Five Year Snapshot of Hospice Industry - What Does It Say About the Spread of Palliative Care?

Hospices and hospitals are the two principal organizational models delivering palliative care. The Center to Advance Palliative Care (CAPC) has consistently documented, through its regular studies, the growth of hospital-sponsored palliative care services over the most recent five years. During the same period, little has changed among certified hospices.

A close look at NHPCO’s Annual Facts and Figures Reports from 2009 and 2014 tells a lot (note:2014 report, which captures data from 2013, is most recent Report published by NHPCO).

From 2009 to 2014,

• ·        % of decedents enrolled on hospice benefit for 7 days or less remained steady at 35%
• ·         median length-of-stay fell slightly to 18.5 days from 21.3
• ·         % of hospices with fewer than 500 admissions per year rose slightly to 79% from 77%. 45% of hospices admit fewer than 3 patients per week
• ·         median Average Daily Census (ADC) served by hospices increased notably, to 79.5/day, up from 60/day
• ·         % of total hospice billed at General Inpatient (GIP) days  jumped to 4.8, up from 2.9.

So, short-stays persist, as do subscale hospices. I believe there is a correlation.  And I also believe that the subscale, and highly competitive, nature of the hospice organizational structure inhibits the spread of palliative care.

On the promising side, larger hospices are getting larger. I describe this development as promising because size does bring proficiency (read this previous post on my reasoning about minimum volume thresholds).

In a 2010 post on this blog (read here), a similar five-year snapshot was taken. Taken together, one could conclude that little has changed over the past 10 years in the hospice industry.

Your thoughts and comments are invited.

Palliative Care - Diffusing the Health Innovation

A graduate student in a Health Policy program asked me during a Q&A session at a national colloquium why I characterize end-of-life care in this country as three parts potential for two parts accomplishment. I've been asked similar questions before, but what gave me pause this time was the context of the query (the workshop was addressing the issue of access to hospice). The previous speaker had just presented a strong case statement on why access to hospice has been threatened by the "cap". And why the main reason for the decelerating growth of hospice was poor reimbursement.
I replied that the delivery system for late-life care is fragmented, and there is insufficient collaboration among providers within most communities. Thus, conditions are uninviting for the "spread of the science" (palliative medicine and nursing).


 The Center to Advance Palliative Care (CAPC) has effectively spread the science throughout the hospital sector, as it relates to hospital-based palliative care services. No small accomplishment, to be sure. But the other major palliative care providers (hospices) have been slow to scale, in part because hospices have taken competitive stances to protect their market share rather than the collaborative approach which studies have shown to be more conducive to the dissemination of best practices.  Communities known as providing high-value late-life care are characterized by several attributes - one of the most defining is a coalition (some might say network) of palliative care stakeholders (organizations and individuals) which come together to deliver care across settings and boundaries. The beginning of an Accountable Palliative Care Organization (APCO), some speculate.



The structure of the social system can facilitate or impede the diffusion of health care innovation, concluded Thoms Bodenheimmer, MD, in a September 2007 report for the California Health Care Foundation on how innovations in health care become the norm. Do the current social systems in our communities best position HPM leaders to 'spread the science"? As always, your comments are invited.

Use of Hospice Benefit has Slowed – What This Means for Palliative Care

A recent analysis of Medicare claims by Healthcare Market Resources found that enrollment onto the hospice benefit has plateaued (see blog post Hospice Utilization: Is Hospice Stuck in a Rut?). When one considers that the hospice benefit has been the principal source of reimbursement for palliative care, and that Medicare-certified hospices have been the principal delivery model for palliative care, these findings should raise concern among advocates of palliative care and those dedicated to improving its access.

What does the evidence suggest? States that historically have had among the highest utilization rates (such as Florida and Arizona) are now experiencing declines in utilization rates, suggesting that the utilization rate of those states may have reached the natural peak of hospice enrollment. Of course, low-utilization states have growth opportunities, as  states in the top quartile of hospice utilization rates use the hospice benefit 75% more often as states in the bottom quartile: 3.23% (on average) versus 1.85% (on average).  The key question to be asked: is growth in hospice benefit use in those lower quartile states sufficient to drive the spread of, and improve access to,  palliative care? I think not.

To be sure, efforts by organizations like Center to Advance Palliative Care (CAPC) have yielded impressive results, especially among hospitals and more recently through outpatient practices, in disseminating the science (and art) of palliative medicine. Yet, when the primary vehicle for reimbursing and delivering palliative care stalls, it may be time to look at newer vehicle models. Perhaps the time has arrived for Accountable PalliativeCare Organizations.

As always, your feedback and thoughts are invited. And more will follow on this subject.