Hospice and Palliative Care (07/08/2009)

Final
STAFF SUMMARY OF MEETING

HOSPICE AND PALLIATIVE CARE

Date:	07/08/2009	ATTENDANCE

Time:	09:01 AM to 03:29 PM	Balmer	X
		Cadman	X
Place:	HCR 0107	Kester	E
		Newell	X
This Meeting was called to order by		Roberts	X
	Representative Riesberg	Soper	X
		Tochtrop	X
This Report was prepared by		Tyler	X
	Kelly Stapleton	Williams	X
		Riesberg	X
		X = Present, E = Excused, A = Absent, * = Present after roll call

Bills Addressed:		Action Taken:
Introductory Comments Urban Hospice Overview Introduction to Palliative Care National Hospice Overview and Medicaid Rural Hospice Challenges Adjournment		- - - - - -

09:01 AM -- Introductory Comments

Representative Riesberg, Chair of the committee, welcomed the committee and introduced Representative Max Tyler, a newly appointed member to the General Assembly. Representative Riesberg spoke to the charge of the Hospice and Palliative Care Interim Committee. He also outlined the agenda for the July 8 and 9, 2009, meetings. He spoke to the committee deadlines, specifically that legislation must be requested by the September 24, 2009, meeting.

09:05 AM -- Introduction to Hospice and Palliative Care and Hospice Utilization

Dr. Cordt Kassner, Executive Director, Colorado Center for Hospice and Palliative Care, provided introductory remarks and a handout on his presentation (Attachment A). He spoke to the amount of money spent on health care at the end of one's life. He provided an explanation of the function of hospice care. He stated that hospice is designed to treat pain and the symptoms of end-stage illness, provide care for individuals and families, neither hasten or postpone death of the individual, but rather focus on quality of life for the individual and family members on the final journey of life. Dr. Kassner provided an overview of services provided by hospice, the composition of a hospice team who treats the individual, where an individual may access hospice care, and payment methods of the care. Dr. Kassner spoke to the benefits of hospice care for the sick individuals and family members.

09:28 AM

Dr. Kassner provided an overview of palliative care. He stated that palliative care focuses on relief of physical and personal distress for individuals with a terminal illness or a chronic disease. He stated that full spectrum palliative care services are not reimbursed under Medicare. Representative Riesberg asked for a bit more explanation regarding why palliative care is not covered by Medicare. Dr. Kassner stated that many primary care physicians do not have a board certification to administer palliative care and therefore it is not covered by Medicare. He stated that Medicare is seen as a very fragmented system. The committee discussed palliative care versus curative care.

09:57 AM

Dr. Kassner provided information to the committee regarding hospice utilization. He provided statistics regarding the number of patients using hospice, the average stay for a patient in hospice, and where Colorado stands on a national level compared to other states regarding hospice utilization. He provided information regarding Medicare reimbursements from a state perspective and a national perspective.

10:04 AM -- Urban Hospice Overview

Darla Scheuth, Executive Director, HospiceCare of Boulder and Broomfield Counties, introduced herself and provided background information to the committee regarding her credentials. She provided a packet to the committee with information regarding hospice care and Medicare funding for hospice care (Attachment B can be viewed in archives). She spoke to the utilization of hospice. She commented that two main comments she hears from the public regarding hospice care are, "I wish we would have known about you sooner" and "We couldn't have dealt with situation without you." She stated that these comments are indicative of the value of hospice care. Ms. Scheuth explained various payment methods for palliative and hospice care. She stated that Medicare reimburses hospice care centers a set amount of money per day, a per diem, for care and services. She explained the four levels of payment and the corresponding level of payment. She highlighted that the highest level of payment is for general inpatient care, but that is capped at 20 days. She stated that the way Medicare is structured is to encourage hospice providers to provide services in the home rather than a hospital. Committee members discussed the reimbursement levels and which program, Medicaid or Medicare, that pays for services. Ms. Scheuth stated that the longer an individual stays at the hospice, the better she is able to spread her costs. She stated that HospiceCare raises about $1 million from the community in order to subsidize the costs of operating the hospice.

10:41 AM

She spoke to solutions to eliminating barriers to care. She stated that offering options to the patient could help immensely. She stated that some families and individuals are not able to 'make the leap' to call in hospice. There was some discussion regarding how people come to the decision to enter into a hospice program. She stated that physicians are paid to 'treat' or cure patients, but that there is a disconnect between treating patients and helping someone die in peace.

11:01 AM

The committee took a brief recess.

