CHF Hospice (Adjusted)

Delivered January 16th, 2018. Contributors: Jerry T., Sian N., Isabelle R., Adesola A. and

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Congestive Heart Failure - Patient Volume

We researched the number of patients diagnosed annually with Congestive Heart Failure in the US and provided a breakdown of CHF diagnoses per state according to each stage of CHF. To determine patient volume, our findings required many calculations and several triangulations. For each triangulation and calculation that we made, we have provided an explanation for how we arrived at our conclusion. The final result of our findings has been compiled into a spreadsheet. 
Congestive Heart Failure in the United StatesAccording to the Centers for Disease Control, about 5.7 million Americans suffer from heart failure. Each year in the US approximately 550,000 individuals are diagnosed with Congestive Heart Failure. About 75% to 80% of the victims of heart failure are above the age of 65. Every year in the US about 1 million people are admitted to hospitals with Congestive Heart Failure. Of those hospitalized, about 30% to 60% are "readmits." Deaths from Congestive Heart Failure in the US have increased by 35% in the past 25 years. The most recent data shows that about 53,000 Americans die each year from Congestive Heart Failure. 
Stages of heart Failure Stage A is a classification for individuals who are typically asymptomatic and at risk for heart failure. This is commonly "considered pre-heart failure." Since this stage does not cause any symptoms, and since there are no physical abnormalities at this stage, quantitative data is difficult to obtain. For this reason, despite searching extensively through medical journals, government databases, and reputable media sources, we could not determine how prevalent this stage of heart failure is. 

 Stage B is a classification for individuals that are also typically asymptomatic and at risk for developing heart failure. This stage is commonly "considered pre-heart failure." These types of individuals may have been previously diagnosed with other complicating heart conditions such as "systolic left ventricular dysfunction." According to the most recent population based study of the prevalence of each of the stages of heart disease in 2006,  21.4% of those diagnosed with heart disease experienced "asymptomatic cardiac structural or functional abnormalities." While our source does not explicitly state that these individuals were Stage B, the aforementioned medical definition of this stage indicates that these individuals could be classified as Stage B. Using this data, we calculated that the total number of people diagnosed with Stage B Congestive Heart Failure in the US each year is 117,700 by multiplying the 21.4% that were Stage B by the 550,000 total diagnosed with CHF.  Please note that our research found a lack of recent population based studies on the prevalence of each of the individual stages of heart failure despite searching extensively through medical journals, government databases, and reputable media sources. 

 Stage C is a classification for individuals who are diagnosed with heart failure and are experiencing symptoms such as "shortness of breath," fatigue, and difficulty exercising and doing daily tasks. According to the most recent population based study of the prevalence of each of the stages of heart disease in 2006, 7.2% of those diagnosed with heart disease are in Stage C. Using this data, we calculated that the total number of people diagnosed with Stage C Congestive Heart Failure in the US each year is 39,600 by multiplying the 7.2% that were Stage C by the 550,000 total diagnosed with CHF.  Please note that our research found a lack of recent population based studies on the prevalence of each of the individual stages of heart failure despite searching extensively through medical journals, government databases, and reputable media sources.

Stage D is a classification for individuals who are diagnosed with advanced heart failure, experience severe symptoms, and do not respond to treatment. Stage D is the final and most severe stage of heart failure. According to the American Heart Association, about 10% of all patients diagnosed with Congestive Heart Failure are Stage D. We calculated that the total number of people in the US diagnosed with Stage D Congestive Heart Failure each year was 55,000 by multiplying the 10% that were diagnosed with Stage D by the 550,000 total that were diagnosed with CHF. 

It is important to note that our research found a lack of recent population based studies on the prevalence of each of the individual stages of heart failure despite searching extensively through medical journals, government databases, and reputable media sources. In other words, determining what recent percentages of the US population suffer from which stage of heart failure is difficult. There is currently a need for a large study of the US population that focuses on the prevalence of each of the stages of heart failure. 
limitationsAs mentioned, we uncovered a dearth of recent population based studies on the prevalence of the specific stages of heart failure despite searching extensively through medical journals, government databases, and reputable media sources. In other words, determining what recent percentages of the US population suffer from which stage of heart failure is difficult. There is currently a need for a large study of the US population that focuses on the prevalence of each of the stages of heart failure. 

