The State of Hospice in the State of Oregon 2009 in Review and 2010 Challenges

1. The State of Hospice in the State of Oregon2009 in Review and 2010 Challenges2009 Annual Membership MeetingJanuary 29, 2010Deborah Whiting JaquesExecutive Director & CEO

2. The State of Hospice in the State of Oregon2009 in Review and 2010 Challenges • OHA Programs • Hospice in Oregon – Profiles of Care • Oregon Drug Takeback • POLST Registry • Hospice Licensure • Health Care Reform – Hospice impacts • Upcoming Challenges

3. OHA ProgramsResource Development - Meg McCauley Fund development to increase services for Oregon’s terminally ill and to support OHA programs. • Memorial Day Campaign • Portland Marathon • Ernst Family Golf Tournament • Light Up a Life • Grants/Bequests

4. OHA ProgramsMe Too & Company - Meg McCauley Through a partnership with Legacy and Providence, ensure Oregon’s grieving children have a place to heal. • Professionally staffed 8 week grief counseling for children and families provided at no cost. • Renamed Me Too • Three sessions • Providence Child Center • Portland First Church of the Nazarene • Helped 24 families in 2009

5. OHA ProgramsProfessional Education Be a premier source of staff and professional education for hospices and palliative care organizations serving Oregonians. • Offer Continuing Medical Education (CME) Credits for Physicians • OHA is accredited by the Oregon Medical Association • Offer Continuing Education (CE) Credits for Nurses • OHA is licensed by the California Board of Registered Nursing

6. OHA ProgramsData Collection New OHA Data Set (effective January 2010) • Annual (not quarterly) • Aggregate (not patient level) • Data collected in Oregon as in the rest of the nation. • Consistent data collection processes • 2009 data due to Flickers by 2/28/10 • Hospice specific comparison reports delivered in May 2010

7. OHA ProgramsAccreditation & Technical Assistance Denis Carnaby Help hospices to help Oregonians receive high quality hospice care. Perform collaborative (rather than adversarial) reviews to identify program strengths and weakness to raise the overall quality and consistency of care in our state. • Re-scoped Hospice Consultation Services • Linda Downey – RN, MSHA • Denis Carnaby

8. Oregon Hospice Registry 2009 98% providing services to public are Medicare certified (prisons are not) • 40 certified by Medicare and accredited by OHA • 22 certified by Medicare and accredited by JCAHO • 5 certified by Medicare and accredited by OHA and JCAHO • 3 are accredited by OHA (Includes 6 hospices from Idaho and Washington who provide care in Oregon)

9. Oregon Hospice Registry 2009 76 hospices on Registry • 68 locations in Oregon where hospice care is provided • Includes 4 prisons • 6 Idaho or Washington hospices who provide care in Oregon • 1 referring agency • 1 developing hospice 66% members of OHA in 2009

10. 2010 Oregon / National State Report Data Year= 2008 1/19/10

11. Oregon Hospice Association

12. 2008 Demographics & Hospice Utilization Oregon Hospice Association

13. 2008 Hospice Utilization(Medicare Hospice Deaths / Total Medicare Deaths) Oregon Hospice Association

14. 2008 Total Days of Hospice CareNational= 73,140,336 Days Oregon Hospice Association

15. 2008 Mean Days / Patient of Hospice Care Oregon Hospice Association

16. 2008 Median Days / Patient of Hospice Care Oregon Hospice Association

17. 2008 Total Medicare PaymentsNational= $11,147,122,355 Oregon Hospice Association

18. 2008 Mean Medicare Payments Oregon Hospice Association

19. Oregon Hospice Association

20. 2008 Demographics & Hospice Utilization Oregon Hospice Association

21. Oregon Drug Takeback Why? • Reduce avoidable poisonings • 77% pediatric hospital visits – drug poisoning • 2nd leading cause of death for 35-54 year olds • Prevent prescription drug abuse & addiction • Prescription drugs are the nation’s second most prevalent drug problem. • Young people get drugs from family and friends – “pharming parties” • Protect water quality • USGS study found microcontaminants in 80% of the streams sampled (included Oregon) • 3% of prescribed drugs disposed of in toilet and trash • 40 millions pounds annually in the US; 60,000 pounds estimated in Oregon • Hospices must provide drug disposal education to comply with CoPs.

