The Hospice e-News

What the Media Said about End-of-Life Care This Week

Week of February 06, 2006

…a service of Florida Hospices and Palliative Care

ARTICLE ASSESSES VALUATION OF HOSPICE

An article in the January Remington Report, “Home Care Mergers and Acquisitions,” reviews last year’s activity and expectations for the coming year. The Remington Report covers “predictions, trends and business and clinical strategies” for homecare executives and clinical managers.

In reviewing hospice’s risk profile, the article says that while there was little activity from the standpoint of reimbursement to affect hospice risk, the “perception of risk edged upwards again in 2005 following a difficult 2004 when the stock prices of several publicly traded providers plunged 50%.” A major difficulty, says the article, was the problem of maintaining cost caps. “Monitoring and maintaining the delicate balance between typically higher profit margin, longer lengths of stay (LOS), non-cancer patients with lower margin, shorter LOS cancer patients to remain under cost limits remains a difficult and speculation-laden task.”

To manage costs, the article says, “Some firms have even resorted to offering incentives to sales reps to identify and bring in shorter LOS patients when threatened with cap exposure. Firms are beginning to scrutinize the markets they are serving, the theory being that the most acute patients tend to cluster around urban markets with hospitals that generally have greater resources to treat the sickest patients, leaving rural markets with a disproportionate number of less acute, longer term patients.”

The author says that the solution to the problem “may lie in an initiative that many providers fear: moving from fixed daily rates that do not vary from patient to patient to those that vary based upon patient acuity,” but that “such a change is not likely to occur over the short term.”

Acquisitions are down slightly from 2004, but the nature of those transactions has changed. Nearly half of the 2004 deals were in excess of $20 million in price, but only one such transaction had occurred in 2005 through September. According to the article, this trend probably reflects that the hospice industry has moved from an initial acquisition phase to smaller, “layer-on” deals and that many hospices have turned toward the home health market.

Hospice valuation models have changed from capacity-driven to profitability-driven. As a result, the willingness of purchasers to “pay premium value to enter a market, regardless of a provider’s profitability, has declined.” “For the first time in a long time,” the author concludes, “valuation in this sector has declined.” (The Remington Report, 1/2006)

EXAMINING END OF LIFE CARE IN NURSING HOMES

“Making Room for Dying: End of Life Care in Nursing Homes” is another article in the recent Hastings Report. Written by Sandra H. Johnson, professor of health care law and ethics at the School of Law and the Center for Health Care Ethics at Saint Louis University, the article examines the regulatory and cultural changes needed to improve care at the end of life in nursing homes.

Johnson, who is also Director of the Mayday Project on Legal and Regulatory Issues in Pain Relief at the American Society of Law, Medicine and Ethics, begins by saying that 20% of all older Americans die in nursing homes and another 30% die in hospitals just a few days after transfers from nursing homes. Those late transfers, Johnson says, do not provide the resident with better care, but, rather, may impede it. “Reducing the incidence of unnecessary hospitalizations can improve care of the dying significantly in the nursing home without facing a stalemate over the moral values of human life and human caring,” she writes.

Over the past few years, nursing homes have reacted to the perception that they are places to warehouse residents until death. Regulators and healthcare professionals have successfully worked at “maintaining, if not improving, the physical, mental and social health of nursing home patients.” In addition to better care, these changes have also helped expose substandard facilities and care “that had once hidden behind routine acceptance of physical and mental decline.”

One unintended result of those efforts is a “death-denying culture” in many nursing homes. Regulatory standards assume that signs of decline are the results of deficiency in care, unless proved otherwise. But signs of decline may also be indicators of approaching death. Risk-averse nursing home administrators may insist on adherence to standards that discourage good care for dying residents.

