tag:blogger.com,1999:blog-12993734395558489422024-03-14T11:25:38.543-04:00Palliative Care SuccessA commentary on how palliative care programs and palliative medicine physicians can play a role in the improvement of late-life care in the USTIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.comBlogger122125tag:blogger.com,1999:blog-1299373439555848942.post-74735907807939917342021-04-13T15:13:00.000-04:002021-04-13T15:13:25.538-04:00A Competency-Based Model for Evaluating Performance of Palliative Care Practitioners<p><span style="font-family: verdana;"><span style="background-color: white; color: #333333; font-size: 13px;">At a recent regional (virtual) assembly of hospice executives and Hospice and Palliative Medicine (HPM) physicians who had gathered to strategize about the advantages (and disadvantages) of building a provider network for late-life care, I was asked what tools are available to measure performance of HPM physicians (and nurse practitioners). I suggested turning to the Joint Commission's standards on OPPE (which I have written about previously, read</span><span style="background-color: white; color: #333333; font-size: 13px;"> </span><a href="http://palliativemedicine.blogspot.com/2010/10/evaluating-performance-of-hospice-and.html" style="color: #5588aa; font-size: 13px; text-decoration-line: none;">here</a><span style="background-color: white; color: #333333; font-size: 13px;">) for a closer look into how hospitals are expected to evaluate their medical staff practitioners. How might these standards be applied for HPM physicians in the hospice setting? Here's one approach to applying physician performance core competencies to HPM practitioners we've found successful: </span></span><span style="background-color: white; color: #333333; font-family: inherit; font-size: 13px;"> </span></p><strong style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">Patient Care.</strong><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;"> Providing patient care that is compassionate, appropriate and effective for managing</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">late-life care.</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><strong style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">Medical/Clinical Knowledge</strong><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">. Degree of knowledge of established and evolving practices and principles of HPM, as well as the application of that knowledge to patient care and the education of others.</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><strong style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">Practice-based Learning and Improvement.</strong><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;"> Use of scientific evidence and methods to investigate, evaluate and improve late-life care practices.</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><strong style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">Interpersonal and Communication Skills</strong><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">. Establish and maintain professional relationships with patients, families and other members of health care teams.</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><strong style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">Professionalism.</strong><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;"> Commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward patients, the profession and society.</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><strong style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">Systems-based Practice.</strong><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;"> Understanding of the contexts and systems in which palliative care is provided and the ability to apply this knowledge to improve late-life care.</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><span style="font-family: verdana;"><span style="background-color: white; color: #333333; font-size: 13px;">Of course, specific metrics need to be developed to evaluate performance in each of these domains. The metrics will vary from organization to organization and are less important than the process of sitting down to collaboratively develop the metrics. Yet, doing so will take executives and physicians a long way toward satisfying one of the building blocks of a high-performing HPM practitioner staff - </span><strong style="background-color: white; color: #333333; font-size: 13px;"><em>to foster an unswerving commitment to performance improvement to minimize unwarranted practice variation, reduce regulatory risk, and win the confidence of referring sources.</em></strong></span><div><strong style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;"><em><br /></em></strong></div><div><span style="background-color: white; color: #333333; font-size: 13px;"><span style="font-family: verdana;">More to follow on this blog regarding the use of competency-based models to elevate the performance of palliative care practitioners.</span></span></div>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-36812110266159866062020-08-19T13:47:00.001-04:002020-08-19T13:49:25.060-04:00How Effective are Hospices in Spreading the Science of Palliative Care?<p> Medicare-certified hospices are the principal organizational model delivering palliative care to those with life-limiting illnesses. A close look at NHPCO's Annual Facts and Figures (2020 version recently published) reveals much about the hospice industry and the spread of the science of palliative care.</p><p>The industry continues to be subscale, hindering the development of clinical proficiency. For example, more than half of US hospices admit fewer than 2 patients per week (same as five years earlier). See <a href="http://palliativemedicine.blogspot.com/2010/03/minimum-volume-thresholds-do-they-apply.html">here</a> for previous blog post arguing the case that proficiency in health care is related to volume. Furthermore, more than 25% of hospices have been newly certified in the last few years, another important consideration in the development of proficiency. One might argue that the number of people utilizing the hospice benefit to receive palliative care has been growing (in 2018, more than 50% of Medicare decedents received palliative care through a certified hospice), thus justifying a greater number of hospices in the country, but the % growth in the number of hospices in the US exceeds the growth in the number of Americans utilizing the Medicare hospice benefit. I suggest that the large variations in late-life care will continue until the hospice industry gains in scale. (read <a href="http://palliativemedicine.blogspot.com/2011/04/variations-in-late-life-care-persist.html">here</a> for more on clinical variations in late-life care).</p><p>On a more promising note from the 2020 NHPCO report, the percentage of short-stay patients (those receiving palliative care through the hospice benefit for seven days or less) dropped to 27.9%, from 35% five years ago. So an issue (timely use of hospice benefit) some thought intractable 10 years ago (read <a href="http://palliativemedicine.blogspot.com/2011/11/short-stay-hospice-patients-intractable.html">here</a>) may be gradually improving.</p><p>As always, your insights and feedback are invited.</p>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-44312742187402412652020-08-18T18:00:00.003-04:002020-08-18T18:11:40.431-04:00Exemplary Performance in Late-Life Care - How Much More Do We Know Than 10 Years Ago? <p> </p><h3 class="post-title entry-title" style="font-weight: normal; line-height: 1.4em; margin: 0.25em 0px 0px; padding: 0px 0px 4px;"><span style="background-color: white; color: #444444; font-family: verdana; font-size: medium;">The post below (Improving Late-Life Care...) appeared in 2010, pondering what outcomes constituted exemplary performance within a community as it pertained to late-life care practices. Over the intervening decade, the analysts at DAI Palliative Care Group have been gathering a few more insights. </span></h3><h3 class="post-title entry-title" style="font-weight: normal; line-height: 1.4em; margin: 0.25em 0px 0px; padding: 0px 0px 4px;"><span style="background-color: white; color: #444444; font-family: verdana; font-size: medium;">To name a few:</span></h3><h3 class="post-title entry-title" style="font-weight: normal; line-height: 1.4em; margin: 0.25em 0px 0px; padding: 0px 0px 4px;"><div style="font-size: medium;"><p class="MsoNormal"></p><ul style="text-align: left;"><li><span style="background-color: white; color: #444444; font-family: verdana;">Palliative care specialists within these communities recognize life’s completion can present serious financial challenges. Their competencies "extend" into resourceful coordination of reimbursement so that access to care is not limited by unaffordable services.</span></li><li><span face="" style="background-color: white; color: #444444; font-family: verdana; line-height: 17.12px;">Palliative care leadership in these communities believe in "positive dissatisfaction, that is, they always strive to do better. They are insistent upon measuring quality, closely monitoring outcomes, implementing improvements, and tracking patient and family satisfaction. </span></li><li><span style="background-color: white; color: #444444; font-family: verdana;"><span face="" style="line-height: 17.12px;">These community exemplars commit themselves to the three As of access: affordability, availability, and awareness.</span><span face="" style="line-height: 17.12px; mso-ansi-language: EN-US; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-bidi-theme-font: minor-bidi; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin;"> </span></span></li></ul><p></p></div></h3><h3 class="post-title entry-title" style="font-weight: normal; line-height: 1.4em; margin: 0.25em 0px 0px; padding: 0px 0px 4px;"><span style="background-color: white; color: #444444; font-family: verdana; font-size: medium;">We'll explore these communities, and practices, in more detail in future posts. In the meantime, your thoughts and reactions are appreciated.</span></h3><h3 class="post-title entry-title" style="background-color: white; color: #cc6600; font-family: georgia, serif; font-size: 18.2px; font-weight: normal; line-height: 1.4em; margin: 0.25em 0px 0px; padding: 0px 0px 4px;"><br /></h3><div><br /></div><div><br /></div><div><br /></div><div><br /></div><h3 class="post-title entry-title" style="background-color: white; color: #cc6600; font-family: georgia, serif; font-size: 18.2px; font-weight: normal; line-height: 1.4em; margin: 0.25em 0px 0px; padding: 0px 0px 4px;">Improving Late-Life Care - Do We Know Exemplary Performance?</h3><div class="post-header" style="background-color: white; color: #333333; font-family: georgia, serif; font-size: 13px;"><div class="post-header-line-1"></div></div><div class="post-body entry-content" id="post-body-4480956452525198713" itemprop="" style="background-color: white; color: #333333; font-family: georgia, serif; font-size: 13px; line-height: 1.6em; margin: 0px 0px 0.75em;">We're starting to learn more about late-life care, thanks in large measure to the Dartmouth Atlas Project.<br /><br /></div><div class="post-body entry-content" id="post-body-4480956452525198713" itemprop="" style="background-color: white; color: #333333; font-family: georgia, serif; font-size: 13px; line-height: 1.6em; margin: 0px 0px 0.75em;">For example, in a recent report <em>Trends and Variation in End-of-Life Care for Medicare Beneficiaries</em><br /><em>with Severe Chronic Illness</em> (read <a href="http://www.dartmouthatlas.org/downloads/reports/EOL_Trend_Report_0411.pdf" style="color: #999999; text-decoration-line: none;">here</a>), we learned more about the final 30 days of life of a patient with cancer. More than half (54.7%) were hospitalized during that period. 