West Virginia Health Care Authority

HOME HEALTH & HOSPICE

CON STANDARDS MEETING

10/7/2008 – 1:00 pm EST

Conference ID # 137202

 

 

 

 

Ms. Sonia Chambers:  I think we seem to have a fairly full house, so we can go ahead and get started. My name is Sonia Chambers for those of you who don’t know me. I see some folks I don’t know. I’m the Chair of the West Virginia Health Care Authority and with me here I have the other two board members, Sam Kapourales and Marilyn White. We are going through a process of seeking public input on whether West Virginia ought to have Certificate of Need for the various different services and activities for which we have Certificate of Need. This is actually the second meeting we have had and we’re marching our way through the list of services between now and, I guess we’re now up to December, going through them. I think it’s good public policy to revisit all of these issues every so often. We have tried to identify all the people who might want to have some input into the discussion and I hope that most, if not all of you are represented here today. What I’d like to do is start with those who are on the phone and have everybody identify themselves and then go around the room. Those of you who are back along the wall or the peanut gallery, as I refer to it sometimes, may have to speak up. We are having these meetings recorded and there will be transcriptions of the meetings, so if you would like to have your comments correctly attributed to you, then you have to identify yourself before you say them and we’re actually kind of going through the process with the transcription service of having to make sure that names are spelled correctly, because the transcript from the first one, they’ve got some really kind of interesting spellings of the names, so if we do not have a sign-in sheet, if you could make sure that you sign in so that we can get your name corrected on the transcript and then all of this will be available on our website. So with that, why don’t we identify ourselves and then I’m going to have our Certificate of Need analyst briefly go through the standards and I guess we will start with Home Health and then go to Hospice. We will briefly go through the Standards and then just open it up for everybody’s comments. We also welcome written comments. If you would like to say something in addition or if someone who was not able to be here today would like to give their input, we would be happy to have those and I would ask you to direct those to Dayle Stepp who is our Director of Certificate of Need. All right, with that, who do we have on the phone?

 

Ms. Karen Craig:  Karen Craig and Diane Hunter, Interim Healthcare, Bridgeport, Ohio.

 

Ms. Linda Carte:  Linda Carte, Susie Godfrey, and Julie Mitchell from United Home Health and People’s Hospice.

 

Ms. Sonia Chambers:  I tell you what, you know what would be helpful instead of us trying to scribble these names really quickly? Could you please send an email to Linda Hedrick, who sent out the original email, indicating that you were on the call? I think that would be easier. I want you to go ahead and identify yourselves, but instead of us taking time to try to make sure we get your name correctly, if you would do that we would appreciate it. Anyone else? Is that it on the phone? Okay, for those of you who are on the phone, I don’t hear a lot of background noise. If you do not have a mute button on your phone, you can press *1 to mute the call and the same thing to un-mute it if you would like to do that, but it doesn’t seem to be a problem right now. Okay, why don’t we start around the room? We’ll start over here, move our way around the table, and then we’ll go around to the peanut gallery. Okay, Dayle.

 

Mr. Dayle Stepp:  Dayle Stepp, CON Director.

 

Mr. Tim Adkins:  Tim Adkins, I’m CON analyst.

 

Mr. Larry Disney:  Larry Disney with the LHC Group.

 

Mr. Richard MacMillan:  Richard MacMillan with the LHC Group.

 

Mr. Bob Coffield:  Bob Coffield with Flaherty, Sensabaugh & Bonasso.

 

Ms. Karen Nichols:  Karen Nichols with Valley Hospice in Wheeling, West Virginia and I am retiring from that position and will assume the duties of the Executive Director of the Hospice Council of West Virginia in January.

 

Ms. Margaret Cogswell:  I’m Margaret Cogswell. I’m President of the Hospice Council of West Virginia and the Executive Director of Hospice of the Panhandle based out of Martinsburg.

 

Ms. Laura Friend:  Laura Friend. I’m the Executive Director of the West Virginia Council of Home Care Agencies.

 

Ms. Beth Chambers:  Beth Chambers. I’m the Director of Gentiva in Charleston, representing all [inaudible].

 

Mr. Greg Varner:  Medi Home Health Agency.

 

Ms. Cindy Dellinger:  I’m Cindy Dellinger and I represent the West Virginia Health Care Authority.

 

Mr. Jim Thomas:  My name is Jim Thomas and I’m an attorney with Jackson Kelly in Charleston.

 

Ms. Kay Myers:  I’m Kay Myers. I’m with the CON division.

 

Ms. Jill McDaniel:  Jill McDaniel, Hospital Association.

 

Mr. Bob O’Neill:  I’m Bob O’Neill with Dinsmore & Shohl.

