Cordt Kassner, PhD CEO, Hospice Analytics The Impact of Evidence-based Practices on Current and Future Hospice Trends A Proud Supporter Of Cordt Kassner, PhD CEO, Hospice Analytics April 11, 2016

Introduction & Background Cordt T. Kassner, PhD CEO Hospice Analytics 2355 Rossmere Street Colorado Springs, CO 80919 P: 719.209.1237 E: CKassner@HospiceAnalytics.com W: www.HospiceAnalytics.com www.HospiceAnalytics.com 2

Evidence-based Practices in Hospice & Palliative Care Topics Evidence-based Practices in Hospice & Palliative Care Hospice Payment Methodologies Regulations & Public Policy The Future of Hospice www.HospiceAnalytics.com 3

Evidence-based Practices in Hospice & Palliative Care

This slide shows utilization of hospice services among: Hospice Utilization = #Medicare beneficiary deaths in hospice / #Medicare deaths. National average is 45.9% (absolute maximum possible probably about 70%). www.HospiceAnalytics.com 5

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2014 Demographics & Hospice Utilization Oregon Washington National Population 3,970,239 7,061,530 318,750,821 Total Deaths 33,295 52,257 2,593,535 Medicare Beneficiaries 762,349 1,201,611 55,371,221 Medicare Beneficiary Deaths 27,757 42,224 2,104,171 Medicare Hospice Beneficiary Admissions 19,187 72% of Medicare deaths 24,235 57% of Medicare deaths 1,320,405 63% of Medicare deaths Medicare Hospice Beneficiary Deaths 14,656 52.8% of Medicare deaths 18,322 43.4% of Medicare deaths 965,882 45.9% of Medicare deaths Medicare Hospice Total Days of Care 1,109,883 Days 1,378,125 Days 90,781,803 Days Medicare Hospice Mean Days / Beneficiary Medicare Hospice Median Days / Beneficiary 58 Days 23 Days 57 Days 22 Days 69 Days Medicare Hospice Total Payments Medicare Hospice Mean Payment / Beneficiary $188,558,194 $9,828 $243,224,404 $10,037 $14,922,383,020 $11,313 www.HospiceAnalytics.com 11

2013 Demographics & Hospice Utilization Oregon Washington National Population 3,930,065 6,971,406 316,022,508 Total Deaths 32,529 51,052 2,529,792 Medicare Beneficiaries 734,877 1,155,920 53,838,457 Medicare Beneficiary Deaths 27,836 41,560 2,081,847 Medicare Hospice Beneficiary Admissions 19,368 70% of Medicare deaths 24,021 58% of Medicare deaths 1,304,994 63% of Medicare deaths Medicare Hospice Beneficiary Deaths 14,827 53.3% of Medicare deaths 17,961 43.2% of Medicare deaths 946,017 45.4% of Medicare deaths Medicare Hospice Total Days of Care 1,312,213 Days 1,385,256 Days 91,044,459 Days Medicare Hospice Mean Days / Beneficiary Medicare Hospice Median Days / Beneficiary 58 Days 24 Days 23 Days 70 Days Medicare Hospice Total Payments Medicare Hospice Mean Payment / Beneficiary $191,544,733 $9,890 $240,695,096 $10,021 $14,917,921,218 $11,444 www.HospiceAnalytics.com 12

2014 Hospice Utilization (Medicare Hospice Deaths / Total Medicare Deaths) www.HospiceAnalytics.com 13

2013 Hospice Utilization (Medicare Hospice Deaths / Total Medicare Deaths) www.HospiceAnalytics.com 14

2014 Hospice Utilization x County – OR (Medicare Hospice Deaths / Total Medicare Deaths) 52.8% National: 45.9% www.HospiceAnalytics.com 15

2013 Hospice Utilization x County – OR (Medicare Hospice Deaths / Total Medicare Deaths) 53.3% National: 45.4% www.HospiceAnalytics.com 16