5.6% received life-sustaining procedures. Half of the final month was spent in hospice (11 days) and an acute-care hospital bed (4 days). Interesting, but without context. Likely, the past 10 years has seen considerable improvement in these measures. How much more improvement should we expect? Can hospitalizations be cut in half? If so, what might be the most effective methods? A transitional care document , like POLST? A provider reimbursement structure where collaboration, rather than procedures, is more highly valued? A community palliative care officer who's accountable for late-life care across settings within a specific community or region? Any of these, or all of them?<br /><br />And how much better can the health care system do to encourage earlier referral to palliative services, so that greater than 11 days out of the final 30 can be spent under hospice care? As always, your ideas and opinions are invited.</div>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-24871738791061894942020-08-04T17:14:00.000-04:002020-08-04T17:14:20.576-04:00The Power of Palliative Care - Has Potential Turned Into Accomplishment?<font face="times">Using publicly available data, such as the Dartmouth Atlas, annual NHPCO Facts and Figures reports, and MedPacDataBooks, the DAI Palliative Care Group has been preparing late-life care performance profiles for our clients and selected audiences. See <a href="http://palliativemedicine.blogspot.com/2017/06/the-power-of-palliative-care.html">here</a>, <a href="http://palliativemedicine.blogspot.com/2017/01/choosing-where-to-retire-based-upon.html">here</a>, and <a href="http://palliativemedicine.blogspot.com/2011/10/exemplar-hospitals-for-late-life-care.html">here</a> for previous blog posts on this subject.</font><div><font face="times"><br /></font></div><div><font face="times">These performance profiles have been measuring and tracking the performance of communities, hospitals, and states, using key indicators of palliative care, since the early 2000s. By identifying exemplary performers, our reports have inspired individual and institutional providers, collaboratives, as well as entire communities, to aim higher, thus strengthening the power of timely palliative care interventions to improve late-life care in the United States. Our analysts have recently produced another report which tracks outcomes over time for a set of key indicators.</font></div><div><font face="times"><br /></font></div><div><font face="times">Several highlights of the report:</font></div><div><font face="times"><br /></font></div><div><font face="times">-fewer Americans are dying in the hospital. In 2007, 31.7% of US deaths occurred in a hospital. The high-performance
benchmark , that is, 10% of communities across the nation achieved this performance level, was 22.5% for that year. In 2017, 20.1% of deaths occurred in a hospital. So, over the span of a decade, the nation's performance moved from average to high-performing. How much more potential for improvement is there? The cities of Sarasota, Fla. and Asheville, N.C., which were high-performers in 2007, are now at 14.2 and 14.1% respectively.</font></div><div><font face="times"><br /></font></div><div><font face="times">-Americans spend less time in a hospital during last six months of life. An American who died in 2007 spent almost 13 days in a hospital during the last six months of life. In exemplar communities, that figure of days in hospital was almost 30% less (9 days). Ten years later (2017), the national figure had dropped to 8.1. Once again, a significant improvement.</font></div><div><font face="times"><br /></font></div><div><font face="times">-fewer Americans in 2017 were admitted to intensive care (14.7%) during their last six months of life than 10 years earlier (19.2%). Again, impressive improvement.</font></div><div><font face="times"><br /></font></div><div><font face="times">Undoubtedly, many factors contribute to these improvements. Surely, one factor has to be the greater accessibility to timely, high-quality palliative care.</font></div><div><font face="times"><br /></font></div><div><font face="times">I'm interested in your thoughts.</font></div>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-28337679999714379422017-06-13T17:32:00.001-04:002017-06-13T17:32:22.618-04:00The Power of Palliative Care Interventions in Late-Life CareA previous post on this blog <a href="http://palliativemedicine.blogspot.com/2011/07/improving-late-life-care-do-we-know.html">(read here)</a> asked whether we're moving closer to identifying exemplary performance in late-life care. <br />
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A recent DAI Palliative Care Group analysis of data from the Dartmouth Medical Atlas suggests that palliative care professionals are indeed making a difference in late-life care, at least in some measure.<br />
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Our analysts looked at results over a ten-year period from 2004 to 2014, using top 10% of performers as a proxy for exemplars. For example, in 2004, 29.5% of all Medicare deaths occurred in a hospital. That same year, the top 10% performing communities saw fewer than 22.7% of deaths occurring in hospitals. Ten years later, the national average stood at 20.3% (or put another way, average performers were doing 10% better than exemplars 10 years earlier). Meanwhile, exemplar communities were now seeing less than 16.3% of deaths taking place in a hospital.<br />
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Almost as impressive is the reduction of inpatient days per decedent in last 6 months of life. In 2004, the average decedent spent 10.9 days in a hospital during last 6 months of life, while exemplary performance weighed in at 7.3 days or fewer. In 2014, average performance was down to 7.9 days (while an improvement of nearly 30% it fell short of reaching exemplar performance of 10 years earlier), and exemplar performance now stood at 5.3 days. Likely, many factors contribute to this improvement, but one cannot underestimate the power of palliative care interventions toward this improvement.<br />
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Any measure that did not see significant improvement? Yes, % of decedents spending at least 7 days in ICU during last 6 months of life. Average in 2004 - 14.1%. In 2014 - 13.8%. Meanwhile, in late-life exemplar communities in 2014, only 5.3 % of decedents spend 7 days or more in an ICU during last 6 months. A considerable opportunity for palliative care professionals to once again demonstrate the power of timely palliative interventions to match patient and family preferences with the care they receive.<br />
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<br />TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com1tag:blogger.com,1999:blog-1299373439555848942.post-29769208427465596342017-06-08T12:04:00.001-04:002017-06-08T12:04:28.827-04:00Accountable Palliative Care Organizations - An Opportunity to Improve Late-Life Care<br />
The days of open access for hospice, regrettably, have yet, with few exceptions, to come to fruition. The hospice industry in the US has been taken over by single-purpose organizations who are adept at "enrollment management" - that is, identifying both low-cost patients who would be financially attractive (and encouraging these patients to enroll on the hospice benefit) AND high-cost patients who would be financial drains (and discouraging those patients from enrolling). And it is difficult to fault these organizations, as their managers are merely responding to the financial incentives built into the hospice benefit by Medicare and other payers.<br />
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We are faced with the paradox that introduction of the hospice benefit has improved access to better end-of-life care, yet at the same time has come to define end-of-life care, and by extension, palliative care. It's similar to how 28 days of inpatient care came to define alcohol and drug rehab treatment merely because that's what the payers would cover.<br />
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How can we see further improvement in end-of-life care? By reorganizing how end-of life care is provided, so that "accountable palliative care organizations", of which hospices are an integral but not the whole piece, are the center of late-life care within health systems and communities.<br />
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Some of you have asked about the characteristics of APCOs. First, they are virtual enterprises, that is to say, unincorporated structures, that are 'sponsored" by a community-based health care organization, most often either a hospital (health system) or hospice.<br />
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Simply, the key elements of an APCO are:<br />
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<ul>
<li>A Chief Palliative Care Officer (full-time physician credentialed in hospice and palliative medicine) accountable for palliative care services across all settings,</li>
<li>Integrating tools that encourage dissemination of knowledge and promote collaboration across settings and disciplines (for example, APCOs have found Physician Orders for Life-Sustaining Treatment (POLST) www.polst.org to be just such an integrating tool),</li>
<li>Multiple sources of revenue (hospice, home health, physician services) that offer opportunities for cross-subsidization of individual patient care and economies of scale on the expense side.</li>
</ul>
How one constructs an APCO depends on many factors, mostly related to the amount of "palliative intellectual capital" already in place at the sponsoring organization.TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-2025221279114124012017-05-30T14:29:00.000-04:002017-05-30T14:29:30.220-04:00Salary Compression Stalls Growth of Hospice and Palliative Medicine SpecialtyHospices and hospital-sponsored palliative care programs are experiencing increased demand for physician services in clinical and quasi-administrative capacities (read <a href="https://www.capc.org/about/press-media/press-releases/2014-9-2/palliative-care-growth-trend-continues-according-latest-center-advance-palliative-care-analysis/">here</a> for an analysis by the Center to Advance Palliative Care on the growth of palliative care programs). As these organizations build their medical staffs by employing additional HPM physicians, they're finding that creating and filling "leadership" opportunities are proving to be a formidable challenge. Why?<br />
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The features of a compensation program that enable staff growth become liabilities when the principal objective of medical staff development turns to leadership building. Some compensation experts label it salary compression. Others refer to it as salary stagnation. Either way, it is the result of forces currently converging in the palliative medicine sector.<br />
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When there is a shortage of credentialed professionals, the imbalance between qualified people available to fill positions and the demand for physicians forces hospices, hospitals, and other program sponsors to offer higher salaries to attract the limited number of qualified applicants. And when insufficient revenue sources limit funding for medical staff development, those limited funds are typically used to attract new staff members. While such a priority enables staff growth, compression at the "senior" medical director levels typically results. Salary differentials between the ranks have an increased potential for erosion. And so leadership opportunities look unattractive, and prospects (both inside and outside the organization) shun opportunities that in all other respects represent a professional advancement opportunity.<br />
