Search

Objective: To describe patterns of healthcare resource utilisation and associated costs for patients with advanced melanoma in the United Kingdom (UK), Italy, and France., Methods: For patients receiving systemic treatment, or supportive care, data describing hospitalisations, hospice care, and outpatient visits were retrieved retrospectively from advanced disease diagnosis as part of a multicountry observational study. Costs were estimated by multiplying utilisation level by unit cost. In an exploratory analysis, costs were compared between individuals who died within one year of initiating first-line treatment (short-term survivors) and those with ≥ 1 year follow-up (long-term survivors)., Results: Hospitalisation costs were highest in France (€6262 per-person compared with €3225 in the UK and €2486 in Italy), reflecting higher rates of hospitalisation. In contrast, outpatient costs were highest in the UK (€782 per-person, compared with €115 in France and €72 in Italy), reflecting the highest rate and frequency of outpatient visits and the highest cost per visit. Hospitalisation rates were consistently higher during supportive care compared with systemic therapy. Roughly one-third of patients entered clinical trials and were not included in the analysis. In exploratory analysis, total costs were generally higher for long-term survivors, but monthly per-patient costs were generally lower for long-term survivors, consistent with a hypothesis that resource utilisation and costs do not necessarily increase proportionally with extended survival., Conclusion: Total costs associated with resource utilisation for advanced melanoma patients varied across countries. Overall cost differences were due to differences in frequency and intensity of utilisation patterns and variation in unit costs of health resources., (Copyright © 2012. Published by Elsevier Ltd.)

Background: Patients and carers may face challenges in the out-of-hours period, with inadequate support and variations in service provision, including access to specialist palliative care. A pilot was undertaken to extend availability of the community clinical nurse specialist (CNS) team to include weekends and public holidays., Aim: To examine the need for a 7-day community CNS service., Method: Activity data was collected for 6 months and feedback was sought from service users and the CNS team., Results: There were 132 out-of-hours telephone contacts in the 6-month period, generating 35 home visits. Almost two thirds of these calls were proactive, 'planned' contacts. Most unplanned calls (68%) were from a carer for advice about symptom management and support as the patient's condition changed., Conclusion: The pilot demonstrated the need for a CNS service 7 days a week, and the service is now embedded in practice. Seven-day working benefits patients and families while being valued by the professional team.

Health care technology provides the key to becoming the high performing efficient organization you want to be. But how do you sift through the many available solutions and determine which technology to acquire? Do you fully understand the best practices for choosing and using technology and measuring the value gained once your new solutions are in place? Get a map to the digital road from Suzanne Sblendorio, director of Healthcare Information Technology Consulting at Simione Healthcare Consultants.

Get the highlights of the HHFMA Leadership Panel, always a high point of the Financial Management Conference. This year home care and hospice providers face increasing pressure from Congress, CMS, MedPAC, Medicaid, and other payer initiatives to restrict service and compress margins. Yet home care and hospice will continue to bring value and quality to the health care delivery system and its patients. The dynamics created by the new health reform legislation--such as ACOs, bundling, and the home medical model--combined with the exploding Medicare and Medicaid populations and technological advances will change the face of home care and hospice. The esteemed panelists, representing a wide range of interests in home care and hospice, offer their five, ten, and 15 year vision into the future of the health care delivery system and the role home care and hospice will play.

The way we deliver health care is changing fast and going in the direction of home care and hospice. This timely program addressed the threshold question of how your organization should play a part in a new arena that includes accountable care organizations, bundling of post-acute care, and integrated transitions in care. Should you be a partner with other health care sectors, assuming some of the financial risk for the success or failure of the endeavor? Should you choose instead to be an active participant or possibly a vendor to an integrated health delivery model? Join our panel as they discussed how to determine your role and gauge the community of health in which you function.

Potential Medicare and Medicaid reimbursement cuts have made it critical for home health agencies to manage their gross and net operating profit margins. Agencies need to develop tools to analyze their margins and make sure they are following best practices. Try as you may, your agency might still face the question, "Why am I not meeting my budget?" Get some answers in this session from David Berman and Andrea L. Devoti. Berman is a principal at Simione Healthcare Consultants in Hamden, CT, where he is responsible for merchant acquisitions, business valuation due diligence, and oversight of the financial monitor benchmarking tool besides serving as interim chief financial officer. Devoti is chairman of the NAHC board and President & CEO of Neighborhood Health Visiting Nurse Association in West Chester PA.

