Ron Panzer, President
Hospice Patients Alliance
4680 Shank Street
Rockford, MI 49341
Presented on December 7, 2006
Tom Gallagher, C.F.O.
State of Florida, Department of Financial Services
Diana Evans, Director & the Board
State of Florida, Division of Funeral,
Cemetery & Consumer Services
Tel. (850)413-3039 Fax (850)413-4087
Re: Why Application by Hope Hospice for Licensure
as Funeral Services Provider Must be Denied
Thank you for the opportunity to speak before this Board of the Florida Division of Funeral, Cemetery & Consumer Services. I am Ron Panzer, hospice and home care nurse and founder and President of the Hospice Patients Alliance, a nonprofit charitable patient advocacy organization serving patients, families, caregivers and hospice staff throughout the United States. I currently provide direct nursing care to patients who are terminally ill or to patients who are chronically ill in a home care setting, as well as serving the public through my services at Hospice Patients Alliance. I have written two books on hospice and end-of-life care: The Hospice Patients Alliance Family Guide to Hospice Care and The Heart of End-of-Life Care as well as many articles about hospice and palliative care.
I have been consulted about hospice and end-of-life care issues by numerous news media outlets including the St. Petersberg Times, CNN, ABC news, the A.P., the Washington Post, Chicago Tribune, USA Today and many others. I have also provided information to the Congressional Government Accountability Office. Our Vice-President, Barbara Becker has provided testimony directly before Congress’s Senate Committee on Aging.
The Hospice Patients Alliance mission is to promote excellence in end-of-life care whether provided in a hospice or other health care agency. We strongly support the original hospice mission which is to care and provide support for the dying, relieve the symptoms of their terminal illnesses till a natural death occurs in its own natural timing.
We provide information regarding hospice and end-of-life care to hundreds of thousands of individuals throughout the United States each year through our website at www.hospicepatients.org which contains the most detailed explanation of the hospice standards of care, governmental regulations and services, available on the internet. We assist the public in resolving difficulties encountered at the end-of-life, whether in a hospice, nursing home or other setting. We serve as a watchdog group for the hospice industry and have received complaints from all over the country regarding some hospices that transgress the regulations governing the industry. We are uniquely positioned to be aware of the realities occurring in the hospice industry.
Hospice as an industry has enjoyed unprecedented and continuing public approval, promotion and protection. It is the “sacred cow” of health care in that nothing seriously negative about the industry is allowed to be publicized in the major media; this is in part due to the vast effort put forth by the federal and state governments to promote hospice (since it saves the federal and state governments billions of dollars on the health care budget), in part due to the very significant and ongoing purchases by hospices of advertising in the print, radio and television media, in part due to the predominantly charitable or nonprofit nature of many hospice corporations and the fundraising done by many in the business community for local hospice agencies, and because the plan put into place by the national healthcare policymakers is that utilization of hospice will increase each year till virtually all individuals die within hospice.
Hospice, as an industry, is booming and enjoying increased business and utilization in a range from 15% to 20% per year during many of the previous years. Some who move into hospice ownership or administration as a business undertaking (whether nonprofit or for profit) are not dedicated personally to the original mission of hospice; some are in the industry because they wish to seize a business opportunity and have entered the field to make a lot of money. Top administrators in some of the larger hospices command quite “handsome” salaries in the several hundred thousand dollar range. In many areas, hospice is fiercely competitive with regard to the procurement of referrals from local physicians, hospitals, nursing homes, and other agencies.
The United States Justice Department, Office of Inspector General, has repeatedly warned the public about unfair and fraudulent business practices that have occurred in some hospice agencies. An attachment from the US OIG about unethical and illegal hospice practices and “Fraud & Abuse in Nursing Home arrangements with Hospices,” along with a notice about Odyssey Hospice paying $12.9 million to the government in July, 2006 to settle the hospice fraud case it was involved in, are presented to demonstrate that hospices may, in fact, and do engage in business practices that are unethical and illegal for financial gain. This does not mean that all hospices are engaging in such practices, but clearly it is certain that some will do so; the point being that hospice as an industry is not immune to the problems of unethical business practices that are well-known to impact every other industry in society.
Any hospice agency is a health care provider, and patients in a hospice are extremely vulnerable, physically, emotionally, psychologically as well as economically. This board needs to be vigilant with regard to the potential for harm to the public that will certainly arise as a result of any hospice becoming dually licensed as a funeral services provider.