2014 Hospice Utilization x County – WA (Medicare Hospice Deaths / Total Medicare Deaths) National: 45.9% WA: 43.4% www.HospiceAnalytics.com 17

2013 Hospice Utilization x County – WA (Medicare Hospice Deaths / Total Medicare Deaths) National: 45.4% WA #26: 43.2% www.HospiceAnalytics.com 18

Change in Hospice Utilization 2013-2014 (Medicare Hospice Deaths / Total Medicare Deaths) www.HospiceAnalytics.com 19

Change in Hospice Utilization 2012-2013 (Medicare Hospice Deaths / Total Medicare Deaths) www.HospiceAnalytics.com 20

2005-2014 Hospice Utilization 10 Year Trend Note: Hospice Utilization= Medicare Hospice Deaths / Total Medicare Deaths. www.HospiceAnalytics.com 21

2014 Medicare Hospice Admissions National= 1,320,405 www.HospiceAnalytics.com 22

2013 Medicare Hospice Admissions National= 1,303,602 www.HospiceAnalytics.com 23

2014 Medicare Total Days of Hospice Care National= 90,781,803 Days www.HospiceAnalytics.com 24

2013 Medicare Total Days of Hospice Care National= 91,044,459 Days www.HospiceAnalytics.com 25

2014 Medicare Hospice Mean Days of Care / Beneficiary National: 69 OR: 58 WA: 57 www.HospiceAnalytics.com 26

2013 Medicare Hospice Mean Days of Care / Beneficiary National: 70 OR: 58 WA: 57 www.HospiceAnalytics.com 27

2005-2014 Hospice Mean Days of Care 10 Year Trend www.HospiceAnalytics.com 28

2014 Medicare Hospice Median Days of Care / Beneficiary OR: 23 National: 23 WA: 22 www.HospiceAnalytics.com 29

2013 Medicare Hospice Median Days of Care / Beneficiary OR: 24 National: 24 WA: 23 www.HospiceAnalytics.com 30

2005-2014 Hospice Median Days of Care 10 Year Trends www.HospiceAnalytics.com 31

2014 Medicare Hospice Total Medicare Reimbursement / Beneficiary National= $14,922,383,020 WA: $243,224,404 OR: $188,558,194 www.HospiceAnalytics.com 32

2013 Medicare Hospice Total Medicare Reimbursement / Beneficiary National= $14,917,921,218 WA: $240,695,096 OR: $191,544,733 www.HospiceAnalytics.com 33

2014 Medicare Hospice Mean Medicare Reimbursement / Beneficiary www.HospiceAnalytics.com 34

2013 Medicare Hospice Mean Medicare Reimbursement / Beneficiary WA: $10,021 OR: $9,890 www.HospiceAnalytics.com 35

2014 Medicare Hospice Beneficiaries Top Six ICD-9 PRIMARY Diagnoses (out of 19 categories) www.HospiceAnalytics.com 36

2013 Medicare Hospice Beneficiaries Top Six ICD-9 PRIMARY Diagnoses (out of 19 categories) www.HospiceAnalytics.com 37

2014 Medicare Hospice Beneficiaries Status at Discharge www.HospiceAnalytics.com 38

2013 Medicare Hospice Beneficiaries Status at Discharge www.HospiceAnalytics.com 39

2014 Medicare Hospice Beneficiaries Race: Medicare Beneficiaries vs 2014 Medicare Hospice Beneficiaries Race: Medicare Beneficiaries vs. Hospice Admissions 4.0% Minority 7.2% Minority 7.1% Minority 12.2% Minority 12.7% Minority 18.9% Minority www.HospiceAnalytics.com 40

2013 Medicare Hospice Beneficiaries Race: Medicare Beneficiaries vs 2013 Medicare Hospice Beneficiaries Race: Medicare Beneficiaries vs. Hospice Admissions 4.0% Minority 6.9% Minority 6.9% Minority 11.8% Minority 12.5% Minority 18.6% Minority www.HospiceAnalytics.com 41