“Before nursing homes can improve end of life care, dying will have to find a place in the nursing home culture,” Johnson says. These changes in culture must accompany changes in regulation, because the two together go hand in hand to govern patient care. Johnson recommends using palliative care models that view “support of the dying as active, positive, and promoting of health and human values, even as aggressive medical interventions aimed at cure are relinquished.”

The challenge, Johnson writes, “is to encourage the regulatory system to accept the process of dying, with its accompanying physical and mental deterioration; to exercise restraint in the use of interventions, including inquiries, that would otherwise be pursued; and to do so without creating a shield for neglect. Nursing homes are plagued by a reputation for neglect and abuse, but gearing the entire system to account for the bad apples can inadvertently have the effect that all homes provide less than optimal care for the dying.”

Another required adjustment is that of “the general framework for end of life decision-making to better account for the nursing home context.” The focus of the current legal and ethical forces in end-of-life care is on the extreme cases, such as whether persons in persistent vegetative states should receive nutrition and hydration. Johnson cites Rosalie Kane as saying that long-term care should emphasize “everyday ethics,” and suggests that nursing home residents would receive better care if the focus were on the routine rather than the extreme.

Another focal point for improvement is that of pain and symptom management. Both families and health care providers underestimate pain in the elderly, Johnson writes, while the elderly themselves often underreport it so as not to be considered a burden. “Improving pain management will not grab the headlines or fuel the debates that withdrawal of nutrition and hydration does, but it is the foundation for compassionate care for the dying.”

Regarding feeding tubes, Johnson compares their use to that of restraints, saying that “common knowledge” held that restraints keep patients safe and feeding tubes keep them healthy. Newer research has identified negative effects of artificial nutrition and hydration, which Johnson hopes reduces the incidence of their use. But, she says, “Unless this common practice is uncoupled from its association with the crucible of the provision of nutrition and hydration to the patient in PVS, the shared values that support its reduction in use will not be recognized.”

The article cites three fundamental assumptions regarding decision-making at the end of life as being “particularly ill-suited to the nursing home environment.” In the first place, Johnson says, “end of life care” is not synonymous with “care of the dying.” Not only is it difficult, or even impossible, to tell when someone begins the process of dying, but there is “a lack of language an even a lack of concepts for this stage of human life, even though it is a stage typical of so many nursing home residents.”

Second, the patient is not the only person who has a stake in dying. Family and caregivers also are affected and should have a voice. And third, the current legal presumption in favor of sustaining life by all means gives weight to medical intervention, not the “individuals life history and values or the more complex goals of care.” It’s time, Johnson says, to consider whether this should be “changed to a presumption in favor of care that provides comfort, relieves suffering, or promotes activities of daily living.” Such a change would put the emphasis on palliative care and relegate life-sustaining interventions to their proper perspective.

Johnson concludes by saying, “Advocates for nursing home residents and those nursing homes in the leadership of best practices have worked hard to dismantle the stereotype of the nursing home as a warehouse for those who are declining into death. This work needs to be protected. However, once dying is recognized as an undeniable part of living – including living in a nursing home – it is clear that the ideal of health promotion will have to embrace care for the dying.” (Improving End of Life Care: Why Has It Been So Difficult?)

Editor’s note: This is one of a series of articles from a recent The Hastings Report, “Improving End of Life Care: Why Has It Been So Difficult?” We will continue the series as space permits.

RESEARCH AND RESOURCE NOTES

* A new PBS series, ”A Lion in the House,” will look at the lives of five pediatric cancer patients and their families over a six-year period. The program, which will be aired on June 21 and 22, “offers an intimate view of patients, families and professional caregivers when a cure for cancer is beyond reach.” Community engagement efforts will be led by NHPCO, NHPCO’s Caring Connections Initiative, the Children’s Project on Palliative/Hospice Services, the Independent Television Service and other organizations. PBS information is available at www.pbs.org/independentlens/lioninthehouse. (NHPCO NewsBriefs; 2/2; PBS Website)