Hospice agencies are administered and staffed by human beings, just like any other industry, and are therefore subject to the same temptations to violate standards of care or laws as any other industry, and they have done so in some cases. It is disingenuous for any hospice administrator to express dismay that the public would express serious reservations and outrage about a hospice becoming dually licensed as a funeral home and that the public is deeply concerned about the glaring conflicts of interest which would of necessity provide incentives for the hospice to steer business into its own funeral home while exerting undue influence and intimidation upon the patients and their families, simply because it is the agency caring for the patients and has a “captive audience” with the patients and family under their control, and the lives of the patient literally in their hands!
The funeral, cemetery and memorial services industry provides a vital service to the public and is regulated by the State of Florida in order to promote public health, welfare and safety.
This Board is not only vested with the authority to approve or deny an application for licensure as a funeral services provider, this Board is obligated to approve or deny such applications based upon the criteria set forth in the Florida Statutes, especially Title XXXIII, chapter 497.103 and the Florida Administrative Code Rule 69K.
There are rare instances where members of a State Board, acting in their usual and customary role, have the opportunity to drastically alter the balance in society and to potentially completely change the industry being regulated. This application by a hospice (to become dually licensed as a funeral services provider as well) is such an instance.
An independent funeral services industry is vital to the welfare of the residents of the State of Florida. An independent funeral home industry serves as an important protective link among others that provide a “check,” or oversight, to the health care industry. The health care industry and the funeral services industry are closely related since the dying are served by the health care industry and then transferred upon death to the funeral services industry. The two industries must be kept separate in order to retain the integrity of both industries. To join the two, with the capability of dually licensing any health care agency as a funeral services provider as well, would certainly taint the integrity of the agency eventually, would destroy the sense of trust that the public has in either, and would be the direct cause of serious harm to the public.
A health care agency or hospice that is licensed both as a health care agency and a funeral services provider (a “dually licensed hospice”) will be placed into a position where a conflict of interest certainly exists and cannot be avoided, no matter how ethical or idealistic its CEO or administrators are at the current time.
Whether nonprofit or for profit, a dually licensed hospice (and its staff) would have a monetary incentive to act in ways that increase its revenue in the funeral services business which would very likely alter the usual decision-making within the health care agency.
Health care agencies and their staff physicians, nurses, social workers, counselors (and other staff) literally hold the lives and well-being of the patients in their hands, and the patients place great trust in those who serve them in a health care setting.
Patients in a hospice are among the most vulnerable of all patients, physically, emotionally, psychologically, spiritually and economically and, in a majority of hospice cases, are elderly and/or disabled as well as suffering from their terminal illness.
Hospice exists to relieve the symptoms experienced by patients as they approach the end-of-life and it exists to allow a natural death in its own timing. Hospice agency staff have for decades stated that hospice neither prolongs life nor attempts to hasten death. Having a dually licensed hospice would tip the scales in favor of hastening death at a point in the patients’ stay at a hospice, for financial reasons.
While quite unknown to the public, and perhaps to this Board, hospice is an industry experiencing fiercely competitive business practices, some of which are unethical, anticompetitive and damaging to other hospice agencies. Some of the larger hospice agencies (whether nonprofit or for profit) have worked to squeeze out smaller hospices, working to corner the market on referrals to hospice from physicians, hospitals and nursing homes (especially) in the community they serve. Kickbacks, mentioned by the US Dept of Justice OIG, serve the purpose of assuring referrals to the hospice, to the detriment of the other smaller hospices in the community.
Hospice is being promoted by the state and federal governments as well as private insurance carriers, as a way to save billions of dollars formerly spent on futile treatment and stays at the acute care hospitals where attempts were made to cure the incurable terminal illness. The federal Medicare hospice benefit was created in the early 1980s with the express purpose of saving billions of dollars compared to acute hospital care and would never have been created if there were no budgetary savings. The state Medicaid hospice benefits were also created for the same reasons. The huge financial benefits to the budgetary process, at both the state and federal levels, serve as an overwhelming force in the push to increase utilization of hospice by the terminally ill.
Because national and state policymakers have irrevocably chosen to steadily increase utilization of hospice services, the pressures exerted upon the terminally ill to enter hospice is extremely strong, coming from physicians, nurses, hospital discharge workers, social workers, counselors and many others. The plan is that all patients (or nearly all) enter hospice at the end-of-life.