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Some hospices, and a few hospital-based palliative programs, have implemented structural modifications to their HPM physician compensation program, with varying degrees of success. But success, nonetheless. It all begins with a reevaluation of the "value" placed upon HPM physician activities and responsibilities.TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-74398354639113445872017-01-19T16:05:00.001-05:002017-01-19T16:05:27.136-05:00Choosing Where to Retire Based upon Experience Ratings About Late-Life Care<span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">In an earlier post (read </span><a href="http://palliativemedicine.blogspot.com/2009/06/choosing-where-to-live-based-upon-end.html" style="background-color: white; color: #999999; font-family: Georgia, serif; font-size: 13px; text-decoration: none;"><span style="color: #5588aa;">here</span></a><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">) , I wondered if ratings of retirement towns and cities would eventually include information about their culture and practices around late-life care. Our study of "retirement cities" and their palliative care practices, using data drawn from the Dartmouth Medical Atlas, reveals that a huge distance separate better performers from lesser performers.</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">One community recognized widely among desirable retirement towns is Asheville, North Carolina. Turns out that Asheville is among the better-performers in late-life care.Residents of the Asheville region are 20% less likely to die in a hospital than the state average, and 30% less likely during their final six months of life to spend time in an ICU. Asheville's overall results have earned an A grade in the DAI Community Palliative Performance Grading, placing it among exemplar communities.</span><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><br style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;" /><span style="background-color: white; color: #333333; font-family: Georgia, serif; font-size: 13px;">Sarasota, Florida is another "retirement" community scoring high in the DAI Community Palliative Performance grading. We conclude, upon further analysis, that these exceptional results don't happen by accident. Rather, they are produced by design, including the presence of palliative medicine physician-champions and a large hospice with close relationships with the community's health care providers.</span>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-2448189894360622092015-04-07T11:32:00.000-04:002015-04-07T11:32:15.210-04:00Five Year Snapshot of Hospice Industry - What Does It Say About the Spread of Palliative Care?<div class="MsoNormal">
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.<o:p></o:p></div>
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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). <o:p></o:p></div>
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From 2009 to 2014,<o:p></o:p></div>
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<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
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<ul>
<li><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><span style="text-indent: -0.25in;">% of decedents enrolled on hospice benefit for 7
days or less remained steady at 35%</span></li>
<li><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><span style="text-indent: -0.25in;">median length-of-stay fell slightly to 18.5 days
from 21.3</span></li>
<li><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><span style="text-indent: -0.25in;">% 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</span></li>
<li><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><span style="text-indent: -0.25in;">median Average Daily Census (ADC) served by
hospices increased notably, to 79.5/day, up from 60/day</span></li>
<li><span style="font-family: Symbol; text-indent: -0.25in;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><span style="text-indent: -0.25in;">% of total hospice billed at General Inpatient
(GIP) days</span><span style="text-indent: -0.25in;"> </span><span style="text-indent: -0.25in;">jumped to 4.8, up from 2.9.</span></li>
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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.<o:p></o:p></div>
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On the promising side, larger hospices are getting larger. I
describe this development as promising because size does bring proficiency
(<a href="http://palliativemedicine.blogspot.com/2010/03/minimum-volume-thresholds-do-they-apply.html">read this previous post</a> on my reasoning about minimum volume thresholds).<o:p></o:p></div>
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In a 2010 post on this blog (<a href="http://palliativemedicine.blogspot.com/2010/10/hospice-industry-data-from-nhpco-look.html">read here</a>), 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.</div>
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Your thoughts and comments are invited.<o:p></o:p></div>
TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com4tag:blogger.com,1999:blog-1299373439555848942.post-3531698642480843672015-04-06T10:18:00.000-04:002015-04-06T10:18:06.441-04:00Palliative Care - Diffusing the Health InnovationA graduate student in a Health Policy program asked me during a Q&A session at a national <span class="blsp-spelling-corrected" id="SPELLING_ERROR_0">colloquium</span> 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.<br />
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).<br />
<br /><br />
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. <a href="http://palliativemedicine.blogspot.com/2010/04/how-do-they-do-that-providing-high.html">Communities known as providing high-value late-life care </a> 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.<br />
<br /><br />
<br />
The structure of the social system can facilitate or impede the diffusion of health care innovation, concluded Thoms Bodenheimmer, MD, in a <a href="http://www.chcf.org/publications/2007/09/the-science-of-spread-how-innovations-in-care-become-the-norm">September 2007 report</a> 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.TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com2tag:blogger.com,1999:blog-1299373439555848942.post-42195344480559399242015-04-01T17:37:00.002-04:002015-04-01T17:37:42.278-04:00Use of Hospice Benefit has Slowed – What This Means for Palliative Care
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">A recent analysis of Medicare claims by Healthcare Market Resources
found that enrollment onto the hospice benefit has plateaued (see blog post <a href="http://www.healthmr.com/hospice-stuck-in-a-rut/?inf_contact_key=0621b30123a85788d234ec9a566977279288b6f9976312e0a453991a513dac9c">Hospice Utilization: Is Hospice Stuck in a Rut?).</a> 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.</span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">What does the evidence suggest? States that historically
have had among the highest utilization rates (such as Florida and Arizona) are
now experiencing <i style="mso-bidi-font-style: normal;">declines </i>in
utilization rates<i style="mso-bidi-font-style: normal;">, </i>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 <span style="mso-spacerun: yes;"> </span>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).<span style="mso-spacerun: yes;"> </span>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, <span style="mso-spacerun: yes;"> </span>palliative
care? I think not.</span></div>
<br />
<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">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 <a href="http://palliativemedicine.blogspot.com/2015/02/accountable-palliative-care.html">Accountable PalliativeCare Organizations</a>.</span></div>
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<span style="font-family: Calibri;">As always, your feedback and thoughts are invited. And more
will follow on this subject.</span></div>
TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-35072916536966395092015-03-31T18:12:00.000-04:002015-03-31T18:12:15.555-04:00Medical Staff Development Plan - Why It's Essential to a Hospice's Growth <br />
Resourceful (and strategic) use of physicians in hospices and palliative care programs has proven to accelerate the success of creating Accountable Palliative Care Organizations (APCOs) in some of our nation's communities (we'll explore several of these success stories in future posts). And while building an APCO is a test of endurance, will, and collaboration, the process of developing an APCO is stalled more frequently by the slow, fitful, and fragmented process of acquiring the palliative medicine "intellectual capital" requisite to an APCO. A Medical Staff Development Plan (MSDP) will serve as a management guide for the alignment of the physician staffing plan with the Hospice strategic plan.<br />
<div>
</div>
<br />
The MSDP will allow a hospice to:<br />
<ul>
<li>identify the opportunities and risks of the current medical staff complement relative to the development of a community APCO ;</li>
<li>define a reasonable range of investment required to meet recruitment needs; and </li>
<li>demonstrate the strategic and proactive thinking of hospice/palliative service senior leadership to the community, its hospitals, and other key stakeholders.</li>
</ul>
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</div>
<br />
The MSDP comprises five sections:<br />
<div>
</div>
<br />
<ol>
<li>Community Assessment of palliative care practices - identifies improvement opportunities and provides competitive intelligence about peer and neighboring programs,</li>
<li>Three-Year Staffing Plan - translates community needs into physician staffing requirements and associated financial commitments, </li>
<li>Responsibility Chart and Professional Performance Profile–these tools enable leadership to systematically identify decisions and activities that must be accomplished and to pinpoint the functions (positions) that will take on roles relevant to those results, </li>
<li>Compensation Plan –recommends physician compensation models to produce desired physician behavior and translates administrative, supervisory and teaching (AS&T) activities for physicians into fair and reasonable compensation ranges, </li>
<li>Recruitment Plan - the articulation of "community hospice and palliative care" practice opportunities that attract talent and fill competency gaps.</li>
</ol>
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</div>
<br />
Securing executive/Board support for building a HPM staff is easier when it's the result of a well-thought out, comprehensive and strategic plan that pegs recruitment to milestones.TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-81594332629540145862015-03-31T15:13:00.001-04:002015-03-31T15:13:44.794-04:00Building Blocks of a High-Performing Hospice Medical StaffI'm asked from time to time what makes for a better- performing hospice medical staff. I'm unsure that there is a straightforward answer. The strategy of hospices building medical staffs is a recent and uncommon practice. Uncommon because the median daily census (in 2010) of U.S. hospices was just over 50, and more than three-quarters of hospices admitted fewer than 500 patients annually. Hardly sufficient scale to employ a single full-time physician, let alone a medical staff of five or more. By one rule of thumb oft cited for physician staffing levels (1 FTE per 100 ADC), only 18% of the U.S. hospices would consider employing a full-time HPM physician.<br />