Background: Survival and the quality of life more comprehensively evaluates the survival conditions of cancer patients. This paper aims to analyze the survival time and quality of life (QOL) of hospice lung cancer patients and discusses the influencing factors to provide a basis for ameliorating their survival conditions., Methods: Advanced lung cancer patients who are receiving hospice care in the Shengjing Hospital were retrospectively analyzed and followed-up. The data were analyzed using SPSS 13.0. The median survival of patients was determined using the Kaplan-Meier method, and their QOL were evaluated using the tumor patient's QOL scale. Finally, the relationship between the survival index and the various factors were determined., Results: For 269 patients, the average QOL score was 28.76 and the median survival was 10 months. Awareness of their illness, pain relief, Karnofsky performance status (KPS) score, and nutritional status are the independent factors of QOL. Surgery, time of the occurrence of pain, pain relief, and KPS score are the independent factors of survival time., Conclusions: The survival of patients with advanced cancer is poor; hence, we should strengthen and improve hospice care in terms of the influencing factors to enhance the QOL of patients and prolong their survival.

This final rule provides several necessary revisions to the regulation in order for TRICARE to be consistent with Medicare. These revisions affect: Hospice periods of care; reimbursement of physician assistants and assistant-at-surgery claims; and diagnosis-related group values, removing references to specific numeric diagnosis-related group values and replacing them with their narrative description.

This article, Part 2 of a 2-part series, continues the examination of the Medicare compliance climate and its impact on hospice providers. This 2nd part focuses on hospice-specific compliance risk areas and specific risk-reduction strategies. The case example from Part 1 is continued.

Dementia is a leading cause of death in the United States. This article outlines the current understanding of advanced dementia and identifies research priorities for the next decade. Research over the past 25 years has largely focused on describing the experience of patients with advanced dementia. This work has delineated abundant opportunities for improvement, including greater recognition of advanced dementia as a terminal illness, better treatment of distressing symptoms, increased access to hospice and palliative care services, and less use of costly and aggressive treatments that may be of limited clinical benefit. Addressing those opportunities must be the overarching objective for the field in the coming decade. Priority areas include designing and testing interventions that promote high-quality, goal-directed care; health policy research to identify strategies that incentivize cost-effective and evidence-based care; implementation studies of promising interventions and policies; and further development of disease-specific outcome measures. There is great need and opportunity to improve outcomes, contain expenditures, reduce disparities, and better coordinate care for the millions of persons in the United States who have advanced dementia.

Background: Few cancer centers have developed acute palliative care units (APCUs). The purpose of this study is to highlight clinical interventions and financial outcomes during a typical 1-month period on an APCU., Methods: We evaluated consecutive patients admitted to our APCU from February 1 to 28, 2009, regarding demographic information, sources of and reasons for admissions, resuscitation status, clinical interventions, disposition, and reimbursement data., Results: Forty-two patients were admitted during a 1-month period. Of these, 30 (71%) were referred from the inpatient palliative care consultation team. In all, 10 (24%) patients had a full code status on admission, and 8 had their status changed to do not resuscitate (DNR) prior to discharge. A total of 11 (26%) patients were discharged home with hospice care, 12 (29%) died on the APCU, and 10 (24%) were discharged home with outpatient follow-up visits. All patients received intravenous medications and the majority received intravenous antibiotics. All patients met acute care criteria for hospitalization, and financial reimbursement was satisfactory and comparable to that of other oncology patients., Conclusion: The APCU model is designed for the care of very complex advanced cancer patients. Palliative interventions are given simultaneously with other medical interventions. The APCU is labor intensive and well reimbursed.