 

Ms. Ramona Kinneberg:  Ramona Kinneberg with Bill J. Crouch Associates.

 

Mr. Ed Hamilton:  Ed Hamilton, Mountain State Blue Cross and Blue Shield.

 

Mr. Thom Stevens:  Hi, I’m Thom Stevens. I’m a Healthcare Consultant and I’ll be assisting the Hospice Council today.

 

Ms. Shelley Baston:  I’m Shelley Baston with West Virginia Medicaid. 

 

Ms. Sonia Chambers:  Can those of you on the phone hear everybody?

 

Ms. [??] [??]:  Yes, we can.

 

Ms. Sonia Chambers:  Good.

 

Ms. Pam Wigglesworth:  I’m Pam Wigglesworth and I’m with the LHC group.

 

Ms. Dee McKahan:  Dee McKahan, I’m with Preston Memorial Home Health.

 

Ms. Mary Herbert:  Mary Herbert, ResCare Home Care.

 

Ms. Sonia Chambers:  Okay, great. Happy to have everybody here today. All right, Tim are you going through the Home Health Standards briefly?

 

Mr. Tim Adkins:  We’ll go real briefly. The Home Health Standards, the Authority is responsible for providing this information. We have developed a new methodology from the numbers that we received from the annual Home Health survey. The first calculation compares the county and state’s home utilization rates. The second calculation determines the extent of the potential Home Health recipient in the county to reach the state utilization level. Calculation number three determines the number of Home Health recipients in the county below the state Home Health utilization rate and calculation number four involves an adjustment factor for the agencies receiving CON approval in the previous 12 months to allow for their initiation and development of Home Health services and this number is, we all 229 as the adjustment factor. In addition to the need methodology, there are other areas of quality and accessibility dealing with training, quality of care, and the last issue is financial feasibility to make sure that the project is financially feasible to the agency.

 

Ms. Sonia Chambers:  Short, sweet, and to the point. I guess the first issue is, are there questions, any clarification needed about the Standards before we get to general comments?

 

Mr. [??] [??]:  [inaudible]

 

Mr. Tim Adkins:  78 that responded during the last survey, which was 2007.

 

Ms. Sonia Chambers:  And that’s 78 agencies. Some of them may be owned by the [noise inaudible]

 

Mr. [??] [??]:  [noise inaudible]

 

Ms. Sonia Chambers:  [noise inaudible] decreasing number. And it’s fair to say, I think, that there has been some consolidation in the market over the last five to 10 years. I don’t hear any burning questions. It looks like everybody’s just ready to jump right into their comments.

 

Mr. Ed Hamilton:  I have a question.

 

Ms. Sonia Chambers:  All right, you’re going to identify yourself and then state your question, right?

 

Mr. Ed Hamilton:  My name’s Ed Hamilton. I’m with Mountain State Blue Cross and Blue Shield. My question is on page 5, the next to last [noise inaudible], right in the middle of the page, it says population data is for the year 1995. Is that what we’re currently using or [inaudible]?

 

Mr. Dayle Stepp:  Well yeah, I thought we had an example in here. When these were done we used ’95 to do the example in the appendix. Yeah, we’re going to use current populations, current figures.

 

Ms. Sonia Chambers:  Any more questions? All right, who wants to go first? Let’s start with Home Health and then we’ll go to Hospice. Okay, so the question is, to sort of jog the debate here, the question is should Home Health services be subject to Certificate of Need review or not?

 

Mr. Phil Wright:  No. The answer is no. Let [inaudible].

 

Ms. Sonia Chambers:  Phil Wright from the Health Plan says no, they should not be subject to CON.

 

Ms. Karen Craig:  Interim Health Care would agree.

 

Ms. Sonia Chambers:  Interim Health Care would agree?

 

Ms. [??] [??]:  I’d like to speak for ResCare, ResCare Home Care, West Virginia. Basically we believe that CON should be not a requirement. I have a statement in writing I’d like to give you, as well.

 

Ms. Sonia Chambers:  That would be great, so ResCare, not subject to CON review. LHC Group, you guys came all this way to sit here. I’m just going to pick on you and everyone else around the room, so…

 

Mr. [??] [??]:  I’ll say that we’re going to submit written comments following this session, but that LHC group would be in favor of maintaining the CON status. We’re operating in 14 states currently, four of which have CON procedures, the others of which don’t, and we’ve seen a proliferation of home heath agencies, in some of the states that are not regulated, that have caused a number of problems, not the least of which is in the Florida, Miami, Dade County area, so we would be in favor of maintaining CON for that and other reasons that I’ll submit.

 

Ms. Sonia Chambers:  Okay, that you’ll submit in writing?

 

Mr. [??] [??]:  Right.