2014 Medicare Hospice Beneficiaries Levels of Care (days) www.HospiceAnalytics.com 42

2013 Medicare Hospice Beneficiaries Levels of Care (days) www.HospiceAnalytics.com 43

2014 Medicare Hospice Beneficiaries Locations of Care (days) Note: Oregon has an unusually high number of days in the “Not Otherwise Specified” location of care. www.HospiceAnalytics.com 44

2013 Medicare Hospice Beneficiaries Locations of Care (days) Note: Oregon has an unusually high number of days in the “Not Otherwise Specified” location of care. www.HospiceAnalytics.com 45

InfoMAX Review OR/WA information www.HospiceAnalytics.com 46

Physician Reports

Step 1: Where We Started 2014 Medicare Records by Provider Type www.HospiceAnalytics.com 48

Step 2: Added Years Medicare files are available by calendar year – so to take the date of hospice admission and look back 365 days typically requires two years of data. Therefore, to run 2014 reports, we combined 2014 and 2013 records to look back 365 days. To run 2013 reports, we combined 2013 and 2012 records to look back 365 days. We wanted to provide you the ability to trend physician patterns over a two year period from the beginning. www.HospiceAnalytics.com 49

Step 3: How the Look Back Works Specify years and counties Step 2 We identify all Medicare beneficiaries admitted to hospices located in selected years and counties Step 3 We identify all Hospice, Hospital, Home Health, Skilled Nursing, and Outpatient records for each beneficiary over the 365-days prior to hospice admission www.HospiceAnalytics.com 50

Step 3: How the Look Back Works We identify all Primary Attending Physicians listed in these records Step 5 We identify all records associated with these physicians Step 6 Finally, we circle back and link these physicians to how many of their beneficiaries were served by each hospice www.HospiceAnalytics.com 51

For Example… Login to InfoMAX at www.HospiceAnalytics.com/InfoMAX:

For Example… Let’s take a quick look at the Hospice Physician Report for Seattle (King, Pierce, and Snohomish Counties). www.HospiceAnalytics.com 53

Hospice Payment Methodologies

Health Affairs Blog

Acknowledgements This presentation is based on a Health Affairs Blog, “Evaluating A New Era In Medicare Hospice And End-Of-Life Policy” published online 12/22/15 at http://healthaffairs.org/blog/2015/12/22/evaluating-a-new-era-in-medicare- hospice-and-end-of-life-policy. Authors: Donald Taylor, PhD; Nrupen Bhavsar, PhD; Matthew Harker, MPH MBA; and Cordt Kassner, PhD. Taylor, Bhavsar, and Harker are all on faculty at Duke University; Kassner is CEO of Hospice Analytics. www.HospiceAnalytics.com 56

The Three Biggest Changes in Hospice Policy On January 1, 2016, Medicare is implementing three major policy changes to the Medicare Hospice Benefit, each of which individually would be the most consequential modification to the benefit since its inception: Hospice Reimbursement Reform Payment for Advanced Care Planning Discussions Medicare Care Choices Model www.HospiceAnalytics.com 57

The Three Biggest Changes in Hospice Policy This presentation will: Briefly review each policy change Discuss implications of each policy change Pose several questions and metrics to be used in evaluating each policy change www.HospiceAnalytics.com 58

Hospice Reimbursement Reform Review of the Policy change: Historically hospice has been reimbursed based on a per diem (in 2015, $159.34 per day for Routine Home Care (RHC)). Reimbursement for other levels of care are detailed on the following slide. The Medicare Hospice Benefit also includes a spending restraint termed the Aggregate Cap (in FY2015, the Aggregate Cap amount= $27,382.63). Now… Hospices are reimbursed with a two-tiered methodology: More during the first 60 days of admission ($186.84 per day for RHC) Less for days 61+ ($146.83 per day for RHC) Plus a Service Intensity Add-On ($38.75 per hour for RHC) for in-person Nursing and Social Work visits during the last week of life www.HospiceAnalytics.com 59

