Larry Beresford

Hospice Fraud Reports Reach Critical Mass

I just came back from the Association of Health Care Journalists conference in Atlanta, Ga., four days of networking with print, broadcast and web journalists who cover health care. I often said to those I met there that I have been writing about hospice care for many years, but increasingly my reporting has turned to covering regulatory scrutiny of hospice quality and eligibility, claims denials and Medicare payment recoupments, whistleblower and anti-Medicare fraud lawsuits against hospices, and government concerns about patterns of prolonged-stay patients. In virtually every case, I received a sad, knowing head nod in response.

Journalists are accustomed to looking for trouble, and they have other examples of health care fraud to draw upon. But it made me think that the depth of hospice’s “quality problem” –- which is also a compliance problem and a public relations problem –- is not fully appreciated by hospice industry leaders. The answer to this problem, I believe, is for hospices to get much more serious, systematic and public about how they address quality.

Hospice care, while not always well understood or sensibly utilized by patients or their physicians, used to be celebrated for its mission, its commitment to transforming end-of-life care in America, and its expert, compassionate care of dying patients. Something has turned, at least in my unscientific sampling of working journalists. It makes me wonder whether the recent spate of negative press for hospice by Bloomberg's Peter Waldman, Kaiser Health Network's Jordan Rau and others, the widely publicized lawsuits, MedPAC's critiques of hospice reimbursement and a veritable alphabet soup of government scrutinizers of hospice claims have reached critical mass -– risking a radioactive meltdown of the movement’s good name.

You could argue that much of the recent criticism of hospice has been unfair, that the government’s close scrutiny of hospice eligibility determinations ignores the impossibility of making accurate six-month-or-less prognoses, that the lack of nuance in its scrutiny fails to separate the good from the bad hospices, even that the government has failed in its responsibility to perform routine compliance surveys of hospices at reasonable intervals. And indeed that’s what hospices and their national organization say. However, that may all turn out to be beside the point -- insufficient in the court of public opinion.

Much of the recent bad press for hospices has emphasized the “for profits,” which seems over-simplified in a system where other health care provider types and professions are free to pursue profit in the marketplace. Certainly, problems in the quality of hospice care are not limited to the for-profits. But consider the nursing home industry, whose founders often were highly motivated to provide excellent long-term care for elders. Many nursing home operators today are non-profit and often highly committed to caring for challenging patients under a difficult system of heavy government regulation. But nursing homes generally must deal with a reputation that’s very different than what hospice care used to enjoy.

No doubt, the more sophisticated for-profit hospice chains have already budgeted for a similar kind of negative fallout and the costs of regulatory scrutiny and Medicare paybacks. If hospice’s reputation ends up looking more like the nursing home industry’s, hospice care would survive, and the services still would often be very good. But for those of us who remember what hospice’s mission and idealism once meant, something of incalculable value will have been lost.

At a workshop on hospital quality data reporting initiatives at the health care journalists’ conference, it was suggested that the best hospitals can be characterized by transparency: their candidness about quality problems and inevitable medical errors and what they’re doing to fix them; the quality measures they use and how they use them to improve; the role of quality outcomes in determining senior managers’ compensation -- even how often published minutes from board meetings reflect serious engagement with quality. I wonder if those same standards could -- and should -- become quality yardsticks for America’s hospices, as well.

Are Hospice Costs a Problem?

Growing national concerns about the rampant growth of hospice expenditures under Medicare, particularly for patients who have very long stays in hospice care and for the "cherry-picking" of more profitable patients by some hospices, received further momentum this week from an article in the New York Times (June 27, 2011). In a collaboration with Kaiser Health News, Jordan Rau reported that "the nation's bill for hospice care is rising at a staggering rate, prompting charges that many providers, particularly for-profit companies, are inappropriately enrolling patients."

Rau pointed out that Medicare outlays for hospice care more than quadrupled between 2000 and 2009, from $2.9 billion to $12 billion. The Medicare Payment Advisory Commission (MedPAC), the Office of Inspector General and the federal Centers for Medicare and Medicaid Services (CMS) are all concerned that this rampant growth is more a reflection of admitting long-stay patients who may not actually be terminally ill than of increased access to hospice care for the patients who truly need it. MedPAC, which advises Congress on Medicare policy, even proposed a plan to reform hospice payment under Medicare, which now pays hospices a flat per-diem rate for most of the days Medicare patients spend enrolled in hospice care, regardless of how many services or indeed if any services are provided on that particular day.

