OPENING REMARKS. J. Donald Schumacher, PsyD President and CEO National Hospice and Palliative Care Organization

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2 OPENING REMARKS J. Donald Schumacher, PsyD President and CEO National Hospice and Palliative Care Organization

3 INTRODUCTION OF PANEL MODERATORS Ron Fried, VITAS Innovative Care, Moderator Linda Rock, Prairie Haven Hospice, Moderator

4 What Do Short and Long Hospice Stays Tell Us about Medicare Policy? DONALD H. TAYLOR, JR. Sanford School of Public Policy Duke University

5 Some Work Funded by 2 Grants HCFO Initiative of RWJ: Identifying the Use, Cost and Quality Tradeoff in the Medicare Hospice Benefit AHRQ 1RO1 HS018360: Priorities for Medicare Advanced Cancer Coverage Sponsors are not responsible for the presentation/my conclusions

6 Cordt Kassner, Hospice Analytics helped with slides & some of the empirical work I discuss. Policy conclusions/suggestions are my responsibility

7 2012 Medicare Hospice Percentage of Discharged Deceased x LOS 100% 80% 60% 40% Of those discharged deceased from hospice: - 25% die in 4 days or less - 50% die in 13 days or less - 75% die in 43 days or less DC Deceased 20% 0%

8 2012 Medicare Hospice Percentage of Discharged Alive x LOS 100% 80% 60% 40% Of those discharged alive from hospice: - 25% are discharged by day 17-50% are discharged by day 57-75% are discharged by day 127 DC Alive 20% 0%

9 Short Stay Concerns Quality Foregone cost savings Persistent: 1 in 4 dying 4-5 day LOS ~10 yrs Problem or preference? How can we lengthen short stays? Worry: will changes exacerbate short stay

10 Long Stay Concerns More likely to be discharged alive Fraudulent Inappropriate Back door LTC benefit? Increase cost at longer length of use

11 Hospice Saves Medicare $ even w/long stays in N.C. (preliminary; static use) Hospice Observed MEDPAC U-Curve Rebase -10%, No Update N Mean Difference N Mean Difference N Mean Difference Total 24,058 $11,925 24,058 $11,821 24,058 $11,452 Control 12,029 $13,158 12,029 $13,161 12,029 $13,102 Hospice 12,029 $10,692 -$2,466 12,029 $10,482 -$2,679 12,029 $9,802 -$3,300

12 Conclusions/What Next? More focused audit Hospice policy change inevitable. What is the goal? With appropriate comparison, hospice saves Medicare money even with long stays Could save more (worry unintended conseq) Some long stay hospice back door LTC What do patients want?

13 Final Thoughts The hospice benefit in Medicare has been expected to improve quality & save money since the beginning A very rare standard in health care Hospice shouldn t be the only part of Medicare subjected to such questions

14 JOANNE KENEN Health care editor, Politico Kaiser Family Foundation media fellow (2006/7) Association of Health Care Journalists Contributed to: The Atlantic, Kaiser Health News, the Washingtonian, CQ, The Washington Post, the Center for Public Integrity, Health Affairs, AARP s The Magazine and Bulletin, National Journal, Slate, Miller- McCune, PBS NewsHour, C-SPAN, and msnbc.

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20 What s Missing from Coverage? What is best for the patient. What is appropriate care given the complicated diseases such as Alzheimer's and dementia.

21 Don t conflate quality and quantity Long hospice stays may be a poor use of taxpayer/medicare money, but so are very short stays. How would small community and rural hospitals survive under some of the new payment models being discussed. Some studies suggest that patients who receive hospice care may live longer than similar terminally ill patients who do not. When asking whether there s too much hospice care in nursing homes don t forget to ask what happens when there is not enough. Hospice was not designed to be a substitute for, or side door to, long-term care.

22 Bruce Scott, MD FACP Medical Director, Crossroads Hospice Assistant Professor, Departments of Medicine & Geriatrics Wright State University, Boonshoft School of Medicine

23 Live Discharges Should not be seen, on the face of it, as failures, errors, or indicators of fraud. Types of live discharges: Stabilized/improved: 38% Revoked to pursue more aggressive medical interventions 32% For-profit vs not-for-profit differences (19.6% vs 11.6%) Largely accounted for by increase in revocation to seek more aggressive treatment (7.6 to 3.2%)

24 Dementia Progressive, terminal illness. Assertion that patients are not actually dying. Prognostic uncertainty compared to cancer. Life expectancy vs life span. Outliers are not indicators of fraud or errors. Still provide important services regarding symptom management, family support. Improve outcomes of OTHERS in facility.

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26 Plea to legislators/regulators Consider the unintended consequences Regulations change tenor of hospice (for the worse) Already can audit the admissions if suspect

27 PANEL DISCUSSION AND AUDIENCE Q&A Ron Fried, VITAS Innovative Care, Moderator Linda Rock, Prairie Haven Hospice, Moderator

28 PATIENT AND FAMILY STORIES Marci Overmiller, Smith Center, Kansas, with Linda Rock

29 CLOSING REMARKS J. Donald Schumacher

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