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Those who have closely followed other health care sectors, such as home health and infusion therapy, are quick to point out that consolidation swept rapidly through these sectors once reimbursement was tightened or reformed, and sub-scale agencies found that size did indeed matter. Will hospices follow a similar pattern? I wouldn't want to wager a hospice's existence against it. So the hospices of the future will likely be larger. And with size comes the need for a medical staff structure that enables access and quality.<br />
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</div>
<br />
The structure may vary from hospice to hospice, but most will arrive at the right structure by careful and thoughtful building of the medical staff. Here follows, from our study, the eight building blocks.<br />
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</div>
<br />
<ul>
<li>Create full-time “blended” practice opportunities that attract and retain HPM physicians</li>
<li>Develop bench strength to account for volume fluctuations, departures, back-up coverage</li>
<li>Amass “intellectual capital” for an infrastructure that supports an effective and efficient medical staff</li>
<li>Deploy hybrid compensation models to align physician and hospice incentives, and reassess at least annually</li>
<li>Maintain relentless focus on capturing information on physician activity to provide timely and constructive feedback and aid performance management</li>
<li>Clearly articulate expectations among medical staff practitioners, medical leadership, and hospice management</li>
<li>Create virtual organizational structure to extend influence of medical staff into greater community to reduce fragmentation of late-life care</li>
<li>Foster an unswerving commitment to performance improvement to minimize inappropriate practice variation, reduce regulatory risk, and win the confidence of referring sources.</li>
</ul>
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</div>
<br />
We'll examine, over the coming months, each of these building blocks with a little more precision. As always, your comments are invited.TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-57681939986579544032015-03-11T21:10:00.000-04:002015-03-11T21:10:45.265-04:00The Evolving Role of Hospice and Palliative Medicine LeadershipAs hospices and palliative care services evolve into accountable palliative care organizations with greater scope and influence over late-life care within their communities, a "new" physician executive role is emerging along the career path for HPM physicians. This role is broader than the traditional senior medical director or chief medical officer positions, and is progressing toward what we refer to as the "chief community palliative care officer". <br /><br /> These physician executive positions have proven to be instrumental in shaping late-life care practices by applying management competencies to:<br /><br /> -build and sustain relationships that evolve into community-wide palliative care networks<br /><br /> -disseminate throughout a community the use of metrics and evidence-based practices to hold practitioners to high standards of performance<br /><br /> -inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics <br /><br /> -envision and stimulate a change process that coalesces the community around new models of late-life care<br /><br /> Daunting challenges, to be sure. As hospice executives and HPM physicians (and nurse practitioners) come to grips with rules around eligibility and face-to-face recertification requirements, we would all do well to remain mindful of the strategic leadership objectives that will ultimately determine how successful we are in transforming late-life care in the US. We've seen the importance of HPM leadership in exemplar communities across America (some of which have featured in this blog) - assembling the right mix of intellectual capital, at the right time (what we refer to as bellwether practices) becomes one of the must-have competencies of late-life care organizations.TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com1tag:blogger.com,1999:blog-1299373439555848942.post-24890310933904749802015-02-17T13:48:00.000-05:002015-02-17T13:48:19.949-05:00Hospice and Palliative Care - Are We Giving a Mixed Message?<br />
Is there a difference between Hospice and Palliative Care?<br />
Some say this is merely a matter of semantics, so why bother? I'd like to offer my thoughts, as someone who has been involved with "hospice" since the mid-80s.<br />
<br />
The reason why this is an important issue is quite simply because it matters to the public. It matters because use of the terms together suggests to some that they are synonymous, and to others that they are distinct. I submit they are neither the same nor distinct.<br />
<br />
In its earlier days, hospice described a concept of care. Over the past quarter-century (once hospice became covered by Medicare as a benefit), it has come to describe (define?) an organized and highly prescribed system through which end-of-life services are provided. The practitioners of these services have taken on, perhaps out of convenience, the name of hospice into their titles.It's analogous to surgeons describing themselves as Operating Room and Surgical Medicine physicians, or ER docs referring to their specialty as Hospital and Emergency Medicine. I'm sure you could think of other analogies. <br />
<br />
Those receiving palliative care do so in many settings (home, hospital, SNF, outpatient office, assisted living, hospice inpatient unit) while utilizing various health benefits/coverages (of course the hospice benefit but also home health benefit, physician services, i.e Medicare part B )to pay for these palliative services. In other words, palliative care is provided by a host of professionals to patients during "late-life". Some, but certainly not all of these patients use the hospice benefit (provided by Medicare and most private health insurance plans) to cover the cost of palliative care.<br />
<br />
A recent study commissioned by the Center to Advance Palliative Care found that much of the public did not understand or was not familiar with the term palliative care. But it's not only the public who is confused. The specialty's own practitioners are confused, and are unintentionally adding to the general misunderstanding. On the website of a prominent Midwest medical center, a reader comes across this comment,“Palliative care and hospice are different,” explained the medical director of the palliative care service. “Hospice is restricted to people who have a prognosis of less than six months to live. However, palliative care does not have that restriction because it does more than just help people at the end of their life.” What does a patient, or family member do with such information? For that matter, what does a prospective referring source (a discharge planner, or family physician) do with that information?<br />
<br />
The question we in the field should be asking is how we can best increase access to palliative care. If some of that palliative care is provided by a licensed hospice, reimbursed by the hospice benefit, fine. If some of the care is provided by a hospital, or a SNF, reimbursed by the physician services benefit, all to the good. If some of the palliative care is provided by a home health agency, reimbursed under a home health benefit, all the better. What matters is that a patient (and family) receive timely access to palliative care and its practitioners.<br />
<br />
More on this subject in future posts. in the meantime, I invite your feedback.TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com2tag:blogger.com,1999:blog-1299373439555848942.post-26438706841376160842015-01-12T19:10:00.000-05:002015-01-12T19:10:09.243-05:00Valuable Experiences of a Hospice and Palliative Medicine (HPM) Fellowship<h3 class="post-title entry-title" itemprop="name" style="background-color: white; color: #cc6600; font-family: Georgia, serif; font-size: 18px; font-weight: normal; line-height: 1.4em; margin: 0.25em 0px 0px; padding: 0px 0px 4px;">
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When asked by HPM fellows what experiences one should seek to strengthen skill set, I'll recommend the following (a currently practicing HPM physician would also do well to gain these experiences):<br /><br /><em>-Actively participating in any end-of-life care coalitions in the community, and if one doesn't exist, assemble several HPM practitioners in the community to start a coalition. Coalitions working to change the model of late-life care in the community are a common element in those regions known for their exemplar practices in late-life care.</em><br /><em></em><br /><em>-Engaging in initiatives aimed at reducing late-life care clinical variation within the community. These often take the form of interdisciplinary work groups standardizing protocols or tools, either within a palliative care organization or the community at-large.</em><br /><em></em><br /><em>- Joining with other clinicians in institutional or community-wide intiatives to ensure safe transitions across settings and reduce hospital readmissions. There is a strong palliative care component in prevailing readmission reduction programs, among those the commonly used Interact (<strong>Inter</strong>ventions to <b>R</b>educe <b>A</b>cute <b>C</b>are<b>T</b>ransfers) tool.</em><br /><br /><br />The skills and competencies gained from these experiences will hold an HPM physician in good stead in securing the most attractive professional opportunities emerging in the HPM sector (see this <a href="http://palliativemedicine.blogspot.com/2010/11/the-evolving-role-of-hospice-and.html">previous post </a> for more on the emerging role of HPM physicians).<br /><br />I'm curious to hear from current and recent fellows about what experiences you've found most valuable.</div>
TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-91956189306319694112013-03-26T20:23:00.000-04:002013-03-26T20:23:31.294-04:00Stranger than Fiction: SDHIPC Demise a Painful and Difficult Story to Understand
Posted by Shelley Sansbury, health care strategist<br />
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<span style="font-family: "Lucida Grande"; mso-fareast-language: JA;">This is a difficult story for <i style="mso-bidi-font-style: normal;"><u>everyone</u></i><u>
</u>involved, most certainly the patients and their families and physicians, as
well as many hundreds of ex-employees and volunteers, donors and creditors. <o:p></o:p></span></div>
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<span style="font-family: "Lucida Grande"; mso-fareast-language: JA;">It is a difficult story to report…like chasing chickens…particularly when transparency
doesn’t appear to be a value embraced by the current regime. Local reporters
must rely on the Freedom of Information Act to get past the obfuscation of the
spokesman for the distressed organization.<o:p></o:p></span></div>
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<span style="font-family: "Lucida Grande"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Lucida Grande"; mso-fareast-language: JA;">How and why a hospice practically venerated as an industry leader after 35
years could disintegrate in a matter of months is more than a little perplexing.