CMS has been ordered by Congress to test alternate payment approaches for hospice care, including MedPAC's proposed "U-shaped curve," which would pay hospices a higher rate for the first few days of care and for the last few days before the patient's death, which are known to be more expensive care to provide. But for the days in between for long-stay patients, the hospice would be paid at a lower rate.

Although the hospice industry has often complained about the kind of coverage seen in this week's Times article, it has been too slow to embrace accountability, self-policing and quantifiable demonstrations of quality for the care it provides to vulnerable, terminally ill patients and their families. Although some of the criticism of hospice care has oversimplified the industry's problems as a clash between for-profit and non-profit sectors, I think most consumers would be surprised to learn that for-profit companies now constitute half of the $12 billion U.S. hospice industry, which historically has been lauded for its compassion and idealism. In some cities, dozens of small, privately owned "mom-and-pop" hospices, some of them with marginal expertise and experience, now compete for limited hospice referrals but fail to demonstrate enhanced end-of-life care or access overall for those communities.

The Times article describes a whistleblower fraud case against "Trinity Hospice, a now-defunct Texas-based chain," which "strongly encouraged" its employees to find ways to keep patients on service as long as possible, whether they were dying or not. Any serious advocate for hospice care, which I consider myself to be, would feel a chill down their spine to hear that phrase, especially given the government's growing concerns about Medicare fraud. I believe it's time for America's hospices to step up to the plate and get serious about demonstrating their quality and accountability -- especially for long-stay patients and for patients with Alzheimer's disease, who are a particular focus of this week's Times article as well as for the government's Medicare watchdogs.

hospital readmissions

Hospice and palliative care have been my primary specialties as a medical journalist for the past 25 years, but I also write for The Hospitalist magazine, which is published for physician members of the Society of Hospital Medicine. Hospitalists, physicians whose jobs are basically spent inside the hospital, have been a rapidly growing part of the U.S. health care system since the term was coined in 1996. Preventing unnecessary readmissions for patients discharged from the hospital has become a huge and growing obsession for this field -- especially under health care reform. The government recently announced a $500 million grant program to support innovative community coalitions working together with hospitals to help prevent the communication breakdowns and other dropped balls that frequently cause discharge plans for seriously ill patients coming home from the hospital to go awry -- which too often necessitates a return to the emergency room or to a hospital bed. And in the not too distant future, Medicare will penalize hospitals that have higher-than-average rates of readmissions.

Hospices and palliative care programs believe they offer beneficial services shown to prevent unnecessary hospitalizations for seriously ill patients, in part by encouraging patients and families to reflect on their values and goals for treatment at this time of life, and then by providing effective coordination of care that makes it easier for patients to remain at home -- rather than returning to the most-unhomelike atmosphere of the hospital. But these advocates aren't necessarily communicating with the hospital administrators and health policy leaders who are now zeroing in on the phenomenon of the preventable hospital readmission, rates of readmissions, and their costs -- economic and personal -- to the patient, to the hospital and to the health care system. These conversations about readmissions and about palliative care seem to operate in parallel universes that just aren't talking to each other. In a time of rapid change in the health care system, there needs to be a way to connect the dots, and to have hospice and palliative care advocates step forward as major parts of the solution to the problem of readmissions.

Earlier this week the health care technology company Care Team Connect offered an audio seminar on "The Role of Palliative Care In Reducing Preventable Readmissions", presented by Dr. John Loughnane, director of hospice and palliative medicine at Commonwealth Care Alliance in Boston. Much of this presentation was about the basics of palliative care, how to make the case for it in a hospital -- the same program that The Center to Advance Palliative Care has been promoting for the past decade.

But Dr. Loughnane showed how a family conference with seriously ill, repeatedly hospitalized patients and their families can point to a care plan that is more likely to succeed once the patient leaves the hospital. He also extolled the practical benefits of hospice care for those patients sick enough and emotionally ready to qualify for hospice -- particularly the 24-hour availability of a hospice nurse able to respond to crises in the care of patients in their own homes. He was asked who should palliative care advocates talk to in the hospital and he identified several likely targets. These include intensivist physicians in the ICU, the manager of the hospital's hospitalist program, the most respected nurses on the floor, the care managers responsible for coordinating discharge planning, and the hospital administrator most likely to be open to this conversation.