Hospice Reimbursement Reform www.HospiceAnalytics.com 60

Summary of the 8/6/15 Hospice Final Rule www.HospiceAnalytics.com 61

Hospice Reimbursement Modeling (2014 data) (based on levels of care only, no SIA or wage index adj.) www.HospiceAnalytics.com 62

Hospice Reimbursement Reform Implications of the Policy change: “This changes everything regarding how hospices collect information”. Average Daily Census may not be as important as Live Length of Stay. The prior flat per diem reimbursement encouraged providers to pursue a 180-day mean length of stay – maximizing potential revenue while avoiding the Aggregate Cap. Will the new two-tiered reimbursement methodology encourage providers to pursue a 67-day mean length of stay to maximize potential revenue? Does a shorter length of stay increase or decrease the likelihood of hospices providing comprehensive, high quality care? Will increased reimbursement for shorter length of stay patients push hospices towards the Aggregate Cap? www.HospiceAnalytics.com 63

Hospice Reimbursement Reform Implications of the Policy change: Will the Service Intensity Add-On change the number of Nursing and Social Work visits in the last week of life? How will the focus on patients “discharge alive” change, given the new payment methodology? Will the Service Intensity Add-On decrease chaplain utilization in the last week of life? www.HospiceAnalytics.com 64

Hospice Reimbursement Reform Evaluation of the Policy change: Will the payment changes increase shorter lengths of stay, and decrease longer lengths of stay, in hospice? Will the changes impact quality of care and quality of life for hospice patients? Will overall Medicare costs be affected? Will Nursing and Social Work visits increase during the last week (or month) of life? www.HospiceAnalytics.com 65

Hospice Reimbursement Reform Evaluation of the Policy change: Will increased visits during the last week of life result in higher patient satisfaction or better quality performance measures? How will Service Intensity Add-On payments impact Aggregate Cap calculations? How will additional Service Intensity Add-On payments impact overall hospice costs? www.HospiceAnalytics.com 66

Regulations & Public Policy

Payment for Advance Care Planning Discussions Review of the Policy change: Advance Care Planning (ACP) discussions support patient autonomy and choice by having informed discussions with healthcare professionals regarding realities and consequences of decisions made for end-of-life care. However, historically these conversations have not been reimbursed, and therefore occurred infrequently. Now… Two CPT Codes have been issued to reimburse ACP discussions. 99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate ($85.99 for first 30 minutes) 99498: As above, each additional 30 minutes ($74.88 for additional 30 minutes) www.HospiceAnalytics.com 68

Payment for Advance Care Planning Discussions Implications of the Policy change: Reimbursement is low – will anyone do this? Will it really change anything? What about training in conducting ACP discussions? Without qualified, trained professionals conducting these discussions, will anything improve? Are we reinventing “death panels”? Is this an opportunity for hospices to “own” ACP discussions? Hospices can train people and work with local hospitals and others to conduct these conversations. Will they? Hopefully ACP discussions will drive more people to hospice who otherwise may not have elected hospice. www.HospiceAnalytics.com 69

Payment for Advance Care Planning Discussions Evaluation of the Policy change: Will ACP discussions affect what care patients decide to receive? Will this result in more frequent and earlier hospice admission? How might these discussions impact referrals to palliative care? www.HospiceAnalytics.com 70

Medicare Care Choices Model Review of the Policy change: Historically Medicare beneficiaries had to choose either curative care or hospice – they could not have both. Now… The Medicare Care Choices Model tests the general notion of receiving curative care and concurrently receiving hospice. A 2014 study by Tayor found ~40% of Medicare beneficiaries with cancer would be willing to forgo some medical care in return for the flexibility of concurrent palliative care. Eligible participants in the Care Choices Model must be hospice eligible – meaning they could elect the hospice benefit, but are choosing not to in order to also receive curative care. www.HospiceAnalytics.com 71

