Hospice Palliative Care in the United States

1. Hospice Palliative Care in the United States J. Donald Schumacher, Psy.D. National Hospice and Palliative Care Organization – USA October 16, 2003 National Hospice and Palliative Care Organization

2. National Hospice and Palliative Care Organization

3. History of Hospice in the U.S. 1973 Connecticut Hospice 1978 National Hospice Organization (NHO) 1979 First U.S. Hospice Standards 1980 Medicare Hospice Demonstration Project 1982 Congress Passes Medicare Hospice Benefit 1986 Medicare Benefit Made Permanent 1989 Hospice 4th benefit and NF patients 1995 Support Study 1997 IOM Report Approaching Death 2000 NHO becomes National Hospice and Palliative Care Organization National Hospice and Palliative Care Organization

4. Hospice Program Growth National Hospice and Palliative Care Organization

5. Over 2.4 million people die annually in the US (1.8M over 65) today By 2030 over 3.5 million will die annually (over 2.6 million over 65) Nursing facility residents In 1999 1.6 million In 2030 5.3 million Aging Problem in the U.S. National Hospice and Palliative Care Organization

6. Growth in Older Americans 1900-2030 National Hospice and Palliative Care Organization

7. 2.4 million deaths from all causes Five major causes of death in the US*Total % Heart diseases 725,000 30% Cancer 542,000 22.7% Cerebro-vascular 158,000 6.6% Lung diseases 112,500 4.7% Injury/Adverse event 98,000 4.0% Totals 1,635,500 68% Death and End of Life Care in the U.S. National Hospice and Palliative Care Organization

8. As many as 7 in 10 of those dying annually Cancer – Chronic Organ failure – Frail/demented Those not served: Non HIV Infectious disease – sudden onset MI & Stroke – Accidents, homicide, suicide - acutely ill without ADL dependencies Hospice in US now reaching almost 3 in 10 who die Who Needs Hospice Palliative Care? National Hospice and Palliative Care Organization

9. A comprehensive set of benefits for the terminally ill Medicare 80% - Private Ins. 12% - Medicaid 5% Eligibility: Prognosis of six months or less if the illness runs its normal course Palliative not curative care Informed consent for hospice care Care delivered by a certified hospice provider in their service area Medicare Hospice Benefit National Hospice and Palliative Care Organization

10. Conditions of Participation/Core Services Physician services Nursing services Including homemaker/home health aide services Social work services Counseling services Chaplain, bereavement, dietary, etc Physical, speech, and occupational therapies Waivers Medicare Hospice Benefit National Hospice and Palliative Care Organization

11. Determination of payment rates – Per Diem Payment for physician services Hospice cap amount Coinsurance/co-pays Four levels of care Routine home care Continuous home care General inpatient care Inpatient respite Payment for hospice care under Medicare National Hospice and Palliative Care Organization

12. How much hospice care is provided in the U.S.? National Hospice and Palliative Care Organization

13. 2,600 hospice organizations deliver care at over 3,200 locations in the US 78% Nonprofit 17% For profit 5% Government 66% Accredited 18% with own inpatient facilities Only 1% of US has no access to hospice care Hospice Care in the US National Hospice and Palliative Care Organization

14. Hospice Care in the US • Hospice patients • Cancer 50% • 80% over 65 • Average length of service 51 days, median 21 days, 1/3 seven days or less National Hospice and Palliative Care Organization

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16. CBO Analysis of Hospice Benefit $1.26 saved for every $1.00 spent Lewin VHI Study $1.56 saved for every $1.00 spent In US cost effectiveness of hospice results from decreased hospitalizations and more appropriate use of high cost diagnostics and treatments Hospice Benefit Cost/Benefit National Hospice and Palliative Care Organization

17. Variable performance issue Family satisfaction survey and evaluations of care A Pathway for patients and families facing terminal illness Safe and Comfortable Dying Self-Determined Life Closure Effective Grieving Hospice Benefit/Quality Control National Hospice and Palliative Care Organization

18. Over 800 hospitals in the US (20% of all hospitals) have access to a palliative care program including hospice One-third of hospices hospital based 25% of academic medical centers >1200 physicians certified by ABHPM >7000 registered nurses, 43 advanced practice nurses and nearly 1,000 nursing assistants are certified in palliative care Palliative Care National Hospice and Palliative Care Organization

19. National Consensus Project for Quality Palliative Care: The Development of Voluntary Standards Payment for palliative care in the U.S. DRG’s CPT’s Home health care Private support Palliative Care National Hospice and Palliative Care Organization

20. 42 postgraduate medical fellowship programs 2 graduate nursing programs in palliative care Institutes and Centers 4 Major North American Journals publishing on hospice palliative care Journal of Pain & Symptom Management Journal of Palliative Medicine Journal of Palliative Care American Journal of Hospice and Palliative Care Palliative Care National Hospice and Palliative Care Organization

21. Palliative vs. Curative Treatment Originally hospice patients received a combination of palliative and disease modifying treatments With the advent of the Medicare Hospice Benefit (MHB) curative therapies could not be given while in hospice Current research on blending disease treatment with palliative care shows benefits Future Trends National Hospice and Palliative Care Organization

22. Hospice care is a blend of palliative and curative therapies* NHO Standards 1979 “Appropriate therapy is the blend of curative and palliative therapies that produce the greatest degree of relief from distress caused by disease for the longest period of time with the least number of distressing therapy related side effects.” Appropriate Therapy National Hospice and Palliative Care Organization

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25. Biggest issues: Who qualifies for services? Time frame vs. objective criteria vs. clinical judgment What treatments they can/cannot receive? Curative and experimental treatments vs. PC only vs. mixed Incentives for home care vs. inpatient care Concerns to Address National Hospice and Palliative Care Organization

26. Future Thoughts on Hospice Palliative Care in the United States National Hospice and Palliative Care Organization