 

Mr. Dayle Stepp:  What are the problems? Is it maintaining your staff or the other agencies coming in and hiring your staff away or exactly what are the problems caused by this cooperation?

 

Mr. [??] [??]:  The problems that we see in non-CON states is, in a lot of cases, operators that come in and establish agencies and don’t adhere to the regulatory requirements and are not what we would call legitimate providers. We’ve seen a lot of that. Miami, Dade is really turning out to be the classic example where there’s not been any regulation in Florida to speak of. 60% of the nation’s outlier payments are being made to Miami, Dade County in this country. Their growth and Medicare spending for Home Health in Miami, Dade County has increased 1,300% in the last five years. This was all in the USA Today yesterday, which I’ll submit a copy of that article. 1,300% in the last five years when there’s only a 10% increase in beneficiaries during that time period, so CMS is now focusing on that area.

 

Ms. Sonia Chambers:  And that’s a non-regulated state?

 

Mr. [??] [??]:  It’s a non-regulated, well no, they have licensure regulations. They do not have a CON process. They recently adopted legislation that’s become much more restrictive for entry into the field, but it’s not in the nature of the CON.

 

Ms. Sonia Chambers:  It’s in licensure?

 

Mr. [??] [??]:  Licensure, but that hasn’t had time to take effect. It was effective July1.

 

Ms. Sonia Chambers:  Okay, so you say that there are a lot of operators who get into the business that are really not legitimate and heretofore the licensure has not been strong enough to prohibit those?

 

Mr. [??] [??]:  In other states, that’s correct.

 

Ms. Sonia Chambers:  Well I was asking specifically about Miami, Dade County. You said that licensure had not effectively regulated them, but they now have passed stricter… 

 

Mr. [??] [??]:  They’ve passed stricter regulations, but there’s sort of a…those don’t take effect except for new entrants or for a change of ownership of an agency, so the existing agencies are remaining under their regular licensure standards without the increased requirements.

 

Ms. Sonia Chambers:  And have you seen that happen in other states, as well.

 

Mr. [??] [??]:  We’ve experienced it in Louisiana, our home state, prior to a moratorium that was imposed in the late ‘90s. We’ve seen it in Texas. Texas, California, and Florida have the reputation for being the hot spots for Home Health problems. We’re not in California, but we’ve seen it in Texas and Florida. That’s pretty much it. Those are the loosest states that we operate in.

 

Ms. Cindy Dellinger:  Are there quality issues?

 

Mr. [??] [??]:  Yeah, we think that there are, although the quality monitoring is not that great in the Home Health field. They’ve just started with the home care compare, but we believe but mature, established agencies, that are present in a CON state, have a higher level of care, quality of care than a new entrant. They have better resources and they have the mature field staff that can provide better quality care.

 

Ms. Cindy Dellinger:  I guess I was talking about quantifiable evidence or articles or research that you can point to.

 

Mr. [??] [??]:  I don’t have that.

 

Ms. Sonia Chambers:  Let’s go to the other side of the table. I’m sorry, do you have anything else?

 

Mr. [??] [??]:  No, like I said, we’ll supplement our comments with written comments after the proceeding.

 

Ms. Sonia Chambers: All right.

 

Ms. Laura Friend:  Well I’m Laura Friend and I’m the Director of the West Virginia Council of Home Care Agencies and we represent the Medicare-certified Home Health agencies in West Virginia. [noise inaudible] health authority and licensure currently list 61 who met your certified Home Health agencies in the state of West Virginia. We represent 48 of those agencies [noise inaudible] see the abolishment of the CON process, but we would like to see a review of the standards of methodology.

 

Ms. Beth Chambers:  I’m Beth Chambers, as I said, with Gentiva and we have Gentiva offices in 39 states and our corporate level has had first hand experience and we would like to see the CON stay [inaudible].

 

Ms. Sonia Chambers:  Do you want to elaborate on that at all?

 

Ms. Beth Chambers:  They will have a written statement.

 

Ms. Sonia Chambers:  Okay, go right down the table here.

 

Mr. Greg Varner:  Greg Varner, Medi Home Health Agency. We would like to see the local market drive the Home Health agencies within the state and would be looking for non-CON [inaudible].

 

Ms. Sonia Chambers:  Would you like to elaborate now or are you going to submit that in writing?

 

Mr. Greg Varner:  We’ll submit statements in writing.

 

Ms. Sonia Chambers:  Okay. Anybody else? This seems to be a fairly cut and dry, yes, no, we’ll submit more in writing. Blue Cross? Ramona? Mr. O’Neil?

 

Mr. Bob O’Neil:  No ma’am. No comment.