Medicare Care Choices Model Implications of the Policy change: 141 Hospices nationally have been selected to participate in the Medicare Care Choices Model. www.HospiceAnalytics.com 72

Medicare Care Choices Model Implications of the Policy change: Participating hospices will only receive $400 per month per beneficiary. Certainly this will result in “abbreviated hospice services”. Will hospices provide similar services for $400 per month, or might this lead to inconsistency? For those receiving abbreviated hospice services, will that diminish their overall experience and expectations of hospice? Will concurrent care result in additional hospice referrals, or less? Will concurrent care result in additional palliative care, or less? How will quality be assessed? www.HospiceAnalytics.com 73

Medicare Care Choices Model Evaluation of the Policy change: What case mix of care will be provided under the demonstration? How will patient quality of life be affected? What proportion of demonstration patients will elect hospice? What will the demonstration project disenrollment rate be? Will there be other demonstrations of the concurrent palliative care concept that result in earlier delivery of palliative care, before patients become hospice-eligible? www.HospiceAnalytics.com 74

Additional Outcomes How will outcomes be attributed to policy changes? This is an important question requiring careful study, raising some additional questions: How much change in outcomes is ‘good enough’? Related, there is a hole in Medicare data – no Medicare Advantage information is available. We will need good proxies for advance care planning payments – allowing comparisons of groups receiving ACP discussions vs. those without. This is similar to challenges faced with identifying palliative care in claims. Full-scale evaluation of the Medicare Care Choices Model? www.HospiceAnalytics.com 75

Quality Rankings

Summary of the Quality Metrics We are currently reviewing 34 hospice quality metrics, e.g.: Percentage of beneficiaries who died or were discharged in <7 days. Utilization of each of the four levels of care. Hospice provides its own hospice trained nurses to provide or direct the GIP care wherever that care is provided (hospital, hospice facility, SNF). Mean number of nurse (RN, LPN) visits per beneficiary receiving Routine Home Care is 2.5x/week or greater.

Summary of the Quality Metrics We plan to integrate educational information into the National Hospice Locator (www.NationalHospiceLocator.com). At this point, we do not plan to publically release quality ranking scores for each hospice in the country.

CMS TEP Updates

CMS Technical Expert Panels on Hospice Quality (per publically available information) Hospice Quality Measures Patient / Proxy reported outcome measure for pain treatment (PROMPT) – assesses patient’s perspective on the treatment / care received for managing pain. Hospice visits when death is imminent – assesses hospice staff visits to patients and caregivers in the last week of life. Care responsiveness – assesses hospice’s responsiveness to patient and family needs during / after business hours and after hours requests for help. Hospice communication with patients and caregivers – assesses the patient and caregiver’s perception of communication between the hospice team and the patient / family about hospice care and preparation for active dying and death. Hospice Composite Measure The composite measure would provide consumers and providers with a single measure regarding the overall quality and completeness of assessment of patient needs at hospice admission, which can be used to compare providers. www.HospiceAnalytics.com 80

Palmetto GBA Hospice Cap Reports Selected States 2013-2014 Preliminary Reports

Estimated Number of Hospices Reaching 80th Percentile+ By State For Live Discharge Rate (N=814 Hospices >=34.3750%) 2014 National= 4,064 Hospices; Mean= 24.5%; Median= 18.6% 50% of Hospices www.HospiceAnalytics.com 82

Estimated Percent of Hospices Reaching 80th Percentile+ By State For Live Discharge Rate (N=814 Hospices >=34.3750%) 2014 National= 4,064 Hospices; Mean= 24.5%; Median= 18.6% 50% of Hospices www.HospiceAnalytics.com 83