Here, in broad brush strokes, are a few of the major milestones associated with
the rapid devolution of one of the largest and most respected hospice and
palliative care organizations in the U.S. <o:p></o:p></span><br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Jul 1, 2010 – <o:p></o:p></span></div>
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</span><span style="font-family: "Helvetica","sans-serif"; font-size: 12pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "MS Mincho"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>The Board
Chairman announces the appointment of a former public relations
and fundraising functionary with the San Diego Hospice Foundation
as President and Chief Executive Officer, succeeding Jan Cetti who has retired
after 14 years at the helm of SDHIMC</span></div>
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<!--[if !supportLists]--><!--[endif]--><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Feb, 2011
– <o:p></o:p></span></div>
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>A
team of 8 Medicare auditors spend 5 days on site reviewing 149 charts of patients admitted
to service between 1/1/09 and 11/30/10, the results of <span style="mso-tab-count: 2;">which </span>are, more than 2 years hence, yet to be disclosed,
according to CEO Pacurar.<o:p></o:p></span></div>
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Sept, 14
– Sept 22, 2011 – <o:p></o:p></span></div>
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>A
team of 4 surveyors arrive from the CA Dept of Public health arrive to <span style="mso-tab-count: 3;"> </span>conduct a routine
Medicare re-certification survey. Initially 20 patients are <span style="mso-tab-count: 3;"> </span>sampled. The
survey which lasts 8 days includes home visits to 5 patients. <span style="mso-tab-count: 2;"> </span>Nine deficiencies are cited
including agency leadership for failure to assure
reporting of Adverse Events including errors in the use of a<span style="mso-tab-count: 3;"> </span>Computer-aided Drug Delivery (CADD)
pump resulting in a patient <span style="mso-tab-count: 4;"> </span>receiving
5x the prescribed dose of morphine sulfate. In the course of the survey
the agency spontaneously reports two additional similar recent events. The survey
sample is amended to include these patients. According
to the survey: <span style="mso-tab-count: 4;"> </span><o:p></o:p></span></div>
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 3;"> </span></span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">The facility failed to implement immediate</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">corrective actions to prevent <span style="mso-tab-count: 3;"> </span><span style="mso-tab-count: 1;"> </span>reoccurrence
of</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">CADD pump (continuous ambulatory delivery</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">device <span style="mso-tab-count: 4;"> </span>used
to deliver narcotic analgesia)</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">narcotic
overmedication incidents, <span style="mso-tab-count: 4;"> </span>after
the first incident on 8/7/11. Within 40 days of the first</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">incident, 2 <span style="mso-tab-count: 4;"> </span>more
patients were involved in CADD</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">pump
narcotic overdose incidents. <span style="mso-tab-count: 4;"> </span>The
Vice</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">President of Inpatient &
Nursing Services and the</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">Manager of
<span style="mso-tab-count: 4;"> </span>Pharmacy
were notified of an</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"> </span><span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;">Immediate
Jeopardy on 9/16/11 at 5:05P.M.</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p></o:p></span></div>
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<span style="color: #262626; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Courier;"><o:p> </o:p></span></div>
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<span style="color: #262626; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Courier;"><span style="mso-tab-count: 1;"> </span>Less
than two hours after the Immediate Jeopardy designation, the Vice President of Inpatient & Nursing
Services.presents a 7-point plan of <span style="mso-tab-count: 1;"> </span>correction.
Surveyors respond favorably and the Immediate Jeopardy is <i style="mso-bidi-font-style: normal;">abated</i>
at 6:40 P.M.<o:p></o:p></span></div>
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<span style="color: #262626; font-family: "Helvetica","sans-serif"; font-size: 11pt; mso-bidi-font-family: Courier;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Dec 12, 2011 - <o:p></o:p></span><br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>State
surveyors return to verify implementation of the Plan of Correction<o:p></o:p></span></div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Jan 12, 2012<span style="mso-spacerun: yes;">
</span>-<span style="mso-spacerun: yes;"> </span><o:p></o:p></span><br />
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>A
senior official of the Survey and Certification Division of Medicare <span style="mso-tab-count: 3;"> </span><span style="mso-tab-count: 1;"> </span>writes: <o:p></o:p></span></div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<br />
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<span style="color: #262626; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Courier; mso-fareast-language: JA;">Contrary to
your allegations of correction, however, this resurvey, completed on December
12,2011, documented your continued noncompliance with Federal health and safety
requirements. More specifically, as detailed on the enclosed the Statement of
Deficiencies (Form CMS2567), the contents of which are incorporated by
reference herein, the survey completed on December 12, 2011, documented
deficiencies that, on balance, reasonably support a conclusion…of continued
noncompliance with Federal health and safety requirements”.<o:p></o:p></span></div>
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<span style="color: #262626; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Courier; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="color: #262626; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Courier; mso-fareast-language: JA;">As a result
of continued non-compliance with Medicare Conditions, a warning of
de-certification is re-instituted.<o:p></o:p></span><br />
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<span style="color: #262626; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Courier; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Feb
2012 <span style="mso-spacerun: yes;"> </span>- <o:p></o:p></span><br />
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>Medicare
lifts its decertification warning, as a result of a revised Plan of <span style="mso-tab-count: 3;"> </span>Correction, which
perhaps includes engagement of an outside clinical <span style="mso-tab-count: 3;"> </span>compliance team. It is unknown whether a
formal Medicare Compliance Plan
exists, or if this represents the advent of such.<o:p></o:p></span></div>
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Aug 2012 – <o:p></o:p></span><br />
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>Pacurar
implements a patient care staff retraining program, presumably in response to the
findings reported by the outside clinical review team she has engaged. <o:p></o:p></span></div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Nov 8,
2012 -<o:p></o:p></span><br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>A
moratorium on patient admissions is imposed for a weekend<o:p></o:p></span></div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Nov 12,
13, 2012 <span style="mso-spacerun: yes;"> </span>- <o:p></o:p></span><br />
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 2;"> </span>In apparently
the first press report(s) (<i style="mso-bidi-font-style: normal;">SD Union Times</i>)
of the organization’s distress, several almost contradictory
claims are attributed<span style="mso-tab-count: 3;"> </span>to
President and Chief Executive Officer Pacurar. <o:p></o:p></span></div>
<br />
<div class="MsoNormalCxSpMiddle" style="margin: 1em 0px 1em 0.75in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l4 level2 lfo4; mso-pagination: none; tab-stops: 11.0pt .5in; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New"; mso-fareast-language: JA;"><span style="mso-list: Ignore;">o<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times; mso-fareast-language: JA;">Although post
payment audit results are still unknown, Pacurar said she believes there will
be enough financial pain to require layoffs of up to 200 of the hospice’s 870
employees. “The organization, after the first of the year, will look different
than it does today,” Pacurar said. “<b style="mso-bidi-font-weight: normal;">It
will be smaller. It will focus solely on the great care of hospice patients.”</b></span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p></o:p></span></div>
<br />
<div class="MsoNormalCxSpMiddle" style="margin: 1em 0px 1em 0.75in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l2 level1 lfo5; mso-pagination: none; tab-stops: 11.0pt .5in; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New"; mso-fareast-language: JA;"><span style="mso-list: Ignore;">o<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times; mso-fareast-language: JA;">Pacurar said
she believes the hospice is vulnerable to millions in rebates to Medicare
because the program has not been strict enough in making sure that its patients
are truly suffering from an illness likely to cause death within six months.