I am still very interested in how to connect the dots between these two huge trends in the American health care system, but it was encouraging to see others starting to talk about how to do this.

Completing my own Advance Directive -- and Living to Tell the Tale

This article posted in three installments earlier this week at the website of National Healthcare Decisions Day, a collaborative initiative to inform Americans about the opportunity to communicate and document their healthcare decisions.

When I set out to do my own advance directive, I obtained several standard documents, including my HMO’s advance directive package, the "Five Wishes" document, and the California Natural Death Act Declaration form from the California Medical Association. Then I made a date with my partner, Rose, who I was planning to marry.

We met at a North Beach coffeehouse to sit and talk about my feelings about medical care at the end of my life. Rose, who had come straight from her special education classroom in the neighborhood, wanted to know why these kinds of treatment decisions should be so fraught for people, although I assured her that in the chaos of the ICU, they often were. But in the end, she said she could be a tenacious advocate for my values. I had seen her temper and I knew how determined she could be when she thought it was important.

The next morning, I kept an appointment with my HMO primary care physician. We talked about my father’s recent, seven-week stay in a Kansas hospital for complications from cancer surgery. Like the six wise men of Hindustan who went to meet the elephant, none of his multiple physician specialists, each in charge of a different internal organ, had been able to speak for his overall medical state or propose a sensible care plan for my father as a person.

After a long course of treatment that felt fruitless to our family, he chose to go home with hospice care for the final 36 hours of his life. My doctor said in cases such as his, there is a need for a strong general internist to step in, negotiate between the specialists and advocate for the patient’s wishes, which she tries to do for her patients. She asked me to send her a copy of my completed advance directive and we both agreed that I should get more exercise and lose some weight.

I also spoke with some experts around the country and reviewed the 1998 public opinion poll, “The Quest to Die with Dignity”, by American Health Decisions, which documented that Americans believed it was important to plan for the end of life but were reluctant to actually do so.

The experts I spoke with agreed that the living will, which is more of a laundry list of desired or unwanted treatments, was less useful than the Durable Power of Attorney (DPOA) for health care decisions, which empowers someone else to speak for me at the moment of truth. They also said the formality of completing a legal form was less important than the process of considering, clarifying and talking about my values. The larger conversation should happen with loved ones multiple times over months and years.

Bud Hammes, director of medical humanities at Gunderson Lutheran Medical Center in La Crosse, WI, suggested to me that the process could greatly benefit from a professional guide. But I thought that might be easier to find in La Crosse, which had become the advance care planning capital of the world. He also said it’s important to list what you would want in such situations, not just what you don’t want, for instance, a religious rite or a mechanism for family members to express their love and concern. I pictured a Cajun accordion trio playing mournful ballads at my bedside as my respirator was turned off.

In the end I went for the DPOA and named Rose as my agent, but it still felt incomplete. So I decided to write an addendum -- an attached advisory outlining my values as best I could express them and what would be most important to me regarding medical treatments and decision-making. Reading it 13 years later, I can see the influence of my experience in hospice care, both as a writer and a patient care volunteer. I still feel the same way about these issues, so I can’t say the experience of planning for my death was a waste of time. Here are my nine values as I wrote them in 1998:

1) To know the fullest and most complete truth about my medical condition and prospects.

2) To have an opportunity to find peace, understanding and closure at the end of life.

3) To receive all reasonable and appropriate comfort care measures when I am terminally ill, and to be kept clean, dry and warm.

4) To NOT be maintained on ventilators or other physically invasive therapies unless they offered a reasonable chance of restoring me to a better state of health and functioning.

5) To not be a severe, prolonged caregiving burden to my wife or family. If I become so, I would want them to consider alternative placement.

6) Otherwise, I would like to be at home to the greatest extent feasible during a life-threatening illness.

7) If I lose the ability to communicate or interact with and to recognize my loved ones (such as from advanced Alzheimer’s disease), I would not want medical measures to prolong my life, even antibiotics. But in the meantime, I would like full comfort measures and to be housed in a comfortable nursing facility with a rich activities program.

