A Closer Look at San Diego Hospice, Part 2

Posted by Blog Contributor Shelley Sansbury, health care strategist and former hospice and home care executive

 

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%).

 

One of the measures I believe is useful in an assessment of a hospice is resource consumption as expressed in visits per patient-day

 

Discipline	Visits	Costs	Cost per Visit	Visits per Patient	Visits per Routine Home Care Day
RN & LVN	77,017	$17,743,679	$230.39	17.1	0.22
Social Services	22,435	$3,520,629	$156.93	5.0	0.06
Hospice Physician Services	23,930	$3,808,858	$159.17	5.3	0.06
Homemaker and Home Health Aide	60,020	$1.286,740	$21.44	13.3	0.17
Chaplain	16,968	$1,951,767	$115.03	3.8	0.05
Other*	0
Total	200,370			44.5	0.58

 

 

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.

 

 

REVENUE
Medicare	$104,918,252	83.3%
Medi-Cal	$12,022,848	9.6%
Other 3rd Party	$7,274936	5.8%
Private Pay	$1,413,167	1.1%
Other	$337,818	0.2%
Total Gross Patient Revenue	$125,898.449
Total Write-offs & Adjustments	<$54,722,163>
Net Patient Revenue	$71,176,286
EXPENSE
Visiting Services	$30,150,474	37.2%
Admin & General	$22.810,068	28.2%
Inpatient General Care	$8,915,012	11.0%
Hospice Service Cost Centers	$11,221,369	13.9%
Other Costs	$5,059,371
Total Operating Expenses	$80,980,525
Net Operating Margin	<$9,804,239>
Non-Operating Revenue including Memorials, Contributions, grants, etc.	$12,471,646
NET INCOME	$2,667,407

 I invite your comments. Anything extraordinary I'm missing?

 

A Closer Look at San Diego Hospice

Posted by Blog Contributor Shelley Sansbury, health care strategist and former hospice and home health care executive

Is the Decision to Close San Diego Hospice Reasonable?

 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.

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.

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.

On Nov 12, 2012 the San Diego Times Union reported:  “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.”   

As noted recently by the same reporter a 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 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. “We fought every one of those cases, and we ended up winning all of them,” Herbst said.

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.

Among the many important accomplishments (and assets) of this organization is the Institute of Palliative Medicine 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.

 

Improving Performance in Late-Life Care - A Modest Effort Starts in Philadelphia

I’m working with a small group of Philadelphia-area  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.

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  hospital exemplars.  The Philadelphia region’s performance similarly lagged.

Examples abound.  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.  On a positive note, at 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  remains for improvement.
How much? Consider that in 10% of communities  across the nation (the exemplar benchmark)  more than 55% of their decedents utilized the hospice benefit.

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 Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness, the authors concluded that  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.”

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  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 here for an earlier blog post on this subject) and how do they do that?

Short-Stay Hospice Patients? Intractable?

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).

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.

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.

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.

I'm curious to learn your experiences in this regard. Does this "concurrent care "disabling" theory hold true in your experience? 

Use of Hospice Benefit Grows, Late Referrals Persist

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.

• 30% growth in the percentage of Medicare decedents using hospice benefit. Impressive! 
• Short-stay patients (7 days or less) remained level at one-third of total deaths and discharges. Intractable?
• The size of hospices remained small - nearly 8 out of 10 have fewer than three admissions per week. Subscale?

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.
Does volume matter? No studies to prove either way. What do your professional instincts tell you?

Trends in Hospice and Palliative Medicine (HPM) Physician Compensation

Compensation for expertise does not always follow the supply/demand imbalance. Hospice and Palliative Medicine (HPM) physicians are a current example.

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).

As I review the reports over the preceding five years, several observations come to mind:

• 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.
• 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.
• 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.
• 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.
•  Compensation lags behind that of other specialties and primary care physicians (according to the 2010 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) .

The 2010 AAHPM report is chockful of information relative to compensation, benefits, and workload. I recommend its purchase (click here).