Hospice in the United States Policy Forum Research

1. Hospice in the United States Policy Forum Research Stephen R. Connor, PhD Vice President Division of Research and International Development

2. What we will cover • The growth of hospice in the US from the 1970’s to the present • NHPCO Dataset Data • Medicare Hospice Benefit Data (OSCAR) • A look at death in the US in 2002, including who uses hospice care covering geography, disease, race, age, & sex • Using the Complete CDC Compressed Mortality File • The 100% Standard Analytic File for Hospice • A look at hospice costs and new research on survival

3. Growth in Hospice Sites Continues:500 new sites

4. Recent Growth in Hospice Sites 2003 2004 2005 2006* • Hospice Programs 2,500 2,807 3,145 3,635 • Multiple Locations 822 850 1,015 1,114 • Total All Sites> 3,322 3,657 4,160 4,749 • *Preliminary Numbers • >Includes approximately 200 non-certified volunteer hospices

5. Growth in Patients Served

6. Hospice Caring for a Larger Proportion of all US Deaths • One of every 3 deaths from all causes under hospice • 800,000 deaths in 2005 • 200,000 admitted in 05 carried over to 2006 • 200,000 discharged alive (14.8%) • =1,200,000 served

7. Who Needs Hospice Palliative Care? • As many as 7 in 10 of those dying annually • Cancer – Chronic Organ Failure – Frail/demented • Those not needing palliative care: • Non HIV Infectious disease – sudden onset MI & Stroke – Accidents, homicide, suicide - acutely ill without ADL dependencies • Now reaching about half the need

8. More Non-Cancer Admissions Especially Lung, Debility, and MND

9. Average & Median Hospice Length of Service Continue to Rebound

10. Patients in Hospice < 7 days Patients in Hospice > 180 days 40% 40% 36.9% 35.1% 31.7% 30% 30% 20% 20% 10.3% 9.2% 10% 10% 7.3% 0% 0% 2003 2004 2005 2003 2004 2005 LOS <7 days starting to dropLOS >180 days increasing

11. More hospice patients dying in the place they call home • 75.9% died in private residence, nursing home, or residential facility • 24.1% of hospice patients died in • Inpatient hospice unit (4.7%) • Freestanding hospice facility (9.9%) • Acute care hospital only (9.5%) • Compared to 50% of all deaths in acute hospitals in the general population

12. OSCAR Data • OSCAR is the CMS database that captures information on all Medicare certified providers. Information is updated at each recertification • Information in this database includes: • Identifying information on providers • Type of ownership and incorporation • Medicare provider numbers and dates of certification • Actions by CMS including types of closure/merger • Staffing by all disciplines and for volunteers • All information is at the provider number level

13. OSCAR Findings • A total of 3,868 providers have been certified since the beginning of the Medicare Hospice Benefit • As of last October there were 3,019 (78%) active provider numbers* • 649 (16.8%) providers have voluntarily closed due to merger • 165 (4.3%) providers have voluntarily closed for other reasons • 35 (0.9%) providers have been involuntarily closed • Of the 848 closed programs • 48.6% were non profit • 44% were proprietary • 7.4% were governmental or other *Many hospices bill more than one hospice location through the same provider number. Approximately 25% of hospices are provider multiple locations, giving us over 4,000 locations

14. OSCAR – All providers • Currently Active by Provider Type – US Totals Type # % of Total • Hospitals 6,182 18.4 • Nursing Facilities 15,923 47.5 • Home Health Agencies 8,418 25.1 • Hospices 3,019 9.0 • TOTAL 33,542

15. OSCAR Incorporation Status Incorporation Type* Hospice Hosp NF HH • Governmental 6.5 24.9 6.0 7.3% • Proprietary 47 21.8 66.2 67.2% • Non profit 42.2 53.3 27.8 25.5% • Other 4.3 - - - • *By provider number

16. OSCAR Data – New Hospices • Since the beginning of 2001 there have been 1,019 new hospice provider numbers issued. They break down as follows: • Governmental 2.3% • Proprietary 80.4% • Non profit 11.8% • Other 5.5%