8) I do not believe in and would not want euthanasia or assisted suicide, unless my suffering was obvious, extreme, relentless, long-lasting and untreatable. In that case, I would appeal to my family’s best judgment.

9) Most of all, I want everyone involved in my care to be as honest and realistic and reasonable as they can be.

What instigated me to begin this journey of advance care planning at a young age and prior to personally experiencing serious illness?

In 1997, I was asked by an editor at the Washington Post Health Section to review several new books about hospice care, the subject of my specialization as a freelance newsletter editor. When I finished, I proposed another article: to undertake and to describe my own process of advance care planning to complete an advance directive, either a living will or DPOA for health care decisions.

I would try to imagine and spell out what kinds of medical treatments I might want or not want in some future crisis when I was incapacitated and no longer able to express my preferences. Mostly, I wanted to see how difficult it would be -- whether it was something ordinary people could do without discomfort.

The whole process felt unnatural and uncomfortable, like a role-play exercise at a company training seminar. From the vantage of middle age and good health, trying to visualize and then discuss some undefined, distant future crisis just felt stiff. I couldn’t figure out how to bring the process to life until I decided to write the addendum, outlining my values as best I could express them and what would be most important to me regarding medical treatments and decision-making.

I completed my advance directive and then filed the article. But my editor promptly decamped for Paris. His replacement found it unconvincing and it never saw the light of day... until now. So my hope is that highlighting my process will show that it is possible to complete an advance directive and live to tell the tale, and perhaps remind others with an interest in care at the end of life that they should bring that interest down to the personal level and do their own. For themselves and those they love.

But I learned a few things about advance care planning along the way. I learned that a living will containing a laundry list of wanted and unwanted treatments for some distant future crisis is less useful than thinking about underlying values and then communicating them to someone who could represent them through a DPOA. I think a professional guide to the process could be a lot of help; otherwise, don’t feel surprised if it feels a little formal and stiff and unnatural.

Hospice Eligibility Challenge Examined in Special Report

Eligibility for hospice care under Medicare requires a terminal prognosis of six months or less to live, assuming that the disease follows its normal course. This must be certified in writing by two doctors -- the patient's attending physician and the hospice's medical director. Increasingly, however, a third party has inserted itself into these difficult decisions: a government agent responsible for reviewing claims submitted to Medicare by hospices or one of a growing number of Medicare watchdog agencies authorized to review and overturn hospice claims after they've been paid.

When I set out to examine the impact of the government's scrutiny of hospices' admissions practices for the Hospice Compliance Letter newsletter, I found that hospices are spending more time and money trying to satisfy the government's second guessing of their physicians' admitting decisions. Some are becoming too careful in who they will admit, turning away deserving patients or performing invasive diagnostic tests that are unlikely to change the patient's course of treatment -- merely satisfy the government that the patient in fact is terminally ill. And yet other hospices seem to be flying under the radar, ignoring or blissfully unaware of the heightened government scrutiny directed at their peers.

While the government is penalizing hospices for admitting patients "too soon," no other health professionals are held accountable for the large numbers of patients who are referred to hospice too late -- in the last seven days or less before they die, past the point when the hospice team could work its magic to make the dying experience more comfortable and peaceful for the patient and family. But we also know there are some hospices out there misusing the hospice benefit, making it their practice to admit large numbers of patients who are not actually dying. We don't know how many hospice are abusing the benefit in this way, and we can't figure out how they persuade patients to consent to a benefit designed for the terminally ill when they are not terminally ill.

In a special report on hospice eligibility, which we are releasing to the public at www.hospicecompliance.net, we explore the medical and emotional difficulties of making clear and accurate terminal prognoses and the troubling nuances of hospice payment and regulation under Medicare. We ask the question: How does an industry such as hospice, advertised as a compassionate and idealistic form of care for vulnerable dying patients, hold all of its members to the same idealistic standards -- while more forcefully advocating for the needs of those patients? We believe these issues need to be openly discussed within the hospice industry and larger health care system, by the government and, eventually, by all Americans who will some day want and need this service in the final phases of their lives. But only if the government says they are sufficiently terminally ill to qualify for hospice care.

hospice sued for failing to provide "palliative sedation"

A recent report in the San Jose Mercury News details a lawsuit filed in Alameda County, CA, against the Miami-based VITAS Healthcare Corporation national hospice chain by family members of a hospice patient served by VITAS. They allege that she endured a painful death because the hospice failed to inform her that she could receive "palliative sedation."

