From the August 2, 2002 print edition
Puget Sound Business Journal (Seattle)
Demand continues to grow for hospice care
Frank Nelson Contributing Writer
Hospice care is a sensitive, often-sad subject, but in the United States it's also big business.
According to the National Hospice and Palliative Care Organization, hospice admissions rocketed from about 1,000 in 1975 to around 700,000 in 2000. NHPCO estimates that close to 6 million Americans have benefited from this special end-of-life care during those 25 years.
Such care is generally available to those diagnosed as having no more than six months to live. Usually these are cancer sufferers, those in the terminal stages of heart, kidney and liver disease, and more recently those stricken with HIV/AIDS.
While states like Florida, with their older populations, account for a large number of hospice beds, Washington is also providing its fair share.
Anne Koepsell, executive director of the Washington State Hospice and Palliative Care Organization, estimates that around 10,000 families per year access hospice services in the state.
Meanwhile, those involved in providing this service all report that demand continues to grow.
Pam Gehrig, director of hospice for Swedish Medical Center's home-care services, says Swedish now has about 90 hospice patients, an increase over recent years. She thinks the numbers will continue to rise as baby boomers age.
Along with the numbers, the nature of hospice care has also expanded to include a suite of services intended to meet the medical, social, emotional and spiritual needs of patients.
"It's an holistic approach," says Gehrig, who describes the main goal as the patient's physical comfort.
Others involved in the care package may include medical social workers, chaplains, bereavement counselors and teams of dedicated volunteers, plus the patient's family and friends.
Hospice care is a model for all long-term care, says Rheba de Tornyay, dean emeritus of the University of Washington School of Nursing.
"Hospice provides comprehensive services - physical, psychological and spiritual - which in a lot of other cases are very fragmented. Hospice does the best job of coordinating all these elements," de Tornyay says.
Much hospice care is given in the patient's own home, though the service is also provided in places such as nursing, retirement, assisted living and adult-family homes.
Dedicated hospice facilities, often found in Europe, are rare in the United States, though there is one attached to Evergreen Hospital Medical Center in Kirkland.
Evergreen Hospice is relatively small with just 15 beds and an average occupancy of about 12. At the same time, says Christina Armstrong, director of patient care services, Evergreen is caring for close to 120 hospice outpatients, with demand constantly increasing.
Armstrong says the hospice fills an important role for patients who live there, others who must come in for special, short-term medical attention, and as a temporary home for those whose families and other caregivers need some respite.
Sarah Johnson, director of Seattle's Providence Hospice, which attends to an average of 180 patients each day, says the primary reimbursement for end-of-life care is through Medicare and Medicaid hospice benefits.
Eligible patients must be certified by a physician as having a terminal illness with a life expectancy of six months or less; they must also agree not to seek more aggressive curative treatment for their condition.
Latest NHPCO estimates put the daily cost of routine home hospice care at $117 which, according to the organization, is less expensive than conventional care for the terminally ill. But for hospice-care providers, the economic pressure is beginning to build.
The problem, says Johnson, is that the hospice receives a set amount per patient per day but, while equipment, medication and other treatment costs are rising, stays are becoming shorter.
Research shows the average stay shrunk from 64 days in 1992 to 36 days in 1999. In addition, approximately 30 percent of patients die within a week of admission to hospice care.
"The short length of stay, during which the intensity of service provided is high, places an extreme financial burden on hospices relative to the reimbursement received," Johnson says.
Elizabeth Vig, acting instructor in the division of gerontology and geriatric medicine within the University of Washington's Department of Medicine, says there are a number of reasons hospice stays are becoming shorter even as enrollments increase.
Vig, who is based at Veterans Affairs Puget Sound Health Care System, says doctors may be uncomfortable predicting the progress of terminal illness or discussing it with patients.
At the same time, many dying patients are reluctant to enter hospice care if it means they must forego access to more aggressive, potentially life-extending treatment.
Hospices are having to consider a variety of solutions to maintain an even business keel in the face of what Johnson describes as a "death-denying culture."
These range from marketing strategies aimed at increasing community awareness, to programs designed to educate physicians on ways of talking about hospice care to their terminally ill patients.
Hospices also see the benefit of introducing their services to prospective patients much earlier.
This could mean professional staff consulting about hospice care with groups and individuals, for example in nursing homes, well before they reach those critical last six months of life.