Estimated Number of Hospices Reaching 80th Percentile+ By State For LOS 180+ Days Rate (N=818 Hospices >=20.3524%) 2014 National= 4,091 Hospices; Mean= 13.2%; Median= 12.2% 50% of Hospices www.HospiceAnalytics.com 84

Estimated Percent of Hospices Reaching 80th Percentile+ By State For LOS 180+ Days Rate (N=818 Hospices >=20.3524%) 2014 National= 4,091 Hospices; Mean= 13.2%; Median= 12.2% 50% of Hospices www.HospiceAnalytics.com 85

Estimated Number of Hospices Reaching 80th Percentile+ By State For BOTH Live Discharge Rate with LOS >+180 Days (National Total N=376) 50% of Hospices www.HospiceAnalytics.com 86

OIG Examines Hospice Use of GIP The OIG reviewed 565 charts with GIP to draw the following conclusions: Some states had higher percentages of inappropriate billing (FL=52%; OH=54%; AZ=55%) than others (there were no state-by-state breakouts). SNF location of care had higher percentages of inappropriate billing (48%) than other locations (30%). For-profit hospices had higher percentages of inappropriate GIP billing (41%) than nonprofits (27%). Part D inappropriately paid for 56% of drugs. Hospices did not meet care planning requirements for 85% of GIP stays. Hospices sometimes (9%) provided poor-quality care and often did not provide intense services. www.HospiceAnalytics.com 87

OIG Examines Hospice Use of GIP Some concerns with the study: GIP accounts for 2% of hospice days of care. This study was based on chart review of 565 beneficiary admissions that included GIP – out of 282,225 such admissions (0.2%). The “stratified simple random sample” is disproportionately weighted for GIP stays with payments $16K+ (1.2% of these admissions, compared to 0.2% of four other groups; see p. 21 of report). The whole process of reviewing a few records and extrapolating findings to all records is currently being challenged by hospices and researchers, and the question is being elevated through the courts (Agape Hospice, SC) Lastly, the OIG report is based on chart review. While hospices continually work to improve documentation practices to clearly articulate clinical services provided, there are still gaps. Will this decrease hospice use of GIP / intensive services? www.HospiceAnalytics.com 88

Percentage of GIP Days of Total Days National: 1.04% WA #33: 0.81% OR #47: 0.32% www.HospiceAnalytics.com 89

Palliative Care Differentiation from hospice services? Reimbursement? Future of palliative care?

The Future of Hospice

The 20 Great Challenges of Health & Medicine 4/12: TEDMED 2012 Conference generates the following list: http://challenges.tedmed.com/greatchallenges/index 1. The role of the patient 11. Make prevention popular & profitable 2. Managing chronic diseases better 12. Improving medical communication 3. Obesity (adults) 13. Faster adoption of best practices 4. The caregiver crisis 14. Addressing the impact of poverty 5. Eliminating medical errors 15. Addressing costs and payment systems 6. Achieving affordable innovation 16. Promoting active lifestyles 7. Obesity (children) 17. Wellness programs that work 8. End-of-life care 18. Addressing sleep deprivation 9. Preparing for the dementia tsunami 19. Coping with stress 10. Addressing whole-patient care 20. Personalized medicine

Why 1/3 of hospitals will close by 2020 by David Houle America must bring down its crippling health care costs. Statistically speaking, hospitals are just about the most dangerous places to be in the US. Hospital customer care is abysmal. Health care reform will make connectivity, electronic medical records, and transparency commonplace in health care. How does hospice fair in these comments? http://www.kevinmd.com/blog/2012/03/onethird-hospitals-close-2020.html (found on LinkedIn)

Transforming Care Through Transparency 10/5/12: Anne Weiss posts the following on the Health Affairs blog: By year’s end, the Department of Health and Human Services will announce plans for making its Physician Compare website into a consumer-friendly source of information for Medicare patients about the quality of care provided by doctors and other health care providers. In doing so, Physician Compare will take its place alongside Hospital Compare and more than 250 other websites that offer information about the quality and cost of health care. More importantly, perhaps, it will send an important signal that transparency in health care is the new normal. http://healthaffairs.org/blog/2012/10/05/transforming-care-through- transparency/?utm_source=rss&utm_medium=rss&utm_campaign=transforming-care-through-transparency.