She said doctors and care givers operated for decades on an “open access”
policy that kept patients on hospice care for longer than six months, sometimes
without being able to demonstrate that their condition was worsening.</span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p></o:p></span></div>
<br />
<div class="MsoNormalCxSpMiddle" style="margin: 1em 0px 1em 0.75in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l2 level1 lfo5; mso-pagination: none; tab-stops: 11.0pt .5in; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New"; mso-fareast-language: JA;"><span style="mso-list: Ignore;">o<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times; mso-fareast-language: JA;">The executive
said she also dismissed the hospice’s previous chief medical officer (also the
Chief Financial Officer…reported elsewhere) and instituted a new compliance
department that will regularly audit patient charts before requesting payment
from Medicare. </span><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p></o:p></span></div>
<br />
<div class="MsoNormalCxSpMiddle" style="margin: 1em 0px 1em 0.75in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l2 level1 lfo5; mso-pagination: none; tab-stops: 11.0pt .5in; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New"; mso-fareast-language: JA;"><span style="mso-list: Ignore;">o<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times; mso-fareast-language: JA;">It remains to
be seen, she said, how much of that amount the federal government will want
back. At first, officials said they worried that the number could be as high as
60 percent. However, <b style="mso-bidi-font-weight: normal;">a recent
conversation with a Medicare official gave them hope to believe any rebate will
not be so high that it will cripple the operation.“I’m quite excited about
moving forward. I have recently added new leadership to help me execute the
plan that we’ve developed to take us through this difficult time</b>,” she said</span><b style="mso-bidi-font-weight: normal;"><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p></o:p></span></b></div>
<br />
<div class="MsoNormalCxSpMiddle" style="margin: 1em 0px 1em 0.75in; mso-add-space: auto; mso-layout-grid-align: none; mso-list: l6 level1 lfo6; mso-pagination: none; tab-stops: 11.0pt .5in; text-indent: -0.25in;">
<!--[if !supportLists]--><span style="font-family: "Courier New"; mso-fareast-font-family: "Courier New"; mso-fareast-language: JA;"><span style="mso-list: Ignore;">o<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";">
</span></span></span><!--[endif]--><span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Within weeks of that report, Medicare notifies the
organization they will be subject to 100% pre-payment claims review, but that
decision is almost immediately revised to 100% post payment claims review is instituted;
serious payment interruption is averted<o:p></o:p></span></div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Dec, 2012 – <o:p></o:p></span><br />
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><span style="mso-tab-count: 1;"> </span>In a December
meeting of the Board of Directors, the month-old <span style="mso-tab-count: 3;"> </span>Hospice Chief Operating Officer, who as
subsequently revealed in a Bankruptcy
Court deposition has no operational health care experience, much less
hospice, presents an "analysis" to the Board of Directors and the CEO, ostensibly a
strategic plan that features <span style="mso-tab-count: 3;"> </span>two
very grim options: (a.) continue to operate as best as possible, <span style="mso-tab-count: 2;"> </span>under
intensified regulatory scrutiny and possible financial damage as may potentially result from the Medicare
audits, repair the organization and <span style="mso-tab-count: 1;"> </span>maintain
the 35 year-old mission or (b.) accept the second option which the gentleman admits he favors: Shut it
down…<o:p></o:p></span></div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Feb 4, 2013 –<o:p></o:p></span><br />
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">San Diego
Hospice and Palliative Care Corporation files Chapter 11. <span style="mso-tab-count: 1;"> </span>Subsequent reports reveal the Board of
Directors decision made in <span style="mso-tab-count: 1;"> </span>December
to close the organization. Reports also cite some type of <span style="mso-tab-count: 1;"> </span>affiliation arrangement with Scripps
Memorial Hospital that provides (a.) SDHIPC
a $5M operating loan, (b.) an offer to purchase SDHIPC-owned <span style="mso-tab-count: 1;"> </span>real estate for $10.7M subject to bankruptcy
court approval (c.) absorption of
remaining employees as well as (d.) patients (subject to Scripps <span style="mso-tab-count: 1;"> </span>qualification of eligibility) into a small (<i style="mso-bidi-font-style: normal;">2012 unduplicated census: 86 patients</i>), for-profit, licensed and
certified hospice in Poway, which Scripps
has acquired in the preceding days and weeks.<o:p></o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"></span><br />
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Mar 12, 2013 – <o:p></o:p></span><br />
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">Deposition of San Diego Hospice & Institute of
Palliative Care Chief Operations Officer:<o:p></o:p></span></div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> read <a href="https://www.documentcloud.org/documents/618238-banrkruptcy-testimony.html">here</a>:</o:p></span></div>
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p></o:p></span> </div>
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;">This is a troublesome story with substantial ramifications
for free-standing community-based not-for-profit hospice and palliative care
organizations across the country. More to follow.<o:p></o:p></span><br />
<br />
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<span style="font-family: "Helvetica","sans-serif"; mso-fareast-language: JA;"><o:p> </o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<o:p> </o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<o:p> </o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<o:p> </o:p></div>
TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com1tag:blogger.com,1999:blog-1299373439555848942.post-72280639565503444362013-03-15T07:53:00.000-04:002013-03-15T07:53:40.374-04:00A Closer Look at San Diego Hospice (continued)Contributor Shelley Sansbury responding to comment (below) about CEO's effort to change culture:<br />
<br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
Please
be assured my intention was not to cast aspersions on anyone. Rather it was to
question the necessity of the decision to shut down the very highly regarded
San Diego Hospice and Institute for Palliative Medicine in the wake of a
Medicare Post-Payment Review of 149 patients.<o:p></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
What
you call <i>a 15 year long cultural disregard for the compliance requirements
of Medicare</i> mischaracterizes the Open Access policy pioneered by HSDIPM and
now employed by more than one in four hospices throughout the country. Medicare
eligibility rules clearly do not allow hospices to serve patients who seek curative
care, and both the hospice physician as well as the patients’ physician must
certify (and periodically re-certify) that the patient is terminal with a
prognosis of less than 6 months to live. Within this framework however hospices
are permitted to establish their own policies, procedures and criteria for
admission and discharge. Whether a patient has a willing and able caregiver
available at home can affect whether a hospice accepts or declines to serve a
patient who meets all Medicare Hospice eligibility requirements. Abundant
research has examined restrictive enrollment policies as barriers to hospice
care. (The Debate in Hospice Care, <i>J Oncol Prac</i>, May 1, 2008: 153-157 <a href="http://jop.ascopubs.org/content/4/3/153.full"><span style="color: blue;">http://jop.ascopubs.org/content/4/3/153.full</span></a>).
It appears to me SDHIPM's efforts to maintain an Open Access policy is
commendable. You ascribe the fate of this organization to a new CEOs
attempt to change <i>the culture</i>, purge the executive team, but it was too
late…for what? Too late to manage to achieve proper alignment between a
commitment to provide the best possible hospice care and Medicare regulatory
compliance, an intention the executive expressed in a Nov 13 press report.<o:p></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
I
am familiar with the financials, as reported to the CA Office of Statewide
Health and Development (and available to anyone with an internet connection).
In 2011 this hospice, with an annual unduplicated census of 4,665 patients
spent $320K in palliative radiation therapy alone. In total for 2011, net
operating expenses of $81M exceeded net patient revenue of $71M. Non-operating
revenue including community support such as “donations and contributions”
amounted to $12.5M, producing a positive total fund balance.<o:p></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
Another
interesting item included in this report is the 78,375 “Medicare Reportable
Hours of Volunteer Services”. While this may be of little relevance to the
bankruptcy court, it is, and I hope you would agree, a genuine asset, and
perhaps one more small reason to hope that those involved in the governance of
this voluntary non-profit organization would muster the devotion to emerge from
Chapter 11, rather than permanently abandon operations and put an end to the
mission on which the organization was built.<u1:p></u1:p><o:p></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">
<span style="color: #343434;"> </span><o:p></o:p></div>
<u1:p></u1:p>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-83022276340820916912013-03-08T11:17:00.002-05:002013-03-08T11:17:51.421-05:00A Closer Look at San Diego Hospice, Part 2
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><em>Posted by Blog Contributor Shelley Sansbury, health care strategist and former hospice and home care executive</em></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"></span> </div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Here are the facts according to 2011
SDH Annual Report furnished to the state. (Please note these data exclude
services provided to patients in the SDH Acute Care Center, the license for
which is in suspense.) SDH admitted 3,759 patients to hospice care in 2011.
Including patients already on service their unduplicated census for 2011
amounted to 4,665. A total of 3.157 deaths occurred (67.5%). 543 non death
discharges were reported. including 51 for whom prognosis was extended. The
report specifies that 4,505 patients were actively served, and this
unduplicated census accounted for a total of 363,629 Total Patient Care Days,
including 346,350 Days of Routine Home Care (95.2%) and 12,059 Days of
Inpatient Care (3.5%).<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">One of the measures I believe is
useful in an assessment of a hospice is <i style="mso-bidi-font-style: normal;">resource
consumption</i> as expressed in visits per patient-day<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background-color: transparent; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Discipline<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Visits<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div align="center" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: center;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Costs<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Cost per Visit<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Visits per Patient<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Visits per Routine Home Care Day<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">RN & LVN<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-layout-grid-align: none; mso-pagination: none;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">77,017<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">$17,743,679</span><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$230.39<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">17.1<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">0.22<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Social Services<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">22,435 </span><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$3,520,629<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$156.93<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">5.0<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">0.06<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Hospice Physician Services<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">23,930 </span><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$3,808,858<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$159.17<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">5.3<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">0.06<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Homemaker and Home Health Aide<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">60,020</span><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$1.286,740<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$21.44<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">13.3<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: center;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">0.17<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Chaplain<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">16,968</span><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$1,951,767<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$115.03<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">3.8<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">0.05<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Other*<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt; mso-layout-grid-align: none; mso-pagination: none;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">0 <o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.2pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Total<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 50.6pt;" valign="top" width="67">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: "Arial","sans-serif"; font-size: 11pt;">200,370</span><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 78.1pt;" valign="top" width="104">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 92.4pt;" valign="top" width="123">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 74.05pt;" valign="top" width="99">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">44.5<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 91.45pt;" valign="top" width="122">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">0.58<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">A review of the financial data for
