Hospice in the United States Policy Forum Research

Hospice in the United States Policy Forum Research Stephen R. Connor, Ph. D Vice President Division of Research and International Development

What we will cover • The growth of hospice in the US from the 1970’s to the present – NHPCO Dataset Data – Medicare Hospice Benefit Data (OSCAR) • A look at death in the US in 2002, including who uses hospice care covering geography, disease, race, age, & sex – Using the Complete CDC Compressed Mortality File – The 100% Standard Analytic File for Hospice • A look at hospice costs and new research on survival

Growth in Hospice Sites Continues: 500 new sites

Recent Growth in Hospice Sites 2003 2004 2005 2006* • Hospice Programs • Multiple Locations • Total All Sites> 2, 500 2, 807 3, 145 3, 635 822 850 1, 015 1, 114 3, 322 3, 657 4, 160 4, 749 » *Preliminary Numbers » >Includes approximately 200 non-certified volunteer hospices

Growth in Patients Served

Hospice Caring for a Larger Proportion of all US Deaths • One of every 3 deaths from all causes under hospice – 800, 000 deaths in 2005 – 200, 000 admitted in 05 carried over to 2006 – 200, 000 discharged alive (14. 8%) • =1, 200, 000 served

Who Needs Hospice Palliative Care? • As many as 7 in 10 of those dying annually § Cancer – Chronic Organ Failure – Frail/demented § Those not needing palliative care: – Non HIV Infectious disease – sudden onset MI & Stroke – Accidents, homicide, suicide - acutely ill without ADL dependencies – Now reaching about half the need

More Non-Cancer Admissions Especially Lung, Debility, and MND

Average & Median Hospice Length of Service Continue to Rebound

LOS <7 days starting to drop LOS >180 days increasing Patients in Hospice < 7 days 40% 36. 9% Patients in Hospice > 180 days 40% 35. 1% 31. 7% 30% 20% 10% 0% 0% 2003 2004 2005 7. 3% 2003 9. 2% 10. 3% 2004 2005

More hospice patients dying in the place they call home • 75. 9% died in private residence, nursing home, or residential facility • 24. 1% of hospice patients died in – Inpatient hospice unit (4. 7%) – Freestanding hospice facility (9. 9%) – Acute care hospital only (9. 5%) • Compared to 50% of all deaths in acute hospitals in the general population

OSCAR Data • OSCAR is the CMS database that captures information on all Medicare certified providers. Information is updated at each recertification • Information in this database includes: – – – Identifying information on providers Type of ownership and incorporation Medicare provider numbers and dates of certification Actions by CMS including types of closure/merger Staffing by all disciplines and for volunteers • All information is at the provider number level

OSCAR Findings • A total of 3, 868 providers have been certified since the beginning of the Medicare Hospice Benefit – – As of last October there were 3, 019 (78%) active provider numbers* 649 (16. 8%) providers have voluntarily closed due to merger 165 (4. 3%) providers have voluntarily closed for other reasons 35 (0. 9%) providers have been involuntarily closed • Of the 848 closed programs – 48. 6% were non profit – 44% were proprietary – 7. 4% were governmental or other *Many hospices bill more than one hospice location through the same provider number. Approximately 25% of hospices are provider multiple locations, giving us over 4, 000 locations

OSCAR – All providers • Currently Active by Provider Type – US Totals Type – – – Hospitals Nursing Facilities Home Health Agencies Hospices TOTAL # % of Total 6, 182 15, 923 8, 418 3, 019 33, 542 18. 4 47. 5 25. 1 9. 0

OSCAR Incorporation Status Incorporation Type* Hosp NF HH – – • Hospice 6. 5 47 42. 2 4. 3 24. 9 21. 8 53. 3 - 6. 0 66. 2 27. 8 - 7. 3% 67. 2% 25. 5% - Governmental Proprietary Non profit Other *By provider number

OSCAR Data – New Hospices • Since the beginning of 2001 there have been 1, 019 new hospice provider numbers issued. They break down as follows: – – Governmental Proprietary Non profit Other 2. 3% 80. 4% 11. 8% 5. 5%

