1. Originally presented April 2009

2. PURPOSE
 To utilize hospice penetration as a metric for access to
care
 To identify those states with high and low levels, on a
relative basis, of hospice penetration
 To compare and contrast various market factors, at the
state level, to understand differences between high and
low penetration states

3. AGENDA
 Background
 Identification of High and Low Penetration States
 Market Factors Influencing Penetration
 Conclusions

4. SPEAKER BACKGROUND
 BA Lehigh University Mathematics, MBA MIT Sloan
School
 Marketing and planning positions with Fortune 100
companies, with emphasis of consumer products
 20+ years in all aspects of home care with for-profit
and non-profit organizations
 President, Healthcare Market Resources, a local
market competitive intelligence firm

5. DATA SOURCES
 Medicare hospice claims files
 Medicare reports
 Center for Disease Control publications
 Department of Commerce, Census Bureau
 State Departments of Health websites

6. RESEACH APPROACH
 Regression Analysis
 See if hospice penetration is dependent on a given
variable
 Utilizes entire set of state data
 Very high or very low correlation can be relied upon
 High/Low Penetration
 Identify high and low penetration states & see if these
groups’ results mirror top 10 or bottom 10 performers for
that indicator
 Better able to identify factors that enhance or inhibit
penetration

7. HOSPICE PENETRATION METRIC
Patients Served
Medicare Eligible = Hospice Penetration

8. PENETRATION BY STATE 2006
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
AL AK AZ AR CA CO CT DE DC FL GA HI ID

9. PENETRATION BY STATE 2007
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
AL AK AZ AR CA CO CT DE DC FL GA HI ID

10. PENETRATION BY STATE 2006
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
IL IN IA KS KY LA ME MD MA MI MN MS MO

11. PENETRATION BY STATE 2007
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
IL IN IA KS KY LA ME MD MA MI MN MS MO

12. PENETRATION BY STATE 2006
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
MT NE NV NH NJ NM NY NC ND OH OK OR PA PR US

13. PENETRATION BY STATE 2007
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
MT NE NV NH NJ NM NY NC ND OH OK OR PA

14. PENETRATION BY STATE 2006
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
RI SC SD TN TX UT VT VA WA WV WI WY US

15. PENETRATION BY STATE 2007
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
RI SC SD TN TX UT VT VA WA WV WI WY US

16. HIGH PENETRATION STATES 2006
•OKLAHOMA •ARIZONA
•ALABAMA •UTAH
•MISSISSIPPI •FLORIDA
•IOWA •GEORGIA
•NEW MEXICO •TEXAS

17. HIGH PENETRATION STATES 2007
•ARIZONA •FLORIDA
•UTAH •IOWA
•OKLAHOMA •DELAWARE
•ARIZONA •TEXAS
•MISSISSIPPI •MISSOURI

18. LOW PENETRATION STATES 2006
ALASKA HAWAII
WYOMING NEW YORK
DISTRICT OF PUERTO RICO
COLUMBIA
VERMONT SOUTH DAKOTA
MAINE WEST VIRGINA

19. LOW PENETRATION STATES 2007
ALASKA WYOMING
HAWAII NEW YORK
DISTRICT OF VERMONT
COLUMBIA
SOUTH DAKOTA KENTUCKY
WEST VIRGINA MAINE

20. PENETRATION GROWTH 2006
100.00% 98.20%
90.00%
80.00%
70.00%
60.00%
48.00% 51.20%
50.00%
40.00%
40.00%
30.00%
20.00%
10.00%
0.00%
HIGH LOW LOW w/o AK AVG

21. PENETRATION GROWTH 2007
100.00% 97.26%
90.00%
80.00%
70.00%
60.00% 56.38% 55.21%
50.00% 47.56%
40.00%
30.00%
20.00%
10.00%
0.00%
HIGH LOW LOW w/o AK AVG

22. HIGH GROWTH STATES 2006
•ALASKA •MAINE
•DELAWARE •RHODE ISLAND
•SOUTH DAKOTA •IDAHO
•MISSISSIPPI •ALABAMA
•KANSAS •TENNESSEE
High Penetration-Bold; Low
Penetration-Italics

23. HIGH GROWTH STATES 2007
•ALASKA •MAINE
•DELAWARE •RHODE ISLAND
•IDAHO •SOUTH DAKOTA
•SOUTH CAROLINA •NORTH DAKOTA
•TENNESSEE •IOWA
High Penetration-Bold
Low Penetration-Italics

24. LOW GROWTH STATES 2006
KENTUCKY COLORADO
HAWAII NEVADA
ILLINOIS MICHIGAN
FLORIDA OREGON
WASHINGTON MARYLAND
High Penetration-Bold
Low Penetration-Italics