Eliminating Waste in US Health Care Berwick & Hackbarth (1/2) The need is urgent to bring US health care costs into a sustainable range for both public and private payers. Typically, programs to contain costs focus on cuts. Berwick suggests a better way to contain costs is to reduce waste in 6 areas, with estimated savings of $558B – $1.2T: Overtreatment: Use best / evidence-based practices (i.e., to avoid treatments that cannot possibly help); $158B. Failures in Care Delivery: Use best / evidence-based practices (i.e., practices shown to improve outcomes); $102B. Administrative Complexity: Eliminate inefficient rules, increase standardization; $107B. JAMA, April 11, 2012; 307(14), 1513-1516.

Eliminating Waste in US Health Care Berwick & Hackbarth Berwick suggests a better way to contain costs is to reduce waste in 6 areas, with estimated savings of $558B – $1.2T: Pricing Failures: Increased transparency for fair use and fair pricing; $84B. Fraud & Abuse: Eliminate fake bills and scams, and reduce inspection and regulation of the majority because of the misbehaviors of a few; $82B. Failures in Care Coordination: Increase appropriate level of care, communication, and independence (from the health care system); $25B. JAMA, April 11, 2012; 307(14), 1513-1516.

Big Med 8/13/12: Atul Gawande in The New Yorker Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care? The Cheesecake Factory restaurant serves millions of people at a reasonable cost with a consistent level of quality. Can health care? They are computerized and use prediction modeling – are we? They have multiple “layers” of training (including “train-the-trainer”) and checking before product is delivered – do we? They aim to waste no more than 2.5% of food – how is health care doing? They use consistent methods nearly always – consider how many knee-replacement models and the variance of outcomes we provide. http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande

Additional Considerations EMRs: Is your hospice using electronic medical records? Benchmarking: Can your hospice reliably compare it’s strengths and weaknesses to other hospices? Business Intelligence: Is your hospice a resource for other community leaders regarding local, state, and national trends? Palliative Care: How is your hospice leading the provision of palliative care in your community? ACOs: How do hospices collaborate with Accountable Care Organizations? How many are pursing these relationships?

How Much Does It Cost to Die in America? According to a study published in the Journal of General Internal Medicine surveying over 26,000 Americans aged 50+, between 2000-2010 Medicare beneficiaries spent: An average of $38,688 in out-of-pocket costs during the last 5 years life. At least 75% of beneficiaries spent $10,000+. At least 25% of beneficiaries spent $100,000+, At least 25% of beneficiaries spent ALL of their assets to pay for health care expenses. On average, people with dementia or Alzheimer’s disease paid the most ($66,155), more than twice what those with cancer or gastrointestinal illness spent ($31,069). How does this impact health policy? How does this impact hospice – and the role of hospice advocacy? http://www.theepochtimes.com/n2/united-states/study-final-years-can-bankrupt-medicare-patients-290903.html http://www.californiahealthline.org/articles/2012/9/10/study-gauges-out-of-pocket-medicare-costs-at-end-of-life.aspx http://www.upi.com/Health_News/2012/09/07/One-quarter-on-Medicare-spend-101000-out-of-pocket/UPI-93141346995268/