 

Ms. [??] [??]:  I’m one of the agencies [noise inaudible] and they didn’t tell me one way or the other before I came. I’m owned by Preston Memorial Hospital [noise inaudible] fall under their Certificate of Need, so that’s what [noise inaudible].

 

Ms. Sonia Chambers:  ARH is in support [noise inaudible]    of CON?

 

Jeff:  yes.

 

Ms. Sonia Chambers:  All right.

 

Ms. [??] [??]:  [inaudible] from LHC, we’re in support.

 

Ms. Sonia Chambers:  Okay. Mr. Wright, we already heard from you. You’re just monitoring, yes?

 

Mr. Phil Wright:  I just think the ones that have the CON are going to say they want to continue it, the ones that don’t have it say they don’t want it and the trade off is really how do you drive the marketplace without competition? You can’t drive these things unless you have competition pushing it. There’s no competition [inaudible].

 

Mr. [??] [??]:  That’s too much from the peanut gallery.

 

Ms. Sonia Chambers:  Well no, I’m a little interested in that because that’s not necessarily the position you’ve had before this agency on other issues.

 

Mr. Phil Wright:  On other issues, [inaudible] issues.

 

Ms. Sonia Chambers:  Oh how convenient. [laughter] Shelley I presume you’re just here to listen. Okay, Mr. Stevens?

 

Mr. Thom Stevens:  Here for Hospice.

 

Ms. Sonia Chambers:  Here for Hospice, all right. Okay now would you like to elaborate, Mr. Wright?

 

Mr. Phil Wright:  Well on the other thing we were talking about, there was very limiting volume. On this there’s not. In the formula you have in place kind of, the thing that I looked at, the first time I’d ever seen the formula, it kind of dictates how much you can get in with by applying the numbers. In other words, if you don’t have a certain number you don’t get in. I’m of the opinion that you can have great Home Health agencies, but sometimes they can get lackadaisical if there’s no competition driving it. We’ve had situations where we have to scream to get some Home Health help in this state, okay? Not everywhere, just in certain pockets, but I mean competition drives it and the thing we were talking about before, let me throw it at you, it was a transplant issue and you had a hospital doing one transplant. Well, if you take the volume out of the transplants you have a lesser service and there weren’t enough to do them everywhere, so that was really the issue for that one. That’s why I said what I did. In this, I think competition helps the marketplace for a lot of reasons, okay? And that’s the only reason I said what I did. I also know we don’t want over-utilization in this area. That’s another issue.

 

Ms. Sonia Chambers:  Well, I guess that would be my question.

 

Mr. Phil Wright:  But the carriers have to sort that out and they can do that.

 

Ms. Sonia Chambers:  So you think the carriers can sort out…

 

Mr. Phil Wright:  We don’t have to contract with everyone. We can pick and choose and at will, go forward, okay?

 

Ms. Sonia Chambers:  Anybody want to respond to that, those of you who favor keeping CON?

 

Ms. Mary Herbert:  I’m with ResCare, my name is Mary Herbert. I fully agree. I believe competition is one of the most advantageous things that you can have in order to insure service and freedom of choice is something that everyone’s entitled to and just because there are 30 agencies out here that have been around for 100 years, what’s to say that my corporation can’t provide adequate service or do better, but you won’t give me the chance? That’s all we want is an opportunity and competition in the non-medical service division, which is what I specialize in, I have to compete on a daily basis and we provide excellent [noise inaudible] first of all, a commitment to good quality care, but that’s how we survive. With no competition you have to reason to provide good care other than just give the bare minimal to meet your requirements. I go above and beyond every day for that very reason, because I plan to be top in the non-medical and I would do the same in health care.

 

Ms. Diane Hunter:  This is Diane from Interim Health Care. I would have to agree with Bill and I didn’t catch the person’s name from ResCare. We get called continuously. We’re up here in the panhandle and Wheeling is right across the river [blank space inaudible]  a lot of weekend visits and we get calls from physicians who want to use us because they’re pleased with the quality of care that we provide, plus we do the PM visits that most agencies will not do. What we’re seeing is [noise inaudible] that agencies that are in West Virginia and have CON approval, just say hey, stop, we don’t want you in just because they don’t want us to compete with them. [noise inaudible]           

 

Ms. Sonia Chambers:  I’m sorry, did you say something else?

 

Ms. Diane Hunter:  Can you hear me?

 

Ms. Sonia Chambers:  Now I can.

 

Ms. Diane Hunter:  Okay, I don’t know what happened. There’s also as far as an expense to open the office, we rent an office. [blank space inaudible] and a secretary, so as far as capital expenditure, it’s not like us opening a nursing home or having a lot of infrastructure. [bland space inaudible] up there either.

 

Ms. Sonia Chambers:  Okay, anybody else want to respond, pro, con?