Introduction: The German Cancer Aid funded 12 regional projects which developed different models of palliative home care. The realization of the projects were concurrently monitored and evaluated., Material and Methods: The funded projects were asked to document all patients who were cared for beginning in January 2009 using HOPE (Hospice and palliative survey), MIDOS (Minimal documentation system for palliative patients) and the Barthel index. Documentation was mandatory at the beginning and the end of care as well as when patients changed settings, for example when patients were transferred from a palliative care unit to a palliative home care service. Additionally the projects were visited by an independent observer., Results: Overall the 12 projects documented 2,663 patients. Analysis revealed differences between the projects mainly concerning target groups and interventions., Discussion: The results of this evaluation can support the discussion about the development of palliative home care in Germany with particular focus on possible interrelations between structures, target groups and possible outcomes of care.

Background: U.S. children with life-limiting illness face barriers to accessing palliative care. In 2006, Massachusetts signed into law a statute providing for the creation and funding of the Pediatric Palliative Care Network (PPCN). This innovative, exclusively state-funded program provides comprehensive direct and consultative community-based pediatric palliative care services including: (1) pain and symptom management, (2) case management and assessment, (3) social services, counseling, and bereavement services, (4) volunteer support services, (5) respite services, and (6) complementary therapies. Provision of care is through a network of state-licensed hospice programs, and an array of professional and volunteer services., Objective: To describe Massachusetts' experience in implementing a novel pediatric palliative care program., Design: Enrollment and service trends were identified using Massachusetts Department of Public Health administrative data. Responses to a written family satisfaction survey provided to each family enrolled on PPCN are summarized., Results: In fiscal year 2010, PPCN partnered with 11 hospice programs to provide services to 227 children with life-limiting illness. A total of $680,850 (86.7%) of state funding went to direct contract funds for hospices. Admitting diagnoses included cancer (30%), chromosomal abnormalities (17%), neurodegenerative disorders (15%), and other (38%). There were 11 deaths, 100% of which occurred in the family's requested location. Median length of stay on service prior to death was 233 days. Families most commonly implemented psychosocial and case management services, followed by complementary therapies, and volunteer services., Conclusions: Successful implementation of a statewide pediatric palliative care program as modeled in Massachusetts is highly feasible at relatively low cost.

Background: Although hospice use may be increasing among heart failure patients, its association with both cost and intensity of care in this population has not been well examined., Objective: To assess the association of hospice care with resource utilization among a national sample of Medicare beneficiaries with heart failure during the last 6 months of life., Methods: We performed a cross-sectional analysis of the 5% sample of Medicare claims data. Negative binomial regression models were used to compare expenditures, hospitalization rates, and intensive care unit (ICU) days between hospice and nonhospice beneficiaries. We used Poisson regression models to compare utilization of certain procedures between hospice and nonhospice beneficiaries., Results: Among 16613 Medicare beneficiaries who died with heart failure in 2007, 6436 (38.7%) received hospice care during the last 6 months of life. The mean total medical expenditures were $31,793 (SD 25,691) among decedents with hospice care, in comparison to $34,067 (SD 40,561) among decedents without hospice care. However, after adjustments for covariates, hospice care was associated with 4% higher expenditures (cost ratio, 1.04; 95% confidence interval, CI: 1.01-1.07). Hospice use was associated with reduced hospitalizations (adjusted incidence rate ratio, 0.87, 95% CI: 0.84-0.89), ICU days (adjusted incidence rate ratio, 0.68, 95% CI: 0.63-0.73), and procedures, including cardiac catheterization, noninvasive ventilation, and mechanical ventilation., Conclusions: Despite lower rates of hospitalization, ICU days, and invasive procedures, hospice care was not associated with reduced expenditures in heart failure. Financial savings related to reduced intensive medical care seems to be offset by the expenditures related to hospice care itself.

