those who never enrolled. And even up to a year out across diagnoses, every diagnoses including neurodegenerative diseases, costs less for those enrolled in hospice compared to not. Overall it was 3.1% or $3.5 billion in one year hospice saved Medicare, and that was by focusing on what matters to people, to patients and families.

Eric: Ira, did you have something to say about that?

Ira: No, I think it’s just another piece of evidence that what we do is the right care. We do so much right that I’m not sure why we are so resistant to using our force for good in helping to transform American healthcare. I mean, one of the things we have that we haven’t spoken about is, we have a reasonably bizarre structure we’re working within, which is the Medicare benefit. And again, I sound like an OG, but I guess I am, railing against and pointing out the need to transform the Medicare benefit and update it since really actively, since 2001 when I was running a program for the Robert Wood Johnson Foundation and we were looking at integrating hospice-like care within mainstream healthcare.

We showed that if you did concurrent care, people felt better. They sometimes lived longer, their families did better. And cost didn’t go up. They went down comparative to the chain, the diminution of the area under the curb of hospital base. But we are still laboring under this Medicare benefit. Frankly, the industry stood in the way of transforming it. Congress was far more ready than providers were, but now we’re in a situation where we are the only discipline that I know of, hospice particularly that if our patients get better and live longer, we are accused of fraud for ever admitting them. Why is it embarrassing when our patients get better under our care? Something is wrong in that scenario.

Eric: Yeah, that issue with graduation, Lauren.

Lauren: I mean, I think that’s true and maybe it’s a positive thing if you take really good care of your patient and they get better. But I think the concern is around this perhaps fraudulent, perhaps unethical enrollment of people who are marginally eligible for the benefit. And that goes back to the profiteering.

Ira: Just to support the for-profits, again in the long arc of things I saw in 1996, ’97 when the office of OIGs Operation Restore Trust came out that under the direction of NHO, frankly the nonprofits retreated from caring for people in nursing homes, including dementia care patients. They basically abandoned, and some of us were outraged and yelling at the time. And I personally was sent to the desert. I became the vox clamantis in deserto for basically a decade for complaining about this. The for-profits stepped up and they have been serving people in nursing homes, including with dementia who deserve our care, and the nonprofits haven’t. And so when somebody gets better under hospice care in a nursing home, is that a good thing or a bad thing?

Eric: Well, I guess the question is if one of your goals is to make a profit, there’s only several ways to increase efficiency. Co-locating everybody in a nursing home, admit patients who are going to have a longer length of stay, dementia patients, decrease the amount of providers going out there. So how much of it is they have … their hearts are gold and they’re going into this nursing home to provide better care versus that is actually how we increase our profit margins or does it even matter?

Ira: I just think we ought to help them succeed in increasing their margins as long as we have as a field put parameters in place so we can assess that they are providing good care.

Joseph: I think the point Ira is making is you can’t point fingers. The non-for-profit hospices walked away from a population. It still exists where many providers are afraid to take care of dementia patients because of the audits CMS are doing because of the natural uncertainty of the disease. It doesn’t mean their prognosis isn’t six months or less if the illness runs its normal course.

And I bring up the case, I’m going to use somebody’s name of Cynthia Boyd. At American Geriatric Society in Orlando, got up during Amy Kelly’s talk, which was about dementia and said, “My mother cannot get hospice care because no hospice will take a chance on her. Because no hospice will take a chance on her because she has end stage dementia every time she falls, she’s got to go to the er. Every time she has a change in level of consciousness, she has to go to the ER. I don’t want my mom to do that, but nobody will take care of her.” How is that right?

Eric: Okay. I realize we’re running out of time, but the pointing fingers, is there a role to point fingers? What about pointing fingers internally? What is the role of the physicians, the nurses, the social workers in hospice? I’m going to turn to physicians first because you’re putting out a physician statement on the role of physicians in hospice. Tell me about that.

Ira: In May there will be a special report in the Journal of Palliative Medicine called Core Roles and Responsibilities of Physicians in Hospice Care, A Statement by and for US Hospice and Palliative Medicine Physicians. And it is really just a statement by us to us to help first of all our colleagues who are working for or looking to work for hospice programs to be able to know what their roles and responsibilities are. This is not even best practices, this is min specs drawn from the hospice medical director manual and our conditions of participation, Medicare conditions of participation, that’s all.

And then what hospice physicians need from hospice programs to do their job well to succeed. And finally, when hospice physicians should be concerned that they may not be able to provide good clinical care ethically sound care because of the limitations that their work environment or their employment agreement impose on them.

Eric: Including potentially non-complete clauses, which I know is FTC is taking it up where there may be a 30-mile radius where you’re not able to join another hospice, except in California, may not be able to continue or work. So you’re kind of handcuffed in a way unless you can move to another city. Joe, what are your thoughts on that?

Joseph: I mean, like I said before, his paper is very well written, reflects our job description for a medical director. But I do want to talk about one thing that you said-

Ira: And you’re going to sign it?