22. Oregon Drug Takeback Now What? • Senate Bill 598 did not pass at 2009 Legislature • Hospice & Palliative Care Drug Take Back Trial • Mail back program (including opioids) • Clatsop and Columbia Counties • Partnership with • Oregon Association for Clean Water • Lower Columbia River Estuary • Astoria Police Department • Grant funding acquisition is underway

23. POLST Registry State-wide implementation on December 3. • 5,906 POLSTs in Registry (May-Dec 2009 as of 1/4/10) • Not registry ready (NRR) reasons: • No signature (50%) • Must be signed by NP, PA, MD, DO • No date (66%) • Can not determine what the patient’s most recent wishes are. • Are you submitting POLSTs for your patients? • Signer is required by statute to submit to the Registry • Use a fax face sheet! • Data will be provided at Hospice Providers’ Council • POLST Education – 4,208 health care professionals trained

24. Hospice Licensure Oregon SB 161 became effective July 23, 2009 (http://pub.das.state.or.us/LEG_BILLS/PDFs_2001/SB161.pdf) • Will be implemented in March or April 2010 • DHS will license hospices – like most other states in the nation • $750/year license fee (set in statute) • Hospices will apply for a license • All current hospices will be grandfathered for a license in 2010.

25. Hospice Licensure -continued The Department of Human Services (DHS) may accept certification by a federal agency or accreditation by an accrediting organization approved by the Department as evidence of compliance with the requirements for licensure. (ORS 443.850) • Certification • By DHS (who is the contractor for CMS) • By JCAHO, CHAPS, DME or others who have deemedstatus authority • Accreditation • Oregon Hospice Association (as approved by DHS) • JCAHO, CHAPS, DME or others who provide accreditation

26. Hospice Licensure-continued DHS will survey hospices every each three years • DHS may conduct on-site investigation whenever deemed necessary • Hospices may choose to have licensing survey done by • DHS (as part of license fee) • Other accrediting bodies (like the OHA, JCHCO, CHAPS, DME, etc) • The standards for licensure in Oregon are the Medicare Conditions of Participation • No additional requirements are proposed. • Advisory Committee lead by DHS and including OHA and representatives of Oregon’s hospices are working on a draft of the Oregon Administrative Rules (OARs).

27. Ho Health Care Reform – Hospice Impacts • Nobody knows what’s next for Health Care Reform; predictions that health care is dead may be premature. • We expect to hear a strategy by February 15 (before Presidents’ Day Recess). • What is clear: Hospice rates remain in jeopardy • MedPAC’s January 2010 calculated hospice margins to be 4.6%. • However, that figure does not included required bereavement or volunteer costs. • NHPCO has asked that the projected margin should be 2.6% to reflect all mandatory services.

28. Hospice Rate Reform – Hospice Impacts What is lost if House or Senate Health Care Reform do not move ahead? • Demonstration project for concurrent care (bad) • Pediatric palliative care – curative + palliative (bad) • Physician Assistants could not follow and bill services as an employee of a hospice (bad) • Revised Advanced Care Consultation billing (bad) • Physician or NP Visits required at 180 days and each subsequent recerts(you decide!) • Rate cuts for productivity factor (gone for the moment!) (good) • 1 year delay of BNAF (would mean we will lose this compensation)(House Bill) (bad) • .5% market basket reduction (Senate Bill) (good)

29. Upcoming Challenges MAC and RAC Attack • MAC • Noridian won the MAC contract: NGS remains the operator for foreseeable future. • RAC (Recovery Audit Contactor ) • Health Data Insights, our Region D RAC, has identified two issues that impact hospices. • Claims pull of records from DME providers to see if Medicare was billed by the DME provider and hospice. • Claims pull of records from hospitals to see if Medicare was billed by the hospital and hospice. • RAC is expected to contact the DME providers or hospitals. • However, if these providers must pay back dollars, we can expect the providers to come back to us. • ACTION: Please advise the OHA if you are contacted by the RAC or other providers.

30. Upcoming Challenges - continued CR 6440 • Time reporting for social work telephone contacts • Initial understanding: ALL telephone contact that supports palliative of illness go on the claim form. • Subsequent ruling: ONLY telephone contact with the family or care-giver that supports palliative illness goes on the claim form. • Calls to arrange new locus of care, for instance, are not billable. • Charges for visits • Question: How should a hospice report the total charges field on the line item reporting a visit? By time/charge or total for visit? • CMS: Report your total charge based on your charge structure. • NHPCO advice: Do a unit charge per 15 minute increment. • Back channel conversations indicate that CMS will absolutely use the cost data, so be careful how you populate these claims.

31. Upcoming Challenges - continued Nurse as Agent – A hospice issue or not? • RNs at SNFs may take verbal orders for Schedule 2-5 medications from physicians and phone the order to a pharmacy. • FDA has released a “Dear Registrant” letter saying • Unless the RN and the physician work for the same agency, the script must be faxed. • Huge fines are being levied again pharmacies • Big question: Does this apply to hospices? • Potentially significant impact for our patients in facilities. • Short term: NHPCO is getting to the hospice question. • Bigger picture: DEA/FDA and other agencies will be involved.

32. Questions and Discussion

33. Resources • OHSU Center for Ethics • CMS • DOJ • NHPCO • Hospice Analytics • Association for Clean Water (ACWA) • MedPAC • OHA