Also, the diagnosis of individuals with early symptoms of heart failure is frequently delayed because some individuals commonly attribute symptoms such as tiredness to aging. In these cases, there may be a significant portion of the population which remains undiagnosed.
State by Stage breakdown | CalculationsDespite searching extensively through medical journals and government databases we could not find any data that directly indicated the number of CHF diagnoses per state. Even the CDC only provided information on deaths and hospitalizations. Therefore, we found it necessary to triangulate this information.

We were able to establish a mathematical relationship between the number of individuals diagnosed and the number of individuals that died from CHF. From our research we found that each year in the US there are about 53,000 deaths from Congestive Heart Failure. Since we already know that 550,000 people are diagnosed annually with CHF in the US each year, we calculated that the number of deaths is about 1/10 the number of diagnoses by dividing the total number of diagnoses (550,000) by the total number of deaths (53,000). 
Using this mathematical relationship we were able to calculate the number of individuals diagnosed with CHF per state by multiplying the CDC prevalence rate by the state population by 10 (due to the aforementioned mathematical relationship.)

Since the calculations involved more than 50 data pulls from the US Census Bureau and the CDC, we created a calculations document which fully lists and details each calculation made. 

To make the results of our research easier to read, our results have been organized into a spreadsheet.
ConclusionWe examined the patient volumes of those diagnosed annually with Congestive Heart Failure in the US and provided a breakdown of CHF diagnoses per state according to each stage of CHF. Our findings required multiple calculations and several triangulations. For each triangulation and calculation that we made, we have provided an explanation for how we arrived at our conclusion. The final result of our findings has been compiled into a spreadsheet. 

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Companies that offer specialized heart failure hospice services

We have compiled a list of ten companies that provide care for patients with heart failure or end stage heart disease within the US. The name, location and services offered can be found in the attached spreadsheet.  

METHODOLOGYWhile an exhaustive list of hospice care providers that specialize in caring for patients with heart failure was requested, due to time restraints and limited service offerings, we have provided a detailed list of ten relevant providers. During our research, we came across an article published in The New York Times which discusses the focus on surgery and treatment of heart conditions and the apparent lack of hospice care for end stage heart conditions. This may be the reason why finding hospice care centers with a specialized heart failure program was difficult. However, we have provided a robust list of ten providers who offer congestive heart failure programs or specialized care for those with end stage heart disease within the US. A summarized list has been provided below and further details can be found in the attached spreadsheet.

SUMMARYThe ten providers of heart failure and end stage heart disease hospice care are:

1. All Care 
2. Arlington Court Skilled Nursing and Rehab Center
3. Compassionate Care Hospice 
4. Crossroads Hospice 
5. PruittHealth Corporation 
6. Harbor Light Hospice 
7. Interim Healthcare 
8. Alliance Hospice 
9. All Caring Hospice 
10. VITAS Healthcare 

Details on the location and services offered by each provider can be found in the attached spreadsheet.

ConclusionA list of ten companies that provide care for patients with heart failure or end stage heart disease within the US has been complied, with the name, location and services offered by each, detailed in the attached spreadsheet.

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Hospice Companies

We have provided a list of hospice companies located in the states of Pennsylvania, New Jersey, Delaware, Virginia, West Virginia, North Carolina, Texas and California. While an exhaustive list was requested, we have found as many listings as possible within Wonder's standard request time-frame. The resulting research provides a list of 30 hospice companies including the provider's name, states served, services provided and company website, all of which has been entered into the attached spreadsheet.
MethodologyAs previously mentioned, the standard Wonder research time-frame is 2 hours, so we endeavored to find as many hospice companies as possible within the states mentioned. We used the Caring website as a basis for our research as it provided extensive listings of healthcare providers throughout the US and also had specialized listings for hospice care. We also made sure to devote time to each of the eight states to ensure all aspects of the research brief were answered. Below we provide a summary of our findings.
SUMMARYThe hospice companies are listed below, as well as the states each provider services. 