Joseph: And we’ll talk about me signing it. He tries to get me under the gun. I’m going to try not to get emotional about this, but when the ProPublica article came out and when other articles come out about differences between non-for-profit and for-profit hospices, when I have given my life to the academy, I am an advocate for palliative care and for hospice. I’ve worked at non-for-profits, I’ve worked at for-profits. I give my life to patient care. When COVID happened, I was flying across the country, going to our programs, encouraging our staff to go out, showing in those spaces. I was doing palliative care in the hospital, I was doing inpatient hospice, letting people know we need to meet patients and families where they are and care for them.

And these articles come out and we have attendees at this meeting posting on HPM sites about how horrible for-profit hospices are, how they need to be kicked out of the academy, how they do all these wrong things. All I have to say is if we can’t look in internally and embrace ourselves, and I have to go to the plenary session today and hear about what makes me happy when I wake up and self-care and all this other stuff, and my own colleagues can’t support what I do every day? That’s very disheartening.

I think people have to have a reality check about who they’re pointing the finger at and have to look internally about what’s really driving their thoughts and their behavior, because it’s not about the care that we provide. I shouldn’t have to spend my time building up my doctors to help them feel good about what they do because people at this meeting tear them down.

Eric: That was incredibly eloquent and passionate. I mean, there is a reason I invited Joe here in particular because even at our AAHPM board view, again, Joe gives a lot to the academy, the passion that comes out. Alex, just like one slide, I remember one slide saying there are benefits for for-profits and you make an eloquent case. I think what I’m also hearing is it’s not really for-profit, non-for-profit, it’s variability. The bottom one third, that the people who have these hospices where you got 10 different hospices in a basement in Van Nuys, each covering not many patients. Ira, I know you were going to say something. Thoughts on that?

Ira: No, I’m in radical agreement with Joe. Again, it’s not about tax status, it’s about whether you provide consistently, reliably good care. I think below that, I would point to the presence or absence of physicians in hospice care. These are the sickest patients in the healthcare system. I’m not trying to be chauvinistic about physicians, but we are an interdisciplinary team. But there is a role for physicians in hospice care. We created this field, I’m old enough and it was in it early enough to, one of the reasons we created hospice care in America was to remove the barriers between dying patients and seeing a physician. And now ironically, cruelly in many hospice programs across the country, the hospice is the barrier to dying patients seeing physicians. I think that’s what I’m against, bad care. I want the for-profits to succeed. I think it’s a legitimate way of organizing your provider organization, and I agree.

Eric: Lauren, as an RN, two questions for you is what are your thoughts around the role of the physician in hospice and also what’s the role of the RN? We need the same physician statement for what is the role of RN and what do we do when you’re in these situations, you’re questioning the quality of care.

Lauren: Yeah, it’s interesting in hearing Ira talk, I’m not entirely sure I agree that we necessarily need physicians, but I do think we need access to a provider which could potentially be a nurse practitioner. I think that is actually probably what is actually happening in the field right now because there are not enough physicians to fill that role. And so working on training up that population so that they can give great quality care. And then I would probably agree that I need to maybe get on writing that paper.

Eric: Because your hair’s on fire.

Lauren: Finding my nurse colleagues to write that paper. I mean, I think the role of nurse on the hospice team I think is to just continue to advocate for high quality care to leadership at all times and then broader communication to the field as a whole.

Eric: Okay. We are running out of time. I want to be mindful of that. Lightning round. You got a magic wand, you can fix one thing with hospice. What would that one thing be? Ira?

Ira: Well, I’m doing it in the sense that I think the one thing that I can do and that physicians can do is we can provide a clear articulation of what the physician role is in hospice care and what we need from our programs to succeed and what to be concerned about when we cannot fulfill those basic roles and responsibilities.

Eric: So I got a question. If Joe or anybody else here wants to sign your position statement, can they just go click on the link on GeriPal? And we’ll have that link up tomorrow.

Ira: Yeah. Until March 28th will be receiving signatories that will appear in the May issue of the Journal of Palliative Medicine.

Eric: Okay. So we all got a week. Joe, and again, we’ll have a link to that on the GeriPal website up tomorrow. Joe, what’s your one thing?

Joseph: I wish the Academy would be more supportive of what we do every single day. And instead of trying to tear us down, continuing to build us up and look at us as colleagues and not as something with three heads.

Eric: Do you feel the same way about NHPCO?

Joseph: No, I do not feel the same way about NHPCO.

Eric: Okay. Lauren?

Lauren: Oh, I hate this question. I think what my magic wand right now would really be to increase transparency so that we can better understand what this variability looks like and who the players are involved, and so we can target regulation where it would be best served.

Eric: Yeah. Well I want to thank all of you for joining us. I got to say, I actually have been part of that where I am reframing how I think about this issue because it’s so easy to blame just for-profits, venture capitalists. So it’s so easy to point a finger without actually thinking. The more I think about it, the thing that I get most upset about isn’t profit status, it’s variability. And what are we doing to actually boost everybody up?

I think I actually heard that from Joe too is, how do we boost the entire field up instead of cutting people down? So with that, thank you guys for joining us.

Ira: Thanks for having us.

Joseph: Thank you.

Eric: Lauren, thank you. But I think before we end, we got a little bit more of Alex singing.

Alex: (singing)

Eric: Thank you all, and we got an audience here too. Thanks for joining us for this podcast. I really appreciate it. And with that, everybody have a great time in Montreal.