NHO conference offers glimpse of industry’s redefined future
How will the new hospice emerge?
For years, management consultants, keynote speakers at hospice conventions, and industry leaders have insisted that change is the only constant for America’s hospices. More recently, some have suggested that hospice needs to change itself in more fundamental ways, redefining programs, services, and product lines perhaps even changing its name to palliative care or end-of-life care to deflect hospice’s stigma of death which now discourages some patients.
Pressures driving this restructuring include the following:
- plummeting lengths of stay (see Hospice Management Advisor, May 1997, pp. 49-53);
- Operation Restore Trust audits and governmental scrutiny;
- new hospice-like competitors unconstrained by regulations hospices must follow;
- emerging national initiatives in end-of-life care that sometimes appear to undervalue hospice’s contribution (see story, p. 78);
- calls to widen restrictive admission criteria and expand access beyond the 17% of dying Americans now served by hospice;
- momentum for vertical integration of the larger health care system;
- the shift to managed care.
A growing number of hospice leaders now say that major changes are needed in hospice’s model of care and reimbursement structure, starting with the current Medicare requirement that patients must have a prognosis of six months or less to live.
At the same time, experts say this call for change should be balanced with the industry’s continued growth in both numbers of providers and patients served. For now, the per diem Medicare hospice benefit remains the industry’s dominant pay source. The challenge is to keep utilizing this familiar and comfortable funding stream while experimenting with new models and approaches that better meet the needs of an evolving health care system.
A glimpse into the future
A glimpse into hospice’s future was offered at the recent Arlington, VA-based National Hospice Organization (NHO) Senior Management and Leadership Conference, held May 20-23 in Washington, DC. Conference presentations and subsequent interviews with hospice leaders suggest some of the ways hospices may need to change to reach this future.
"Is hospice over?" asked one of the most provocative NHO sessions. Three innovative hospice CEOs concluded that hospice as we know it is over. "It doesn’t work for our patients anymore," said J. Donald Schumacher, PsyD, CEO of the Hospice Association of Western New York in Cheektowaga. With ever decreasing lengths of stay in hospice, "we’ve moved from the end of life to the brink of death."
"Hospice doesn’t work in the new health care environment because it doesn’t meet payers’ needs," added Gretchen Brown, MSW, president and CEO of Hospice of the Bluegrass in Lexington, KY. New payers, including managed care systems, HMOs, and large medical groups, "want less expensive and more integrated services. The Medicare benefit doesn’t give them what they want. They also need services without regard to a six-months-or-less prognosis," Brown added.
Carolyn Cassin, BA, MPA, CEO of Hospice of Michigan, said her statewide agency created through merger in 1994 had explored various survival options, including vertical and horizontal integration. It concluded that what was needed was to change hospice itself by expanding services, developing new products and models of care, and entering the emerging field of palliative care.
The Michigan hospice also explored various strategies to improve length of stay, including advertising and promotion aimed at the public, one-to-one education of physicians, and inpatient and medical office liaison teams. The only approach that increased length of stay was a new program called Supportive Care, in partnership with an academic medical center. This program offers many of the same services as hospice to cancer patients receiving active treatment, but without the name hospice, so these patients with life-threatening illnesses do not need to overtly acknowledge the issue of dying, Cassin said.
Other speakers at NHO offered similar perspectives. "We’re all looking for answers integration, managed care contracting and re-engineering," observed Mary Labyak, MSW, LCSW, president of Hospice of the Florida Suncoast in Largo. "The answer is probably all of those, combined together to take us in new directions we can’t even conceive of yet." Labyak added that she is not a fan of discarding the name hospice. But marketplace changes and consumer demand clearly require more than just tinkering or re-engineering.
"What is going on? Why do things seem so untenable when we have finally gained the national spotlight?" John Carney, MEd, CEO of Hospice Inc. in Wichita, KS, and NHO’s chairman, questioned in the conference’s keynote presentation. "How do we make sense of all this? How do we lead through the change rather than react to it?"
One answer, he said, lies in recognizing the distinction between crisis and chaos. When people believe they are in crisis, they tend to abandon their usual and most effective coping mechanisms because they believe they wouldn’t be in this mess if the usual coping strategies were working.
Actually, Carney said, America’s hospices today operate in an environment that is highly chaotic, partly for reasons beyond their control and partly because hospice was the instigator in shaking up how the larger system addresses care of the dying. "The chaos need not invoke a crisis response. If we can step back dispassionately, we can read it differently and adapt to the new environment," he said.
"Nobody else has our sacred trust [to serve the dying]. We have the knowledge. We know the simple steps to build the complex systems" that address the real human needs of patients and families facing a terminal illness, Carney said. "They don’t know how to do it. They don’t even value it. That’s our job our mission to transform care at the end of life. [But if hospice is to] profoundly change how people die in this country, we have to be prepared to profoundly change ourselves."
Rather than seeing emerging end-of-life trends and the creation of institutional palliative care programs as a threat, hospices should seize the opportunity to design and lead these new initiatives, he added.
"My hunch is that there’s not going to be one new hospice. Hospice itself will become increasingly diverse in how it’s organized and delivered," says Paul Brenner, MDiv, coordinator of Jacob Perlow Hospice at Beth Israel Medical Center in New York City. Brenner adds that most hospice professionals today have only known hospice as defined by the Medicare hospice benefit and have no experience with the diversity and experimentation of the movement’s early days.
"I think the Medicare hospice benefit is still a viable part of what we do, but we’re going to have to find ways to take care of people who don’t fit the benefit," says Anne Thal, LCSW, DCSW, President and CEO for Hospice of Hillsborough in Tampa, FL. "We’ve got to start by being proactive, not reactive, and stop feeling like victims. I believe that one of the goals of the hospice movement from its beginning was to increase awareness about choices at the end of life. Lo and behold, that is happening, partially due to what we’ve done. But now some hospice folks are upset about everyone else wanting to get into our territory," Thal says.
For True Ryndes, ANP, MPH, president and CEO of VNA and Hospice Foundation of Northern California in Emeryville, the challenge is to more clearly define "hospice’s core competencies, which I see as transition management. That includes helping people to die well, but we could also be supporting and helping people with tasks and decisions associated with many phases of chronic and terminal illness. It makes a lot of sense to pay attention to people further upstream" in their disease progression, and introduce hospice as a transition management service before they see themselves as dying, Ryndes explains.
"There is such a need for improved care of the dying. We welcome the country getting involved in end-of-life care," adds Jan Cetti, BSN, MS, CEO of San Diego Hospice. Cetti’s hospice is currently working with the University of California-San Diego (UCSD) Medical Center on research and development to get involved earlier with patients without worrying about the Medicare reimbursement. A joint task force with UCSD’s home care and San Diego Hospice also is planned, Cetti says. The hospice also is looking at how to work with other acute care providers and develop palliative care services through its hospice program.
"I see a very positive future for hospice if we can get creative and take a new look at our mission and the principles of our services and not be hemmed in by the payment mechanism." The six-month prognosis, too, has become an albatross for the industry, necessitating fundamental changes, she says.
But can the industry make these changes before the dominant payment mechanism changes? "That’s what we ought to be talking about as an industry," Cetti replies. "The advantage of the community-based hospice is that it is or should be service-driven, not dollar-driven. Our community supports what we do. I think it’s important to commit dollars to testing these new products and then figure out how we’ll pay for them on the back end."
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