25. LOW GROWTH STATES 2007
KENTUCKY COLORADO
NEVADA ILLINOIS
OREGON HAWAII
WYOMING MARYLAND
NEW YORK FLORIDA
High Penetration-Bold
Low Penetration-Italics

26. CON STATES PENETRATION 2006
2.50%
2.25% 2.29% 2.19%
2.00% 1.82%
1.71%
1.50%
1.00%
0.50%
0.00%
CON CON Non-CON Nat'l Wght Nat'l
States States w/o States Avg Unwght
FL Avg

27. CON STATES PENETRATION 2007
3.00%
2.43% 2.41%
2.50% 2.30%
2.00% 1.92%
1.82%
1.50%
1.00%
0.50%
0.00%
CON States CON States Non-CON Nat'l Wght Nat'l Unwght
w/o FL States Avg Avg
CON States - 25% of Total

28. ACCESS IN CON STATES 2006
(Hospices per Counties)
3 3
2.5
2
1.5 1.4
1.28
1.17
1 0.95
0.82 0.8 0.82 0.79
0.68 0.63 0.71
0.6
0.5
0.33
0.23
0
AR DC FL HI KY MD NY NC SC TN VT WA WV US AVG

29. ACCESS IN CON STATES 2007
(Hospices per Counties)
3.50
3.00
3.00
2.50
2.00
1.60
1.48
1.50
1.17
1.02
1.00 0.81 0.82 0.82
0.65 0.71 0.68
0.64 0.60
0.50 0.33
0.23
-
AR DC FL HI KY MD NY NC SC TN VT WA WV US AVG

30. HIGH PENETRATION STATES 2006
CON STATES IN BOLD
•OKLAHOMA •ARIZONA
•ALABAMA •UTAH
•MISSISSIPPI •FLORIDA
•IOWA •GEORGIA
•NEW MEXICO •TEXAS

31. HIGH PENETRATION STATES 2007
CON STATES IN BOLD
•ARIZONA •FLORIDA
•UTAH •IOWA
•OKLAHOMA •DELAWARE
•ARIZONA •TEXAS
•MISSISSIPPI •MISSOURI

32. LOW PENETRATION STATE 2006
CON STATES IN BOLD
ALASKA HAWAII
WYOMING NEW YORK
DISTRICT OF PUERTO RICO
COLUMBIA
VERMONT SOUTH DAKOTA
MAINE WEST VIRGINA

33. LOW PENETRATION STATE 2007
CON STATES IN BOLD
ALASKA WYOMING
HAWAII NEW YORK
DISTRICT OF VERMONT
COLUMBIA
SOUTH DAKOTA KENTUCKY
WEST VIRGINA MAINE

34. LOW GROWTH STATES 2006
CON STATES IN BOLD
KENTUCKY COLORADO
HAWAII NEVADA
ILLINOIS MICHIGAN
FLORIDA OREGON
WASHINGTON MARYLAND

35. LOW GROWTH STATES 2007
CON STATES IN BOLD
KENTUCKY COLORADO
NEVADA ILLINOIS
OREGON HAWAII
WYOMING MARYLAND
NEW YORK FLORIDA

36. HOSPICE PENETRATION
(Hospice Deaths as % of Anticipated Deaths)
50.0% 45.3% 44.4%
45.0%
40.0%
33.6%
35.0%
30.0%
25.0% 20.1% 20.4%
20.0%
15.0%
10.0%
5.0%
0.0%
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg

37. METRIC COMPARISON BY STATE
High Death % High Penetration % Low Death % Low Penetration %
Arizona Oklahoma Alaska Alaska
Utah Arizona Dist of Columbia Hawaii
Alabama Alabama Hawaii Wyoming
Florida Utah Wyoming New York
Mississippi Mississippi Puerto Rico Dist of Columbia
Colorado Florida New York Puerto Rico
New Mexico Iowa Vermont Vermont
Oklahoma Georgia South Dakota South Dakota
Oregon New Mexico North Dakota Maine
Iowa Texas Maine West Virginia

38. HOSPICE GROWTH
(% Change in Hospice Penetration % 2002-6)
80.0% 79.9%
70.0%
60.0%
51.0%
50.0% 48.0%
40.0%
40.0%
30.0%
23.1%
20.0%
10.0%
0.0%
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg
w/o AK w/o AK

39. HOSPICE GROWTH
(% Change in Hospice Penetration % 2002-7)
100.0%
92.6%
90.0%
80.0%
70.0%
60.0% 56.4% 55.2%
47.6%
50.0%
40.0%
30.0% 27.3%
20.0%
10.0%
0.0%
Top 10 w/o High Pent Bottom 10 Low Pent Nat'l Avg
AK w/o AK

40. POPULATION DENSITY
Population per Square Mile
700
604.57
600
500
400
300
200
100 92.9 90.2 83.8
14
0
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg
w/o DC w/o DC

41. ACCESS TO CARE
(Hospices /10K Medicare Eligible)
2 1.98
1.8
1.6 1.49
1.4
1.2
1
0.84
0.8 0.73
0.6
0.4 0.36
0.2
0
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg

42. GEOGRAPHIC ACCESS TO CARE
(Hospices per 1K Sq Miles)
6 5.83
5 4.73
4
3
2
1.28
1 0.61 0.81
0.28
0
Top 10 High Bottom Low Low Nat'l
ex DC Pent 10 ex Pent Pent ex Avg
AK AK, DC,
PR

43. NON-WHITE PATIENTS
(% Non-White Discharges)
35.0% 32.5%
30.0%
25.0%
20.1%
20.0%
15.0% 14.7%
12.1%
10.0%
5.0%
2.0%
0.0%
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg

44. NON-WHITE HOSPICE PENETRATION
(% Non-White Discharges/% Non-White Population)
70.0% 67.5%
60.0%
50.0%
41.0% 42.4%
40.0% 36.5%
31.3%
30.0%
20.0% 18.1%
10.0%
0.0%
Top 10 High Bottom Low Low Nat'l
Pent 10 Pent Pent ex Avg
DC, HI

45. DISEASE MIX
(% Non-Cancer Hospice Deaths)
70.0% 67.2%
60.0% 61.9%
60.0%
53.8% 54.8%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg
80+% Correlation between Hospice Penetration & Non-Cancer Hospice Deaths

46. ALZHEIMER’S IMPACT
(% Alzheimer’s/Dementia Deaths of Total Deaths)
35.0%
30.9%
30.0%
25.0%
19.9%
20.0%
16.9%
14.8%
15.0%
10.0%
7.1%
5.0%
0.0%
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg

47. FOR-PROFIT PRESENCE
(FOR-PROFIT MEDICARE REVENUES/TOTAL MEDICARE REVENUES)
80.0% 77.4%
70.0%
63.0%
60.0%
50.0% 49.4%
40.0%
30.7%
30.0% 25.0%
20.0%
10.0% 9.7%
0.0%
Top 10 High Bottom Low Low Nat'l
Pent 10 Pent Pent ex Avg
AK

48. LENGTH OF STAY
(Days per Discharge)
100 99.8
91.7
90
80
69.8
70 64.5
60 53.2
50
40
30
20
10
0
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg

49. LONG STAY PATIENTS
(% Patients w/LOS>180 days)
18.0% 17.0%
16.0% 15.4%
14.0%
12.0% 10.8%
10.0% 9.2%
8.0% 7.2%
6.0%
4.0%
2.0%
0.0%
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg

50. LONG STAY PATIENTS
(% Patients w/LOS>90 Days)
30.0% 28.6%
26.7%
25.0%
19.7% 20.6%
20.0%
15.1%
15.0%
10.0%
5.0%
0.0%
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg

51. NURSING HOME MARKET
 On currently available claims data, there is no data on
place of service; must infer
 Claims data has place of death; if patient dies in a medical
facility, it is either a hospital or a skilled nursing facility
 If patient dies in a hospital, they were likely there to
receive inpatient services
 So if a patient dies in a medical facility and has no
inpatient days on the last claim, we infer that they must
have did in a SNF

52. NURSING HOME MARKET
(% DIED IN MED FAC W/NO INPT DAYS)
35.0%
30.9%
30.0%
25.0%
19.9%
20.0%
16.9%
14.8%
15.0%
10.0%
7.1%
5.0%
0.0%
Top 10 High Pent Bottom 10 Low Pent Nat'l Avg

53. CORRELATION SUMMARY
(Hospice Penetration)
INDICATOR CORREL INDICATOR CORREL
Hospice Growth -.265 Alzheimer’s Impact .257
Population Density -.217 For-Profit Presence .477
Access to Care .372 Length of Stay .597
Geographic Access -.198 Long Stay Patients .645
Non-White Patients -.129 Long Stay Patients 90+ .583
Non-White Penetration .017 “Nursing Home” Market .124
Disease Mix .807 Hospice Death Penetration .949

54. CONCLUSIONS
 Few market factors appear to consistently influence
hospice penetration(access to care)
 Those factors with the greatest influence
 Non-Cancer Hospice Deaths
 Length of Stay, particularly driven by 180+ day patients
 Presence of For-Profits
 CON appears to inhibit hospice penetration

55. CONTACT INFORMATION
Rich Chesney
President, Healthcare Market Resources
rchesney@healthmr.com
215.657.7373
215.657.0395(f)
www.healthmr.com