I have not spoken about this case with the company or with the family of Michelle Hargett Beebee, mother of three in Los Gatos, CA, who was 43 when she died of pancreatic cancer last December. The website of Compassion & Choices, whose director of legal affairs, Kathryn Tucker, filed the suit on the family's behalf, has more details. VITAS, based in Miami, FL, is the largest or one of the largest providers of hospice care in the United States.

I know that VITAS is a for-profit enterprise, part of the same company, Chemed, that owns Roto-Rooter, but also that the company has developed innovative services aimed at improving quality of care in such areas as ethics, chaplain training and physician education. I have done work for VITAS as a contract writer, but not in the past year.

There are several factors that make this case important to end-of-life care providers. First of all, the allegations involve the clinical care provided by the hospice and whether it was able to deliver a comfortable, pain-free dying experience for its enrolled patient. In a country where "death panels" are a more typical illustration of the caliber of public discourse around care at the end of life, to actually engage with issues related to the clinical quality of death provided by the hospice surely represents some kind of milestone. Hospice's whole reason for being is to relieve dying patients' pain and suffering and provide them with an opportunty to achieve some degree of comfort and peace at the end of their lives. Countless studies have documented the larger system's failure to relieve pain and suffering at the end of life, and hospice is proposed as the remedy.

But the allegation in the California lawsuit, that the hospice failed to inform the patient that she could receive palliative sedation, touches on a complex, not-well-understood and ethically fraught treatment that is still subject to debate among medical ethicists. Palliative sedation is the use of sedative medications to relieve extreme suffering by making the patient unconscious while the disease continues its relentless march toward death. In other words, in rare cases where the patient's pain is absolutely intractable and unbearable, the palliative sedation option involves knocking the patient out, often until death, ending the experience of suffering in this way. Given the ongoing ethical debate over palliative sedation, is it reasonable to expect this procedure to be standard practice in hospice care?

Compassion and Choices grew out of the Hemlock Society, a euthanasia advocacy organization founded in 1980. It has been a major advocate for physician-assisted suicide initiatives such as those enacted in Oregon and Washington state. Hospice leaders, by and large, have historically opposed legalization of euthanasia or PAS. In Oregon, the first state to implement PAS, hospices have learned to co-exist with it, although they don't participate in administering lethal medications to end their patients' lives. Despite the controversy leading up to its implementation, it has been rarely utilized by patients, only dozens per year in Oregon, although a significant proportion of those few were receiving the care of hospice.

If lawsuits are war by other means, the case from California may signal a new front in the euthanasia/PAS debate at a time when the Scottish Parliament has just overwhelmingly rejected a bill proposing to allow terminally ill patients to "legally access assistance" to end their lives. But once again, hospice, which is dedicated to the thankless work of bringing comfort to patients at the most difficult time of their lives, may be caught in the middle.

"Report to Hospice"

A friend of mine recently shared with me an email about a parking lot encounter some friends of hers had with an older woman who had just left her HMO doctor's office in a despondent state. "She had been directed to drive home, get some clothes, and report to hospice. She was alone and told it is time to die." My friend wanted to know what help is available for people in such situations, and what else her friends could have done for this woman, who refused further assistance from them.

The image of "reporting" to hospice, as if to incarceration or a train station for deportation to a concentration camp, is indeed shocking. But while I was not in that doctor's office, and it's possible I could be proven wrong, I just can't imagine that was really what the doctor said to the woman in the parking lot.

I fervently hope her physician said something more like: "We know you are having difficulty taking care of yourself on your own. I think the best alternative we have to care for you safely at this time, given the advanced state of your disease, is our inpatient hospice. There we have personnel who are skilled in addressing all of the needs you are now experiencing." I also expect that those personnel would be available to talk with and support this woman regarding the impending and actual losses in her life -- not just terminal illness but loss of home and of independence, in the context of not having any friends or family to accompany her on this journey. If only they could expedite her entrance through the hospice's doors.