SDH represents what one might expect of an eleemosynary organization, with a
service mission. That is, an operating loss subsidized by non-operating income,
including memorials, donations, gifts and grants. Although the 28.2 %
administrative cost burden seems possibly excessive, nothing in
this report suggests anything other than the performance associated with an industry
leader.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid windowtext .5pt; mso-border-insideh: .5pt solid windowtext; mso-border-insidev: .5pt solid windowtext; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td style="background-color: transparent; border: 1pt solid windowtext; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">REVENUE<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: windowtext windowtext windowtext rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Medicare<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$104,918,252<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">83.3%<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Medi-Cal<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$12,022,848<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">9.6%<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Other 3<sup>rd</sup> Party<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$7,274936<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">5.8%<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 5;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Private Pay<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$1,413,167<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">1.1%<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Other<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$337,818<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">0.2%<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Total Gross Patient Revenue<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$125,898.449<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Total Write-offs & Adjustments<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><$54,722,163><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 9;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Net Patient Revenue<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$71,176,286<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 10;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">EXPENSE<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 11;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Visiting Services<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$30,150,474<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">37.2%<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 12;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Admin & General<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$22.810,068<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">28.2%<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 13;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Inpatient General Care<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$8,915,012<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">11.0%<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 14;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Hospice Service Cost Centers<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$11,221,369<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">13.9%<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 15;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Other Costs<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$5,059,371<o:p></o:p></span></div>
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 16;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Total Operating Expenses<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$80,980,525<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 17;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Net Operating Margin<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><$9,804,239><o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 18;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Non-Operating Revenue including Memorials,
Contributions, grants, etc.<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$12,471,646<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
<tr style="height: 28.3pt; mso-yfti-irow: 19; mso-yfti-lastrow: yes;">
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext; border-style: none solid solid; border-width: 0px 1pt 1pt; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 182.2pt;" valign="top" width="243">
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<b style="mso-bidi-font-weight: normal;"><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">NET INCOME<o:p></o:p></span></b></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 178.7pt;" valign="top" width="238">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">$2,667,407<o:p></o:p></span></div>
</td>
<td style="background-color: transparent; border-color: rgb(0, 0, 0) windowtext windowtext rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; height: 28.3pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt; width: 117.9pt;" valign="top" width="157">
<div align="right" class="MsoNormal" style="margin: 0in 0in 0pt; text-align: right;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> </o:p></span></div>
</td>
</tr>
</tbody></table>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><o:p> I invite your comments. Anything extraordinary I'm missing?</o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<o:p> </o:p></div>
TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com1tag:blogger.com,1999:blog-1299373439555848942.post-41270064322360367392013-03-06T20:18:00.001-05:002013-03-06T20:18:29.099-05:00A Closer Look at San Diego Hospice
Posted by Blog Contributor Shelley Sansbury, health care strategist<span style="font-family: "Times New Roman","serif"; font-size: 12pt; mso-ansi-language: EN-US; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"> and former hospice and home health care executive</span><br />
<br />
<span style="font-size: 14pt;"><em>Is the Decision to Close San
Diego Hospice Reasonable?<o:p></o:p></em></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<o:p> </o:p>A review of available reports suggests the possibility that
the decision to close San Diego Hospice may have been made in haste by a CEO
with no previous hospice operations leadership experience and with limited involvement
by its Board of Directors.<o:p></o:p></div>
<br />
While it’s never easy to evaluate a situation based entirely
upon press reports, one can piece together the salient events that led to a
decision to (a.) terminate the Chief Medical Officer (b.) declare bankruptcy
(c.) disclose plans to become subsumed by Scripps Memorial Hospital.<o:p></o:p><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
It has been reported that the Medicare audit examined
records of 149 patients admitted to service between Jan 1, 2009 and Nov 30,
2010. Undoubtedly the audit selected those patients for whom Medicare made the
largest payments, that is, patients with the greatest length of stay. I have
been unable to ascertain the actual audit results. <br style="mso-special-character: line-break;" />
<br style="mso-special-character: line-break;" />
On Nov 12, 2012 the San Diego Times Union reported:<span style="mso-spacerun: yes;"> </span><i style="mso-bidi-font-style: normal;"><span style="font-family: "Helvetica","sans-serif"; mso-bidi-font-family: "Times New Roman";">“</span></i><i style="mso-bidi-font-style: normal;"><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Pacurar said she believes the hospice
is vulnerable to millions in rebates to Medicare because the program has not
been strict enough in making sure that its patients are truly suffering from an
illness likely to cause death within six months. She said doctors and care
givers operated for decades on an “open access” policy that kept patients on
hospice care for longer than six months, sometimes without being able to
demonstrate that their condition was worsening.” </span></i><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"><span style="mso-spacerun: yes;"> </span></span><span style="mso-spacerun: yes;"> </span><o:p></o:p></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
As noted recently by the same reporter a <span style="font-family: "Helvetica","sans-serif"; mso-bidi-font-family: "Times New Roman";">similar
Medicare audit was conducted in 1997. In that situation of 37 patient records examined
with the greatest lengths-of-stay, Medicare sought repayment from SDH of $2.1M.
According to the report, Chief Medical Officer Laurel Herbst, MD said</span><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;"> the organization fought hard to convince the government that
its decisions to keep the patients on hospice service for so long, in one case
four years, were appropriate.</span><span style="color: #343434; font-family: "Times","serif"; font-size: 17pt;"> </span><span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">“We fought every one of those cases,
and we ended up winning all of them,” Herbst said.<o:p></o:p></span></div>
<br />
<div class="MsoNormal" style="margin: 0in 0in 20pt; mso-layout-grid-align: none; mso-pagination: none;">
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">One should also note that while press
reports cite millions of dollars in Medicare payments potentially subject to
recovery, according to the Annual Report as filed with the California Office of
Statewide Planning and Development, the agency received $7.15M in memorials and
contributions in 2011 alone. By way of perspective it seems that even absent
any effort whatsoever to appeal the audit findings, at the very least a
Medicare overpayment repayment plan could and should be proposed. One doubts
that DHHS Secretary Kathleen Sibelius and the Centers for Medicare and Medicaid
Services under her command have any desire to deliberately contribute to the
demise of this esteemed organization.<o:p></o:p></span></div>
<span style="color: #343434; font-family: "Helvetica","sans-serif"; mso-bidi-font-family: Times;">Among the many important
accomplishments (and assets) of this organization is the Institute of
Palliative Medicine </span><span style="color: #363636; font-family: "Helvetica","sans-serif";">In addition to patient care, The Institute for Palliative
Medicine is internationally recognized for its excellence in palliative care
education and research and has achieved international recognition for its
innovative education programs, patient/family-centered research and
evidence-based advocacy since 1989. The Institute for Palliative Medicine
trains more than 2,000 healthcare professionals each year in the advances in
hospice and palliative care. One would hope in the weeks and months to come, as
the bankruptcy proceedings ensue as does the absorption of San Diego Hospice by
Scripps Memorial, the Institute for Palliative Medicine would find a means to
emerge with the autonomy it deserves.<o:p></o:p></span><br />
<br />
<div class="MsoNormal" style="margin: 0in 0in 20pt; mso-layout-grid-align: none; mso-pagination: none;">
<span style="color: #363636; font-family: "Helvetica","sans-serif";"><o:p> </o:p></span></div>
TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com1tag:blogger.com,1999:blog-1299373439555848942.post-70961714401599258572011-11-28T09:51:00.000-05:002011-11-28T09:51:34.013-05:00Improving Performance in Late-Life Care - A Modest Effort Starts in Philadelphia<span style="font-family: Calibri;">I’m working with a small group of Philadelphia-area<span style="mso-spacerun: yes;"> </span>hospital executives who have joined together in a campaign to improve late-life care in the region. While recognizing that many factors influence the overall performance of communities in how patients are treated in the final stage of life, these executives appreciate the enormous sphere of influence their institutions exert on their respective communities.<o:p></o:p></span><br />
<br />
<span style="font-family: Calibri;">Until shown the DAI Palliative Performance Reports for their respective hospitals, these executives, all of whose hospitals reportedly have a palliative care service, felt their institutions had been effectively caring for the late-life needs of their patients. Yet the hospitals’ performance lagged behind state and national benchmarks, and well behind the performance of<span style="mso-spacerun: yes;"> </span>hospital exemplars.<span style="mso-spacerun: yes;"> </span>The Philadelphia region’s performance similarly lagged.<o:p></o:p></span><br />