Because of the increasing role of hospice in society, the integrity of the hospice industry is vital to the welfare of the society. If a hospice were to become dually licensed, the hospice would enjoy an unfair competitive advantage over any independent funeral home, because the patients would be subject to the control or influence of the hospice and its staff. Simply being a patient in a health care facility makes a patient subject to intimidation or undue influence with regard to decisions suggested by the health care facility staff, should those suggested decisions involve the use of the health care facility’s other business: funeral services. The dually licensed hospice would necessarily and inescapably exert an undue influence that would in many cases coerce the patient and family to choose to purchase services from the hospice’s own funeral home business.
The dually licensed hospice would necessarily and inescapably be engaged continuously and unceasingly in a solicitation to sell its funeral services to the patient and/or family. Patients and family would, upon admission to the dually licensed hospice (and quite likely even before admission) be made aware of the funeral services available at the hospice (through the hospice’s literature as well as verbal representations to that effect), and would be encouraged to use such funeral services under many pretexts, whether the “convenience,” staff recommendations, or simple physical proximity. Hospices have been known to pay commissions to its staff for the procurement of hospice patients. See the attached Washington Post article, "Hospices Big Business, Thanks to Medicare, "Exploitation of Some Patients is Alleged.” Why would some unethical hospices even hesitate to pay commissions to its staff to induce funeral services contract sales?
The promises made (by a financially-interested hospice applicant for a funeral services license) that it would allow “freedom of choice” in funeral services for all patients, ring hollow, as a dually licensed hospice would of necessity be interested in promoting its own “other business,” the funeral services. The plaintive declarations of such hospice owners and CEOs as to the professed ethical unassailability approach the ridiculous in a fantastic, Polyannish evaluation of the realities of human nature, business, and hospice in particular.
This Board has already promulgated Rules regarding the residential solicitation to a person or family, Florida Administrative Code Rule 69K-9.002 which states, in part (3):
“No licensee or preneed licensee, officer, director, employee, or agent shall knowingly initiate, conduct, or attempt to conduct pre-need residential solicitation, for the purpose of selling or other transfer of burial rights, merchandise, or services, of any person, or of any family of any person, who is suffering ill health except upon the prior express request of the person solicited.”
A dually licensed hospice would, of necessity, be continually (if only subliminally at some times and overtly at other times) soliciting persons who “suffer from ill health” and that is forbidden by this Rule (unless expressly requested beforehand by the person solicited). How would a dually licensed hospice avoid soliciting an ailing person when their very literature would mention their funeral services business and staff would likely mention it with an intimidating and undue influence simply because they were caring for the patient.
This Board has already promulgated Rules regarding the solicitation to residents or patients in health care facilities: Florida Administrative Code Rule 69K-9.003 part (3), which states:
“The Board finds that the uninvited solicitation of sales for burial rights, funeral merchandise or funeral services of persons who are residents of or patients in healthcare facilities is not in the public interest and constitutes intimidating, overreaching and vexatious conduct. Such solicitation constitutes an uninvited invasion of personal privacy.”
How would a dually licensed hospice avoid soliciting patients when its literature would be designed to promote and market such services, and its staff would be encouraged to promote the sale of the funeral services at the hospice? It could not! A dually licensed hospice would, of necessity, be soliciting patients in a health care facility, and this is expressly forbidden by this Rule.
Common sense informs us that any patient in a health care facility (a hospice) when solicited for funeral services would be subject to intimidating, overreaching and vexatious conduct, and would, in fact be an “uninvited invasion of personal privacy,” as this Board has already determined in this rule!
Florida Statute Title XXXIII, chapter 497.152 enumerates grounds for discipline and termination of a funeral services provider’s license. In particular, Subsection (9)(a) forbids:
“Soliciting by the licensee, or by her or his agent, assistant, or employee, through the use of fraud, undue influence, intimidation, overreaching, or other means that takes advantage of a customer's ignorance or emotional vulnerability.”
A dually licensed hospice would, of necessity, exert undue influence on vulnerable terminally ill patients, some of whom might fear not receiving proper hospice care should they refuse the hospice’s own funeral services. The patients would, of necessity, be intimidated, and the hospice would, unavoidably, be placed in a position to take advantage of the patients’ emotional (and other) vulnerabilities.
Subsection (9)(b) forbids:
“Exercising undue influence on a client for the purpose of financial gain of the licensee or a third party in connection with any transaction regulated by this chapter.”
The dually licensed hospice would, of necessity and unavoidably, exercise undue influence and would do so, of course, for its own financial gain in connection with sales transactions for its funeral services.
