Providing comfort

CEDAR RAPIDS - Hospices provide comfort for the terminally ill. The care givers and medical professionals provide pain management and emotional support.

But it's also a billion-dollar business dealing with increased regulation and change - something that two not-for-profit hospices in the Corridor are experiencing first hand.

'There is such a regulatory scrutiny of hospice care,” said Dr. Amanda Sommerfeldt, the medical director of Hospice of Mercy, which provides care to patients in their homes and nursing homes as well as in a 12-bed inpatient facility in Hiawatha.

This scrutiny to which Sommerfeldt refers comes from Medicare, which has implemented new rules over the past few years to cut down on fraud.

Medicare gives hospices a daily payment per patient throughout his or her enrollment in hospice care. Critics believe this gives larger, for-profit hospices a financial incentive to enroll more patients early.

'They'll get patients in hospice and stabilize them, and then keep them forever,” said Dr. James Bell, UnityPoint-Health St. Luke's Palliative Care medical director.

Under Medicare's regulations put into place over the past few years, Sommerfeldt said two physicians must say a patient's life expectancy is six months or less to enroll him or her into hospice care. The patient must then be recertified, or approved to continue care, every 90 days.

Bell said this 'justification process” means it's possible that some patients may be discharged from hospice.

'It's a scary thing for patients and provides,” he said.

A ballooning industry

Over the past decade, the number of hospices as well as the number of patients they care for have grown significantly.

A 2013 review prepared for the U.S. Health and Human Services's Centers for Medicare and Medicaid Services (CMS) reported that the number of people using hospice care has increased 211 percent over the past decade - rising from 513,000 in 2000 to 1.16 million in 2010.

Meanwhile, the total number of hospice providers nationwide increased 50 percent - growing from 2,318 to 3,476.

An influx of for-profit agencies drove the increase in supply of hospice providers. In 2009, about 53 percent of hospices were for-profit, according to the report.

But during this time period, Medicare hospice expenditures more than quadrupled, rising from $2.9 billion in 2000 to $13 billion in 2010, according to the report. And Medicare spending on hospice hit $14 billion per in 2013.

The report said that this increase in expenditures comes from higher enrollment as well as a longer average length of stay. Among hospice users, the average length of stay grew from 54 days in 2000 to 86 days in 2010.

And the industry is expected to continue on this growth trajectory. Harris Williams & Co., a middle-market investment group that works with health care companies, projects the industry to grown 7.4 percent annual through 2017.

Changing populations

Some of these changes the industry is seeing come from the types of people hospices are serving.

'The kinds of patients are changing,” Bell said, who pointed out that when he started his career 25 years ago, the majority of patients he saw had cancer. 'Now it's only about one-third.”

This follows national trends. According to the National Hospice and Palliative Care Organization, cancer diagnoses account for about 37 percent of hospice admissions today.

Other leading causes are:

l Dementia at 13 percent

l Heart disease at 11 percent

l Lung disease at 8 percent.

Another 14 percent of admissions have unspecified debilities.

Bell said this change in patients is, in part, responsible for the ballooning of hospice organizations as they have a wider variety of patients to serve and equipment and medicine needed.

According to the CMS report, patients with non-cancer diagnoses, including dementia, respiratory diseases and Alzheimer's, have longer lengths of stay than those with lung cancer, blood cancer or colon cancer.

But Bell said he hasn't seen a change in the average length of stay.

'You would think it would increase, but it hasn't really changed,” he said. 'Partially because we still get referrals pretty late, when patients are in the last stages of their lives.”

Hospice care is most expensive in the first few days and the last few days of a patients' stay, Sommerfeldt said. This can make taking care of patients very expensive, when all of his or her care is squished into a few days.

'We prefer people to come several weeks beforehand so we can monitor them and help them be as comfortable as possible. ...

We have to change perceptions from this is a type of care you receive in the last few days or hours of someone's life to this is a way to prepare when there aren't a lot of options for treatment.”