1. 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

2. Introduction & Background
Cordt T. Kassner, PhD
CEO
Hospice Analytics
2355 Rossmere Street
Colorado Springs, CO P: E: W: 2

3. 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 3

4. Evidence-based Practices in Hospice & Palliative Care

5. 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%). 5

6. www.HospiceAnalytics.com 6

7. www.HospiceAnalytics.com 7

8. www.HospiceAnalytics.com 8

9. www.HospiceAnalytics.com 9

10. www.HospiceAnalytics.com 10

11. 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

12. 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

13. 2014 Hospice Utilization (Medicare Hospice Deaths / Total Medicare Deaths)

14. 2013 Hospice Utilization (Medicare Hospice Deaths / Total Medicare Deaths)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

34. 2014 Medicare Hospice Mean Medicare Reimbursement / Beneficiary

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

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

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

38. 2014 Medicare Hospice Beneficiaries Status at Discharge

39. 2013 Medicare Hospice Beneficiaries Status at Discharge

40. 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

41. 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

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

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

44. 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.

45. 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.

46. InfoMAX
Review OR/WA information

47. Physician Reports

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

49. 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.

50. 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

51. 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

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

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

54. Hospice Payment Methodologies

55. Health Affairs Blog

56. 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 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.

57. 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

58. 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

59. Hospice Reimbursement Reform
Review of the Policy change:
Historically hospice has been reimbursed based on a per diem (in 2015, $ 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= $27,382.63).
Now… Hospices are reimbursed with a two-tiered methodology:
More during the first 60 days of admission ($ per day for RHC)
Less for days 61+ ($ 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

60. Hospice Reimbursement Reform

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

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

63. 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?

64. 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?

65. 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?

66. 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?

67. Regulations & Public Policy

68. 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)

69. 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.

70. 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?

71. 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.

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

73. 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?

74. 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?

75. 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?

76. Quality Rankings

77. 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.

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

79. CMS TEP Updates

80. 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.

81. Palmetto GBA Hospice Cap Reports Selected States
Preliminary Reports

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

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

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

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

86. 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 86

87. 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.

88. 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?

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

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

91. The Future of Hospice

92. The 20 Great Challenges of Health & Medicine
4/12: TEDMED 2012 Conference generates the following list:
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

93. 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?
(found on LinkedIn)

94. 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.
transparency/?utm_source=rss&utm_medium=rss&utm_campaign=transforming-care-through-transparency.

95. 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),

96. 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),

97. 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.

98. 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?

99. 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 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?

100. 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

101. Future Projections

102. 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

103. 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

104. 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.

105. 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?

106. 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.

107. 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?

108. 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?

109. Discussion

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