Q&A:
Hospice Leaders Weigh In on the Future of the Industry

Samira Beckwith, Gretchen Brown, and Malene Davis are three of the most influential voices in hospice leadership today. All three serve as board members of the National Hospice and Palliative Care Organization (NHPCO) and members of the National Hospice Work Group (NHWG), a national think tank of the most influential authorities on end of life care. Here's what they have to say about industry challenges, opportunities and what the future holds....

1. The end of life care environment has its share of challenges and opportunities. What keeps you up at night?

SB: I worry about how we can keep the essence of what is good hospice care in a changing health care system. Some believe that if we teach everyone how to provide end of life care, there won't be a need for hospice. But just as you can’t teach an OB gyn to be a good pediatrician, some organizations—like managed care, chronic care, and senior programs—think they can replace good hospice care.

Then there's the issue of providers competing for the money against each other in an environment of declining reimbursement. Unless we see a fundamental shift of how health care is paid for, we need to find a way together to take care of everyone in the community.

GB: Collaborative competition will be key for hospices to find their niche. Investors are seeing the aging baby boomer as a market much like China: Pampers for every baby bottom. I believe it’s a large market that can be very segmented. Hospices will need to develop preferred partners horizontally and vertically in the health care system to give so many kinds of consumers everything they want.

I think we're seeing an opportunity for "mass customization." While we all order coffee at Starbucks, I like an extra hot skim latte. In the same way, hospice has core competencies or "ingredients" that can be added or taken out based on whether the patient is a tech-savvy baby boomer caring for an elderly parent or someone who wants more private duty and medication delivered.

The biggest challenge is making the Medicare benefit more congruent with how health care has changed in the past 30 years. Palliative care would be so much more accessible if patients didn’t have to give up curative care to get it. Patients will be happier if we can provide coordinated care to extend quality of life. I'm hoping more research will propel change.

2. What's on your personal To-Do list?

MD: I've been out teaching the business of hospice. When hospice was in its infancy 30 years ago it attracted a lot of nurses and clinicians. Today, there’s still a lot of self-taught people who are in it for the right reasons but lack the business training they'll need to survive and succeed.

When we look at the challenges on the horizon—paying for outliers, open access, reimbursement, and the choices in end of life care that baby boomers want—we need to be better business managers. We've always been able to run a budget on a fixed reimbursement, but when we talk about executing a budget in the most prudent way within a competitive environment, that's a whole new skill set.

SB: I'm working on ways to reduce barriers to access while maintaining quality so that the patients who need us find us sooner. For example, many physicians find it easier to prescribe a third level drug rather than have that difficult conversation with a patient about palliative care. Also, consumers have misconceptions about hospice and don't want to plan end of life care.

We find naturally occurring groups (NOGS) in the community—such as senior centers and medical society meetings—and get in front of them. We've also developed a longterm care diversion program that keep elderly in their homes longer. Currently we provide care management services to 250 individuals who don't yet qualify for hospice through a Medicaid waiver from the state of Florida. We seek out reimbursement programs to help people who can benefit from our core competencies but aren't yet eligible for hospice.

3. When you think about the road ahead for the industry, what types of leadership skills—in addition to financial training—will hospice leaders need?

MD: Internal and external relationship-building skills. When your employees look forward to coming to work, they pay it forward to your patients and families. This culture starts at the top with the CEO and reaches to the front lines of the organization. I frequently ask my managers, "Who have you inspired and motivated today?" If it's noon and I haven't been inspired or done that for someone else, I'm looking for an opportunity.

We also need to communicate with physicians so patients get what they deserve. As an industry, we're serving 30% of eligible patients. And they've been through the mill by the time they reach us. My dad suffered through five years of chemotherapy and a battery of tests before hospice. I want all patients to have easy access to quality end of life care when they need it.

GB: Advocacy skills. It's critical for leaders to get involved on the state and national level to be a proactive voice with legislators and policymakers. The Center for Medicare Services is distressed about the rapid growth of hospice (due to investor interest in a high-growth market), making more regulatory action likely. It's always better when informed leaders reach out and weigh in early rather than waiting for new mandates to impact the industry.

4. Last thoughts or suggestions for other leaders?

MD: Quality is huge and is going to be mandated, so incorporate it into your organization’s evaluation goals from the CEO on down. In fact, we use quality as a benchmark for salary increases.

SB: Have a seat at every single table in your community and nationally to help define the future of end of life care. We can't depend on Congress, AARP, or other health care providers to think about it for us. Be involved and represented in policy and programming decisions.