Hospice News recently sat down with Ben Marcantonio, chief operating officer and interim president and CEO of the National Hospice and Palliative Care Organization (NHPCO), to discuss how hospice providers are navigating a sea of challenges.
A change in leadership occurred last month when former NHPCO President and CEO Edo Banach announced that he would be stepping down after five years at its helm.
While the hunt is on for a new top executive, COO Marcantonio has stepped in on an interim basis. After more than two decades in the hospice industry, he reflects on the waves of change he’s seen in the space, and three top-of-mind issues for providers: staffing, compliance, and reimbursement.
What led you to step in as interim CEO? Is the organization currently doing a candidate search, or is this a permanent move?
When Edo decided to step down, I came into the role and will also continue to function in my role as COO for now as well.
NHPCO’s board leadership opened up the conversation with me about next steps and asked if I would temporarily serve, since I have more than 20 years of experience in hospice and palliative care, and I’ve been with the organization for just under two years now. We agreed I’d be capable of helping in this transitional period.
I’ve had experiences as interim CEO before when I was COO at Hospice of the Chesapeake, when their leadership took another position. Having all that experience of helping the team overall to navigate that change and then stepping into the leadership role to continue to help set organizations’ visions and meet its goals is something I felt I could help do at this time.
My primary responsibility is to ensure that NHPCO is as strong of an organization as it possibly can be on the day a new CEO starts in the role. My responsibility is to continue to help us engage and achieve the goals of our strategic plan.
NHPCO’s board is taking all the steps needed to engage a search firm in a national search for the best qualified candidate to lead the organization going forward. The official search should be launched very soon and be underway.
What are the priorities in store for this leadership role, as well as NHPCO?
Our organizational priorities crossover all areas of service for membership, policy, advocacy, regulatory, health equity, and quality and educational programs. It’s leading in all the ways we serve hospice- and palliative care-provider members to keep all of that going in a very vibrant and active way, and continue to build on that work with new leadership as they step in.
Our priorities aren’t just important for NHPCO’s future as an association, but also for the field of hospice and palliative care. We want to make sure that access to this care continues at the forefront, and that people with serious and terminal illnesses are getting their needs met.
We know about 50% of all Medicare beneficiaries who are eligible for hospice care receive it. But that means that there are still 50% that are not, and we want to make sure that we continue to facilitate and advocate for that kind of access to care — especially among underserved communities such as people of color and LGBTQ+ communities. That’s a key priority.
Another key priority is to continue to advance the understanding of hospice care as it has evolved and changed over time. Quality has also been a really critical driver for NHPCO as an association that represents and advocates for our providers and our members. NHPCO has always been there as an organization that really brings people together and brings the community of hospice providers together, offering resources and serving as the voice of providers in Washington.
What has been your journey in the realm of hospice? What are the most significant ways that you’ve seen the industry evolve?
I was led to hospice early in my career. I was in active ministry for a number of years and worked in parish, as well as in the educational realm of ministry. From there, I moved into a behavioral health experience in terms of the hospital and health administration roles with behavioral health programs. And with that, I had acquired along the way a master’s in education and a master’s in counseling. I was looking at that as an option that really brought all the pieces together, because hospice care is really about whole-person care: all the emotional, medical and spiritual needs of the individual.
When I started in hospice, I really was able to bring that study and knowledge, but also the experience and providing service in parish and in behavioral programs to the hospice community. Since then, I’ve served in leadership positions in the hospice field, both on the West and East Coasts. I was in San Diego for about 14 years in hospice care before coming to Maryland and working at Hospice of the Chesapeake and subsequently NHPCO.
I’ve seen hospice change over time with a lot of growth in the field and increased awareness, and yet acknowledging that there’s still a tremendous need to build on that awareness. There’s a need to have it be fully understood of what we do and don’t do in hospice. We’ve seen growth in the number of patients served and large growth in the number of hospices and hospice programs across the country in the last couple of decades. And with this, there’s been a change in the dynamic of hospice providers.