Background: Applying diagnostic techniques in palliative care (PC) requires a thorough balance between a physical, psychosocial (and financial) burden and its therapeutic relevance in far advanced diseases. The extent of diagnostic employment in PC, preferred techniques, application problems, its informative value and therapeutic significance still have to be described., Methods: The Hospice and Palliative Care Evaluation (HOPE) 2007 collected data from the application of microbiological and imaging techniques in German PC institutions. Furthermore, 70 consecutive ultrasound scans in our PC unit have been retrospectively analyzed.In 691 PC patients (from a total of 3184 in HOPE), diagnostic techniques (DIA) were applied and documented., Results: In-patients with DIA (86,1 %) and the HOPE collective showed a comparable age and duration of hospital stay. Microbiological techniques contributed to 26,1 % of all documented in-patient investigations, imaging techniques 69,1 %. Ultrasound was the preferred imaging technique on PC units (67,1 %), whilst radiography, CT or MRI scans were rather employed on oncology wards. Nuclear imaging was rarely documented. In 80,8 %, imaging diagnostics were considered relevant for further treatment decisions (in-patients only); transportation problems and pain during imaging were relevant obstacles. In our own patient cohort, ultrasound was applied rather for general prognostic purposes, less often resulting in immediate therapeutic actions. Transportation problems could be almost entirely avoided by using a mobile ultrasound device., Conclusion: DIA in PC are applied independently of age or duration of hospital stay; its therapeutic significance is considered to be high; procedural problems may be resolvable. Therefore, this survey might challenge the tradition of low technology in PC., (© Georg Thieme Verlag KG Stuttgart · New York.)

Context: It is unclear if advance directives (living wills) are associated with end-of-life expenditures and treatments., Objective: To examine regional variation in the associations between treatment-limiting advance directive use, end-of-life Medicare expenditures, and use of palliative and intensive treatments., Design, Setting, and Patients: Prospectively collected survey data from the Health and Retirement Study for 3302 Medicare beneficiaries who died between 1998 and 2007 linked to Medicare claims and the National Death Index. Multivariable regression models examined associations between advance directives, end-of-life Medicare expenditures, and treatments by level of Medicare spending in the decedent's hospital referral region., Main Outcome Measures: Medicare expenditures, life-sustaining treatments, hospice care, and in-hospital death over the last 6 months of life., Results: Advance directives specifying limits in care were associated with lower spending in hospital referral regions with high average levels of end-of-life expenditures (-$5585 per decedent; 95% CI, -$10,903 to -$267), but there was no difference in spending in hospital referral regions with low or medium levels of end-of-life expenditures. Directives were associated with lower adjusted probabilities of in-hospital death in high- and medium-spending regions (-9.8%; 95% CI, -16% to -3% in high-spending regions; -5.3%; 95% CI, -10% to -0.4% in medium-spending regions). Advance directives were associated with higher adjusted probabilities of hospice use in high- and medium-spending regions (17%; 95% CI, 11% to 23% in high-spending regions, 11%; 95% CI, 6% to 16% in medium-spending regions), but not in low-spending regions., Conclusion: Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of in-hospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending.

Hospice and palliative care services need to be able to compete with finite health care resources. To compete for such funding, the sector needs to continuously improve the evidence base that demonstrates improved outcomes, or else funding will continue to be at the level of a "social good" rather than as services that deliver improved health outcomes. Three questions need to be answered for policy makers and health funders: 1) Why invest health care spending in hospice and palliative care?, 2) Why invest research monies in hospice and palliative care clinical research and health service development?, and 3) How can emerging evidence be more effectively implemented to improve patient outcomes? No single measure captures the net benefit of hospice and palliative care services. By patient-defined parameters, hospice and palliative care services have demonstrated benefits, including physical symptom control. To meet patients' concerns, greater emphasis needs to be placed on maintaining physical independence for a longer period of time. Targeted investment of research funding can deliver further improvements in patient outcomes and models of service delivery. Rigorous studies are feasible and necessary if each patient is going to receive the best possible support. Benchmarking and service development strategies can deliver improved patient outcomes. With routine point-of-care data collection and feedback loops to individual services, patient-valued outcomes and resourcing can be improved in hospice and palliative care. Public-good investments in hospice and palliative care research are vital to building the evidence base for improving the quality of care offered., (Copyright © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Hospice is a major expansion area within the Veterans Health Administration (VHA). The objective of this retrospective study was to explore trends in hospice utilization among older veterans receiving services at the end of life over a 4-year (2006-2009) time period. Reviewing trends, the number of veterans receiving hospice services increased annually, with 5779 veterans receiving services during 2009, up from 1742 veterans in 2006. The total cost of providing hospice rose dramatically, increasing from $1.98 million in 2006 to $5.91 million in 2009. More funds were spent on younger veterans, with an average of $1.5 million spent on veterans aged 55 to 64 and less than $400,000 spent on veterans aged 85 and older. Findings highlight the growing need and demand for hospice within the VHA to provide end-of-life services.