OSCAR – Active providers #’s by state* • States with Most Provider #’s – – – – – Texas California Oklahoma Pennsylvania Alabama Georgia Illinois Mississippi Louisiana Ohio 251 192 140 139 117 106 105 103 102 101 • States with Fewest Provider # – – – – – Virgin Islands DC Alaska Delaware Hawaii Rhode Island Vermont Nevada S. Dakota N. Dakota 1 3 5 7 7 8 10 12 14 15

OSCAR Staffing Data • Staff FTE’s in currently active hospice programs – – – – – 25, 057 5, 586 16, 092 2, 693 6, 501 2, 964 4, 034 17, 125 80, 053 Registered Nurses LPN/LVN’s Home Health Aides Homemakers Medical Social Workers Physicians Counselors Other salaried personnel TOTAL Full time equivalent staff

OSCAR Staffing Data • Volunteer FTE’s in currently active hospice programs: – – – – 432 96 634 2, 288 185 860 1, 375 38, 469 – 44, 340 Registered nurse LPN/LVN Home Health Aide Homemaker Medical Social Work Physician Counselor Other TOTAL Volunteer full time equivalents

Staffing Data • Total Staffing Estimates – 80, 053 Staff FTE’s = approximately 120, 000 individuals • Total Volunteer Estimates – 44, 340 Volunteer FTE’s = approximately 400, 000 individuals • Total Individuals involved in the provision of hospice care in the US (approximate) 550, 000* » *Includes non-Medicare certified hospices

Geographic Variation in Hospice Use in 2002 (In-press, JPSM) • Complete CDC death certificate records and CMS 100% Standard Analytic File for hospice claims for 2002 were used to describe the whole population of hospice users and non-users in the United States. The overall hospice utilization rate for persons 65 years and older was 28. 6%. Our findings highlight opportunities for the hospice industry to provide more care, opportunities defined by diagnostic and geographic axes.

Hospice Utilization by Cause of Death 2002

Geographic Variation in Hospice Use in 2002 (In-press, JPSM) • States with highest hospice utilization in 2002 – – – – – Arizona Colorado Florida Oregon Nevada Texas New Mexico Oklahoma Michigan Utah 49% 45% 42% 37% 36% 35% 34% 34% • States with lowest hospice utilization in 2002 – – – – – Alaska Maine S. Dakota Wyoming N. Dakota D. C New York Vermont Hawaii Tennessee 8% 14% 16% 18% 19% 20%

Overall Hospice Utilization by State

Overall Hospice Utilization by County

Cost Report Data • Come to the session on Medicare Hospice Cost Report data on Saturday 11 G 9: 30 – 10: 30 • National Highlights – – Net Revenue Per Day Total Expenses Per Day Margin Per Day % Margin 2004 2005 $129. 56 117. 86 11. 70 9. 03% $132. 06 123. 12 8. 94 6. 77%

Hospice Cost Studies • CBO Study • Lewin VH 1 Study • Emanuel Study • Rand Study • Milliman Study • Duke Study

Survival of Hospice Patients • Pyenson, B. , Connor, S. , Fitch, K. , & Kinzbrunner, B. (2004). Medicare cost in matched hospice and nonhospice cohorts. Journal of Pain and Symptom Management, 28(3). • Connor S, Pyenson B, Fitch K, Spence C, & Iwasaki, K. Comparing hospice and non-hospice patient survival among patients who die within a 3 year window. Journal of Pain and Symptom Management, 33(3).

Opioids Dosing and Time to Death • Portenoy RK, Sibirceva U, Smout R, Horn S, Connor S, Blum R, Spence C, and Fine P. (2006). Opioid use and survival at the end of life: a survey of a hospice population. Journal of Pain and Symptom Management, 32(6): 532 -40.

Hospice Patients and Families Cared For • In our country on an average day hospices are caring for over 200, 000 patients and their families Of these less than 6, 000 need inpatient care • On an average day hospices are providing support to over 1. 6 million grieving people • Since hospice began in the mid 1970’s in the US we have cared for over 10, 000 patients and their families

THANK YOU