But that's not what she took away from the conversation with her doctor. I believe that is because our culture so strongly resists candor about the hard realities of life-limiting illness that it was only natural for this woman to avoid the conversations and planning and arrangements that should have begun months ago. All she heard was that word: "hospice". It would be terrible for anyone to be told to "report to hospice." But I wonder if she were moving into a nursing home for the next decade, would it have been all that easy to pack her clothes and say goodbye to her home under those conditions. If she had no one in her life to go with her to the most momentous conversation of that life, what does it say about the rest of her life? And what could any hospice or health plan or system of health reform do to make her entrance into the hospice friendlier and more inviting? I can't imagine what form that transportation might take. Especially when talking about hospice, even saying the word, is so fervently resisted for so long by so many.

Those of us in the "death panel" business are still talking about Atul Gawande's landmark article in the New Yorker magazine. While vividly portraying encounters with terminally ill patients, his own and others', Dr. Gawande ultimately catalogues all of the reasons why it is so difficult to offer people appropriate, humane, specialized, expert care such as hospice at the end of life. Even when it would better meet their needs and reflect their professed values -- even when they say that is what they would want at this time of life. Even when it would give them the opportunity to express the things that matter most in life to those who are closest to them. Dr. Gawande identifies the usual culprits, well-meaning physicians such as himself, patients, families, insurance benefits, and the culture at large, which conspire to promote the high-stakes, high-intensity, high-pressure ICU solution rather than high-touch hospice care at the end of life.

It doesn't matter that the mortality rate, according to all reports, remains at 100 percent. We just don't want to think that stark statistic could apply to us.

New Yorker creates end-of-life stir

I have been slow to take up noted surgeon and author Atul Gawande's impressive New Yorker article about palliative care, hospice, end-of-life decision-making and our medical system's chronic inability to guide seriously ill patients toward treatment choices and decisions that reflect their realities and their values. Released online last week and published in the August 2 print issue, this 13-page article really gives the comprehensive New Yorker treatment to issues that hospice and palliative care advocates have long wrestled with. And it has created a great stir across the blogosphere, generating multiple responses and comments, mostly very positive.

Just to take a few examples, Brad Stuart writing at the GeriPal blogsite suggests that helping patients with these issues ultimately takes personal work of a spiritual nature by health professionals. An unnamed blogger at the Health Insurance Resource Center at healthinsurance.org offers a personal take drawn from his mother's hospice work and from caring for his 92-year-old grandmother as her life was winding down. Even the Wall Street Journal's Health Blog and the Healthcare FInancial News blog by Mike Stephens have gotten into the act. And these examples just scratch the surface of what's been coming my way via Google Alerts and Google Reader.

Gawande introduces his readers to hospice care by noting, "I didn't know much about hospice," and then follows hospice nurse Sarah Creed out on her visits to dying patients. He succeeds in capturing the nuances of what hospice really does, as well as acknowledging his difficulties in being honest about prognosis with his own patients. He cites research suggesting that patients who enroll in hospice don't necessarily die faster than equally ill patients who don't, and impressive experiments in simultaneous hospice and curative care by the Aetna insurance company.

And he notes in passing, as do many of his commentators, the ugly political pandering of those who tried to derail health care reform with cries of "Death Panels." They represented a serious setback to the kind of serious, in-depth national conversation that our society and health care system need to engage in around the momentous issues of human mortality and the costs and benefits of intensive medical treatments in life's final stages. A recent article in The Forum of the Berkeley Electronic Press, "The Politics of Health Care Reform" by Brendan Nyhan of the University of Michigan, suggests about these death panel demagogues: "Increasing the reputational costs for dishonest elites might be a more effective approach for improving democratic discourse."

In the meantime, perhaps Gawande's article can give a much needed boost to that national discourse around "how we can build a health-care system that will actually help dying patients achieve what's most important to them at the end of their lives."

'Green' Hospice to Open in Illinois

The Pepper Hospice Home and Center for Care in Barrington, IL, one of the few "green" hospice facilities in the country, is set to open July 1. Built by Hospice and Palliative Care of Northeastern Illinois for approximately $19 million, it is Leadership in Energy and Environmental Design (LEED)-certified. The 42,000-square-foot building houses 16 patient rooms and the non-profit agency's administrative offices. LEED certification added 3.9 percent to its overall construction costs, but hospice officials estimate that long-term savings will repay the investment within 10 years. LEED is the rating system that measures the environmental friendliness of constructed buildings. Support for the hospice facility came from grants and donations, including environmental grants from the state and from the Illinois Clean Energy Community Foundation.

