Cooperation and Competition at the End of Life: Maryland

1
Cooperation and Competition at the End of Life
Marylands Evolving Hospice Policy Arena

• Patricia M. Alt, Ph.D.
• Towson University

2
Presenter Disclosures
Patricia Alt

• (1) The following personal financial
  relationships with commercial interests relevant
  to this presentation existed during the past 12
  months

No Relationships
3
History of Hospice in Maryland

• Hospice care in Maryland began in the mid-1980s
  with an Episcopal church and a group of nuns
  establishing the Joseph Richey House in Baltimore
  City
• Gradually, other programs began, and as of 2013,
  there were 30 hospices licensed in the state.
• In order to operate in a particular county, the
  hospice organization must obtain a Certificate of
  Need from the Maryland Health Care Commission.

4
Characteristics of Maryland Hospices

• Profit Status
• Non-Profit 24
• For-Profit 6
• Medicare Certified 27
• Agency Type
• Freestanding 22
• Hospital-Based 4
• Home Health Agency-based 3
• Nursing Home-based 1
• Data from MHCC

5
Some Key Factors in 2011

• Payment Source
• Medicare 81
• Medicaid 3
• Other 16
• Cause of Death
• Cancer 43
• Debility Unspecified 15
• Other 14
• Dementia 12
• Heart Lung Diseases 8 each
• Data from annual MHCC Hospice Surveys

6
Updating the State Plan

• The State Health Plan is required to be updated
  every five years. Since it had last been updated
  in 2007, a series of workgroups and comment
  periods began in 2011, culminating in revised
  regulations in 2013.
• The utilization of hospice services has been
  growing, and the population over 65 is estimated
  to be expanding by 62 (from 707,642 in 2010 to
  1,148,448 in 2025).
• Data from annual MHCC Hospice Surveys

7
Trends in Maryland Hospice Utilization (FY
2003-2011)

• Total number of patients (75 increase)
• 2003 - 12,427 to 2011 - 21,814
• Patient Days (281 increase)
• 2003 310,714 to 2011 1,185,089
• Deaths (86 increase)
• 2003 8,724
• 2011 16,269
• Data from annual MHCC Hospice Surveys

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Complexities of Maryland Law

• Currently a hospice is defined as a health care
  facility with CON approval required for changes
  in the bed capacity.
• However, the provision of hospice services in
  homes and other facilities is less clearly
  regulated.
• Working with the Hospice and Palliative Care
  Network of Maryland, and with a series of
  workgroups, the MHCC proposed a change in Hospice
  Need methodology.

9
Proposed Changes in CON Methodology

• Age from all ages to 35
• Diagnoses from Cancer only to All diagnoses
• Use Rate Changed from Hospice Cancer Deaths
  divided by Population Cancer Deaths to All
  Hospice Patients divided by Population of
  Potential Hospice Users
• Need would be projected at the jurisdiction
  level, with five years from base year to target
  year
• Data from MHCC Revised Plan

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Hospice Use In Maryland Counties
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Variations in Hospice Providers and Usage

• In Baltimore City, there are 9 providers, but 2
  account for 72 of the market share
• In Prince Georges County, there are 9 providers,
  and 3 account for 78 of the market share.
• These are the two largest jurisdictions among
  those with low rates of hospice use
• African-Americans also constitute larger
  proportions of the population in these areas, and
  are among the least likely groups to utilize
  hospice services.
• Data from MHCC

12
Feedback from Providers and Interested Parties

• Members of previous workgroups on hospice,
  palliative care, and end of life counseling were
  surveyed about the current situation of hospice
  care in Maryland.
• Respondents included hospice directors, aging and
  disability advocates, state policymakers, and
  others with connections to hospice and palliative
  care services. Their responses varied widely, but
  the most mentioned concerns were

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Feedback (continued)

• Lack of education of the public and medical
  professions about hospice and palliative care
• Lack of funding for programs caring for the un-
  or under-insured
• Minority under-utilization of hospice services
• Lack of choices for nursing home patients
• Confusion about how EOL care fits in Accountable
  Care Organizations
• Reluctance of medical providers to refer patients
  to hospice or palliative services

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Assumptions in the State Health Plan Revisions

• Variations in use rates across the state would
  change if more choices for care were available
• Education of the public is a key element in
  increasing interest in hospice use
• Changing the methodology for CON from use to
  need will better allow for the potential usage
  in lower usage and higher diversity areas

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Future Directions

• The regulatory agencies in Maryland are aiming to
  develop better quality measures and incorporate
  them into CON projections
• Smaller hospices are exploring partnerships with
  larger healthcare systems in order to survive as
  Accountable Care Organizations evolve
• Educational sessions are being held to reach out
  to underserved populations and dispel concerns
  about using hospice and palliative care.

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Key Remaining Questions

• Does having more options lead to increased
  willingness to use hospice care?
• Is it ethical for hospices to aggressively market
  to insured patients and avoid the uninsured?
• Are for-profit hospices, operating in nursing
  homes primarily, over-using the Medicare hospice
  benefit?