Talk to people in the hospice business, and they'll tell you that hospice lengths of stay are way down.
That's bad news for hospice agencies, which need longer lengths of stay to maintain patient census.
Average lengths of stay in many states are now reportedly less than two months, and half of hospice patients spend less than three weeks in hospice care, according to 1997 data from several state hospice associations.
But it takes at least two months to establish a relationship between hospice care teams, patients and families, says Judi Lund Person, president and chief executive officer of Hospice for the Carolinas, an association of 110 hospice agencies. The relationship "helps them work through their feelings and say goodbye," she adds.
A two-month stay also helps hospices' bottom line, Person acknowledges.
Patients generally require more-intensive services at the beginning and end of their hospice stays.
Medicare covers about 75% of hospice patients and pays flat daily rates to agencies. Longer stays allow hospices to recoup higher expenses incurred at the front and back ends.
Hospices face another possible problem. On April 1, HCFA will require hospice agencies to begin filing cost reports covering their Medicare patients.
Hospice administrators are concerned that when HCFA gets the cost reports, it may decide to cut reimbursement. Although only patients with prognoses of six months or less are eligible for Medicare-funded hospices, some patients outlive those expectations, and hospices continue to be paid as long as patients are enrolled in hospice care. HCFA already knows that extended lengths of stay cost more.
A 1995 study sponsored by the National Hospice Organization found that for patients at the end of their lives, hospice care costs Medicare less than nonhospice services do.
But as hospice lengths of stay extend beyond one month, the savings to Medicare decrease.
While agencies fear that the cost report system may cut hospice reimbursement down the line, falling lengths of stay are hurting hospices now.
Hospice administrators cite several possible reasons for the slide in length of stay, including the fragmentation of the healthcare system and physicians' fears of regulatory crackdowns. However, many point primarily to the lack of physician knowledge about end-of-life care.
This month the American Medical Association completed a series of physician training programs called "Educating Physicians in End-of-Life Care." The program, funded by the Robert Wood Johnson Foundation, trained 270 doctors from around the country on how to manage pain and break bad news, and other aspects of caring for terminal patients.
Although hospice care is appropriate for a subset of patients, all doctors should learn the "core skills" of caring for dying patients, says AMA principal investigator Linda Emanuel, M.D.
In the training sessions, Emanuel pointed to the short length of hospice stay as evidence that physicians are not doing enough to help their patients access optimum end-of-life care.
Hospice agencies are also trying to educate medical students and physicians about end-of-life care and boost referrals in the process.
The California State Hospice Association, for instance, is working with a coalition of state healthcare associations to promote end-of-life education in medical schools. A $150,000 grant from the Robert Wood Johnson Foundation will help fund a summit of state medical school deans later this year.
The state hospice association and the California Medical Association are co-sponsoring a series of eight conferences this year to provide physicians with peer-to-peer training on pain management and other end-of-life issues.
Carolyn Cassin, chief operating officer at Scottsdale, Ariz.-based VistaCare, says physician education on end-of-life care "is fabulous, but it will not change the length of stay." She argues that physicians refer late because they believe that patients in hospices are forced to give up important therapy options. But Medicare requires only that patients have a six-month prognosis and agree to be admitted to a hospice; the agency does not restrict the kind of treatments patients receive, she says.
VistaCare, the second-largest hospice agency in the country, has developed a system whereby patients can still receive chemotherapy, radiation or other treatments as hospice recipients.
VistaCare, which has a daily patient census of 2,300, pays for those services from its per diem.
So far the system is working, Cassin says. VistaCare's census growth, excluding acquisitions, is 3% to 4% per month, far outpacing the annual 16% growth in hospice users reported by the NHO.
Miami-based Vitas Healthcare Corp.-the largest hospice company in the U.S., with a daily census of 4,900- is trying to increase its census by using an educational approach like the one that pharmaceutical companies use.
Vitas deploys "hospice reps" to visit physicians and other healthcare providers to educate them about appropriate hospice referral and Medicare coverage.
The median length of stay at Vitas is about two weeks, says J.R. Williams, M.D., Vitas executive vice president and chief patient-care officer.
While length of stay is not an accurate benchmark of profitability, it "does have an impact on how fast or slow a program will grow," says David Webster, Vitas vice president and chief financial officer.
"I would hope that (length of stay) has stopped declining," Williams says.