Kindred Hospice — PA, NJ, DE, VA, NC, TX, CA
Interim HealthCare of Pittsburgh, PA — PA
Vitas Healthcare Corporation — PA, NJ, DE, VA, CA
Chandler Hall Health Services — PA
Compassionate Care Hospice — PA, DE
Crossroads Hospice — PA
St. Luke's Hospice House — PA
Heartland Home Healthcare and Hospice — PA, DE, VA
Excela Health — PA
Embracing HospiceCare of New Jersey — NJ
Center For Hope Hospice and Palliative Care — NJ
Delaware Hospice, Inc. — DE
ATHC Hospice LLC — VA
Asera Care Hospice — VA
New Century Hospice (Staunton) — VA
Centra Health Hospice House — VA
Gentle Shepherd Hospice — VA
Sentara Hospice — VA
Amedisys — PA, NJ, VA, WV, NC, TX
Four Seasons Compassion for Life — NC
Interim HealthCare of Rockhill, SC — NC
Hospice and Palliative Care — Charlotte Region — NC
Community Homecare & Hospice — NC
Right at Home — TX
CIMA Hospice — TX
River City Hospice — TX
Encompass Hospice — VA, TX 
Hospice Touch — CA
Procare Hospice — CA
Mid Valley Hospice — CA
ConclusionWe have compiled a list of 30 hospice companies in the spreadsheet attached and have included the company name, states served, services provided and a link to the official company website.

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Hospice - Profitability

During the last decade, the US hospice industry has undergone substantial changes. In 2008, profits averaged 4% and continued to decrease in the following years. In 2012, the industry reflected a profit increase of 6% but decreased to 4% in 2013. In 2015, the use of hospice started to grow and with it, an increase in profit margins. Meanwhile, 2017 was forecast to mark negative profit margins. However, due to the aging population, which is deemed to be 78 million baby boomers, the hospice industry is expected to rise in the upcoming years despite an uncertainty surrounding reimbursement rates.  

the basicsHospice care is designed for patients who are diagnosed with a life-threatening illness and which are considered to be in the advancing stages of their condition. Some of these diseases, among others, include Alzheimer’s disease, stroke, dementia, cancer, Lou Gehrig’s disease, congestive heart failure, COPD and Parkinson’s disease. The idea behind hospice care is to provide not only services that relieve physical symptoms such as pain, shortness of breath, nausea, vomiting, anxiety and restlessness, etc., but also services that cure the emotional and spiritual issues of the patient and the family that often accompanies a terminal illness. 

In the United States, hospice care is covered under Medicare, Medicaid, private insurance plans, health maintenance organizations and other managed care organizations. Over the last 15 years, hospice spending has grown substantially, increasing at a rapid rate between 2000 and 2012, remaining flat between 2012 and 2014, and growing again in 2015. Between 2000 and 2012, Medicare spending for hospice care increased more than 400%, from $2.9 billion to $15.1 billion. That spending increase was driven by greater numbers of beneficiaries electing hospice and by growth in length of stay for patients with the longest stays. 

USE OF HOSPICE SPACE CONTINUES TO RAISE 
The first hospice benefit period is 90 days. Hospice is intended for patients with a prognosis of fewer than six months, but most of the time, stays exceed six months. If the patient’s terminal illness continues to engender the likelihood of death within six months, the hospice physician can re-certify the patient for another 90 days and for an unlimited number of 60-day periods after that, as long as the patient remains eligible. 

The use of hospice care among Medicare beneficiaries has increased since 2015, which has affected the continuing trend of the growing proportion of beneficiaries using hospice services at the end of life. Hospice use varies depending on the beneficiary characteristics such as: age, gender, racial and ethnic group, urban and rural areas, and depending on the different types of diagnoses. For example, in 2015, hospice use was least prevalent among beneficiaries under-age 65 and more prevalent among beneficiaries age 85 and older (about 30 percent vs. 57 percent of these decedents used hospice, respectively). Also, female beneficiaries are more likely than male beneficiaries to use hospice, which also reflects the longer average life span for women and greater hospice use among older beneficiaries. 

