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How to Choose a Hospice

David Casarett, M.D.   |   June 23, 2014    5:31 PM ET

Ben Hallman's June 19 HuffPost blog paints a stark and scary picture of today's hospice industry. Hospice, he warns us, is big business. And it seems that business is booming. But his focus on for-profit hospices is not very helpful to patients and families who need hospice.

When people make a decisions about which hospice to enroll in, they don't need scare tactics. They don't need fear mongering about the evils of for-profit hospices. They need to choose a hospice that will deliver the best possible care for whatever time they have left. That is, they need advice. So here's my advice, based on 15 years as a hospice and palliative care physician.

(Full disclosure: I'm the chief medical officer for a not-for-profit hospice, and I sit on the board of a for-profit, so I'd like to think that I have a pretty balanced view.)

First, ask your doctor for advice. Which hospices deliver the best care? Which have the most skilled staff? Which are the most responsive?

But also ask your doctor if he or she has a financial relationship with that hospice. Some doctors are employed by hospices, and may have a financial incentive to refer. So beware.

Second, pick up the phone and ask questions. Here are a few:

"Do you provide all four levels of hospice care?" (That's routine home care, inpatient care, continuous care at home, and respite care). Medicare-certified hospices are required to provide all four, but many don't.

"Is your hospice certified by The Joint Commission or the Community Health Accreditation Program?" Abbreviated as TJC and CHAP, these are organizations that visit and inspect hospices regularly.

"Are your physicians board-certified in hospice and palliative care?" This is a good indication that a hospice takes its medical care very seriously.

"Do you measure and improve the quality of care that you provide to your patients? How?" Any hospice that doesn't have a quick and clear answer for this question probably isn't serious about patient care.

"How much charity care do you provide?" This may seem like an odd question to ask, but in my experience, it's a pretty good indicator of whether a hospice's heart is in the right place. There's no "right" answer, but beware of a hospice that doesn't offer any.

Third, interview a hospice. That's right, just as you'd interview a job applicant. (Because that hospice is applying for a job to work for you.) Ask the hospice representative to tell you what you can expect. What services will they provide? And when? Ask the representative to explain to you how they'll work around your needs and preferences.

Finally, some general advice. These aren't hard-and-fast rules. But they've served me well in finding hospices for friends and families in cities where I don't know the lay of the land.
Look for larger hospices. Larger hospices are often able to provide services, and to be flexible in ways that smaller ones can't. In my experience, larger hospices also typically have more of an investment in measuring and improving quality. ("Large" might mean a single large hospice, or a hospice with multiple offices across a region.)

Also look for hospices that are affiliated with medical centers and health systems. That's not a guarantee that the hospice will provide high-quality care, of course. But those affiliations mean that there are probably a lot of people keeping an eye on the care that the hospice delivers. That's particularly true of academic medical centers, where standards of care tend to be very high, and tolerance for shoddy care is limited.

Finally, ask around. If you have friends whose family members have used hospice, ask them what
their experience was. I wouldn't dismiss a hospice because of one negative story, but if you hear several, walk away.

If you go through these steps and ask these questions and decide on a for-profit hospice, don't be surprised. There are good for-profit hospices out there, just as there are bad not-for-profits. So above all, keep an open mind.

The facts about for-profit hospice care that Hallman and his team so painstakingly researched need to get public attention. People need to know that hospice has come a long way from the volunteer traditions of hospice care that began decades ago. It's a whole new world.

But we're doing a disservice to the public if we don't provide guidance about how to navigate that world. More people are using hospice every year, and that trend won't reverse. So we all need to know how to choose more widely.

Choosing a hospice solely based on its profit status isn't wise. There are good hospice and bad ones. There are those that are committed to patient care and those that are committed to making money. There are those that serve the community and those that serve themselves. Yes, there are for-profits and not-for-profits, but that's just one variable in a complex equation that will determine whether you or a loved one get the best possible care.

Finally, one last word of advice. Choosing wisely takes time. So start thinking early about what hospice you'd want when the time comes. How early? Well, if you were interested enough in this topic to read this blog, then now would be a good time.

People typically enroll in hospice very late. More than half of patients in the U.S. enroll in the last three weeks of life, and about a third enroll in the last week. That's too late to make careful decisions. So start asking questions now. Think of it as insurance, so when the time comes -- as it will, for all of us -- you'll be ready to make a thoughtful choice that's consistent with your preferences.