Subsection (15)(c) forbids:
“Paying to or receiving from any organization, agency, or person, either directly or indirectly, any commission, bonus, kickback, or rebate in any form whatsoever for any business regulated under this chapter, whether such payments are made or received by the licensee, or her or his agent, assistant, or employee; however, this provision shall not prohibit the payment of commissions by a funeral director, funeral establishment, cemetery, or monument establishment to its preneed agents licensed pursuant to this chapter or to licensees under this chapter.”
The dually licensed hospice would be engaged (by its very nature as duallyl licensed) in the equivalent of these very forbidden practices, as funds received as the result of solicitation and sales of its funeral services would, of necessity, be enjoyed by the hospice agency as hospice agency, and the hospice as funeral services provider would enjoy the benefit of the equivalent of these forbidden practices.
Dually licensing a hospice agency would enshrine the practices of kickbacks, rebates, bonuses (or any other forms of forbidden financial incentives) into the very corporate and legal, licensed structure of the dually licensed hospice. Dually licensing a hospice agency would contradict the very principles which form the basis of most of the Florida Statutes and Rules which serve to protect the public with regard to the funeral services industry!
The Florida Legislature has determined, in Title XXXIII, chapter 497.164(2), that this Board:
“shall regulate such solicitation to protect the public from solicitation which is intimidating, overreaching, fraudulent, or misleading; which utilizes undue influence; or which takes undue advantage of a person's ignorance or emotional vulnerability.
The dually licensed hospice would, of necessity, engage in such forbidden practices and therefore, this Board is statutorily required to deny the hospice’s application for licensure as a funeral services provider.
The Florida Legislature has determined, in Title XXXIII, chapter 497.164(5), that:
“At-need solicitation of sales of burial rights, merchandise, or services is prohibited. No person may contact the family or next of kin of a deceased person to sell services or merchandise unless the person has been initially called or contacted by the family or next of kin of such person or persons and requested to provide services or merchandise.”
A dually licensed hospice would, of necessity, engage in such forbidden practices and therefore this Board is statutorily required to deny the hospice’s application for licensure as a funeral services provider.
The intent of the Florida Statutes regarding the licensure of funeral service providers is (see Title XXXIII, chapter 497.103(4)(a)(1) among other statutes) to:
“Protect… the public from any significant and discernible harm or damage.”
A dually licensed hospice would be placed in a position to significantly and discernibly harm or damage the patients and the families being served, whether financially through undue influence, intimidation or unfair solicitations, or through actual medical killing of the patient to eliminate expenditure for services rendered past the cap placed on reimbursement for hospice services.
Federal and state reimbursements to a hospice agency (as well as reimbursements from private insurers) are not unending. There are specific monetary “caps” placed on reimbursement to a hospice. See the Hospice Patients Alliance webpage at:
for more information. Hospice is reimbursed on a per-diem basis for each day the patient is enrolled to receive hospice services, however a cap is placed on the total reimbursement received per patient by the patient in any one year. Plain and simply put, the patient might be killed to eliminate expenditures on the patient for needed services, once no further reimbursement could be obtained from Medicare, Medicaid or a private insurer. A dually licensed hospice would have the additional monetary incentive of receiving payment for funeral services rendered.
We at Hospice Patients Alliance have received reports from families all across the United States that their loved ones were medically killed (through various means) in a hospice, quite often after the terminally ill patient failed to die within the six month or one year period. When hospices enroll the terminally ill as patients, the patient is normally expected to die within six months or less, given the usual course of the terminal illness. This is what is meant when the physician “certifies” the patient as being “terminal,” though some patients live much less than six months and some live much longer.
As you have already seen, the US Dept. of Justice, OIG, is focused on preventing Medicare fraud. Any hospice that retains a patient past a year or so, is sending out “red flags” to the Medicare fiscal intermediaries that transact the business of hospice and Medicare reimbursements. Having many patients live “too long” in hospice invites an intense OIG federal investigation of the hospice’s business practices, something no hospice would wish to entertain. Therefore, killing the patient who lives too long serves the purpose of minimizing the likelihood of a federal investigation, and also would benefit the dually licensed hospice with added revenue through its funeral services business. An endless supply of the dying removes any concern (some might imagine existing) about the elimination of the patient. Reimbursement for “X” number of patients continues, whether one patient or another, so long as the patients are enrolled in the hospice.
The intent of the Florida Statutes regarding the licensure of funeral service providers is (see Title XXXIII, chapter 497.103(4)(a)(2) among other statutes) to:
“Preventing the unreasonable restriction of competition or the availability of professional services in the state or in a significant part of the state.”
