Hospice: An Industry overview and market analysis for Roanoke, Virginia
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RUNNING HEAD: HOSPICE: AN INDUSTRY OVERVIEW
Hospice: An Industry overview and market analysis for
Roanoke, Virginia
Nia S. Llenas, B.S.
University of Maryland University College
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Hospice: An Industry overview
Abstract
Llenas, N. (2008). Hospice: An Industry overview and market analysisfor Roanoke, Virginia. University of Maryland, University College.
The demand for hospice care in America is projected to doubleby 2018 and communities must be prepared to care for patientswith terminal illness. This paper addresses the importance andfuture of hospice in Roanoke, Virginia and the issues to beaddressed concerning reaching the underserved communities,future opportunities and competing with area hospices.
Research analysis details the lack of African-Americanacceptance of hospice services, relative quality perceived byfamily and patients of hospice, as well as, cost-efficiency of hospice over inpatient care. The data reveals that patientpopulations are similar in Roanoke to the national demographic;and outlying counties are projected to grow up to 20% withsubstantial older populations. These findings suggest that theRoanoke hospice community has a solid system which should bereplicated in the at least two outlying counties, with specialconsideration for diversifying Roanoke’s patient population andrecruiting younger talent in the interim.
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Hospice: An Industry overview
Introduction
Hospice care provides patients at the end of life with supportive
and palliative care while providing families with comfort and
preparation for a family member’s death. This branch of healthcare
began in America in the early 1970’s at Connecticut Hospice as a
privately funded sector, quite independent of modern medicine
(Hospice Association of America, 2008). By 1983, hospice was granted
public reimbursement from Medicaid Part A, known as Medicare
Hospice Benefit (MHB), and now provides comprehensive physical,
emotional and spiritual care, in a cost-effective manner, for patients
with terminal illness (Taylor, 2007).
Patients
Hospice patients suffer from a wide range of diagnoses, the most
memorable being cancer or HIV, but in contrast, today’s hospice
patient is more likely to carry the burden of chronic illnesses such as
congestive heart failure (CHF) or chronic obstructive pulmonary
disease (COPD). In 1998, The Centers for Medicare and Medicaid
Services (CMS) included six cancerous pathologies in the top ten
hospice diagnostic codes; in 2005, only three were considered. Cancer
diagnoses fell 2.8% between 2006 and 2007 (NHPCO, 2008),
complimented by increases in Alzheimer’s, dementia and failure to
thrive (FTT) (CMS).
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Hospice: An Industry overview
Patient demographics are generally consistent each year. The
National Hospice and Palliative Care Organization (NHPCO) (2008),
found that in 2007, out of 1.4 million patients, 94.9% identified
themselves of non-Hispanic or Latino ethnicity, while 81.3% considered
their race to be Caucasian, 7.8% multiracial and 9% African-American.
Also, over 66% of patients were older than 75 in 2007.
Providers
Aforementioned, is the principle that hospice is a comprehensive
service, not fragmented much like home health or nursing home care.
Hospice benefits include:
• Nursing care
• Medical social worker
services
• Physician services
• Counseling
• Inpatient care, respite
care, palliative
• Home health and
homemaker services
• Durable medical
supplies
• Physical and
occupational therapy
• Speech-language
pathology
• Bereavement services
for families (continuing
for 13 months after
death)
(Hospice Association of
America, 2008, p. 1)
Hospice has grown significantly since the 1970’s and as of 2007;
there were an estimated 4700 providers in operation, up from 3300 in
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Hospice: An Industry overview
2003. A typical agency, in 2007, served between 151 to 500
admissions per year and over 58% of hospices are free-standing or
independent of a larger agency/hospital, 20.8% are hospital based and
19.7% are home health based, the remainder are housed in nursing
homes. Each of these organizations falls into one of three tax
designations. In 2007, 48.6% filed as non-profit, 47.1% as for profit
and 4.3% were government owned (NHPCO, 2008).
Financing/ costs
In 2005, 70.8% of MHB were directed towards freestanding
hospices (HAA, 2008) and total expenditures were $8.15 billion (CMS,).
In 2007, MHB spending topped $10 million and Medpac (2008, p 186)
projects that MHB spending will reach $21 million by 2018, showing
room for growth in services and patient admissions in the future.
Also, hospice is considered the most efficient form of healthcare,
especially when substituted for inpatient care during the last stages of
life. Since hospice coverage is presumably available for 180 days,
maximal savings can be attained if the referral is timely. The cost-
effectiveness varies by diagnosis, but in general saves Medicare $2300
per hospice patient death, with cancer patients admitted to hospice
garner the most savings possible at $7000 if admitted 58 to 103 days
prior to death (Taylor et al, 2007). Consequently, the decrease in
cancer admissions has been accompanied by the propensity to exceed
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Hospice: An Industry overview
the MHB cap (Medpac, 2008, p. 191) and increase length of stay
(Mathews & Gaumer, 2008, p.8)
Current Issues
The hospice industry faces many challenges today. Barriers to
access, perceived quality of care, lack of patient and staff diversity,
staff turnover and the stigma associated with death and dying are a
few of the issues that hospice organizations must overcome.