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Three Reasons Why Non-Foreclosed People Should Care About The Foreclosure Crisis

Ben Hallman   |   January 18, 2013   10:12 AM ET

Look, I know what you are thinking. Every day, it seems, comes news of another mortgage lawsuit or settlement, including a foreclosure abuse deal between HSBC and federal regulators announced Friday. It's hard to keep them all straight. Frankly, if you didn't lose your home to foreclosure, or come close to doing so, you might not know what to think. Maybe you manage to muster some vague feeling of irritation about the behavior of U.S. financial institutions, but mentally you're already trying to place that overvalued "Z" in your Scrabulous game.

But what happened, and is happening now, might affect you more than you think. Here are three takeaways from the crisis that should matter to far more than the 8 million or so U.S. households that received a foreclosure notice.

1. Had the federal government acted decisively at the outset, your home would probably be worth more than it is now.

Rising home prices over the last year have finally revived the housing market, pulling millions of underwater borrowers up from the sea. This is fantastic news for some people who clung to their homes, and kept making mortgage payments, as prices collapsed. But millions more, who bought in places like San Bernardino, Calif. or Brockton, Mass., still owe more than twice what their homes are now actually worth.

These borrowers are far more likely to lose their homes to foreclosure, a process that damages neighborhoods and holds down home values across the board. Offering some form of principal reduction, or debt relief, to these borrowers from the outset would have saved homes and likely shortened the housing crisis. Yet in a recent interview with the Wall Street Journal, outgoing Treasury Secretary Timothy Geithner said government-sponsored debt relief wasn't possible, or fair.

And you know, I like explain to people that we didn't have $500 billion or three-quarters of a trillion dollars to provide principal reduction to the American homeowner, and doing so would have been a very inefficient way to help the economy, and really unfair in many ways.

But Congress did give Geithner a $45 billion check to help homeowners as part of the TARP bank-bailout fund. About 90 percent of that money went unspent. Housing groups, and analyses by both Treasury and the Federal Housing Finance Administration, determined that a principal reduction program targeted to those it was most likely to help would both limit foreclosures and save taxpayer money.

Geithner, though, was never really on board, falling back again and again on the "moral hazard" argument -- that bailing out some homeowners and not others wasn't just, and could encourage people to intentionally default. Geithner briefly changed his tune on principal reduction, and went so far as to chastise Edward DeMarco, the acting director of the FHFA, for refusing to allow Fannie Mae and Freddie Mac to write down loans as part of the $25 billion settlement between banks and the states last March. But his recent comments suggest his true position never wavered much.

2. Buying a new home loan is more difficult than it should be.

In the run-up to the housing crisis, millions of borrowers who had no business buying a home did so. Now, millions of would-be buyers who could afford a reasonably-priced home are locked out of favorable interest rates. There are lots of reasons for this, including a reticence by mortgage bankers to lend money without first securing a first-born child as collateral. But the most significant factor is the reluctance of Fannie Mae and Freddie Mac to buy any but the most gold-plated mortgage, a development that marks a significant retreat from the original purpose of the government-controlled mortgage behemoths, which was to provide middle America a broad path to the housing market.

DeMarco, who has run the agency as acting director for two years, has defended this position as looking out for the best interests of taxpayers who spent more than $180 billion to bail out the companies. Obama could put forward a nominee to replace DeMarco at the top of the FHFA, or potentially even fire him, but despite persistent rumors about his imminent departure, DeMarco has held onto his job.

3. The bank regulators have decided that helping homeowners is just too hard.

There's plenty to say about what the recently-announced $8.5 billion foreclosure abuse settlement means for homeowners who applied for relief to the review process that it replaces: good news for people who didn't deserve a dime and probably bad news for those who lost their home because of massive bank errors (and yes, Wall Street Journal editorial board, as dozens of reporters have documented, this definitely happened). The deal is also a boon to the banks, which are no longer on the hook for an open-ended liability and get a tax break on what they pay out, to boot.

But for the rest of us, the takeaway is this: bank regulators simply can't be trusted to clean up the mess from a banking crisis. They failed to make sure that the mortgage companies were dealing fairly with homeowners struggling to make payments and then failed to oversee a review process meant to determine what, exactly, had gone wrong. The upshot now is that we will never really know how many homes could have been saved from foreclosure had banks followed the rules.

The best hope, then, is to prevent future crises. Which is reason to pay close attention to whether the financial sector is able to curb the parts of the Dodd-Frank law most likely to stop all this from happening again.

