1

Certificate of Need – Hospice Services

Notes for Stakeholder Meeting – October 06, 2016

WAC 246-310-290

Meeting began with introductions, agenda overview. Kathy anticipated first presenters to arrive around 1:10PM.

1. Presentation by Continuum Care Hospice: Washington State Hospice Underutilization in theAfrican American Community

Presenters: Cristi Keith, Administrator and Gail Ferguson, RN. Traveled from out of state to present, causing a slight delay in start time.

Cristi: Appreciate you guys allowing us to be here today. Let me get my notes out. Do you have our PowerPoint by chance? Kathy: I do, let me get it up on the screen here. (General conversation regarding slide show and presenter positioning; Kathy asks if everyone received a handout of the slide presentation; Cristi provides additional materials for workgroup use; Kathy asks for electronic versions for distribution to group). Kathy: One other thing before we get going, Nancy Tyson is here, she is our executive director. Thanks, Nancy (T). (Tape: 00:04:03) Cristi: (Began with brief a personal introduction; described her role and experience in hospice care, generally). I am going to stand where I can see the PowerPoint too so we can kind of use it as a guide so we can stay on task and stay on time….I actually run, CEO of Continuum Hospice. We started our first pilot if you will, I’ve been in hospice for about eleven (11) years. Started our first hospice in the California Bay area. (Provides additional general information re Continuum). Cristi: My focus here and our mission here was to be sure that hospice was nothing but quality care, accessibility, and really trying to work as a partner in the community to reduce the healthcare costs overall with end of life care and I feel like there are some deficits in general and I know that Washington, just based on statistics, is doing a good job (Tape, 00:05:22), but again there is some room for improvement and California is the same way. So, we essentially started this program with that in mind. So there’s a lot that we do that might be a little bit different than where I can from or what you might be used to when you think of hospice, but that’s general introduction. (Introduces Gail). Cristi: (Summarized from tape)

• Provided background of core Medicare hospice benefit, described what Continuum’s programdoes to provide the benefit. Music, pet therapy provided as part of benefit. Operates asfreestanding hospice, but partners with local hospitals.

• Hospice utilization is growing nationally; asserts that there is room for growth. New EnglandJournal of Medicine Study cited in PowerPoint notes average lifespan of a hospice patient is 29days longer than someone who is not pursuing hospice at end of life (Tape, 00:08:34). Try to getthat extra month for as many people as we can.

• Brief statistical discussion. 2015 has not been released yet. (Tape, 00:08:55) Numbers are fromNHPCO membership, so if provider is not a member, their numbers are not included. Nationally,in 2013, 45% of Medicare beneficiaries were dying on hospice. 47% of the white Medicare

2

beneficiaries are dying on hospice; 34% of the African American beneficiaries were dying on hospice. Asserts that the focus has not been on narrowing the gap between diverse groups (Tape, 00:10:27) (Also, refer to PowerPoint presentation; Cristi reads through statistics presented in each slide regarding utilization).

• Hospice utilization between white and African American groups is different; benefit is beingused, but there is still disparity (nationally).

• In WA, 43% of Medicare beneficiaries died on hospice; 44% were white, 32% were AfricanAmerican. Trending in the wrong direction. (Tape, 00:12:03)

• Comparing national statistics to Washington data, Continuum would like to see the numbers goup to reduce disparity. Green in the slide is that national hospice utilization total, so obviouslythe Caucasian use is high which is good, and then the WA overall utilization of whites is the redline and then the WA hospice utilization total is the blue line. Then where it falls down a little bitis when we look at here (comparing to national statistics) I think we’d like to see it going more inthe upward trajectory.