 

Mr. [??] [??]:  I have a comment. I’m not here to advocate in favor of review or against review on behalf of anyone, but as an attorney who practices in this area, I was involved in the case in Mason County that lead to a number of disputes and subsequently about how to interpret the existing standards and obviously my client was an established, mature agency in the state of Ohio wishing to serve Mason County, West Virginia, in that particular case, and was allowed to do so by this agency and was basically thrown out of the county by a local circuit judge up there who overruled the agency’s decision. The interpretation of that judge makes a very restrictive situation under the current standard, because it is technically possible, under the standard that has been interpreted by the judge in Mason County, to have an unmet need in a small county in West Virginia of almost 50% and to keep other agencies out and I think if you decide to keep review in, I think those standards need to be looked at and clarified because I think that is a very restrictive standard for a [noise inaudible] to have such a low capital expenditure and has the potential to provide lower costs than institutional care for a lot of patients. That’s just a comment I would make based on my experience with the current standards.

 

Ms. Sonia Chambers:  I think the agency does recognize that these are a set of standards that need to be reviewed and we can certainly do that, get another group together, get everybody’s input on the specific standards, before we would propose any to the Governor. All right, anything else on Home Health? Going once, going twice? Okay, how many people are going to leave for Home Health? Anybody going to leave or everybody going to stay? Are you leaving? Is anybody else leaving?

 

Ms. [??] [??]:  Home Health care will leave, also.

 

Ms. Sonia Chambers:  All righty. I thought we might want to take a little break if we were going to have a mass exodus of people. Yes ma’am?

 

Ms. [??] [??]:  For our written comments, how would you like them sent?

 

Ms. Sonia Chambers:  You can send them to Dayle Stepp, who is Director of Certificate of Need to our agency. Do you have the address?  I thought you might.

 

Mr. [??] [??]:  Is there any deadline on that?

 

Ms. Sonia Chambers:  I would think within 30 days. All right, anybody who would like to come up to the table is more than welcome to. Okay. Why don’t we, I don’t think we’ve had anybody who’s necessarily joined us on the call. We haven’t gotten anybody new in the room. We lost a few. Are you doing to go through the Hospice standards? All right, Dayle Stepp’s going to go through the Hospice standards and then we’ll go through the same process.

 

Mr. Dayle Stepp:  Okay, the Hospice standards, they start off identifying five different types; free standing, hospital-based, nursing home-based, community-based, and Home Health agency-based. The formula is fairly simple. We’ve take the West Virginia vital statistics, we take the total deaths for the county x 25% and that would equal total projected Hospice users. Then from that number we subtract actual current utilization. If the remaining number is 25 or greater then the need would exist and the utilization numbers are derived from the annual survey of the Hospice agencies. Then we go on into the [noise inaudible] accessibility [noise inaudible]…

 

Ms. Sonia Chambers:  Dayle hang on a second. Did somebody hang up from the phone and is trying to dial something else? Well there you go.

 

Mr. Dayle Stepp:  Then we go through the quality, which most of this deals with training, protocols, policies and procedures, requirements for staffing, and continued care as having proper linkage with the referring physicians, family, any services that might be needed by the client and then access and cost. Access has to be 24 hours a day, seven days a week and basically that’s it. We developed these standards in October 2006, so they’re two years old now and when we developed these, we had a work group that we met with in the Hospice Council and went through and developed these standards and this methodology of 25% of the total deaths for a particular county.

 

Ms. Sonia Chambers:  Right, it was a lower number prior to that, wasn’t it?

 

Mr. Dayle Stepp:  Right, it was 15%.

 

Ms. [??] [??]:  15% of cancer deaths.

 

Ms. Sonia Chambers:  15% of cancer deaths. Questions about the standards?

 

Ms. [??] [??]:  It used to be 15% of cancer deaths, and [inaudible[ % of all other deaths. Now it’s 25% of all deaths.

 

Mr. Dayle Stepp:  Right. It’s 25% of all deaths, not just cancer deaths.

 

Ms. Sonia Chambers:  There’s a clarification going back and forth about exactly the numbers in the standards and the question is what were the standards before and to what have they been changed?

 

Mr. Dayle Stepp:  Prior to these current set of standards, we would take the total deaths for the county x 15% to project total Hospice users.

 

Ms. Sonia Chambers:  Potential…

 

Mr. Dayle Stepp:  Potential Hospice users. We changed the 15% to 25% of total deaths for the counties for potential Hospice users and then we put in this placeholder, 25 patients if you have an unmet need. Once you subtract the current utilization from the projected Hospice users, if it’s 25 or more, than an unmet need will be shown to exist.

 

Mr. Phil Wright: What’s that mean?