How's that going? Two-and-a-half years, and $200 million in financial industry lobbying expenditures later, more than half of the required rules still haven't been written.

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Wednesday Water Cooler: The Trillion Dollar Coin, The AIG Crocodiles, Mortgage Applications Up Big

Ben Hallman   |   January 9, 2013    9:36 AM ET

Wait, are we still talking about the Treasury Department minting a trillion-dollar coin to put off the debate on the debt ceiling for a little while longer? How likely is it that Republicans would make political hay out of such a maneuver for the next decade, castigating the Democrats as the party that simply invents money in order to solve serious fiscal problems? And if we are placing orders for novelty coins, might I request one that properly honors the contributions to American society of Clinton Riggs, the Tulsa, Oklahoma police officer who invented the yield sign? I think that coin should be worth 1.7 gazillion dollars and bestow on the bearer the right to ignore all traffic signals.

You could ponder this, or simply read this smart and funny analysis by my colleague Mark Gongloff, who as you will see is still trying to impress his 10th grade English literature teacher (Way too late to change that grade, Mark).

"Thank You America." That's the slogan from AIG's advertising campaign as it seeks to restore its reputation after . . . um, oh, right nearly destroying the world economy. The insurer, which took $182 billion in taxpayer money at the height of the financial crisis in 2008, is pondering joining a $25 billion shareholder lawsuit against the U.S. government that claims the terms of the bailout were too tough.

This is like loading a yacht with crocodiles -- because crocodiles are a great long-term investment, you know, in demand all over the world, especially for some reason in Germany -- sailing to the middle of the Atlantic Ocean, then abandoning ship after those crocodiles eat your crew and gnaw a hole in your hull (the hull is the bottom, right?). So anyway, there you are, adrift, with crocodile bites all over your legs, clinging to a deflating life raft, also filled with crocodiles (WHY WOULD YOU BRING CROCODILES WITH YOU IN THE RAFT?) -- when the entire U.S. Navy steams up, pulls you from the water, and deposits you on shore. You survive, are given money to revive your crocodile-export company (provided you take some minor steps to make it a little bit more safe), but then: well, you ponder joining a shareholder lawsuit against your savior.

The whole thing is being orchestrated by former AIG chief, and king of the crocodiles, Hank Greenberg, by the way.

It's been many years since we could say this, but the housing market is helping to drive the economy again. Mortgage applications for the week ending Jan. 4 shot up 11.7 percent according to the Mortgage Bankers Association, Housing Wire reports. Refinancings are also up, as are interest rates on mortgages, though by just a tad. The housing bubble is dead, long live the housing bubble.

New Foreclosure Settlement Replaces Henhouse Fox With Wolf, Advocates Say

Eleazar David Melendez   |   January 7, 2013   11:00 PM ET

For more than a year, housing advocates and their allies worried that a review of foreclosed loans managed by banking regulators was vulnerable to mortgage industry interference.

On Monday, the Office of the Comptroller of the Currency and the Federal Reserve Board -- the two regulatory bodies that had taken the lead in making the nation’s largest banks accountable for rampant foreclosure fraud -- announced that homeowners no longer need worry about the independence of the reviews. The regulators, essentially admitting that the reviews were too difficult to conduct, and that assigning appropriate compensation to those most harmed by the banks was no longer a priority, said the mortgage companies themselves will determine how to distribute $3.3 billion to more than 4 million homeowners forced into foreclosure in 2009 or 2010.

Housing advocates, while acknowledging that the foreclosure reviews were flawed, said they don't understand how turning the process over to mortgage companies improves a system already insufficiently independent.

"The regulators have decided to replace the fox in the henhouse with the wolf," said John Taylor, president of the National Community Reinvestment Coalition, a Washington-based housing nonprofit. "It is just incomprehensible to me that they could not find a third party that has the wherewithal and independence to fairly determine what the damage is to homeowners."

Regulators said the review process, which sought to determine if specific loans were unfairly foreclosed upon, was too costly and time-consuming. Under the new deal, 10 mortgage companies, including Bank of America, Wells Fargo and JPMorgan Chase, will pay $8.5 billion. Of that, $3.3 billion is earmarked for direct payments to "eligible borrowers" whose foreclosures were handled improperly. The remaining $5.2 billion will help struggling borrowers with programs such as loan modifications.