Early on the predominant presence was community-based nonprofit hospices. But others entering into the hospice provider field are those who have a different business model, the for-profit model. That’s had an effect in the field, and that’s been a change over time. We’ve seen an acceleration of mergers and acquisitions, especially in the last three to five years.
We’ve seen a lot of change in that hospice programs are finding that sometimes it’s worked better for them to collaborate, or even align and merge, with another hospice, another health system, or with a home health agency.
Then also, with the pandemic and even prior to that, we’ve seen the workforce issues and staffing challenges. Hospices are having real challenges in being able to balance that work-life experience, and to really find and recruit staff that are able and willing to do the hard work that we do. But with all of that, we’ve seen incredible service continue to happen for patients and families.
We’ve seen a real progression toward where and how palliative care complements, supplements and interfaces with hospice care. That’s a very important evolution over time in our work and in our industry.
These are some of the things that I think are first and foremost as being impactful in our field. Throughout those years of changes, there’s been a few things that have been very consistent, and that’s that hospice and palliative care providers have always focused on high-quality, patient- and family-centered care.
What are some of the key issues that hospice and palliative care providers are facing? How is NHPCO working with lawmakers to address these?
The workforce is really top of mind for everybody. It’s what keeps our providers up at night, and therefore, us as well. That links with some of our advocacy efforts most closely in the key areas that will help us meet and evolve in that way we support staff and our workforce. And that is through telehealth.
Through a telehealth bill, we’re really working to help alleviate workforce shortage issues by using telehealth in a very responsible way that will cut down the travel time for medical providers when they can support a patient and a family without needing to be in the home. There are certainly those times where staff need to be in the home, and we’ll always be there at the bedside.
But good, responsible use of telehealth is something that’s very important to what we do as community-based providers who deliver care out in the field.
This telehealth bill, which builds on the legislative successes of the pandemic public health emergency, it has passed in the House and is advancing on to the Senate. We are very hopeful that it will be a provision that will be addressed in the omnibus. We’re hoping that will happen in December. There’s still more work to be done, but it’s advancing nicely, and we’ve been very active in helping to move that forward.
Another piece of legislation is a bereavement bill. People’s experience of loss and grief in the last couple of years with the pandemic has been intensified and amplified in ways that no one‘s really experienced before. Congressman Morelle’s office is working on this with our policy team, with a goal of introducing legislation in the fall.
If passed, it provides funding for bereavement programs to expand their services and reach people who might not otherwise have access to grief and support services. It would augment the resources that hospice providers have to make them more available to communities they serve.
Those are other key areas that we’ve been trying to advance through our legislative and advocacy efforts.
What are your thoughts on how the 2023 final rule will affect providers and patients?
One is that the the reimbursement for hospice care in the [U.S. Centers for Medicare & Medicaid Services (CMS)] final wage index rule includes a payment increase for this next fiscal year 2023 of 3.8%. It is a little higher than what had been in the proposed rule, so there was some movement up with CMS having received feedback from all of us who are advocating for the resources needed to provide the care.
But with that, we are continuing to advocate for increases so that all the patient needs, and particularly the workforce needs, can be met by being better resourced through reimbursement.
That 3.8% increase doesn’t really still fully reflect and meet the needs of higher gas prices, labor shortages and the need for providers having to pay out significant sign-on bonuses to engage and recruit good quality staff amid real pandemic-related expenses, materials, protective health equipment, and otherwise. These increased costs aren’t fully met by that 3.8%.
On top of that, there’s still the 2% sequestration reduction that takes place. All of that goes to say that we are strongly advocating and asking the Biden Administration and Congress to step in and continue to look at the reimbursement rates for hospice providers.
It’s a tough battle, but we’ve seen significant successes. We’re just going to continue to advocate and push for the best and the most realistic, but reasonable and adequate, compensation and reimbursement for the care hospices provide.
For hospice providers to be able to keep up with the inflationary increase and not only sustain, but also continue to raise the bar for quality and provision of quality care, we really just have to keep pressing on the administration and legislators to make sure that we don’t fall behind in that.
