Wednesday, September 6, 2017

What's the point? Good question!

Shiny happy people dying*

Last week an astute reader asked this question about the post featuring my conversation with Boo Boo (paraphrasing): "What's your point?"

I'm glad she asked. Not because I had an answer, but because I really had to think about her question.

Poking through the 990's

My initial response: There's a tool called IRS Form-990 that can help us begin to 'unpack' (her term - I like it) some elements of a non-profit hospice, specifically their finances, governance, and mission. Non-profit organizations must submit this information every year to justify their tax-exempt status.

I tried out the tool by selecting a small sample of data submitted for 2014, and comparing it among several hospices I'm familiar with - service revenue, net assets, CEO total compensation, employee count, and the number of other employees who earned over $100,000.

I think service revenue describes the organization's size and activity, and is a decent proxy for the number of admissions and average daily census, since big agency = high service revenue. The employee count also relates to agency size.

I chose net assets as a way to assess an agency's wealth, since that's where I think an organization usually parks any surplus revenue remaining each year after expenses are paid.

It's also where the value of other assets like buildings are accounted for, after subtracting liabilities like mortgages or bonds.

Executive compensation has been a hot topic since it started climbing in the corporate world during the 80's. The latest survey for 2016 shows the top 10 corporate executives earned $94.6M at the high end, and $37M at the low, with an average of $19.3M for the top 200.

That's a lot of money, even for someone at the top of an organization, and begs the question: What did they do to earn it?

Finally, I thought it would be interesting to see how many others in the organization were "highly compensated," which means $100,000 or more; and who they are.

Important caveat - I'm not an accountant, and don't pretend to be. I took a basic course on management control in healthcare many years ago because I had to understand income statements and balance sheets, if only in the simplest terms.

Is this hospice any good?

So, a more complete answer to the question, "What's the point?" goes something like: "I'm curious if this kind of information says anything useful about a non-profit hospice."

If there's a bottom line to my exchanges with Boo Boo, it includes the questions - “Is a particular hospice any good? How can we know? How can we find out?”

Look elsewhere

The astute reader pointed out a different source to help answer these questions - an agency's Medicare Cost Report. She noted the data was harder to access than Form-990, but could more directly identify money going to specific services like bereavement support and patient medications, show what's spent on clinical versus administrative staff, and so forth.

She also said my attempt to assess the quality of care by looking at financial information was "a dubious proposition overall."

I understand. Trying to figure out if a hospice is any good isn't just a matter of putting together a puzzle. It's more like trying to put together several different puzzles at the same time, trying to see if they relate to each other or make sense, and trying to do so when the pieces are all mixed together in boxes that don't even have any pictures that could be useful guides.

Pro Tip for hospices - avoid stock photos

Unless we mean pictures like the one above, which I found on the Vitas website. A quick image search on Google brings up an assortment of stock images from Getty in a selection titled, “african american man helping elderly.”

My mother used to say, "Follow the money. In the end, no matter what else they want you to believe, it's always about the money."

I didn't listen to every piece of her advice, but that lesson stayed with me. Form-990 may not say anything obvious about the quality of care at a given hospice, but I think it shows us something important about an organization, and can even lead to some informed conclusions about its culture and values.

Remember WaPo?

I didn't get my hands on any Medicare Cost Reports, but I did recall that in 2014 the Washington Post put together a Consumer Guide to Hospice based on Medicare Cost Reports and other data.

I also remember how the WaPo Guide, and the series of reports about hospice of which the Guide was a part, generated a fair amount of commentary in the hospice community.

Dale Lupu wrote an excellent analysis of the Guide's usefulness in Pallimed, and suggestions on how to interpret or supplement the information. I gave him my two cents in a comment.

But in re-reading his piece I was struck by his comment that Medicare Hospice Cost Reports, "have all kinds of issues in how data is reported."

I don't know what those issues might be, or what that means, but it's not exactly comforting.

Where else can I get the kind of information that could help me and Boo Boo find an answer to our question, "Is this hospice any good?"

Medicare's Hospice Compare

Just last month, Medicare launched their Hospice Compare website in an attempt to help me and Boo Boo, and anyone else who might be asking those same kinds of questions.

The idea is simple - enter the name of a specific agency, or pop in a zip code to get a list, and the site responds with a report card that shows how often (how well) an agency addresses pain, dyspnea, and constipation; and whether or not they ask about preferences for care, along with values and beliefs.

I can't say I'm impressed. The questions are pretty basic. If this was about commercial airlines, the data would show things like the percentage of passengers who were seated at takeoff, and whether or not a pilot was also on the flight.

A story in MedScape uses the term, "skeletal," to describe the site.

Another criticism sounds like something Garrison Keillor might say. It seems all of the hospices are above average. A hospice medical director who also participates in national discussions about quality says, "If one hospice is 94 percent and one is 92 percent, you don't really know that one hospice is somehow a lot better."

With that said, I think Hospice Compare's best and most helpful feature is a list of helpful questions (pdf) families can ask an agency, including two that I've found are very important:
  • How many patients are assigned to each hospice nurse?
  • Will I have the same hospice nurse?
Finally, I was visiting a friend recently, and learned she's been an avid reader of Consumer Reports magazine for years. The issue for October, 2017 includes a piece on assisted living and elder care. I wondered if they'd done anything on hospice, and sure enough...

What's the point?

To get back to my astute reader's original question - 

I have an advantage when it comes to assessing the quality of care among different hospices, at least in my little corner of the world. I've worked with several as a nurse, educator, and caregiver spouse. I keep in touch with colleagues, and track the stability of staff, or lack of it, along with other activities at the many hospices competing in Eastern Massachusetts. It's sort of a moving target, but the general range is between fifty and sixty (50 and 60!) agencies in this service area.

When people I know ask for my opinions or suggestions, I'm comfortable telling them what I think and what to look, and look out, for. It's very subjective, and I don't share those thoughts more widely because I don't think that's right.

Another astute reader said the public needs, "a hospice comparison tool that takes into account all of these crucial-to-our-experience data."

They're both right, and maybe that's the most important point.

*apologies to R.E.M.