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Hospice in the United States Policy Forum Research. Stephen R. Connor, PhD Vice President Division of Research and International Development. What we will cover. The growth of hospice in the US from the 1970’s to the present NHPCO Dataset Data Medicare Hospice Benefit Data (OSCAR)

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Hospice in the United States Policy Forum Research

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Hospice in the united states policy forum research

Hospice in the United States Policy Forum Research

Stephen R. Connor, PhD

Vice President

Division of Research and International Development

What we will cover

What we will cover

  • The growth of hospice in the US from the 1970’s to the present

    • NHPCO Dataset Data

    • Medicare Hospice Benefit Data (OSCAR)

  • A look at death in the US in 2002, including who uses hospice care covering geography, disease, race, age, & sex

    • Using the Complete CDC Compressed Mortality File

    • The 100% Standard Analytic File for Hospice

  • A look at hospice costs and new research on survival

Growth in hospice sites continues 500 new sites

Growth in Hospice Sites Continues:500 new sites

Recent growth in hospice sites

Recent Growth in Hospice Sites


  • Hospice Programs2,5002,8073,1453,635

  • Multiple Locations 822 8501,0151,114

  • Total All Sites> 3,3223,6574,1604,749

    • *Preliminary Numbers

    • >Includes approximately 200 non-certified volunteer hospices

Growth in patients served

Growth in Patients Served

Hospice caring for a larger proportion of all us deaths

Hospice Caring for a Larger Proportion of all US Deaths

  • One of every 3 deaths from all causes under hospice

    • 800,000 deaths in 2005

    • 200,000 admitted in 05 carried over to 2006

    • 200,000 discharged alive (14.8%)

  • =1,200,000 served

Who needs hospice palliative care

Who Needs Hospice Palliative Care?

  • As many as 7 in 10 of those dying annually

    • Cancer – Chronic Organ Failure – Frail/demented

    • Those not needing palliative care:

      • Non HIV Infectious disease – sudden onset MI & Stroke – Accidents, homicide, suicide - acutely ill without ADL dependencies

  • Now reaching about half the need

More non cancer admissions especially lung debility and mnd

More Non-Cancer AdmissionsEspecially Lung, Debility, and MND

Average median hospice length of service continue to rebound

Average & Median Hospice Length of Service Continue to Rebound

Los 7 days starting to drop los 180 days increasing

Patients in Hospice < 7 days

Patients in Hospice > 180 days























LOS <7 days starting to dropLOS >180 days increasing

More hospice patients dying in the place they call home

More hospice patients dying in the place they call home

  • 75.9% died in private residence, nursing home, or residential facility

  • 24.1% of hospice patients died in

    • Inpatient hospice unit (4.7%)

    • Freestanding hospice facility (9.9%)

    • Acute care hospital only (9.5%)

  • Compared to 50% of all deaths in acute hospitals in the general population

Oscar data


  • OSCAR is the CMS database that captures information on all Medicare certified providers. Information is updated at each recertification

  • Information in this database includes:

    • Identifying information on providers

    • Type of ownership and incorporation

    • Medicare provider numbers and dates of certification

    • Actions by CMS including types of closure/merger

    • Staffing by all disciplines and for volunteers

  • All information is at the provider number level

Oscar findings

OSCAR Findings

  • A total of 3,868 providers have been certified since the beginning of the Medicare Hospice Benefit

    • As of last October there were 3,019 (78%) active provider numbers*

    • 649 (16.8%) providers have voluntarily closed due to merger

    • 165 (4.3%) providers have voluntarily closed for other reasons

    • 35 (0.9%) providers have been involuntarily closed

      • Of the 848 closed programs

        • 48.6% were non profit

        • 44% were proprietary

        • 7.4% were governmental or other

          *Many hospices bill more than one hospice location through the same provider number. Approximately 25% of hospices are provider multiple locations, giving us over 4,000 locations

Oscar all providers

OSCAR – All providers

  • Currently Active by Provider Type – US Totals

    Type#% of Total

    • Hospitals6,18218.4

    • Nursing Facilities15,92347.5

    • Home Health Agencies8,41825.1

    • Hospices3,0199.0

    • TOTAL33,542

Oscar incorporation status

OSCAR Incorporation Status

Incorporation Type*Hospice Hosp NF HH

  • Governmental6.5 24.9 6.0 7.3%

  • Proprietary47 21.8 66.2 67.2%

  • Non profit42.2 53.3 27.8 25.5%

  • Other4.3 - - -

  • *By provider number

  • Oscar data new hospices

    OSCAR Data – New Hospices

    • Since the beginning of 2001 there have been 1,019 new hospice provider numbers issued. They break down as follows:

