NHO conference highlights future

Medicare committee's recommendations offer hope

It was difficult to find a hospice manager among the some 600 in attendance at the recent National Hospice Organization (NHO) management meeting in St. Louis who wasn't discouraged by the industrywide problem of shrinking length of stay on the hospice benefit and its threat to agencies' financial viability. Even programs that are increasing community penetration and total admissions are facing cutbacks, because shorter lengths of stay mean less revenue and higher costs.

But as hospice managers are coming to recognize the need for significant, structural change in the industry, NHO is holding out a ray of hope. The organization's leaders devoted a plenary and five breakout sessions at its conference, held June 1-4 in St. Louis, to new reports by its Committee on the Medicare Hospice Benefit and End of Life Care and its Nursing Home Task Force.

These two groups have been working in tandem over the past year to address barriers to hospice access, regulatory and reimbursement problems, and the special challenges of providing hospice care in the nursing home setting. The two panels' reports (see Hospice Management Advisor, July 1998, pp. 81-83, 92) were approved by NHO's Board of Directors in April, and were set to be mailed to NHO members in late June. A summary of the Medicare committee's wide-ranging report was distributed at the St. Louis meeting. Along with its recommendation that hospices more fully utilize the existing Medicare hospice benefit, key proposals highlighted at the conference included:

o eliminating hospice's current six-month prognosis requirement, in the short run via legislative remedy and in the long run by testing alternate eligibility models;

o undertaking an in-depth, targeted public engagement campaign to improve awareness and understanding of hospice;

o enhancing professional education in end-of-life care, especially physician training;

o promoting end-of-life research, outcomes and standard development;

o enhancing the industry's working relationships with policy-makers, legislators, managed care organizations, and potential partnering organizations at the national level.

If all those could be enacted, they would transform the hospice industry and fundamentally change the way hospices operate - although achieving this ambitious vision will not be easy.

"We have come here to plan the future of hospice in America," said Jan Elder, director of Mera mec Hospice in Rolla, MO, and president of the Missouri Hospice Organization, in welcoming delegates to the meeting. "We have an oppor tunity to begin sculpting hospice for the 21st century."

Amber Jones, MEd, president of the New York State Hospice Association and chair of NHO's Medicare committee, described that panel's achievement as critical recommendations for the continued growth of hospice as preferred care for the dying. The proposals "admittedly are ambitious. But we believe they are achievable, if we all work together," she said. "I have been impressed, heartened, and enthused by your response. What you are saying is you're ready."

Committee member Mary Labyak, CEO of Hospice of the Florida Suncoast in Largo, observed, "In our deliberations there was a lot of high-minded language, calling on NHO to assume the mantle of leadership. But in some respects we had met the enemy and the enemy was us," she added, emphasizing the industry's tendency to blame others for its problems rather than assuming leadership in fixing them.

"We also, in talking about these issues, had an overriding sense that there continued to be something unique about the array of hospice services," Labyak added. She underscored the committee's desire to encourage innovation by hospices, ranging from palliative care consulting teams to complex, risk-driven partnering arrangements where the hospice is involved in a patient's care for years.

In her keynote address, NHO's new president, Karen A. Davie, portrayed NHO as an organization on the move and issued a call to action for the industry to unite behind NHO's new agenda. "Business as usual isn't going to be good enough" for NHO or for the hospice industry, she said. "I realize that what we are about to embark on will take tremendous people resources and financial resources from NHO. It's a multiyear agenda. We cannot accomplish it alone, or just with our current resources," she added.

"NHO's board and staff are prepared to review every [current] product and service, to ensure that we have a laser-like focus and do what's necessary to move the agenda forward," Davie emphasized. "I want you to be assured as you leave this room today that NHO is on the fast track to implementation of these two reports. Clearly, end-of-life care is top of mind of the health care community. Now it's imperative that hospice lead the discussion. We must preserve hospice's reputation as the gold standard in end-of-life care."

David A. Simpson, MA, LSW, CEO of Hospice of the Western Reserve in Cleveland and NHO's chairman, described his vision of hospice in America growing from 500,000 to a million patients a year, with median length of stay growing from 15 to 100 days. But how can such dramatic growth be accomplished?

The industry's biggest problem

At the meeting, NHO leaders repeatedly singled out the six-months-or-less requirement as the industry's biggest problem and most important target of its new agenda. "With the exception of six months, we find the legislation [creating the hospice benefit] to be very flexible, very positive, and very enabling," Jones observed. NHO proposes to seek legislation to modify the six-month requirement to 12 months or less, while stipulating that aggregate length of stay for a hospice program could not exceed six months. A legislative solution is required, because the six-month requirement is written into the original hospice law.

However, Jones emphasized that this is only an interim solution, aimed at making patients and referral sources feel more comfortable in choosing hospice, not a permanent solution. Any duration-based definition of eligibility inevitably is problematic, both scientifically and emotionally. The committee proposes testing and evaluating other approaches, including disease-specific case management models, as well as participating in testing of other end-of-life models.

One example of these alternate models is Medi Caring (see related story, p. 101), and another is PACE, the Program of All-Inclusive Care for the Elderly. The PACE model, based on the pioneering On Lok Senior Health Services program in San Francisco, combines acute and long-term care and integrates care delivery and financing into a single capitated model of community-based care for people 55 and above who are assessed as frail enough to qualify for a nursing home. Eleven PACE demonstration sites across the country were in operation by the end of 1996, with 15 more added last year and current plans to expand rapidly.

PACE participants may not need hospice care, even when they are dying, because the model already is comprehensive and well-integrated, observes J. Donald Schumacher, PsyD, CEO of the Center for Palliative and Hospice Care in Cheek towaga, NY. Hospices must find ways to collaborate with PACE programs or seek to establish their own PACE demo; otherwise, they may see a significant erosion of their own caseloads.

Another key component of NHO's call to action is public engagement. "The public engagement campaign is a critical issue for us," Jones asserted. "It must be broadly based and sustained over time," communicating effectively with hospice's various constituencies, with careful analysis of how to tailor the message to their needs and interest. Such a campaign "would undergird, support and expand what we do," as well as targeting misconceptions and misrepresentations of hospice, Simpson said. "We used to say we want to be at the table" any time end-of-life care was discussed, he observed. "I now say we want to host the dinner. We should be leading the discussion."