This article incorporates findings from the first phase of a Hospice U-shaped Modeling Project conducted by Simione Consultants that were presented on July 14 at the 17th Annual NAHC Financial Management Conference & Exposition in San Diego, CA, by Robert Simione and Theresa M. Forster. SPECIAL NOTE: The National Association for Home Care & Hospice (NAHC) and its affiliated Hospice Association of America (HAA) extend special thanks to the agencies that volunteered to participate in the hospice payment modeling study referenced in this article, and particularly to Robert Simione, Jared Shure Michael Simione, and Kaitlyn Quada of Simione Consultants, LLC, for their significant contributions to advancing knowledge of the potential impact of hospice payment reform.

Context: A small proportion of patients with serious illness or multiple chronic conditions account for the majority of health care spending. Despite the high cost, evidence demonstrates that these patients receive health care of inadequate quality, characterized by fragmentation, overuse, medical errors, and poor quality of life., Methods: This article examines data demonstrating the impact of the U.S. health care system on clinical care outcomes and costs for the sickest and most vulnerable patients. It also defines palliative care and hospice, synthesizes studies of the outcomes of palliative care and hospice services, reviews variables predicting access to palliative care and hospice services, and identifies those policy priorities necessary to strengthen access to high-quality palliative care., Findings: Palliative care and hospice services improve patient-centered outcomes such as pain, depression, and other symptoms; patient and family satisfaction; and the receipt of care in the place that the patient chooses. Some data suggest that, compared with the usual care, palliative care prolongs life. By helping patients get the care they need to avoid unnecessary emergency department and hospital stays and shifting the locus of care to the home or community, palliative care and hospice reduce health care spending for America's sickest and most costly patient populations., Conclusions: Policies focused on enhancing the palliative care workforce, investing in the field's science base, and increasing the availability of services in U.S. hospitals and nursing homes are needed to ensure equitable access to optimal care for seriously ill patients and those with multiple chronic conditions., (© 2011 Milbank Memorial Fund. Published by Wiley Periodicals Inc.)

This final rule will set forth the hospice wage index for fiscal year (FY) 2012 and continue the phase-out of the wage index budget neutrality adjustment factor (BNAF), with an additional 15 percent BNAF reduction, for a total BNAF reduction in FY 2012 of 40 percent. The BNAF phase-out will continue with successive 15 percent reductions from FY 2013 through FY 2016. This final rule will change the hospice aggregate cap calculation methodology. This final rule will also revise the hospice requirement for a face-to-face encounter for recertification of a patient's terminal illness. Finally, this final rule will begin implementation of a hospice quality reporting program.

Objectives: To examine the effectiveness of hospice services for persons dying from dementia from the perspective of bereaved family members., Design: Mortality follow-back survey., Setting: Death certificates were drawn from five states (AL, FL, TX, MA, and MN)., Participants: Bereaved family members listed as the next of kin on death certificates when dementia was listed as the cause of death., Measurements: Ratings of the quality of end-of-life care, perceptions of unmet needs, and opportunities to improve end-of-life care. Two questions were also asked about the peacefulness of dying and quality of dying., Results: Of 538 respondents, 260 (48.3%) received hospice services. Family members of decedents who received hospice services reported fewer unmet needs and concerns with quality of care (adjusted odds ratio (AOR)=0.49, 95% confidence interval (CI)=0.33-0.74) and a higher rating of the quality of care (AOR=2.0, 95% CI=1.53-2.72). They also noted better quality of dying than those without hospice services., Conclusion: Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying., (© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.)