At this time, the approval of a hospice’s application for licensure as a funeral services provider might seem to increase the competition in the funeral services industry, however the Board needs to keep in mind the long-range implications of such a potential licensure approval. As we have seen, national and state policymakers intend that hospice as an industry expand so that utilization increases steadily, yielding huge budgetary savings to the state and federal governments.
If hospices are allowed to become dually licensed, more and more hospices will join in this practice of being dually licensed (why would they not if this Board allows it?). It is likely that over a period of years (ten or twenty perhaps) all, or virtually all, hospices would become dually licensed, since any hospice that was dually licensed would enjoy a financial advantage over other non-dually licensed hospices and would stand a higher chance of surviving in the fiercely competitive hospice industry environment.
If most, or many, hospices become dually licensed (which will certainly occur should this Board approve this unfortunate and misguided hospice’s application for licensure as a funeral services provider), then the hospices throughout Florida will enjoy an unfair advantage in obtaining referrals for funeral business, as they have a “captive audience” of dying patients, ready to be plundered for any and all funeral services that could be sold to the vulnerable patients and families. The independent funeral homes in the State of Florida will be devastated should this Board approve hospices as funeral service providers as well, and such a move by the Board would be contrary to the afore-mentioned Florida statute: Title XXXIII, chapter 497.103(4)(a)(2).
Approving a hospice agency as a funeral services provider would encourage higher prices in the industry (without a benefit to the public) since the hospice could successfully sell its services at higher prices. The hospice could sell its funeral services at higher prices because patients and their families are subject to intimidation, undue influence and even coercion due to the circumstances of being a patient served by a health care provider that also is licensed as a funeral services provider.
I have received reports from funeral home directors of hospices manipulating families to use a specific funeral home, where prices charged for funeral services are higher than usual, and kickbacks to the hospice for such referrals are likely. Such funeral home directors report sharp decreases in their business, as hospice increasingly manages the dying and the transfer of the deceased to the funeral homes.
In addition to all the aforementioned reasons for denying the hospice’s application for licensure as a funeral services provider, this Board must be aware of the societal currents flowing unseen beneath the “radar” of the media. Hospice as an industry was started in modern times by Dame Cicely Saunders in the United Kingdom. She was a prolife, Christian nurse and physician who saw hospice as the ideal way to care for the dying. She strongly opposed assisted suicide and euthanasia. See:
In the United States, however, hospice was promoted by Florence Wald, RN, a Professor Nursing at Yale University and who founded the first hospice in the United States, the Connecticut Hospice. Florence Wald strongly supports euthanasia and assisted suicide and stated that these should be available to a patient for “physical, emotional, psychological, spiritual and economic reasons.” Whose economic reasons? Certainly not the patient’s! The family’s? Society’s economic reasons? Where does that line of reasoning take us: directly to euthanizing (medically killing) the patient for the economic benefit of the family and/or society.
Some studies suggest that up to 50% of physicians and nurses in the United States approve of assisted suicide while the rest oppose it. Hospice as an industry is engaged in a civil war, a struggle between those who support and respect the sanctity of life, those who would never give a lethal agent to cause death, and between those who support ending life if the quality of life is judged (subjectively I might add) to be “inadequate.” This is the line of thinking taken by the Nazis in Germany who determined that some were “unworthy of life,” and were considered “useless eaters.” A hospice that is dually licensed as a funeral services provider (should it not respect the sanctity of life and not pledge itself to never administer lethal agents to cause death) would stand in a position to involuntarily euthanized (medically kill) patients and then cover up evidence of such crimes by destroying the body of the patient. In addition, it would stand to financially benefit from such crimes by receiving payment as a result of its crimes.
The elderly and disabled and the terminally ill are subject to abuse, neglect and worse within some health care settings, as demonstrated by the Congressional research findings of Representative Henry A Waxman. See http://www.democrats.reform.house.gov/story.asp?ID=588&Issue=Nursing+Homes
“In the last two years, nearly one out of every three nursing homes in the United States has been cited for violating federal standards established to prevent abuse of nursing home residents. In over 1,600 of the nursing homes cited for abuse violations, the violations caused actual harm to residents or placed residents in immediate jeopardy of death or serious injury."
Hospices regularly work with nursing home patients as well as patients in their own homes. A dually licensed hospice would be placed in a position to cover up any crimes of abuse, neglect or medical killing, through the use of its funeral services, and the oversight role of an independent funeral services industry would be circumvented. For this and the aforementioned reasons, Hospice Patients Alliance strongly urges this Board to deny the hospice’s application for licensure as a funeral services provider.
Ron Panzer, President
for Hospice Patients Alliance