11:10 AM -- Introduction to Palliative Care

The committee reconvened. Dr. Dave Nowels introduced himself and provided a handout to the committee (Attachment C). He stated that he works at the Life Quality Institute, Department of Family Medicine, University of Colorado at Denver and Health Sciences Center and is Program Director for the Colorado Palliative Medical Fellowship. Dr. Nowels provided the World Health Organization's definition of palliative care which is a interdisciplinary health care service that specializes in the relief of suffering and the achievement of the best quality of life for patients with advanced illness. He went on to further explain that palliative care focuses on relief of pain, stress, and other debilitating symptoms of serious illness. He also provided statistics regarding how individuals die in the United States. He stated that a study reported in the Journal of the American Medical Association indicates that approximately 38 percent of Americans spend the last 10 days of their life in an intensive care unit in a hospital, and that 31 percent of families interviewed reported that they used all or most of their savings on end-of-life care for family members. He stated that a majority of adults prefer to be cared for in their own homes, yet nearly 75 percent of Americans die in a hospital or nursing home.

11:20 AM

Dr. Nowels provided an example of an individual he has cared for using palliative care. He spoke to the palliative care consultant's role. There was discussion regarding where and when it is appropriate to discuss end of life directives with individuals who are seriously ill. Dr. Nowels stated that he often acts as the primary care physician, as well as the palliative care consultant when discussing these types of questions with patients. He stated that often times, living wills do not address many of the situations that patients find themselves in.

11:40 AM

Dr. Nowels spoke to several different care models and how palliative care fits into the various models. He stated that one of the most effective care models is through multi-disciplinary teams, but the main problem with this model is that they are not be reimbursed within the current system. He stated that some hospitals have their own palliative care unit, or they contract with community palliative care centers. He stated that there is a high need for palliative care services in long-term care facilities. He spoke to the board certification for palliative care providers. He stated that there are about 75 slots nationally for training palliative care providers.

12:02 PM

The committee took a recess.

01:40 PM -- National Hospice Overview and Medicaid

The committee reconvened. Christy Whitney introduced herself to the committee and described her organization, Hospice and Palliative Care of Western Colorado. She stated that over the last ten years, her organization has grown from serving 25 patients to over 300. She also told of how her organization offers bereavement services to children in her community and children that are involved in the criminal justice system. Ms. Whitney also described the organization's free bereavement programs for adults.

Ms. Whitney shared a document on "Barriers and Utilization of Hospice and Palliative Care" (Attachment D). She stated that the transition from an assisted living residence to hospital-based hospice can be a barrier. She said that if a resident of an assisted living residence who is receiving hospice care is hospitalized, they often cannot return home to the assisted living home. Senator Williams stated that in Texas, patients are allowed to return to an assisted living facility after going to a hospice center. Representative Reisberg noted that assisted living homes may have liability issues and therefore may not be able to take a patient back after they have been to a hospice center. Representative Roberts asked where the regulations for assisted living residences come from. Ms. Whitney stated that the Department of Public Health and Environment promulgates the rules for assisted living facilities. Ms. Whitney showed a film describing her organization.

01:58 PM

Ms. Whitney stated that Medicaid does not provide coverage for residential hospice care. She stated that if there was reimbursement available, then there will be incentive to provide this service. She commented that currently people do not have the resources to pay for residential hospice, and instead people are served in nursing homes or end up in the hospital. Ms. Whitney discussed how access to hospice is related to transitioning types of care. She stated that there are some palliative care programs, such as hers, that have a gap program which provides a bridge to hospice care. She noted that her organization offers social work services. She stated that this transition program helps get people into hospice earlier. She stated that her organization charges on a fee-for-service basis at about $200 per month.

02:06 PM

Ms. Whitney commented that in Colorado, most private insurance offers hospice benefits, but that it is usually capped at a certain amount. She stated that her organization loses money on Medicaid patients and private insurance patients, and that they break even on Medicare patients. She explained to the committee that she has some concerns with how hospice care centers are reimbursed by private insurance. She proposed that private insurers pay an equal amount to what Medicare pays for benefits. Ms. Whitney discussed a graph which shows cost savings for hospice during the last two years of life (Attachment E). Ms. Whitney acknowledged that licensing fees for hospice centers are low. She stated that the Department of Public Health and Environment should consider setting licensing fees based on the size of the organization.

02:18 PM

Ms. Whitney discussed differences between hospice care in long-term care facilities versus at home. She also noted that some areas have concerns with coroners. Representative Roberts asked her opinion on the process in which coroners in Colorado get elected. Ms. Whitney stated that she did not think that coroners should be elected, that the job should be evaluated on the basis of one's qualifications, such as a pathologist for example. Representative Roberts asked about advanced directives and what can be done legislatively to improve advanced directives. Ms. Whitney responded that she thinks that the POST medical directive is a good concept. She stated that it would be good to have public outreach in order to help people understand the various legal documents, including living wills and advanced directives.