      • Governmental2.3%

      • Proprietary80.4%

      • Non profit11.8%

      • Other5.5%

    Oscar active providers s by state

    States with Most Provider #’s











    States with Fewest Provider #

    Virgin Islands1





    Rhode Island8



    S. Dakota14

    N. Dakota15

    OSCAR – Active providers #’s by state*

    Oscar staffing data

    OSCAR Staffing Data

    • Staff FTE’s in currently active hospice programs

      • 25,057 Registered Nurses

      • 5,586 LPN/LVN’s

      • 16,092 Home Health Aides

      • 2,693Homemakers

      • 6,501Medical Social Workers

      • 2,964Physicians

      • 4,034Counselors

      • 17,125 Other salaried personnel

      • 80,053 TOTAL Full time equivalent staff

    Oscar staffing data1

    OSCAR Staffing Data

    • Volunteer FTE’s in currently active hospice programs:

      • 432Registered nurse

      • 96LPN/LVN

      • 634Home Health Aide

      • 2,288Homemaker

      • 185Medical Social Work

      • 860Physician

      • 1,375Counselor

      • 38,469Other

      • 44,340TOTAL Volunteer full time equivalents

    Staffing data

    Staffing Data

    • Total Staffing Estimates

      • 80,053 Staff FTE’s = approximately 120,000 individuals

    • Total Volunteer Estimates

      • 44,340 Volunteer FTE’s = approximately 400,000 individuals

    • Total Individuals involved in the provision of hospice care in the US (approximate) 550,000*

      • *Includes non-Medicare certified hospices

    Geographic variation in hospice use in 2002 in press jpsm

    Geographic Variation in Hospice Usein 2002 (In-press, JPSM)

    • Complete CDC death certificate records and CMS 100% Standard Analytic File for hospice claims for 2002 were used to describe the whole population of hospice users and non-users in the United States. The overall hospice utilization rate for persons 65 years and older was 28.6%. Our findings highlight opportunities for the hospice industry to provide more care, opportunities defined by diagnostic and geographic axes.

    Hospice utilization by cause of death 2002

    Hospice Utilization by Cause of Death2002

    Geographic variation in hospice use in 2002 in press jpsm1

    States with highest hospice utilization in 2002







    New Mexico35%




    States with lowest hospice utilization in 2002



    S. Dakota16%


    N. Dakota18%


    New York19%




    Geographic Variation in Hospice Usein 2002 (In-press, JPSM)

    Overall hospice utilization by state

    Overall Hospice Utilization by State

    Overall hospice utilization by county

    Overall Hospice Utilization by County

    Cost report data

    Cost Report Data

    • Come to the session on Medicare Hospice Cost Report data on Saturday 11G 9:30 – 10:30

    • National Highlights20042005

      • Net Revenue Per Day$129.56$132.06

      • Total Expenses Per Day 117.86 123.12

      • Margin Per Day 11.70 8.94

      • % Margin 9.03% 6.77%

    Hospice cost studies

    Hospice Cost Studies

    • CBO Study

    • Lewin VH1 Study

    • Emanuel Study

    • Rand Study

    • Milliman Study

    • Duke Study

    Survival of hospice patients

    Survival of Hospice Patients

    • Pyenson, B., Connor, S., Fitch, K., & Kinzbrunner, B. (2004). Medicare cost in matched hospice and non-hospice cohorts. Journal of Pain and Symptom Management, 28(3).

    • Connor S, Pyenson B, Fitch K, Spence C, & Iwasaki, K. Comparing hospice and non-hospice patient survival among patients who die within a 3 year window. Journal of Pain and Symptom Management, 33(3).

    Opioids dosing and time to death

    Opioids Dosing and Time to Death

    • Portenoy RK, Sibirceva U, Smout R, Horn S, Connor S, Blum R, Spence C, and Fine P. (2006). Opioid use and survival at the end of life: a survey of a hospice population. Journal of Pain and Symptom Management, 32(6):532-40.

    Hospice patients and families cared for

    Hospice Patients and Families Cared For

    • In our country on an average day hospices are caring for over 200,000 patients and their families

      Of these less than 6,000 need inpatient care

    • On an average day hospices are providing support to over 1.6 million grieving people

    • Since hospice began in the mid 1970’s in the US we have cared for over 10,000,000 patients and their families

    Thank you


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