That’s why we feel like the 3.8% increase is is not enough, and that the sequestration of a 2% reduction does not help to meet those needs of patients and families that are served and the staff who are carrying out the provision of services outlined in the Medicare Conditions of Participation. Raises in funds would be used just to really support the very fundamental delivery of high-quality service.
What legislative moves should be on hospices’ radar pertaining to the workforce shortage?
There are two things.
The reintroduced [Palliative Care and Hospice Education and Training Act (PCHETA )] has seen a long haul, but it’s still rolling through the process and this keeps it in front of our legislators. Ultimately, it will help nurses, social workers, doctors, palliative care professionals and more to continue to be developed and made available into the community for providing services.
It’s having that avenue for education and professional development so that people can come into the field and provide care and not turn away Americans from services when they need serious illness and end-of-life care. That’s critically important right now. PCHETA will really help us to grow, improve and sustain the hospice and palliative care workforce long-term. We need to keep advocating and bring that to fruition.
Another one under development is a travel nurses agency transparency study that is being proposed. Through the Travel Nurses Agency Transparency Study Act, it’s asking for a study to be done that would examine how travel nurses have made resources available to the medical community at large.
Hospices in particular can’t compete with the very high contract rates that we saw during the pandemic. Those are still there. The act would give full transparency into how those rates are set, established and whether they are sustainable.
It’s important for Congress to know more about how this travel nurse industry functions and whether these agencies have exercised the best practices possible and haven’t engaged in any unfair practices. We’ve signed a letter of support for that act endorsing the study’s activation.
Compliance issues also keep hospice leaders awake at night. With regulators cracking down on the space, what can hospices do to ensure their keeping up with regulatory changes and remaining compliant?
Medicare is just wanting to make sure that hospices are using their resources responsibly and acting responsibly. It’s being on top of that, and knowing what the areas of concern are, and that compliance is the foundational level for quality. Quality is building on top of that foundation to make sure that they create the best experience for patients and families when they receive hospice and palliative care.
Some of the key areas right now are related to utilization, eligibility and length of stay. We’re helping providers know and understand what their patterns are, how utilization is in their community.
It’s manifesting in that they really need to know and understand the eligibility criteria and apply that responsibly to make sure that people get the right care at the right time, and they’re meeting the right needs. That they effectively document that care, and proactively create care plans that support the care. And that all this is carried out in a very responsible way.
Some providers have talked about a “modernization” or expansion of the hospice benefit? Do you think that changes to the benefit are needed to the benefit?
That’s such an important question for people in our field. What we’ve learned in the 40 years since the hospice benefit was designed and articulated is how the manifestation of serious illnesses was different than it is now. It was designed at a time when cancer was the predominant illness and disease that led to death in the United States in a very visible, concrete way. But that’s changed over the decades because of medical advancements, medications, technologies.
The way in which the benefit is described and applied, I think that’s where the modernization comes in. It has to evolve. Fortunately, it’s fundamental and foundational enough to have allowed us to evolve with it over time. But it’s coming to a critical place.
Not only does cancer not behave in the same way it did 40 years ago, but more people die of heart disease, Alzheimer’s, dementia and other illnesses now than they did before. Also, people are living longer, and therefore they’re experiencing other illnesses at the end of life.
When I think of modernizing the hospice benefit, it’s about how do we make it truly relevant and applicable to the way people live with serious illness now and ultimately die from a range of causes.
Why shouldn’t there be a tier that can be applied for people who are dying from different diseases? The benefit doesn’t quite work the same way as it did. How can we in a very responsible and intentional way revise the benefit to the extent that it needs to meet current medical, spiritual and emotional needs?
Is that six months line of prognosis really the right measure for eligibility for what we know about how people live and die? How we can promote quality end of life today? It’s not that the benefit was bad or wrong, it’s just a question of whether it is really the right definition.
Should people have to choose between being comfortable and having a quality of life and a cure? Or are there ways to responsibly provide curative means alongside comfort care without escalating cost of care? In fact, perhaps even better managing cost of care along with providing high quality, comfort and palliative care.