Cooperation and Competition at the End of Life: Maryland’s Evolving Hospice Policy Arena

1. Cooperation and Competition at the End of Life: Maryland’s Evolving Hospice Policy Arena Patricia M. Alt, Ph.D. Towson University

2. Presenter Disclosures Patricia Alt No Relationships (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

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

8. 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

10. Hospice Use In Maryland Counties

11. Variations in Hospice Providers and Usage • In Baltimore City, there are 9 providers, but 2 account for 72% of the market share • In Prince George’s 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:

13. 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

14. 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

15. 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.

16. 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?