An article and photos in the Daily Herald portray an open house held at the new facility on June 15. A grant opening celebration is planned for June 27. Architecturally designed to have a minimal carbon footprint in the surrounding woodland area, with drought- and deer-resistant landscaping and rain collection barrrels and the use of solar lighting, recyling and renewable energy resources, the building also has the kinds of homelike, patient-friendly features associated with other freestanding hospice facilities. Its "healing garden" is accessible from the relatively spacious patient rooms, which also include foldout couches for family visitors.

Some might say the main focus of a hospice inpatient or residential facility should be solely on the patient's comfort and quality of life, along with any applicable health facility codes and laws. But perhaps quality of life could be defined more broadly to include tending to the environment and, ultimately, the health of the planet. At the Barrington facility, patients will be able to engage in gardening or simply bask in the sun and fresh air. A quick web search identified a few other North American hospice facilities going down a similar path.

Last fall another green-certified hospice building was said to be under development by Cedars of Monroeville, an assisted living facility in Monroeville, PA, with 16 private rooms, overnight accommmodations for loved ones, a chapel, spa and massage area, and two-story waterfall in the lobby. Facilities also include bike racks, a reflective roof, use of recycled material and preferred parking for fuel-efficient vehicles. Safe Harbor Hospice of Fredericktown, MO, includes environmental awareness practices in every aspect of its business day, with energy-conserving offices, recycling of all recyclable products, higher mileage company cars and hospice home service routes streamlined for gas efficiency. Ian Anderson Hospice in Halton Hills, Ontario, recently went green with solar panels, with the goal of reducing its carbon footprint and saving on the costs of propane for heating the facility and its water. According to insideHalton.com, the six solar panels are a step in the hospice's Project Green, launched in 2009.

Hospice Lights Up the Big Board

It was reported yesterday that Gentiva Health Services, a home health and hospice company based in Atlanta, GA, was purchasing Odyssey Healthcare of Dallas, TX, one of the country's largest hospice chains, for $1 billion in cash.

Wall Street types are predicting further consolidations in the "hospices and home healthcare space," with natural synergies between home health and hospice operations. The research and brokerage firm Gabelli & Company, Inc., recently published a research report on "the attractive fundamentals of the US Hospice Market" and "clarity in the reimbursement outlook."

But one possible repercussion is that it may become harder for hospice advocates to cry poor to Congress when this kind of money is currently being tossed around to buy hospices. The National Hospice and Palliative Care Organization and others have lobbied that "two cuts are too many" for hospice providers, with productivity enhancement-based rate cuts in the health care reform law and plans to phase out hospice's wage index budget neutrality factor over the next decade.

Odyssey previously had gobbled up another big hospice chain, VistaCare. Gentiva, which in March acquired Mississippi-based Heart to Heart Hospice, is better known for its home health care operations, with 350 community locations nationwide. But it currently operates hospices in the states of Alabama, Florida, Georgia, Mississippi, South Carolina and Tennessee. The merger with Odyssey creates a hospice census of 14,000 in 30 states, making it either the largest or second largest (after VITAS Innovative Hospice Care) provider of hospice care in the country.

According to tradingmarkets.com, Gentiva's offer of $27 per share represents a 40 percent premium on Odyssey's closing stock price of last Friday (May 21). Odyssey reported in late April that it had posted an increase in first quarter 2010 net income to $13.4 million. Gentiva will raise $1.1 billion in new debt financing for the deal, using a syndicate of financial institutions. The transaction is expected to close in the third quarter of this year. Both boards have unanimously endorsed the deal.

What was not discussed, at least on Wall Street, was the two trading partners' level of commitment to an individualized response to the needs of dying patients, to finding innovative ways for enhancing quality of life when its quantity is scant, to measuring and continuously improving the quality of hospice services, or to acting as the go-to source of expert and compassionate support for all the ways people in their communities struggle with terminal illness, death and loss.