<br />
<span style="font-family: Calibri;">Examples abound.<span style="mso-spacerun: yes;"> </span>According to the DAI Palliative Performance Profile (P3) for Philadelphia, a Philadelphia resident will spend 20% more days in a hospital during last six months of life than the national average, and twice as many days as would a resident of the exemplar region of Portland, Oregon. The Philadelphia resident is one-third more likely to die in a hospital than his counterpart in Portland, and twice as likely to have had an ICU stay associated with that terminal hospitalization.<span style="mso-spacerun: yes;"> On a positive note, a</span>t least one indicator shows Philadelphia to be performing better than national benchmarks – while 41.9% of those who die in the US use the hospice benefit, 44.6% of Philadelphia residents received services from a licensed hospices prior to their death. Yet considerable opportunity<span style="mso-spacerun: yes;"> </span>remains for improvement.<o:p></o:p></span><br />
<span style="font-family: Calibri;">How much? Consider that in 10% of communities<span style="mso-spacerun: yes;"> </span>across the nation (the exemplar benchmark)<span style="mso-spacerun: yes;"> </span>more than 55% of their decedents utilized the hospice benefit.<o:p></o:p></span><br />
<br />
<span style="font-family: Calibri;">While few of the executives were surprised by Philadelphia’s poor performance in late-life care, most were surprised by the enormous gaps between the region’s performance and that of exemplar communities. Yet, should we be so surprised? After all, the Dartmouth Medical Atlas (from which the DAI P3 draws its data) has for years documented such variations. In a recent study titled <i style="mso-bidi-font-style: normal;">Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness, </i>the authors concluded that<span style="mso-spacerun: yes;"> </span>geography continues to play a huge role in late-life care, noting that “care patients received in the months before they died depended largely on where they lived, and widespread variations persist.”</span><br />
<br />
<span style="font-family: Calibri;">In future posts, we’ll take a closer look at what the DAI Palliative Performance Profiles tell us, and perhaps more importantly, how they might provide sharper focus for performance improvement campaigns, not unlike the modest effort<span style="mso-spacerun: yes;"> </span>briefly described above. In the meantime, I invite your comments on the state of late-life care in your region, or the US, in general, and welcome your ideas on the sort of performance improvement campaigns which could make a difference. We’ll also take a closer look at exemplar communities (read <a href="http://palliativemedicine.blogspot.com/2010/04/how-do-they-do-that-providing-high.html">here</a> for an earlier blog post on this subject) and <i style="mso-bidi-font-style: normal;">how do they do that?</i><o:p></o:p></span>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-22679158008727983152011-11-25T20:08:00.000-05:002011-11-25T20:08:14.823-05:00Short-Stay Hospice Patients? Intractable?<div class="MsoNormal">Utilization of the Medicare hospice benefit by those dying continues to grow. In 2003, fewer than one out of every three Medicare decedents received care from a certified hospice. By 2007, that number had grown more than 30%, as 42% of decedents used their hospice benefit during their final days (these figures are drawn from the Dartmouth Medical Atlas). <o:p></o:p></div><div class="MsoNormal"><br />
</div><div class="MsoNormal">What hasn’t changed over that period are the number of short-stay (those who use the Medicare hospice benefit for a week or less) patients. One of out every three referrals to the hospice benefit. So, late referrals continue to plague the hospice sector. Why? Theories abound, of course. You know them well, I’m sure. <o:p></o:p></div><div class="MsoNormal"><br />
</div><div class="MsoNormal">And surely, it couldn’t be insufficient knowledge of hospice, as most hospices now deploy “community education” specialists to inform potential referring sources of their service offerings. Prognostication tools have improved, so inability to confirm prognosis probably isn’t an explanation.<o:p></o:p></div><div class="MsoNormal"><br />
</div><div class="MsoNormal">A growing number of HPM practitioners offer an intriguing theory. It is, they say, because the hospice benefit does not “enable” concurrent care ,that is, curative treatment along with palliative measures. Patients, families, and physicians are hesitant to make early referrals to hospice because the patient must choose to forego curative care. Yet that does not lessen the need for, and the value of, palliative care. It simply means the providers of palliative care must be resourceful in marshaling the resources (reimbursement) to provide palliative care. Palliative care, to be sure, may be provided under many health plan benefits, including, of course, the hospice benefit, the home health benefit, and Medicare Part B, for physician outpatient or home-based visit coverage.<o:p></o:p></div><div class="MsoNormal"><br />
</div><div class="MsoNormal">I'm curious to learn your experiences in this regard. Does this "concurrent care "disabling" theory hold true in your experience? </div><div class="MsoNormal"><br />
</div>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com1tag:blogger.com,1999:blog-1299373439555848942.post-81950157265372116952011-11-25T16:47:00.002-05:002011-11-28T08:35:07.683-05:00Use of Hospice Benefit Grows, Late Referrals Persist<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">A recent discussion at a regional meeting of Hospice and Palliative Medicine practitioners grew lively when the subject turned to use of hospice, and whether use has grown. Following the meeting, I reviewed NHPCO reports for 2010 and 2005. Turned out opposing viewpoints were each right, to some extent. Here's what I concluded.</span><br />
<ul><li><span class="Apple-style-span" style="background-color: white; font-family: Times, 'Times New Roman', serif; line-height: 17px;"><i>30% growth in the percentage of Medicare decedents using hospice benefit. <b>Impressive! </b></i></span></li>
<li><span class="Apple-style-span" style="background-color: white; font-family: Times, 'Times New Roman', serif; line-height: 17px;"><i>Short-stay patients (7 days or less) remained level at one-third of total deaths and discharges. <b>Intractable?</b></i></span></li>
<li><span class="Apple-style-span" style="background-color: white; font-family: Times, 'Times New Roman', serif; line-height: 17px;"><i>The size of hospices remained small - nearly 8 out of 10 have fewer than three admissions per week. <b>Subscale?</b></i></span></li>
</ul><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Got me to thinking. If I was considering hospice care for a family member, aware that there is a one-in-three chance that the episode of hospice care will be no longer than a week, I'd want to select a hospice that admits twenty times the number of patients than the average-sized hospice. I figure that the additional volume would mean greater proficiency in short-stay care. </span><br />
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Does volume matter? No studies to prove either way. What do your professional instincts tell you?</span>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com0tag:blogger.com,1999:blog-1299373439555848942.post-52314775138777009062011-11-25T15:22:00.001-05:002011-11-28T12:49:57.349-05:00Trends in Hospice and Palliative Medicine (HPM) Physician Compensation<div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;">Compensation for expertise does not always follow the supply/demand imbalance. Hospice and Palliative Medicine (HPM) physicians are a current example.<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;">I’ve been monitoring compensation practices for full-time HPM physicians for the past five years. Through 2010, I relied upon the Compensation Reports compiled by DAI Palliative Care Group (disclosure: I am employed by its parent company). I now rely upon the recently published report of HPM physician compensation and benefits, drawn from the findings of a survey by the American Academy of Hospice and Palliative Medicine (AAHPM) of its members. Nearly 800 AAHPM physician members responded to the survey conducted in November 2010, providing information regarding their 2009 compensation from practicing Hospice and Palliative Medicine (HPM).<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;">As I review the reports over the preceding five years, several observations come to mind:<o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></div><div class="MsoNormal"></div><ul><li><span class="Apple-style-span" style="font-family: inherit;">Compensation for full-time HPM physicians continues its rise, yet at a slower pace than one would expect from a field marked by a shallow talent pool.</span></li>
<li><span class="Apple-style-span" style="font-family: inherit;">The gap in compensation based upon place of employment is narrowing. Compensation for hospital based HPM physicians is somewhat greater than that for hospice-based physicians, but the difference is decreasing.</span></li>
<li><span class="Apple-style-span" style="font-family: inherit;">Differences are insignificant for physicians practicing in urban, suburban, or rural areas. There are some regional differences, yet these too are insignificant. The greatest determinant of higher compensation is practicing HPM in a certificate-of-need state, such as Florida, where there is a concentration of larger-than-average size hospices who are more likely to deploy full-time physicians.</span></li>
<li><span class="Apple-style-span" style="font-family: inherit;">Salary compression, unsurprisingly, is characteristic of the specialty. Average compensation for three position layers (team physician, associate medical director, and medical director) are little more than 10 percent.The best way to improve one’s compensation is to move into leadership positions, typically within hospices.</span></li>
<li><span class="Apple-style-span" style="font-family: inherit;"> Compensation lags behind that of other specialties and primary care physicians (according to the 2010 <span style="font-size: 11pt;">AMGA Medical Group Compensation and Financial Survey the median salary for is $214,000 for internists, $208,000 for family practitioners, and $267,000 for emergency medicine physicians)</span> .</span></li>
</ul><span class="Apple-style-span" style="font-family: inherit;"><br />
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<div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;"><o:p></o:p></span></div><div class="MsoNormal"><span class="Apple-style-span" style="font-family: inherit;">The 2010 AAHPM report is chockful of information relative to compensation, benefits, and workload. I recommend its purchase (<a href="http://www.aahpm.org/resources/default/10survey.html">click here</a>).</span><o:p></o:p></div>TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com1tag:blogger.com,1999:blog-1299373439555848942.post-4919902677509685522011-10-26T08:12:00.000-04:002011-10-26T08:12:33.996-04:00Reducing Hospital Readmissions: A Role for Hospice and Palliative Medicine Practitioners?Hospices and their palliative medicine specialists have proven, several studies have shown, to be effective at reducing use of hospitals for their patients. In fact, families cite avoiding transitions among multiple settings as one of the benefits of hospice. In a previous <a href="http://palliativemedicine.blogspot.com/2009/05/reducing-hospital-readmissions-role-for.html">post</a>, we've examined the role of palliative medicine physicians in reducing readmissions. <br />
One of the first financial impacts to hospitals resulting from PPACA legislation is a reduction in reimbursement for excessive readmission of Medicare inpatients. Starting with discharges in October 2011, the impact of the payment penalties may be significant.<br />
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The Medicare Payment Advisory Commission (MedPAC) has estimated that nearly one out of every five Medicare patients admitted to the hospital is readmitted within 30 days and unplanned readmissions are estimated to cost Medicare approximately $17.4 billion annually. Readmissions have become a widely accepted measure of hospital effectiveness. Although only one of many performance metrics, low readmission rates do correlate with overall clinical excellence. <br />
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As part of the CMS value-based purchasing program, 30-day readmission rates are a performance measure already closely watched in the industry. Now PPACA legislation allows CMS to withhold a portion of all inpatient Medicare payments due to excessive readmissions, starting with up to 1 percent in federal fiscal year 2013, and rising to 3 percent in 2015 and beyond. <br />
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Hospitals will likely look to post-acute care networks to assist in managing the care of at-risk (for rehospitalization) patients. Should we consider deployment of palliative care specialists (physicians and nurse practitioners) by these networks to visit patients in their homes (especially but not only when a referral has not been made to home health)? If not palliative care practitioners, then who?TIM COUSOUNIShttp://www.blogger.com/profile/12468137829818616339noreply@blogger.com1