The hospice use also varies based on the racial and ethnic group. As of 2015, Medicare hospice use was highest among White decedents, followed by Hispanic, African American, Asian American, and North American Native decedents. Hospice use is higher for urban than rural beneficiaries. In 2015, the share of decedents residing in urban counties who used hospice was about 50 percent; in rural counties adjacent to urban counties, 44 percent; in rural nonadjacent counties, 39 percent; and in frontier counties, 34 percent. 

One driver of increased hospice use over the past decade has been growing use by patients with non-cancer diagnoses, owing to increased recognition that hospice can care for such patients. In 2015, 72 percent of Medicare decedents, who used hospice, had a non-cancer diagnosis, compared with 71 percent in 2014 and 48 percent in 2000. Nationally, the top three non-cancer primary diagnoses for patients admitted to hospice in 2014 were dementia, heart disease and lung disease, according to the National Hospice and Palliative Care Organization. 

HOSPICE INDUSTRY TRENDS AND FORECASTS 
 In 2008, profits of the hospice industry averaged 4%. This profit margin sustained itself until 2011. Since then, profit margin has decreased slightly per each year. According to an article by Hospice Action Network, the industry of hospice was estimated to have a negative profit margin for 2017. However, the industry itself reflected a profit increase of 6% in 2012 and then decreased to 4% in 2013. In 2015, the industry started to increase its profit and thus continued to have successful profit margins. 

Today, approximately 78 million baby boomers (those born between the years 1946 and 1964) are at or near retirement. While Americans are living longer, these breakthroughs are also contributing to the increase in years with which seniors are living with chronic or terminal conditions. 

According to a market research report on Hospices and Palliative Care Centers in the US, hospice care revenue is expected to rise in the upcoming years, despite the uncertainty surrounding reimbursement rates. It also emphasizes that the industry demand will likely escalate alongside the elderly proportion of the population. Along with that, hospice stays and nursing homes will become more expensive. 

 April Anthony, the CEO of Encompass Home Health, also expects volumes, in both home care and hospice, will continue to expand as the baby boomers continue to age and become closer to the average age of a home care patient. 

Based on a survey conducted by Health Care First, regarding the challenges that hospice industry was facing in 2016, reduced profit margins was principal challenge. The home health and hospice agencies were expected to do and offer more, while getting a lot less in return. Another challenge was the recruitment or the hiring of qualified staff. Also, the fear of ADRs, take backs or audits, constitutes one of the biggest challenges for the hospice industry. According to this survey, 18% of respondents indicated that this was a top challenge for their agency.  

CONCLUSIONOver the years, the trends in the hospice industry in the US have changed during different periods of time.  During the last ten years, the industry profitability rates have fluctuated between 4% and 6%. The industry itself faces many challenges but with the aging population in the US, the potential of the industry to grow is substantial.

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Hospice - Merger and Acquisitions.

Humana Inc, Ensign Group, Kindred Healthcare, and Almost Family are some publicly traded company that was actively involved in acquisitions of Hospice service providers in 2016 and 2017. Other privately held companies that were also involved in mergers and acquisitions of Hospice service providers include Optima Healthcare, Jordan Health Services and Procura Healthcare Software. There was also a reported case of a joint partnership between Hackensack Meridian Health and St. Joseph’s Healthcare system to form Visiting Health Services and VHS Hospice Services of New Jersey.

PROCURA ACQUISITION OF SUNCOASTProcura Healthcare Software is a private company located in California. The company provides "home and community care software solutions" for home health agencies, community care agencies, hospices, and residential care agencies in the United States.

 In 2016, the company acquired SunCoast solutions for an undisclosed amount. SunCoast Solutions was formerly the technology arm of Empath Health; a specialized care provider in chronic and advance illness including providing hospices services. 