10/15/12: The Incidental Economist Blog; Austin Frakt Bioethics and $$ 8/1/12: CDC releases latest report on Death in the United States, 2010: Memorial Sloan-Kettering Cancer Center recently decided not to offer Zaltrap, an expensive new cancer drug ($11,000+ / month) to their patients. Zaltrap has proven to be no better than other medications already used for advanced colorectal cancer, yet costs twice as much. However, the FDA only reviews medications for safety and efficacy – not cost. The buck has to stop somewhere – if not with insurers and patients, than with providers. Bottom Line: Cost containment shouldn’t be the only factor in deciding treatment options, but it has to be one of the factors considered. Hospices are / will be challenged soon to provide evidence supporting treatment recommendations, and cost will be one of the factors considered. 10/15/12: The Incidental Economist Blog; Austin Frakt http://theincidentaleconomist.com/wordpress/the-buck-stops-at-memorial-sloan-kettering-cancer-center/

Future Projections

Future Projections (9/13) Short Range 2013-2015 Mission: Hospice continues to be the gold standard of EOL care, but is our mission slipping? Additional Quality / Regulatory reporting Money: Proportionately Decreased Reimbursement New Medicare Hospice reimbursement model effective 2016 Private insurance’s slow movement into EOL care Microscope: Increased Scrutiny OIG, FBI, ZPIC, RAC, MAC, and State investigations of waste, fraud, and abuse / whistleblower suits Hospice / Nursing Facility Relationships, Caps, Long LOS, DC Alive, GIP, and Bereavement / Volunteer services

Future Projections (9/13) Medium Range 2016-2019 Mission: Mission will be refined and communicated via increased public policy advocacy, research, and public reporting of quality data Hospice mission will be challenged by existing providers (e.g., palliative care, home care, and specialty hospitals) and new systems (e.g., ACOs or other acute / post-acute care collaborative models) Mergers & Acquisitions Money: Stable (albeit lower) Reimbursement Detailed studies of costs associated with providing EOL care. Ethics and Money – competition for limited resources? Microscope: Increased Scrutiny Follow up investigations from the Short Range, plus assisted living residencies and profit margins will be added

Future Projections (9/13) Long Range 2020+ With Hospice Without Hospice Mission: Refined, transparent, and collaborative EOL care Providers likely to be very large or very small Money: Modest, but less than past Microscope: Is it possible hospice’s mission will be accomplished – that high quality EOL care will be integrated into all other healthcare provider groups? Perhaps this is via expansion of palliative care, etc.; alternatively this is via elimination of the Medicare Hospice Benefit.

Future Projections – So What? (9/13) What will EOL care look like? How can State Hospice Organizations help prepare hospices? What will State Hospice Organizations look like? What do you want to be doing in 7 4 years?

Future Projections – 6/14 Update State conferences with quite different themes: How do we help our members avoid layoffs and survive? This is designed for those hospices we think will survive.

Future Projections – 12/14 Update Hospice Reimbursement: I think rebasing (like homecare) is now more likely than the U-Shaped Curve. Mergers: We’re seeing them now, not just talking about them – including a unique model of ‘partnership’ between NPs and FPs. ACOs: Hospices expressing increased interest to participate (if you’re not at the table, you’re on the table). State Hospice Organizations: How can state organizations adapt to changes facing their members and the general public – and their changing needs? Are there economies of scale / outsourcing state organizations can do? How to balance the membership / education / other budget?

Future Projections – 4/16 Update Hospice Reimbursement: We’ve got the new curve… Mergers: We’re seeing them now, not just talking about them – including models of ‘partnership’ between NPs. ACOs: Have started in larger markets. State Hospice Organizations: How can state organizations adept to changes facing their members and the general public – and their changing needs? Are there economies of scale / outsourcing state organizations can do? How to balance the membership / education / other budget?

Discussion

Thank you Please contact Cordt Kassner, PhD, at Hospice Analytics with any questions, comments, feedback, or for additional information: P: 719-209-1237 E: Info@HospiceAnalytics.com W: www.HospiceAnalytics.com * Review the new National Hospice Locator at www.HospiceAnalytics.com – geo-maps and detailed information on every known hospice in the United States!