 

Ms. Sonia Chambers:  That’s Phil Wright who’s asking the question of what that means.

 

Mr. Phil Wright:  What does that mean? Just the total projected Hospice users, you exceed the current utilization by 25 patients…

 

Mr. Dayle Stepp:  If you took the total deaths in the county x 25% and it came out to 100, you surveyed everybody that had Hospice services in that county and it was 75, you subtracted 75 from the 100, that leaves 25, therefore you’re showing there’s still an unmet need. Now we based this 25 on, we talked to national companies and [noise inaudible] searches and everything and this was generally thought to be a number which an agency would need to be financially viable to provide the Hospice.

 

Mr. Phil Wright:  All the Hospice needs are being met. [noise inaudible]  threshold, yeah, but all the Hospice needs are being met. We don’t have anybody screaming that they don’t have any Hospice service.

 

Ms. Sonia Chambers:  I’m sorry you’re asking the question do we currently?

 

Mr. Phil Wright:  Yeah, that’s my question.

 

Mr. Dayle Stepp:  We’re not aware of anyone that’s…

 

Ms. Sonia Chambers:  I’m not aware of anybody saying that they cannot get services. What I will tell you is that sometimes we get concerns about people not having adequate choice of Hospice providers. This hasn’t occurred recently, but there was a period of time when a Hospice provider would have a certain part of a county, and these are the more rural counties, but weren’t really providing services to the rest of the county, so there were some areas, in particular, that didn’t seem to have very good coverage of Hospice services, but I’m personally not aware of concerns or complaints in the last, I would say year or two.

 

Mr. Phil Wright:  And how many of these different models do we have in the state?

 

Ms. Sonia Chambers:  Tim, do you have the inventory there?

 

Mr. Tim Adkins:  No.

 

Mr. Dayle Stepp:  Most of them are freestanding. I don’t think we have any hospital-based or nursing home-based.

 

Ms. Sonia Chambers:  Well wait just a second. I think the folks maybe from the Hospice Council can help answer that question and certainly for the future meetings on standards, we’re going to have the answer to that, aren’t we?

 

Mr. Dayle Stepp:  Sure.

 

Ms. Sonia Chambers:  Or the inventory of whatever services that we have.

 

Ms. Margaret Cogswell: We currently have, I think, 19 providers in the state. Eight of them are hospital-based.

 

Ms. Sonia Chambers:  Eight of them are…so close to half.

 

Ms. Margaret Cogswell:  Close to half are hospital-based. We have one Home Health-based and the rest are freestanding. There are no nursing home-based Hospices.

 

Ms. Sonia Chambers:  And of those that are freestanding, are all of those not for profit or are some of them for profit? It seems to me that maybe there are a couple for profits.

 

Ms. Margaret Cogswell:  Yes, I think there are a couple for profits. I have to sort of look for this.

 

Mr. Dayle Stepp:  Are there agencies that are not members of your organization?

 

Ms. Margaret Cogswell:  Yes, there are two Hospices that we see CON data on that are not members of our organization. So, I think there are 18, 8 Hospices, because there’s been some consolidation. 18 Hospices, the Hospice Council represents 16 of those and out of the whole 18, eight of them are hospital-based, one is Home Health-based.

 

Ms. Sonia Chambers:  More of those are probably not for profit, but there are a couple of for profits?

 

Ms. Margaret Cogswell:  Yes, we know of at least one freestanding that’s for profit and I think that there’s just the one and then the Home Health-based, it’s a for profit, also.

 

Mr. Phil Wright:  Are all the counties covered?

 

Ms. Margaret Cogswell:  All the counties are…

 

Ms. Sonia Chambers:  The answer to that, I believe is yes.

 

Woman on phone:  [inaudible] they’re just not covered good. [inaudible] is one of them and

 

Ms. Sonia Chambers:  Would whoever’s on the phone like to identify themselves and make that comment to the whole group?

 

Woman on phone:  not covered good…

 

Ms. Sonia Chambers:  Maybe they think they’re on mute, but they’re not. Okay, we’ll just open this one up. Who wants to go first? Oh Margaret, you look like you’re ready.

 

Ms. Margaret Cogswell:  I’m ready, I’m so ready. So, from the Hospice Council, let me say, first of all, that we do support maintaining Certificate of Need for Hospices in the state of West Virginia. I actually brought some maps with me that might be of interest to individuals. They are Council maps [inaudible] to non-member agencies and then also since it’s basic information about Hospice care and Tom has graciously offered to pass that out. Dayle talked about Certificate of Need and the percentages of deaths served and when we work and are grateful for having input when those revisions were done back in 2006, the average number of deaths that Hospices were serving was about 25% and so we set the Certificate of Need at that. I will tell you on average right now, Hospices in the state of West Virginia serve 34% of all deaths, so that’s all deaths, not cancer deaths, not end stage deaths. That’s a percentage of all deaths and so that’s the average. The national average is about 36%. Right now, the latest figures we have, I believe, are from 2006 on that.