This article critically questions the commercialization of hospice care and the ethical concerns associated with the industry's movement toward "market-driven medicine" at the end of life. For example, the article examines issues raised by an influx of for-profit hospice providers whose business model appears at its core to have an ethical conflict of interest between shareholders doing well and terminal patients dying well. Yet, empirical data analyzing the experience of patients across the hospice industry are limited, and general claims that end-of-life patient care is inferior among for-profit providers or even that their business practices are somehow unseemly when compared to nonprofit providers cannot be substantiated. In fact, non-profit providers are not immune to potentially conflicting concerns regarding financial viability (i.e., "no margin, no mission"). Given the limitations of existing empirical data and contrasting ideological commitments of for-profit versus non-profit providers, the questions raised by this article highlight important areas for reflection and further study. Policymakers and regulators are cautioned to keep ethical concerns in the fore as an increasingly commercialized hospice industry continues to emerge as a dominant component of the U.S. health care system. Both practitioners and researchers are encouraged to expand their efforts to better understand how business practices and commercial interests may compromise the death process of the patient and patient's family--a process premised upon a philosophy and ethical tradition that earlier generations of hospice providers and proponents established as a trusted, end-of-life alternative., (© 2011 American Society of Law, Medicine & Ethics, Inc.)

CMS requirements for hospice face-to-face encounters were effective January 1, 2011, with enforcement beginning April 1, 2011. Hospices still have some questions, however, on how to implement the requirements. In response, CMS has provided clarification on several areas of particular interest to hospices.

Objectives: This study explores the financial consequences of decreased acute care utilization and expanded community-based care for patients at the end of life in England., Method: A Markov model based on cost and utilization data was used to estimate the costs of care for cancer and organ failure in the last year of life and to simulate reduced acute care utilization., Results: We estimated at pounds 1.8 billion the cost to the taxpayer of care for the 127,000 patients dying from cancer in 2006. The equivalent cost for the 30,000 people dying from organ failure was pounds 553 million. Resources of pounds 16 to pounds 171 million could be released for cancer., Conclusion: People generally prefer to die outside hospital. Our results suggest that reducing reliance on acute care could release resources and better meet peoples' preferences. Better data on the cost-effectiveness of interventions are required. Similar models would be useful to decision-makers evaluating changes in service provision.

Purpose: It is necessary to develop a proper payment system for more health care facilities to provide hospice and palliative cares. In deciding the proper level of payment for hospice per diem fee, willingness to pay (WTP) may provide one of the critical information. This study was conducted to determine WTP for hospice care and to analyze those factors affecting WTP., Materials and Methods: A contingent valuation method with a double-bounded dichotomous-choice model was used. Interview survey was organized and conducted by a survey company from April 4 to 18, 2008. The mean WTP was calculated through an infinite integration of survival functions., Results: The average willingness to pay was found to be 42,240 Korean won (KRW) (USD 35), with the amount becoming higher as hospice services were deemed more necessary or where average monthly household income was higher. The amount was also higher among male respondents than females., Conclusion: To compare this WTP with actual cost (32,500 KRW) (USD 27) for hospice care. To facilitate hospice service, hospice specific payment system should be developed. This study provides information regarding the general public's preference of hospice service and their WTP for hospice care, and it may be useful in the decision-making process.

Background: Decisions for the type of palliative care are affected by multiple factors. Currently, most patients die without palliative care, and hospice patients receive only a brief period of services before death., Objective: This study aimed to compare palliative terminal cancer care in inpatient hospice and nonhospice care units in Taiwan for type of cancer, cost, stay, and selected demographic and clinical characteristics., Methods: A retrospective study of terminally ill cancer patients hospitalized in a hospice unit (410 patients) or a general cancer ward (3005 patients) in a hospital in Taiwan was conducted. Patient demographic information, length of stay, cost of treatments, interventions and diagnostic testing, and types of cancer were analyzed. The factors associated with hospice care were revealed by multivariate stepwise regression., Results: In the hospice group, the total cost was lower; there were more female, and more head, neck, and lung tumor patients. The most tumors in nonhospice group are hepatomas. The patients in hospice group received fewer interventions and had a long hospital stay (>14 days) before death; however, most of them were discharged from the hospital due to death., Conclusions: Utilization of hospice care varies by sex and type of cancer. Compared with the nonhospice service, hospice care needs a lower total cost and fewer interventions., Implications for Practice: Hospice care in Taiwan should provide more services and facilities specific for sex (female) and tumors (head and neck)., (© 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins)