BOOM TIMES AND CHALLENGES FOR HOME HEALTH AND HOSPICE MERGERS AND ACQUISITIONS
In two recent articles in Home Health Care News, Bailey Bryant looks to the year ahead for home health agencies and the trends in palliative care and hospice. She foresees a boom in home health and hospice mergers and acquisitions in 2019. It’s also a time fraught with barriers to growth in home-based palliative care, she says, but argues these challenges can be overcome by savvy home health agencies.
Her first article, “Overcoming Barriers to Growth in Home-Based Palliative Care,” argues, “Now is a better time than ever for home health agencies, hospice providers and other organizations to invest in and grow their home-based palliative care offerings.”
One roadblock to this investment is “sustainable financing and quality standards,” she concedes. But she sees hope in a new study published in the Journal of Palliative Medicine by the Center to Advance Palliative Care (CAPC). The study surveyed 25 home-based palliative care programs around the country to “understand the barriers to scaling home-based palliative care” and help “catalyze growth in the field, according to Brynn Bowman, CAPC Vice President of Education.
“For almost all of the barriers uncovered in CAPC’s needs assessment, support resources exist for organizations delivering home-based palliative care,” Bowman says. “We urge [post-acute care providers] to assess whether there are gaps in available services for patients living with serious illnesses in their communities.”
Bowman says hospice agencies would be smart to pursue home-based palliative care. “There are a growing number of opportunities to sustainably finance home-based palliative care, and a plethora of tools to ensure quality program design that achieves results,” she says. “Whether in the context of an ACO, or in partnership with a local Medicare Advantage or other health plan, the quality and cost impact of palliative care means that your palliative care business line is likely to be in-demand.”
- The day after publishing these insights, Bryant published “Home Health, Hospice Deals to Reach Record Numbers in 2019.” This boom follows a record breaking 2018, in which the sector closed 82 deals, and the trend is expected to continue due to the “growing popularity of lower-cost, value-based care.”
“Consolidation is driving the recent activity in this market, despite reimbursement and regulatory headwinds,” says Lisa Phillips, editor of The HealthCare M&A Report which publishes the data. “As health systems seek to drive down costs, we expect more to turn to home health care and hospice agencies over traditional post-acute settings like skilled nursing facilities or long-term acute care facilities.”
Private equity groups continue to be active buyers. Two deals came from Bain Capital Double Impact, which entered the home care space late last year by acquiring and combining Arosa and LivHome to create a national in-home care provider.
Another trend on Bryant’s radar are joint ventures between not-for-profit health systems and for-profit operators. “The sector has seen it already this year with the one of Michigan’s largest health systems and a national provider of post-acute solutions,” she points out. The nonprofit system Beaumont Health also sold 90% of its home health and hospice business to Alternate Solutions Health Network to create Beaumont Home Health and Hospice.
In both articles, Bryant shows sustained trend of consolidation and reconfiguration. For home health agencies with the resources, it could be a time to invest and grow. (Home Health Care News, 1/21, https://homehealthcarenews.com/2019/01/overcoming-barriers-to-growth-in-home-based-palliative-care; Home Health Care News, 1/22, https://homehealthcarenews.com/2019/01/home-health-hospice-deals-to-reach-record-numbers-in-2019)
MEDICAL CANNABIS INTEREST GROWS, BUT RESEARCH LAGS
The Journal of Palliative Medicine offers its readers the “Top Ten Tips Palliative Care Clinicians Should Know About Medical Cannabis.” The article paints a picture of the state of medical cannabis. Despite limited or even contradictory current data, palliative care providers are being asked to consider cannabis as a way to treat symptoms in the United States. At the same time, providers often have little experience recommending cannabis for medical use, as their training occurred before the drug was commercially available. Given this situation, researchers Joshua Briscoe, MD, Arif H. Kamal, MD, MBA, MHS, FACP, FAAHPM, and David J. Casarett, MD, MA, FAAHPM seek to “dispel myths” and provide “a balanced view of the benefits and burdens” to provide guidance to practicing clinicians.
“Any discussion of cannabis must start with clarifying nomenclature,” they write. A variety of names are commonly associated with the drug—some coming from a criminalized and stigmatized era—and language is complicated further by terminology surrounding various routes of ingestion. A fear of endorsing substance abuse can lead clinicians to avoid discussing cannabis, they say, and they offer “medical cannabis” as a term to refer to “products that contain cannabinoids and are used for medical indications.” This includes dronabinol (synthetic THC), nabilone (a synthetic cannabinoid similar to THC), and nabiximols (a combination of CBD and THC not available in the United States).
With terminology in place, the authors lay out their 10 tips for clinicians. These include logistics like navigating local laws and regulations or providing comprehensive pain assessments when medical cannabis is part of a treatment plan. Other tips speak to specific cases of usage in the treatment of neuropathic pain or chemotherapy-induced nausea and vomiting.
A number of sections highlight the degree to which research is still needed. A discussion of the “Differences in Bioavailability Among Routes of Administration for Medical Cannabis” concedes that we still have much to learn. Another section is titled, “The Evidence for the Use of Cannabis in Psychiatric Illness Is Limited and Varied.” Yet another section title regarding cannabis use with anorexia associated with AIDS concludes with “There Is Little Evidence for the Use of Medical Cannabis in Cancer-Associated Cachexia and Anorexia.”
The final sections turn to show research that has already provided insights into the usage of medical cannabis. Smoking medical cannabis is not associated with lung cancer, for instance, nor is it associated with chronic lung disease. Cannabis use has been found to be associated with an increased risk of motor vehicle collision, however, and this “link can likely be extrapolated to medical cannabis.” The researchers also say they’re particularly excited for new research regarding pediatric epilepsy.
The American Medical Association has stated that further trials are necessary and that it “not only opposes the legalization of medical cannabis but also supports legislation that provides immunity to physicians who certify that a patient has an approved medical condition or recommend medical cannabis in accordance with their state’s laws.”
“Such policies provide neither guidance regarding the application of current evidence around medical cannabis,” the authors argue, “nor is there advice for those clinicians who are practicing in environments in which patients will take the substance illicitly, regardless of clinician recommendation.”
“Legalization, promotion, and use of medical cannabis is far outpacing research,” they say. This puts some organizations in a precarious position. The National Hospice and Palliative Care Organization and the American Academy of Hospice and Palliative Care provide education regarding medical cannabis, but take no official position on its legalization or use.
“Even those clinicians who do not recommend medical cannabis must still remain informed regarding its purported and substantiated indications and its adverse effects,” they write. And it will be up to future studies to investigate the role and efficacy of medical cannabis in palliative care and hospice patients. Much territory is left to research about cannabis use in hospice populations, “at least in part because many hospices do not inquire about substance use, even if patients are using cannabis therapeutically and not recreationally.” (Journal of Palliative Medicine, Volume XX, Number XX, DOI: 10.1089/jpm.2018.0641)
HOSPICE AND END-OF-LIFE NOTES
* In an interview with Home Health Care News, Bill Dombi, President of the National Association for Home Care & Hospice (NAHC) says he’s paying attention to Medicare Advantage (MA) developments and the ongoing threat of Medicare fee-for-service cuts. Dombi provides his thoughts on the new Congress, what providers can expect in the new term, and specific reforms “that might modernize the Medicare program.” On “the top of the list,” he says, “would be allowing non-physician practitioners to actually certify Medicare eligibility for home health, in particular.” (Home Health Care News, 1/24, https://homehealthcarenews.com/2019/01/nahcs-dombi-threat-of-payment-cuts-cant-be-ignored)
* Virtual reality simulations are giving home caregivers experiences that can help them provide better care for those with dementia at the end of life, Home Health Care News reports. “People will say, ‘Oh, so you’re teaching empathy, right?’ And I don’t think that’s what we’re doing,” says Carrie Shaw, CEO and founder of Embodied Labs, the company that creates the simulations. Embodying various personas can provide insights into how to provide meaningful care. “We’re uncovering insights and letting people experience what they don’t know that they don’t know.” Daryl Cady, CEO of Hospice of Southern Maine, says this kind of experience is essential for their employees. “Every person that we hire — from our IT guy to our front desk receptionist to our nurse practitioners — needs to understand how hospice affects end of life. We don’t want anyone who works for us to fear it.” (Home Health Care News, 1/23, https://homehealthcarenews.com/2019/01/virtual-reality-helps-in-home-caregivers-experience-dementia-dying)
* Cape Gazette advises its readership on “How to talk to your doctor about end-of-life care.” They cite the statistic that only 12% of patients with advance healthcare directives had received input from their doctors. But the benefits of such input could result in less fear and anxiety, an ability to influence their own care, a belief that physicians had a better understanding of wishes, and a greater level of comfort in the decisions made. The article concludes with a bullet point list of “things to consider when talking to your doctor” including asking for explanations on procedures, talking about pain and symptom control, and other issues. (Cape Gazette, 1/23, www.capegazette.com/article/how-talk-your-doctor-about-end-life-care/172955)
* Getting old isn’t for the faint of heart, says KevinMD. Therese Zink, MD, MPH relates a personal story of being the eldest child who dealt with decline of both a mother and father. In such difficult situations, it’s important to have strategies to cope, Zink says. What helps ease the pain? “A spiritual life helps find meaning in the unpalatable, plugs us into something greater than ourselves, and provides community.” Mindfulness and focusing on small joys are also important. Finally, having “family geographically close who are engaged with the elder, checking in, providing transportation to doctor appointments, bringing meals, engaging him/her in family activities appear to avoid loneliness and isolation.” (KevinMD, 1/22, www.kevinmd.com/blog/2019/01/getting-old-aint-for-sissies.html)
* University curriculums often “go light” on the experience of dying when in training for nurses, NPR News says. But some colleges like Nashville’s Belmont University are boosting their training to include the sights, sounds, and emotions at the end of life. “There’s a sound near the end — the death rattle. People stop swallowing. The lungs fill up. There can be involuntary moaning.” Professor Sara Camp says, “You get all that noise. And that’s really distressing for family members.” Students learn that they will play a critical role, and that their emotional response is important along with the medical services they provide. At the end, loved ones “may not remember what you say, but they’ll remember how they feel when you were there, because you were there.” (NPR, 1/19, https://www.npr.org/2019/01/19/686830475/morphine-and-a-side-of-grief-counseling-nurses-learn-how-to-handle-death)
* The End-of-Life University Podcast presents “Poems and Rituals: A Tribute to Mary Oliver and Megory Anderson.” The episode honors “the memories of two very special women who changed the world around them in different ways throughout their lives and died on the same day.” “Mary Oliver is a beloved American poet whose love of nature inspired her beautiful verses.” “Dr. Megory Anderson trained in comparative religions and theology and founded the Sacred Dying Foundation in 1996. She is the author of the books Sacred Dying: Creating Rituals for Embracing the End of Life and Attending the Dying.” (End-of-Life University, 1/21, https://us2.campaign-archive.com/?e=d0771da91c&u=3ca907a9f101567d342c3f4ef&id=09eae01c22)
- * The New England Journal of Medicine published “End-of-life care and the effects of bereavement on family caregivers of persons with dementia.” The study looks at “the impact of end-of-life care on caregivers who are family members of persons with dementia and the caregivers’ responses to the death of the patient.” Looking at 217 caregivers, they found half reported spending at least 46 hours each week “assisting patients with activities of daily living and instrumental activities of daily living.” More than half also reported feeling they were ‘on duty’ 24 hours a day. Caregivers exhibited high levels of depressive symptoms while providing care, but showed a remarkable resilience after the death. “Within 3 mo. of the death, caregivers had clinically significant declines in the level of depressive symptoms, and within 1 yr. the levels of symptoms were substantially lower than levels reported while they were acting as caregivers. 72% of caregivers reported that the death was a relief to them, and more than 90% reported belief that it was a relief to the patient.” (The New England Journal of Medicine, 349(20), 1936-1942)
PALLIATIVE CARE NOTES
* The Cambia Health Foundation has announced 12 new emerging palliative care leaders of its Sojourns Scholar Leadership Program. The program identifies, cultivates and advances the next generation of palliative care leaders. Scholars receive a two-year, $180,000 grant to “conduct an innovative and impactful project tied to a leadership development plan that positions the scholar for growth as a national leader in the field of palliative care.” Peggy Maguire, president and board chair of Cambia Health Foundation, says, “These palliative care professionals demonstrate that care is better when we focus on what matters to people instead of what’s the matter with them. We hope their leadership will influence compassionate, person-focused care throughout the system.” (eHospice, 1/23, https://ehospice.com/usa_posts/cambia-health-foundation-announces-12-new-sojourns-scholars)
- * The Journal of Palliative Medicine published “Spiritual Pain (SP) Is Associated with Decreased Quality of Life in Advanced Cancer Patients in Palliative Care: An Exploratory Study.” The authors found that, of 208 patients enrolled, the “mean age was 64, 50% were female, and 67% had SP. In univariate analysis, SP was significantly associated with lower QOL … Lower QOL was also associated with being younger, lower KPS, higher physical distress, having anxiety or depression, and decreased religiosity and religious coping. In the multivariate analysis, QOL remained independently associated with SP… religious coping … and physical distress.” (Journal of Palliative Medicine, 1/16, liebertpub.com/doi/abs/10.1089/jpm.2018.0340#utm_source=FastTrack&utm_medium=email&utm_campaign=jpm)
- * What happens when a doctor ignores a living will and prolongs suffering? Hot Air tells the story of a retired periodontist suffering from Alzheimer’s, Dr. Gerald. While he was still in a state of mind to do so, he drew up a living will that established a Do Not Resuscitate (DNR) order. His wife made sure the medical team knew about his wishes when he grew ill. “One doctor ignored those instructions and kept Greenberg alive for more than an additional month, moaning in pain until he finally passed away.” The article relates a personal story of a mother’s advanced dementia, and concludes, “These are hard subjects to tackle, but the majority of us will either have to deal with them ourselves when the time comes or our lives will be touched by others who do. We all make our own choices in life. As free citizens we should be able to make those choices about death as well.” (Hot Air, 1/19, https://hotair.com/archives/2019/01/21/doctors-ignore-living-will-prolong-suffering)
- * The Atlantic published “The Doctors Who Invented a New Way to Help People Die.” It discusses pentobarbital and secobarbital, two “lethal medications used by terminal patients who wish to end their own life.” These two medications “recently became unavailable or prohibitively expensive.” The essay discusses legal battles in states around the country and the lengths to which doctors have struggled to help patients “find a better way to die.” (The Atlantic, 1/22, theatlantic.com/health/archive/2019/01/medical-aid-in-dying-medications/580591)
* Virtual reality is being used to help visualize scans offered by traditional imaging techniques. That offers patients a chance to gain insights into their treatment plans, STAT writes. They profile Bill Hobbs, a 69-year-old man in Massachusetts, who was invited to take part in an early trial of such technology by oncologist Dr. Ray Mak and researcher Christopher Williams, of Brigham and Women’s Hospital and the Dana-Farber Cancer Institute in Boston. “It doesn’t change anything in the sense of, am I going to get better quicker because now I know something I didn’t know? Not particularly,” he says. “But what it does do is show you what they’re doing and they can tell you why they’re doing it, and that’s a good feeling to have.” (STAT, 1/25, www.statnews.com/2019/01/25/virtual-reality-cancer-tumors-brigham-dana-farber)
* New Jersey and Virginia are considering legislation that will regulate the practice and licensure of music therapy. New Jersey’s “Music Therapist Licensing Act” outlines the legality of language surrounding the profession and practices within it. Virginia’s SB 1547 would require the Board of Medicine to regulate music therapy. The Virginia bill was introduced on January 8th and has reached the health professions sub-committee. (State of New Jersey, 1/23, www.njleg.state.nj.us/2018/Bills/A2500/2183_I1.PDF; Virginia’s Legislative Information System, 1/25, https://lis.virginia.gov/cgi-bin/legp604.exe?191+sum+SB1547)
* Optum is suing an executive who left to work for the new health care venture created by Amazon, Berkshire Hathaway and JPMorgan Chase. The lawsuit alleges that the new employment “poses a direct threat to Optum’s trade secrets and other confidential information.” Axios writes, “It’s been a year since the three conglomerates promised to ‘disrupt’ the health care industry with their venture. And the only thing we really know about it now is that Optum — the profitable and growing division of UnitedHealth Group that provides health care, data services and pharmacy benefits — views it as a competitor.” (Axios, 1/23, www.axios.com/optum-lawsuit-amazon-berkshire-jpmorgan-health-care-7141f097-9b6f-4e38-a165-1e4c557b5d98.html)
* What does the word “dead” mean, really? It has been fifty years since Harvard defined the word for the medical community, Forbes says, but the debate continues. “Defining Death: Organ Transplantation and the Fifty-Year Legacy of the Harvard Report on Brain Death” is a new report by leading bioethicists, physicians, and scientists. “Until the mid‐twentieth century, death was defined in terms of the failure of three critical organ systems: circulatory, respiratory and neurological,” Forbes writes. “Mechanical ventilation and organ transplantation in the 1950s,” however, “changed everything.” Increasing legal challenges had some contributors to the report arguing that individuals should be allowed to choose their own definition within a range of options. “Another explores how religion and culture shape our experience of personal identity and death. And still another offers the perspective of a bioethicist who has long observed debates over the end or continuation of life. The report goes on to discuss the possible development of virtually inexhaustible sources of transplantable organs, through xenotransplantation (the process of grafting or transplanting organs or tissues between members of different species, ie. animals) or other technologies such as tissue engineering and 3-dimensional printing which could yield synthetic organs.” (Forbes, 1/16, www.forbes.com/sites/robinseatonjefferson/2019/01/16/what-does-dead-mean-the-debate-continues-some-50-years-after-harvard-defined-death/#21d5d00b4a22)
- * Rural hospitals are at greater risk in non-Medicaid expansion states, according to PEW. “The closures and at-risk hospitals are heavily clustered in the 14 states that have not expanded.
- Those state decisions not to expand have deprived rural hospitals, which already operate with the slimmest of margins, of resources that could be the difference between survival and closure.” For instance, in Texas, “many rural hospitals … and other non-expansion states have closed obstetrics units and other expensive services, forcing patients to travel long distances to seek treatment at the next-closest hospital, which is sometimes hours away.” The article describes the “Burden of Uncompensated Care,” as well as “99 Other Wounds” impacting rural hospitals. (PEW, 1/22, pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/01/22/rural-hospitals-in-greater-jeopardy-in-non-medicaid-expansion-states)
Hospice Analytics is the national sponsor of Hospice News Network for 2019. Hospice Analytics is an information-sharing research organization whose mission is to improve hospice utilization and access to quality end-of- life care. For additional information, please call Dr. Cordt Kassner, CEO, at 719-209- 1237 or see www.HospiceAnalytics.com.
Hospice News Network is published 45-46 times a year. Copyright, 2019. All rights reserved to HNN subscribers, who may distribute HNN, in whole or part, to provider members of the subscribers’ state organizations. If readers need further information, they should consult the original source or call their state association office. HNN exists to provide summaries of local, state and national news coverage of issues that are of interest to hospice leaders. HNN disclaims all liability for validity of the information. The information in HNN is compiled from numerous sources and people who access information from HNN should also research original sources. The information in HNN is not exhaustive and HNN makes no warranty as to the reliability, accuracy, timeliness, usefulness or completeness of the information. HNN does not and cannot research the communications and materials shared and is not responsible for the content. If any reader feels that the original source is not accurate, HNN welcomes letters to the editor that may be shared with HNN readers. The views and opinions expressed by HNN articles and notes are not intended to and do not necessarily reflect views and opinions of HNN, the editor, or contributors. Only subscribing state hospice organizations have rights to distribute HNN and all subscribers understand and agree to the terms stated here.