This new deal is separate from the $25 billion mortgage settlement involving five large banks and the state attorneys general earlier this year, though many allegations of misconduct are the same. Homeowners have complained for more than five years that mortgage companies made widespread errors in the management of home loans, and that in some cases those errors pushed them into foreclosure.

Scrapping the reviews means dismissing the consultants who had already spent hundreds of thousands of man-hours (and more than $1.5 billion) poring through loan files. Regulators will still oversee the new framework by reviewing a sample of the decisions made by the banks, OCC officials said, but will not actively evaluate every case. Instead, the companies -- known as mortgage servicers -- will make broad determinations about who is compensated for lenders' own malfeasance.

Ernie Dobson is one of the 495,000 homeowners who applied for a review. Dobson lost his San Diego home in 2009 to foreclosure while in the midst of a mortgage modification by JPMorgan Chase. He estimated he spent at least 10 hours applying to the foreclosure review. When reached by phone with the news, he said was afraid to tell his wife what he had learned. "I feel fear," he said. "Fear that the person who committed the injustice is now going to be the judge and jury about that injustice."

Many other homeowners -- an additional 3.9 million, according to regulators -- were eligible to apply for the foreclosure review, but never bothered. Some did not know about it, and others may have trashed the confusing application forms by mistake. Still others simply lacked faith that it would be worth their while to apply.

"Most of my clients did not apply because they thought the process was rigged," said Roy Oppenheim, a housing lawyer in Ft. Lauderdale, Fla.

On Capitol Hill, congressional leaders who had asked federal regulators for a briefing on the settlement when rumors started swirling last week, reacted negatively to the announcement.

Rep. Elijah E. Cummings (D-Md.), ranking member of the House Committee on Oversight and Government, said in a statement he was “deeply disappointed” the regulators decided to proceed “before providing Congress answers to serious questions about how this settlement amount was determined, who these funds will go to, and what will happen to other families who were abused by these mortgage servicing companies.”

“I believe that borrowers deserve more answers and transparency than the Federal Reserve and the OCC are currently willing to provide,” Cummings said.

The lack of disclosure -- unusual for such a high-profile agreement shepherded by a bank regulator -- extended to members of the media. OCC officials said they would not provide more than a sketch of the deal Monday, telling reporters the specifics of the settlement may take at least 15 days to be revealed.

Under the new process, OCC officials explained, banks would take the 4.4 million foreclosed mortgages involved in the original review and broadly classify them into 11 “buckets” corresponding to the level of fraud during the foreclosure process. Borrowers with foreclosed loans that fall into the highest-priority bucket, such as foreclosures illegally conducted on U.S. troops while they were fighting overseas, will qualify for a payout of as much as $125,000. Those in the lowest-level group, such as loans with a clerical error, will qualify for at least $250.

Banks will be making all the “slotting” decisions, something OCC officials said was needed to speed the process. Payouts to some borrowers could begin as early as March, OCC officials said. All the aggrieved borrowers will likely get something, if only at the expense of specific determinations of harm being made for those exposed to egregious fraud.

In spite of admitting the new process will not determine “whether or not there was harm” in specific cases, OCC officials contended the latest settlement keeps the Obama administration's promise to discover and correct the wrongs of foreclosure fraud.

“When we began the Independent Foreclosure Review, the OCC pledged to fix what was broken, identify who was harmed, and compensate them for that injury," Comptroller of the Currency Thomas Curry said in a statement. "While today’s announcement represents a significant change in direction, it meets those original objectives by ensuring that consumers are the ones who will benefit.”

The settlement replaces a review criticized as insufficiently independent from the start. ProPublica, an investigative news nonprofit, found that supposedly independent third-party reviewers looking over Bank of America loan files were given the "correct" answers in advance by the bank. These reviewers could override the answers, but they weren't starting from a blank slate.

It was also expensive. Reviews were taking more than 20 hours a loan to file at a cost of up to $250 an hour, according to The New York Times. All told, the banks spent an estimated $1.5 billion on the reviews.

As HuffPost reported last week, the settlement came as the Government Accountability Office, a nonpartisan investigative arm of Congress, was preparing a report critical of the program.

The settlement agreement ncludes Aurora, Bank of America, Citibank, JPMorgan Chase, MetLife Bank, PNC, Sovereign, SunTrust, U.S. Bank, and Wells Fargo.

The original deal included four additional mortgage companies: Ally Financial, EverBank, HSBC and OneWest Bank. The reviews on those loans will continue and are not affected by the settlement.