Minority access
One of the starkest disparities in hospice care is the lack of
minority patients and staff. One would expect a higher saturation of
African-American patients than Hispanic or Asian, but unfortunately,
ratios are not reflective of Cencus (2006) estimates that blacks
comprise 12% of the population. Cort (2004) attributes this problem to
long-held “cultural mistrust” of the healthcare system, disenfranchising
organizations and an overwhelmingly Caucasian workforce. Cultural
mistrust “is taken to mean the fear that African Americans, because of
their ethnicity, will receive experimental or inferior care at the hands of
whites”. Gibson (2001), also noted that the African-Americans’ and
poor Americans’ sentiment towards both palliative care and hospice, is
a product of the continual barriers they have endured to proper
preventative care and pain management.
When African-Americans are admitted to hospice, the prevailing
diagnosis is cancer. As mentioned before, overall admissions of cancer
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Hospice: An Industry overview
patients have steadily declined, but reports from the largest hospice
provider in the US between 1999 and 2003, show a significant increase
in African-American cancer patients (Johnson, 2007). Indeed, this
matches the increase of 28% in cancer deaths from 1990 to 2005,
compared to a 1.6 % increase in deaths caused by heart disease, the
number one killer of African-Americans (CDC, 2007).
Quality
Many agencies have joined together to assess the quality of care
in hospice. The National Association o f Home Health and Hospice
developed a patient and family satisfaction survey, while CMS has
contracted with the Carolinas Center for Medical Excellence to form the
PEACE project for hospice quality. The PEACE project resulted in a “list
of scientific instruments necessary for proper care, quality measures to
improve quality and organizational tools for quality improvement and
care assessment” (Schneck, 2008).
Overall, patients and families, tend to be quite happy with their
hospice experiences. Staff turnover is a concern and is similar to staff
experience in home health and nursing homes. Staff is generally
happy with their role, characterizing it as rewarding, but feel that
communication between teams and educational development should
be emphasized (Haitt, et al., 2007).
Thoughts/Solutions
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Hospice: An Industry overview
Hospice care is a unique specialty and a departure from curative
medicine. It requires a shift in thinking and learned behavior on the
part of staff, patients, families and communities they serve. Of course,
this requirement of change is one of the most significant deterrents of
future acceptance, but despite the challenges, hospice capacity is
projected to double in the next ten years.
Personally, I find hospice to be the best possible solution for
patients and families facing terminal illness and the most-efficient for
society. “The Medicare program appears to have a rare situation
whereby something that improves quality of life also appears to reduce
costs” (Taylor, et al., 2007, p. 1475). That said, there are still
problems that persist as with any industry.
First, the lack of minority patients is troublesome. The industry
has failed to reach out to the very communities that will drive their
business in 2020 and beyond. The barriers and resistance can be
broken with cultural competence training, proper marketing to
churches and community organizations, reaching out to minority
students for volunteering and creating a community presence. Cort
(2004) also suggests that staff ethnic percentages match that of the
target community.
Secondly, staff turnover must be addressed. Hiatt (2007) found
that staff members cite lack of knowledge, stigma, underfunded care
services, communication and barriers to effective care as the
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Hospice: An Industry overview
weaknesses of the hospice industry. This can be addressed through
mentoring, continuing education opportunities, quality assessments
and the formation of interdisciplinary care teams.
Conclusion
Hospice has, for nearly 40 years, provided death with dignity for
the many terminally ill patients in the United States. It has progressed
from a privately funded organization with few options to a
comprehensive Medicare benefit that is both cost-effective and
supportive for the families involved.
The future of hospice depends on its ability to reach the masses,
the minorities, the poor and the disenfranchised and it is a challenge
that is being addressed by organizations such as the Harlem Palliative
Care Network and Hospice by the Sea’s “Abriendo Puertas” program.
Market Analysis
The hospice industry in Roanoke mirrors national trends for
growth and demand. There are 7 hospice providers currently in the
area, two of whom claim non-profit status; one is government-run and
the remainder claim for-profit status. Until recently there were only 6
providers, the last to establish an office here is the national provider
Southern Care.
Each of these providers offers standard hospice services (please
see the list on pg 1-2), as well as, coverage as far as Montgomery and
Franklin counties. Also, there are 8 major non-governmental medical
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Hospice: An Industry overview
centers within a 50 mile radius of Roanoke, 18 nursing homes, 12
home health agencies (CMS, 2008) and patient homes are largely
within the Roanoke City and Roanoke County lines with few patients
living beyond Bedford and Botetourt.