 

I’d like to talk for a minute about why we support Certificate of Need continuing for Hospices. Hospices are reimbursed on a daily basis. Medicare and Medicaid are our largest payers and typically the reimbursement is for 85 to 90% of patients in Hospice care. We are reimbursed at a fixed rate, so they’re our primary payers, those rates don’t change, there’s no way to compete for those rates. The rate is the rate for those individuals. And yet under those regulations for Medicare, and Medicaid follows them almost identically under Medicare, the standards are very specific about what Hospices must provide. Nursing services, social work, chaplain services, they must cover volunteer programs, and must actually provide 5% of all volunteer hours to equal your patient care staff hours, so they’re very specific about what has to be provided by Hospice care and yet you have a fixed rate in order to be able to do that. What a Hospice has to have in order to survive is some volume and it impacts not only the financial feasibility for the Hospice, because you take risks. One patient may come into the program and have very expensive medications and

 

[comment inaudible]

 

no, and we cover medications and durable medical equipment all out of that same fixed rate and there is no acuity standard, so it doesn’t go up as the patient is more complex or more expensive. It’s the rate, so if you have a patient that’s admitted with very expensive medications and you are, by regulation, required to provide them, you’re going to have to find that money from someplace else and so what you hope to be able to do is to have enough patients in your program that you have some that don’t cost you an arm and a leg, so when the patient does come along that costs and arm and a leg, you can balance that out. And I think that’s probably one of the most critical reasons to keep Certificate of Need, because when you dilute that, you dilute the financial stability of the Hospice, but you also really dilute the quality of care. What a Hospice can do when they have three patients in the program on an average day is very different than what a Hospice can do at 20 patients, at 50 patients, at 100 patients a day, because you’re able to spread those overhead costs and the standard costs around. And so it just makes so much sense to be able to keep providers to a limited number so that they can have patients to be able to serve.

 

When I was looking at the numbers prior to coming to this meeting, I looked at the counties and death rates for counties. Out of the 55 counties in West Virginia, 24 of them have 300 or less deaths in a year. If we take that 300 and multiply it by 25%, which is the current CON formula, that’s 75 patients, so for an entire year, 75 patients for an individual Hospice is a small Hospice to provide and it’s a small number of people to sort of spread that risk around. If you took the average length of stay for a typical Hospice patient, which runs between 60 and 70 days, at 68 days, that’s an average daily census of a Hospice of 14 patients a day, so again, then you’re smaller numbers, smaller numbers, smaller numbers and what you can do for 14 patients is very different than what you can do for three patients and what you can do with 50 patients in the program. So I think that’s really the base for why we think that Certificate of Need should continue.

 

Ms. Sonia Chambers:  Counter point anybody? No one thinks we ought to do away with CON for Hospice services?

 

Mr. [??] [??]:  Do not care.

 

Ms. Sonia Chambers:  I thought this was going to be a much longer meeting.

 

Ms. Karen Nichols:  I’d just like to address the quality issue. I believe that competition is good. I mean it’s a foundation of our economy, is competition, but to say that competition is what drives quality, I’m sorry but I don’t believe that. I believe that you can be committed to providing quality in a non-competitive environment and do just as good a job as in a competitive environment and I think Hospice quality data would indicate that. If you look at the national family evaluation of Hospice care that the National Hospice and Palliative Care Organization has developed as an evaluation tool for Hospices, you will see that nationwide, something like 98% of families say that they would use Hospice again if they had the opportunity to do so. If you compare that to hospitals and other health care providers…I went on, just in my local area and did a comparison and obviously Hospices don’t publicly report, but I have the national data because we participate in this benchmarking opportunity. Locally in my area, and it’s been awhile since I’ve done this, but it’s something like, and Phil you may know this, 68 to 70% of people said that they would use that hospital again and so I think that Hospice nationwide has a reputation for providing quality care at the end of life. Now, I’m not about to say that every patient in this country gets quality care at the end of life if they get Hospice care, because there are bad Hospice providers out there and we all know that and all recognize that, but I think that in our environment it’s just a little bit different environment than the rest of health care because of the way we’re reimbursed and because of…the reason that Hospice got started was to improve end of life care, so it’s a basic premise of what we do is improving care for people at the end of life.