02:33 PM

Senator Newell asked about the organization's marketing plan. Ms. Whitney describe her organization's marketing events and community involvement. Ms. Whitney discussed her small marketing team and stated that they do not use traditional marketing. Ms. Whitney stated they talk to important stakeholders in the community, such as ministers. She stated that word of mouth in a small community is the best way to affect opinion in the community. Senator Williams asked about serving tribal areas in southern Colorado. Ms. Whitney discussed a Ute colleague who helped with outreach in the Native American community. Ms. Whitney provided a copy of her powerpoint presentation to the committee and 2 handouts,"Comprehensive Hospice and Palliative Care Organizations Interface Between Chronic, Palliative, and End Stage Interventions" and a comparative chart between the Medical Home and Hospice (Attachments F, G, and H).

02:37 PM

Dr. Kassner responded to a committee member's question from earlier in the day regarding how many certified palliative care providers are in Colorado. He stated that there are 59 palliative care board certified physicians in Colorado, including 7 that serve in rural areas in Colorado.

02:38 PM -- Rural Hospice Challenges

Donna Roberts introduced herself, and described how she worked as a nurse in Greeley at a small hospital, and then became a director of Hospice of the Plains, which serves northeast Colorado. She then began her powerpoint presentation, as shown in Attachment I. Ms. Roberts noted that Medicare guidelines provide that only a physician can certify someone for entrance into a hospice. Her organization has 40 employees, but more than 200 volunteers. Ms. Roberts shared some of the problems that hospice patients encounter medically, and also described the emotional and spiritual issues that patients confront. Representative Tyler asked about length of stay in her hospice. Ms. Roberts answered that the average stay in their area is about 12 days. She stated that when her organization served primarily Yuma county, that the average stay was about 75 days. She described her organizations expansion and stated that they are still getting to know their new communities and are working with new physicians. Representative Tyler asked if they expect the length of stay to increase. Ms. Roberts stated that they do expect the average to increase.

02:51 PM

Ms. Roberts stated that patients in rural areas often have different concerns than patients of a urban hospice, such as feeding the cows or harvesting the crops. She stated that the hospice in the rural community addresses these concerns. Ms. Roberts stated that rural areas are reimbursed under Medicare at a lower rate than urban areas. She discussed the billing rate and the hospitalization rate for her organization. Ms. Roberts then explained the decision to expand services to Morgan County. She stated that they have nurses living in Morgan County, and the area is served from the office in Sterling. She then discussed the number of patients served and the organization's budget. She stated that patients with insurance are responsibilities for deductibles only. She described how the organization operates on a sliding scale and does not deny service. Ms. Roberts stated that often patients do not pay deductibles or copays. Ms. Roberts noted that prescriptions get filled for 7 days, because 30 day prescriptions can lead to waste if patient cannot tolerate the medicine. Ms. Roberts recounted the story of an individual that was on many medicines, including IV medications, and was in constant pain. She stated that the reimbursement for the medications did not cover the services provided. She discussed the amount of uncompensated care that her organization provides.

03:00 PM

Ms. Roberts stated that her organization is impacted by economies of scale. She stated that the cost per patient is much higher, and that a drop in the number of patients can have a large impact on the finances of the organization. Ms. Roberts discussed the recent rodeo death of a 12 year-old boy and the bereavement services provided. She stated that they offer these services to the community, but are not reimbursed by Medicare. Ms. Roberts discussed the hospice Medicare benefit and how some drug costs can consume large portions of the benefit. She stated that the costs for drugs given to hospice patients can be expensive and described some of the common drugs used and why.

03:08 PM

Ms. Roberts described the services that her organization offers under the Medicare for hospice benefits. She also described services that are provided, but may not be reimbursed under Medicare. She stated that patients may also seek treatment for conditions not related to terminal illness. Ms. Roberts discussed services related to the terminal illness that are not covered under Medicare. She stated that Medicare does not allow skilled nursing in a nursing home to occur at the same time as hospice care, unless the nursing home stay is unrelated to the terminal illness. She stated that hospice can save a large amount of money for families that receive hospice care.

03:19 PM

Ms. Roberts thanked the committee and asked if there were questions. Senator Newell asked about the Five Wishes form, and about what the most important change that Ms. Roberts would want to make to the hospice care system. Ms. Roberts explained the Five Wishes form. Ms. Roberts stated that she would want every terminally ill person to seek hospice and for there to be funding to support it.

03:28 PM

The committee adjourned.