Download Cooperation and Competition at the End of Life: Maryland`s Evolving

Cooperation and Competition at
the End of Life: Maryland’s
Evolving Hospice Policy Arena
Patricia M. Alt, Ph.D.
Towson University
Presenter Disclosures
Patricia Alt
(1)
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
No Relationships
History of Hospice in Maryland
• Hospice care in Maryland began in the mid1980s with an Episcopal church and a group of
nuns establishing the Joseph Richey House in
Baltimore City
• Gradually, other programs began, and as of
2013, there were 30 hospices licensed in the
state.
• In order to operate in a particular county, the
hospice organization must obtain a Certificate of
Need from the Maryland Health Care
Commission.
Characteristics of Maryland
Hospices
Profit Status:
Non-Profit
For-Profit
24
6
Medicare Certified: 27
Agency Type:
Freestanding
Hospital-Based
Home Health Agency-based
Nursing Home-based
Data from MHCC
22
4
3
1
Some Key Factors in 2011
Payment Source:
• Medicare
81%
• Medicaid
3%
• Other
16%
Cause of Death:
Cancer
Debility Unspecified
Other
Dementia
Heart & Lung Diseases
Data from annual MHCC Hospice Surveys
43%
15%
14%
12%
8% each
Updating the State Plan
• The State Health Plan is required to be updated
every five years. Since it had last been updated
in 2007, a series of workgroups and comment
periods began in 2011, culminating in revised
regulations in 2013.
• The utilization of hospice services has been
growing, and the population over 65 is estimated
to be expanding by 62% (from 707,642 in 2010
to 1,148,448 in 2025).
Data from annual MHCC Hospice Surveys
Trends in Maryland Hospice
Utilization (FY 2003-2011)
• Total number of patients: (75% increase)
2003 - 12,427 to 2011 - 21,814
• Patient Days: (281% increase)
2003 – 310,714 to 2011 – 1,185,089
• Deaths: (86% increase)
2003 – 8,724
2011 – 16,269
Data from annual MHCC Hospice Surveys
Complexities of Maryland Law
• Currently a hospice is defined as a “health care
facility” with CON approval required for “changes
in the bed capacity.”
• However, the provision of hospice services in
homes and other facilities is less clearly
regulated.
• Working with the Hospice and Palliative Care
Network of Maryland, and with a series of
workgroups, the MHCC proposed a change in
Hospice Need methodology.
Proposed Changes in CON
Methodology
• Age: from “all ages” to “35+”
• Diagnoses: from “Cancer only” to “All diagnoses”
• Use Rate: Changed from “Hospice Cancer
Deaths divided by Population Cancer Deaths” to
“All Hospice Patients divided by Population of
Potential Hospice Users”
• Need would be projected at the jurisdiction level,
with five years from base year to target year
Data from MHCC Revised Plan
Hospice Use In Maryland Counties
Variations in Hospice Providers and
Usage
• In Baltimore City, there are 9 providers, but 2
account for 72% of the market share
• In Prince George’s County, there are 9
providers, and 3 account for 78% of the market
share.
• These are the two largest jurisdictions among
those with low rates of hospice use
• African-Americans also constitute larger
proportions of the population in these areas, and
are among the least likely groups to utilize
hospice services.
Data from MHCC
Feedback from Providers and
Interested Parties
• Members of previous workgroups on hospice,
palliative care, and end of life counseling were
surveyed about the current situation of hospice
care in Maryland.
• Respondents included hospice directors, aging
and disability advocates, state policymakers,
and others with connections to hospice and
palliative care services. Their responses varied
widely, but the most mentioned concerns were:
Feedback (continued)
• Lack of education of the public and medical
professions about hospice and palliative care
• Lack of funding for programs caring for the unor under-insured
• Minority under-utilization of hospice services
• Lack of choices for nursing home patients
• Confusion about how EOL care fits in
Accountable Care Organizations
• Reluctance of medical providers to refer patients
to hospice or palliative services
Assumptions in the State Health
Plan Revisions
• Variations in use rates across the state
would change if more choices for care
were available
• Education of the public is a key element in
increasing interest in hospice use
• Changing the methodology for CON from
“use” to “need” will better allow for the
potential usage in lower usage and higher
diversity areas
Future Directions
• The regulatory agencies in Maryland are aiming
to develop better quality measures and
incorporate them into CON projections
• Smaller hospices are exploring partnerships with
larger healthcare systems in order to survive as
Accountable Care Organizations evolve
• Educational sessions are being held to reach out
to underserved populations and dispel concerns
about using hospice and palliative care.
Key Remaining Questions
• Does having more options lead to
increased willingness to use hospice care?
• Is it ethical for hospices to aggressively
market to insured patients and avoid the
uninsured?
• Are for-profit hospices, operating in
nursing homes primarily, over-using the
Medicare hospice benefit?