Demographics
Roanoke County:Population………………………..90420Aged 45+………………………….45.7%Aged 60+…………………………..22.2%
Caucasian………………………….91.3%African-American………………5.0%
Roanoke City:Population………………………..92600Aged 45+…………………………..42.2%Aged 60+…………………………..22.3%
Caucasian………………………….68.0%African-American………………25.7%
Census Bureau (2007)
Roanoke hospice current patient profile
Age:60-70 yearsold…………………….12.8%
70-80 yearsold……………………..20.4%80-90 years old………………………33.6%90 + years old…………………………21.4%
Race:Caucasian……………………………….90.8%African-American……………………5.9%
Other………………………………………3.22%
Religion (as defined by thepatient):Christian…………………………………..9.9%Baptist………………………………………30.2%
Methodist…………………………………..5.9%Catholic…………………………………
……7.4%Nopreference……………………………..20.6%
Gender:Female………………………………………...67.5%Male…………………………………………….32.5%
Diagnosis:
Neoplasm……………………………………31.5%Mentaldisorder……………………………14.3%Respiratory…………………………………..7.2%Nervoussystem…………………………….6.5%
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Hospice: An Industry overview
Circulatory/ blood………………………28.5%Debility/FTT…………………………………5.9%
Payer:
Medicare…………………………………….86.6%
Commercial…………………………………8.8%Medicaid……………………………………….3.4%Charity………………………………………….1.2%
Data courtesy of email from Alyson Lawson and Sue Moore-Ranson, (2008)
Industry in Roanoke:
Currently, close to 32% of hospice referrals in Roanoke are generated
by nursing homes (Lawson & Ranson, 2008). Roanoke and its
surrounding counties are rich in nursing homes and the estimated bed
total is 2536 (CMS, 2007). The entry of another national for-profit
hospice into the market feels like over saturation, but it remains to be
seen what the impact of Southern Care will be as they have yet to
begin full service in the area. Undoubtedly, they will target the nursing
home and hospital referrals as well as the physician base here.
No company has yet to break into the aging African-American
community. Reports from Hospice A, detail the efforts made to engage
ministers and church boards or send chaplains as an ambassador to
community events. (Lawson, personal interview, 2008) The efforts are
futile and many feel that addressing this population is a profitable
marketing strategy.
Target Communities for future hospice expansion
According to the Virginia State Data Center, the population in Roanoke
will shift significantly by 2020 through 2030, from Roanoke City to
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Hospice: An Industry overview
Roanoke, Botetourt, Bedford and Franklin Counties. This may signal an
opportunity to establish a community presence in the County center
and outlying areas.
Bedford County population will increase 19% between 2010and 2030
Currently, persons ages 45 and over comprise 40.3% of thetotal
Franklin County population will increase 16.07% between 2010and 2030
Currently, persons aged 45 and over comprise 41.5% of the total
(Census Bureau, 2007) (Virginia Employment Commission, 2007)
Marketing
1. Schedule meetings with the local nursing homes and home
health agency executives to probe their referral process and
case mix.
2. Meet with the county Chamber of Commerce to discuss working
with them to advertise and meet other local business owners.
3. Engage in community outreach, school events, elderly
associations, church events
4. Advertise in the local newsletters, nursing home and home
health resident and family pages, recreational facilities, online
and on local radio.
Competition
1. Representatives from the two oldest non-profit agencies in
Roanoke agree that Roanoke has reached its limit.
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Hospice: An Industry overview
2. Carilion Hospice may siphon some patients off of their hospital
Franklin Memorial (37-bed), but they employ full disclosure to
patients and do allow them to choose which hospice they
would like
3. Hospice of Franklin County is 4 years old and depends on a
variety of sources and has a good reputation as a non-profit.
4. Carilion Hospice also serves Bedford Memorial hospital and
houses Oakwood Manor (111-bed) long-term care facility, but
Carilion manages Bedford and full disclosure applies.
5. Amedysis, Home Recovery and Gentiva are the largest and
most visible home health agencies in both Bedford and
Franklin counties with no strict allegiances to any hospital but
they do operate their own home-health agencies.
Conclusion
Roanoke is not an option at this time for hospice expansion. While it is
the center of Southwest Virginia, population shift are trending towards
Bedford and Franklin counties. Currently, both counties have reached
their saturation points for end-of life care and Carillon’s full-disclosure
is an opening for a new agency to attract patients from a hospital
setting in the next 3-10 years as populations grow. Payer mix should
prove profitable, the high senior population suggests Medicare or
private pay and median incomes are quite similar to that of Roanoke
and an early impact is needed.
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Hospice: An Industry overview
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