17. States with Most Provider #’s Texas 251 California 192 Oklahoma 140 Pennsylvania 139 Alabama 117 Georgia 106 Illinois 105 Mississippi 103 Louisiana 102 Ohio 101 States with Fewest Provider # Virgin Islands 1 DC 3 Alaska 5 Delaware 7 Hawaii 7 Rhode Island 8 Vermont 10 Nevada 12 S. Dakota 14 N. Dakota 15 OSCAR – Active providers #’s by state*

18. OSCAR Staffing Data • Staff FTE’s in currently active hospice programs • 25,057 Registered Nurses • 5,586 LPN/LVN’s • 16,092 Home Health Aides • 2,693 Homemakers • 6,501 Medical Social Workers • 2,964 Physicians • 4,034 Counselors • 17,125 Other salaried personnel • 80,053 TOTAL Full time equivalent staff

19. OSCAR Staffing Data • Volunteer FTE’s in currently active hospice programs: • 432 Registered nurse • 96 LPN/LVN • 634 Home Health Aide • 2,288 Homemaker • 185 Medical Social Work • 860 Physician • 1,375 Counselor • 38,469 Other • 44,340 TOTAL Volunteer full time equivalents

20. Staffing Data • Total Staffing Estimates • 80,053 Staff FTE’s = approximately 120,000 individuals • Total Volunteer Estimates • 44,340 Volunteer FTE’s = approximately 400,000 individuals • Total Individuals involved in the provision of hospice care in the US (approximate) 550,000* • *Includes non-Medicare certified hospices

21. Geographic Variation in Hospice Usein 2002 (In-press, JPSM) • Complete CDC death certificate records and CMS 100% Standard Analytic File for hospice claims for 2002 were used to describe the whole population of hospice users and non-users in the United States. The overall hospice utilization rate for persons 65 years and older was 28.6%. Our findings highlight opportunities for the hospice industry to provide more care, opportunities defined by diagnostic and geographic axes.

22. Hospice Utilization by Cause of Death2002

23. States with highest hospice utilization in 2002 Arizona 49% Colorado 45% Florida 42% Oregon 37% Nevada 37% Texas 36% New Mexico 35% Oklahoma 34% Michigan 34% Utah 34% States with lowest hospice utilization in 2002 Alaska 8% Maine 14% S. Dakota 16% Wyoming 16% N. Dakota 18% D.C 18% New York 19% Vermont 19% Hawaii 20% Tennessee 20% Geographic Variation in Hospice Usein 2002 (In-press, JPSM)

24. Overall Hospice Utilization by State

25. Overall Hospice Utilization by County

26. Cost Report Data • Come to the session on Medicare Hospice Cost Report data on Saturday 11G 9:30 – 10:30 • National Highlights 2004 2005 • Net Revenue Per Day $129.56 $132.06 • Total Expenses Per Day 117.86 123.12 • Margin Per Day 11.70 8.94 • % Margin 9.03% 6.77%

27. Hospice Cost Studies • CBO Study • Lewin VH1 Study • Emanuel Study • Rand Study • Milliman Study • Duke Study

28. Survival of Hospice Patients • Pyenson, B., Connor, S., Fitch, K., & Kinzbrunner, B. (2004). Medicare cost in matched hospice and non-hospice cohorts. Journal of Pain and Symptom Management, 28(3). • Connor S, Pyenson B, Fitch K, Spence C, & Iwasaki, K. Comparing hospice and non-hospice patient survival among patients who die within a 3 year window. Journal of Pain and Symptom Management, 33(3).

29. Opioids Dosing and Time to Death • Portenoy RK, Sibirceva U, Smout R, Horn S, Connor S, Blum R, Spence C, and Fine P. (2006). Opioid use and survival at the end of life: a survey of a hospice population. Journal of Pain and Symptom Management, 32(6):532-40.

30. Hospice Patients and Families Cared For • In our country on an average day hospices are caring for over 200,000 patients and their families Of these less than 6,000 need inpatient care • On an average day hospices are providing support to over 1.6 million grieving people • Since hospice began in the mid 1970’s in the US we have cared for over 10,000,000 patients and their families

31. THANK YOU