In a statement by the CEO of Procura, Chris Junker, the acquisition would “have a significant impact on home health care delivery, whose providers are increasingly adding hospice services to their offerings. The acquisition combines Suncoast’s hospice knowledge with Procura’s expertise in deploying large, global, and complex software solutions to the healthcare community." 

ALMOST FAMILY ACQUISITION OF COMMUNITY HEALTH SYSTEMSAlmost Family is a public subsidiary of LHC group and a provider of home health and personal care services based in Louisville. In January 2017, the company acquired the home health and hospice assets of Community Health Systems, Inc. which offers skilled home health and hospice services. Almost Family has over 340 branches in 26 states with projected revenue of about $800 million. The transaction deal was worth $128 million.

KINDRED HEALTHCARE ACQUISITION BY HUMANAIn December 2017, Kindred Healthcare, one of the top three Hospice Providers in the United States accepted to be acquired by Humana Inc and two other companies in a definitive agreement. The acquisition deal is expected to cost $4.1 billion in cash value. Humana would own 40% of home health, hospice and community-based care business and would pay about $800 million for its part of the acquisition. 
Humana is a publicly traded company with it's headquaters located at Louisville, Kentucky, USA.

OPTIMA HEALTHCARE SOLUTION ACQUISITION OF HOSPICESOFTOptima Healthcare Solutions is a privately held company located in Florida, and they offer cloud-based therapy management software for post-acute care providers. In May 2017, the company acquired Hospicesoft for an undisclosed amount. Hospicesoft specialises in providing "EMR, billing and hospice management solutions" for Hospices.

THE ENSIGN GROUP LIST OF HOSPICES ACQUISITIONSThe Ensign group inc is a publicly traded company that provides home health and hospices services. The company was founded in 1999 and located California, USA. According to report, Cornerstone Healthcare, Inc., the home health care and hospice division of The Ensign Group currently operates about 22 hospice operations across 11 states. Between 2016 and 2017, the company made some series of acquisitions which includes;

-Comfort Hospice Care: Located in Southern Nevada, the company was acquired in September 2017 by Ensign's home health and hospice portfolio company.

-Excell Home Care and Hospice: The Oklahoma based company was acquired in November 2017 by Ensign's home health and hospice portfolio company. 

-River City Hospice: Located in Idaho, the company was acquired in November 2016 by Ensign's home health and hospice portfolio company.

-Kinder Hearts Home Health and Hospice: On September 2016, the Texas-based company was acquired by Ensign's home health and hospice portfolio company.

-Hospice for Wright County: Acquired in May 2016 by Ensign's home health and hospice portfolio company. The company is located in Wright County, Iowa.

JORDAN HEALTH SERVICES LIST OF ACQUISITIONS Jordan Health Services is a private company located in Texas and is one of the largest providers of home care and hospices services. The company serves over 37,000 patients in about 116 locations within the states of Texas, Oklahoma, Arkansas, Louisiana and Missouri.   
Some recent acquisitions made by Jordan Health Services includes

-Pyramid Home Health Service in Missouri (2018)
-Health Sense Hospice Inc (2017)
-Grapevine Mission Hospice in Texas (2017)
-CareCycle Solutions in Texas (2017)
-SimCor Home Care in Louisiana  (2016)

HACKENSACK MERIDIAN HEALTH AND ST JOSEPH HEALTHCARE SYSTEMAccording to a 2017 report, New Jersey-based Hackensack Meridian Health and St. Joseph’s Healthcare system combined to form Visiting Health Services of New Jersey and VHS Hospice Services of New Jersey. The home health and hospice agencies seek to expand their services further to other New Jersey counties. The partnership currently has over 1,125 employees with an estimated 400,000 combined home visits in 2016.

CONCLUSIONAccording to Healthcare Finance, mergers and acquisitions in the Hospices sector have been relatively slow with few active players. However, the most significant hospices merger and acquisition based on transaction volume was the acquisition of Kindred Healthcare by Humana Inc in a definitive agreement worth $800 million in December 2017.