* Ladislav Volicer, MD, has written a literature review of End-of-Life Care for People with Dementia in Residential Settings. NHPCO NewsBriefs says that Volicer, of the University of South Florida, “lays the foundation of knowledge and challenges care providers to deliver excellent care to each patient within each health care system and setting.” See http://www.nhpco.org/files/public/newsbriefs/nb_020206.htm#newsfrom2 for a link to download Volicer’s report and an Executive Summary produced by The Alzheimer’s Association. (NHPCO Newsbriefs, 2/2)

* The International Journal for Quality in Health Care recently reported on a study that evaluated “measures that could use administrative data to assess the intensity of end-of-life cancer care.” The standards were drawn from the Medicare claims of nearly 50,000 patients who died between 1991 and 1996. Researchers say that the usefulness of the standards “will depend on whether the concept of intensity of care near death can be further validated as an acceptable and important quality issue among patients, their families, health care providers, and other stakeholders in oncology.” (Cancer Weekly, 1/31)

* Since her mother’s diagnosis with lung cancer seven years ago, Karen Bullock, a researcher at the University of Connecticut School of Social Work, has studied end-of-life choices among African Americans. Bullock says that some of the well-documented resistance of African Americans to hospice stems from a time when they were denied decent health care or were used, without their knowledge, as “laboratory guinea pigs.” Some resistance arises from “a deeply spiritual tradition” which sees God, rather than the doctor, as the determinant of the time of a person’s death. Because most research into racial attitudes at the end of life is anecdotal, Bullock, with funding from the Gerontological Society of America and the John A. Hartford Foundation, is comparing the charts of 200 African Americans who died at Hartford Hospital with a similar group of white patients. Bullock is looking at how black and white patients use living wills and advance directives and also at the rate of use of palliative services. (The Hartford Courant, 1/29)

OTHER NOTES

* The American College of Physicians (ACP) says that the primary care system in the United States is “on the verge of collapse.” Very few young physicians are going into primary care and “those already in practice are under such stress that they are looking for an exit strategy.” The group called for a change in reimbursement that gives primary care doctors the responsibility for organizing a patient’s care and encourages patients to monitor their own health. Bob Doherty, ACP senior vice president, says, “Medicare will pay tens of thousands of dollars … for a limb amputation on a diabetic patient but virtually nothing to the primary care physician for keeping the patient’s diabetes under control.” (Reuters, 1/30)

* Terry Gross interviewed Dr. Christine Cassel, on NPR’s Fresh Air, about the new Medicare prescription drug plan. Cassel says, “Everyone is confused.” Cassel says the new plan worries her, because this model doesn’t make sense for those with low incomes or those who are confused or have mental health problems. She also sees a major problem with the “doughnut hole arrangement,” whereby a certain amount of drugs are covered up to one threshold, then there’s no coverage between there and $5,000 and then the coverage kicks in again. Medicare patients with multiple chronic illnesses will particularly have problems with that, Cassel says. (NPR’s Fresh Air, 1/31)

* On March 8, London’s Westminster Abbey will be the site of a service of thanksgiving for the life of Dame Cicely Saunders, founder of the modern hospice movement. Saunders was also the founder of The Cicely Saunders Foundation, which researches and promotes palliative care. (PR Newswire US, 1/31)

* A growing number of estate-planning attorneys are including religion in their discussions with clients. Martin M. Shenkman, who has been discussing spiritual values with his clients for the last 20 years, says that attorneys who don’t do so are “shortchanging their clients.” (St. Louis Daily Record, 1/31)

Correction: The January 31 issue of HNN, number 5, was incorrectly dated as January 21.

Thanks to Don Pendley for contributions.

Glatfelter Insurance Group is the national sponsor of Hospice News Network for 2006. Glatfelter Insurance Group provides property and liability insurance for hospices and home healthcare agencies through their Hospice and Community Care Insurance Services division. Ask your insurance agent to visit their website at www.hccis.com.