 

The other big quality indicator, of course, is pain control and again, we don’t publicly report, but I looked at pain control results of local health care providers that do have to publicly report and again, nationwide something like 95% of Hospice patients report that their pain was controlled in 48 hours and on the Medicare compare it’s something like 50 to 60% of people, so I think Hospice has a pretty good track record as far as quality goes in a non-competitive environment.

 

Mr. Phil Wright:  End of life care is one of the highest costs per day in health care. We’re all trying to control it, Hospice does a good job. It’s the people not using Hospice that drives the cost, the way I see it.

 

Ms. Karen Nichols:  There was a recent study published by Duke University that said that the average Hospice user saved Medicare $2,300, so what Phil said has been borne out by research.

 

Mr. Phil Wright:  Multiply that by ten million. That would be 25% of the Medicare population. One more space for the bail out [inaudible]. [inaudible]

 

Ms. Sonia Chambers:  [laughter] Always a pleasure to have you Mr. Wright. [laughter]

 

Ms. Cindy Dellinger:  Do have any changes that you would want made to the Hospice standards or are you happy with how they look?

 

Ms. Marilyn White:  We were able to do that two years ago. I think if that was going to be revisited, we would certainly want to be part of that process. I don’t know that the Council has any recommendations at this point in time, but we do recognize the difference between what the CON is and what we are, on average in West Virginia, and what the national average for deaths served is and there is a difference between those numbers.

 

Mr. Phil Wright:  Isn’t the bigger problem the underserved counties, the populated Wheeling, Huntington, Charleston, no problem, but underserved smaller counties? I would think that would be the problem and do you have enough coverage there to take care of all the counties?

 

Ms. Sonia Chambers:  I think technically every county is covered, but what I had heard in a couple of instances was, while somebody had an entire county, they really only served half the counties. They served everything on this side of the mountain and not so much on the other side of the mountain. I think in the one particular instance I’m aware of we were able to remedy that situation because another Hospice stepped up to the plate and said they would take patients in that part of, the underserved part of the county.

 

Mr. Phil Wright:  I thought it was county…

 

Ms. Sonia Chambers:  It is. What happened is they came in and got a Certificate of Need for that county and there was just sort of a mutual agreement between the Hospices that one would serve this part of the county and the other would serve that part of the county, if I remember correctly. This was primarily in Braxton County.

 

Ms. Margaret Cogswell:  I remember that instance, as well, and I’m sitting in the same place. As President of the Hospice Council I have not heard anything in a couple of years, as well, about patients being un-served.

 

Ms. Sonia Chambers:  What I heard more just anecdotally, and what I think may be from a health policy perspective, is that utilization of Hospice is not quite as culturally acceptable in some areas as might be optimal from the numbers you just sited. That people in some areas feel like if you really want health care for grandma or mom or dad it needs to be in a hospital as opposed to in a Hospice and I think that view is changing. I don’t think it’s changing as rapidly, I guess, as by evidence of the number of people who die in Hospice care in West Virginia as opposed to the national average.

 

Ms. Margaret Cogswell:  It is a struggle, because for so long the word Hospice has really been connected with death and to be quite honest, not very many people want to volunteer for that, and actually Tom, can I just get your paper passing one more time because this is a perfect example, because as an individual Hospice trying to change that concept in the community to Hospice instead of being about dying, about living, and I brought newsletters today and this has one of our patients, who was a Hospice patient and died recently, taking a motorcycle trip and she was a nursing home resident for us and enrolled in our Hospice program and what could be further away from the concept of what somebody looks like when they’re dying than this lady who is sitting on the motorcycle getting ready to take off toward Jefferson County. But I agree, it’s been a long struggle and some Hospices have been able to make some inroads in that in the community, but many Hospices have not been able to sort of break that mold that many people put Hospice care in and once they get past that, it really is a wonderful opportunity for patients and their families.

 

Ms. Sonia Chambers:  That’s a great picture.

 

Ms. Margaret Cogswell:  Isn’t that a great picture? That’s Eleanor, Miss Eleanor, and actually I have to tell you, she told our staff as they were going to see her in the nursing home, because we always ask about what is it that you’d like to do, and she talked and talked about traveling and going on a motorcycle ride and this is the husband of one of our nurses who took her in his bike club. When she got back, the staff talked about it and she said, well I always really wanted to go on an airplane trip again, too, and I have to tell you we have a volunteer who has a plane and he took her up, so it’s been wonderful and she was very gracious to allow us to take her.

 

Ms. Sonia Chambers:  Oh, that’s terrific. Anything else? If not, I think that’s a great note to end on. All right, I appreciate everybody’s time and effort coming today. Please, I think the same thing with Home Health, if you’d like to submit written comments, we’d be more than happy to get those within 30 days and we will look forward to this discussion during the legislative session. Thank you all very much.

 

END OF AUDIO