Hospice CEO: Care Must Move Upstream

Florida-based Community Hospice & Palliative Care, one of the largest nonprofit hospice providers in the nation, continues to see substantial growth. In 2019 alone, the hospice is opening a new inpatient unit, revamping its pediatric palliative care program, and launching a Program for All-Inclusive Care for elderly (PACE) location.

CEO Susan Ponder-Stansel sees diversification of her organization’s portfolio as essential to its ability to thrive in a time when payment models for hospice are beginning to change, such as with the Medicare Advantage Hospice carve-in demonstration set to begin in 2021.

Ponder-Stansel spoke with Hospice News at the Coalition to Transform Advanced Care (C-TAC) Summit in Minneapolis to talk about her organization’s growth trajectory, evolving payment models and how the industry is likely to change in a value-based health care environment. 

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Your hospice has a lot going on in terms of expansion, what is driving this growth?

We are looking to the future where the financial metrics will change, so we are looking to first of all is scale the organization. The second thing that is driving it is to really diversify our programs and services to move into what we call the care gap.

We are one of the largest independent hospices in the country, and our median length of stay is 11 days, and our average is 59 days. We are looking at people who are coming in and come to us very late in their care and all the opportunities missed further upstream.

The ultimate goal is to help people live better with advanced illness and to really be a solution provider for anyone, whether it’s a payer, a patient, or a health care system that wants to figure out how to do that. So for me it’s taking what we have learned to do as hospice providers, taking those core principles, particularly those goals of care discussions. and moving it to different sectors.

You are re-envisioning your pediatrics program, CommunityPeds. What precipitated that and what do you think will change?

We have been doing pediatric palliative care since I got involved as a social worker in 1985. And there’s not a lot of guidance on how to do it. This is really our third iteration of how we approach pediatric care. At first we tried to fit the kids into a hospice model, and that doesn’t work; so with this we said let’s just allow the care follow the patient and family.

Many of these pediatric illnesses that will limit life may be long term. That patients may survive into their early 20s, and some of our kids actually graduate the program. If you are involved in palliative care, and you have a model that is intense in its service, and you are following someone for a decade or more, that model doesn’t work.

We divided the program into three levels of care. The first involves patients who have stabilized, but we don’t want to cut them off because you can have an exacerbation and need us again. We still have contact with them, but mostly they want to check in with us when they need to.

That second level of care will be palliative, and that will be very goal directed. We will be interacting with the patient and family when there is an acute episode or something that really has necessitated a change to the care plan. We are looking at a six- to eight-week window, really advanced illness management, like the C-TAC model, to get them to the point where plans and decisions are made, and then we will still be in the background. It’s really an effective model because you want to empower the family to be able to just live their lives.

And of course, hospice is involved when someone is severely ill. We are really looking at doing a lot more to help our medical providers understand when a child is appropriate for hospice and help them open the door to that conversation. Those conversations just weren’t happening. Interestingly enough, since we have been clear about what a palliative offering is, more physicians are recognizing when it’s time for hospice.

For us the challenge is going to be looking at our outcomes and adjusting the program as we go.

Your organization is launching a PACE program. What can you tell me about that project?

We are going to be admitting our first participants during the last week of December or the first week of January. This took a long time because of the way Florida does it. You have to get legislative approval, and then you have to secure funding. When you do obtain funding, you have to go through a very complex process because it’s a three way contract between your state Medicaid office, [the U.S. Centers for Medicare & Medicaid Services] and your organization.

This is a joint venture with our local council on aging. They are not a medical provider; we are a medical provider. So we married what we know how to do best with what they know how to do best. We actually constructed the PACE center site on one of our hospice inpatient facilities, so there were a lot of things that we didn’t have to duplicate to get our site open.

It was a little scary because with PACE there is a lot of risk, but we thought this would be a skill set that the organization needs to take care of people for a longer period of time and get their care plan right. When you look at Medicaid managed care programs, very few PACE participants end up in nursing homes, and many of them are able to stay in the community. So it’s a very effective program.

I think it’s a long game, and it’s about who can manage the risk, who can take that population of patients and provide excellent care. Everything we are doing is aligned with that.

Service diversification has become a watchword among the hospice community. What factors are driving hospices to open these new lines of service?

What concerns me is the Medicare Advantage carve-in pilot. In Florida our legislature turned over all of Medicaid to managed care providers. I think eventually, if you are reading the tea leaves, the government wants to get out of the Medicare fee-for-service business and just hand it over to someone else and let them figure out how to make the numbers work.

That’s what I see happening with the carve-in if it becomes the way that some of our hospice care is reimbursed in markets like mine in Florida where there are more Medicare Advantage plans. I also think the goal is to push more Medicare beneficiaries into those plans, because that works for their economics as well.

I think what you will end up seeing is that the traditional hospice model — that is fee-for-service, even though we’re at risk — I think you will see fewer and fewer of those kinds of patients. I think the Medicare Advantage plans will do a couple of different things in states like Florida where there is a barrier to entry. They will work with existing providers but pay far less money or seek to unbundle the benefit.

And in states where there is no barrier to entry, I think you will see most Medicare Advantage plans just adding hospice to their book of business. And if you put all your eggs into that one hospice basket, you are going to be providing brink-of-death care, or you are only going to get the adverse selection or both. I think that’s really what’s driving it.

That’s kind of an apocalyptic future that I am seeing, but I look at when managed care begins to manage care, they are not going to be giving us more money. They may be giving us more patients, but you are getting the patients later in their care and having to work a lot harder to argue with plans about what services you do and don’t provide.

The other driver is one of the big problems in health care. It’s not the last six months; the battle’s already been lost two years out. Everybody is looking to go build a better mousetrap to get a very seriously ill patients on a different track so they stop getting low-value care. If hospices don’t get into that space then I think their place in the continuum is really going to be brink-of-death care. We need to have a way to move upstream and have revenue to support what we are trying to do.

Your organization is about to open its ninth inpatient facility. Can you talk about how 2020 payment rebasing — which included cuts to routine home care rates and increases to general inpatient care, inpatient respite care, and continuous home care — will affect your business?

It was good for our organization. I do worry though, because my gut feeling is that the routine home care cuts will keep coming until the cost reports show that no hospice is making double digit profits.

We are happy for the moment, but I would bet my paycheck that we are going to continue to see cuts until the margins are reduced to a level that CMS thinks is appropriate.

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