Nancy F: (Tape 00:14:25) Question. Could you remind us if this is admissions or days? Cristi: Days. Well, no, because, well actually, go back a slide. It’s basically off this data. So you’re talking about total population of utilization of hospice in general, so if you’re an African American and you have utilized the hospice benefit and you’re not talking about admissions or days in that perspective, you’re talking about utilization. If you have 43% of African Americans and only 26% of (unintelligible) so it’s basically taking this data and translating it into a bar graph. Frank: But it seems like admissions versus days would matter… Cristi: Admissions versus days matters… Frank…unless length of stay is constant…. Cristi: …but the statistics here are based off, purely based off utilization of Medicare beneficiaries and their race, it’s, that’s, I mean, the statistics here are based on total population, so utilization (unintelligible). So if you were admitted, you know, if you had ten admissions, it’s still, days isn’t going to matter because it’s the total utilization of your hospice benefit, you know what I’m saying, so you could be using it for… Nancy F: (Tape: 00:15:38) You can do that within the state but you can’t compare Washington to the national numbers using days. Cristi:…so…. Nancy F: You can do it race to race, state to state and time, but you can’t do Washington to national because the days are so different. Cristi…because the days are different. You’re bringing a good point, and I think, when basically, when I, at NHPCO when they do nationally and they do break it out by state, I don’t know how they are correlating because they do break out by state by utilization of race and ethnicity so I’d have to figure out how they’re doing that to see how they are pulling the data. Because definitely they are because we pull it, you know, we have it for California too and it’s come straight from them so we’d have to figure out Nancy F: I think these make a lot of sense but when we start comparing Washington to national then you’ve got another factor affecting your numbers that may be skewing it without our knowing what the skew is. Cristi: Right. Frank: So is length of stay the same? Cristi: Well length of stay is not being correlated… Frank: I know that, but I’m just asking the question. Cristi: Length of stay the same for…

3

Frank: Whites versus African Americans. Cristi: You know, honestly, what we’ve seen, I can talk only from our agency because I would have to pull statistics, I don’t want to answer for not having, but for our agency we’re seeing a shorter length of stay because it takes a little bit longer for, in general, it feels like it takes a little bit longer for that ethnicity to trust that it’s the right direction for them. That’s based on our findings, again that’s just my company and I can’t speak to anything beyond that. So a shorter length of stay on average. Yes. Barb: What is your program’s median length of stay, for example, do you happen to know? Cristi: Our average length of stay right now is actually 49 days. Median is about 17. And keep in mind that Continuum has been a Medicare certified program since July 1st of 2015 so our data, although trending in the right direction, it’s gonna change. So, you know, we started this program with all this as a mission so our data is trending in the right direction, but it’s still a small polling when you are starting out. Nancy F: Do you have a percentage on your ethnic breakdown? Cristi: I do. And I’m going to share that with you, yes. Barb: Should we actually just let you do your presentation? Cristi: Did it on the plane, absolutely have my breakdown. I did last quarter, most recent, so anyway… (Summarized from tape):

• Multiple reasons why African American population are less likely to use hospice benefit, eventhough they suffer from inequitable rates of the most common diagnosis (cancer, heart diseaseand stroke) and one would expect them to be over-represented, but they aren’t. As utilizationdeclines, Continuum is working toward remedying situation.

• Reads from slides from most of remainder of her portion of presentation based on timerestraints (see PowerPoint presentation).

• Describes clinical staff and experience levels of that staff.• African American population approaches healthcare and services in a way that does not fully

utilize benefits. Asserts that Continuum is seeing results in an area where there’s a big gap inCalifornia. 4.7% in the past vs 11% currently. Asserts that exceptions in rule language will helppatients fully use benefits.

Gail Ferguson: (Tape: 00:26:36) (Summarized) Begins her portion of the presentation describing roles she’s served at Continuum. Describes specific program components. Notes that Continuum has found that patients really don’t want to be in the hospital, ER, etc. Prefer to be at home, but there are trust issues with use of healthcare services and providers. Healthcare systems and those who represent them are generally associated with government, heightening levels of distrust. (Summarized from tape, Gail quickly moves through and reads through slides)

• Continuum has engaged in patient education - Gail reaches out to communities, health careproviders, etc. to bridge and close trust gap. Wants to build trust before a time of individualpatient and/or family crisis. Describes working with families and discussing access and crisisissues. Describes discrimination in the delivery of services. Inadequate insurance, lack ofadvance directives, lack of diversity in staffing (clinical and otherwise).

• Gail tries to reach out and establish common interests and relationships; clinicians andcaregivers.

• Solutions: move forward. Increase access to hospice for African Americans. Will help to reducehospital costs, strengthen relationships and increase use of benefit.

4

• Believes exception is needed to address these issues, regardless of race. Reduce gap ofaccessibility to all races. Need to create access, understand cultures.

• Question regarding number of providers in community.

Nancy F: (Tape, 00:40: 33) I don’t know if you’ve seen our draft rules, but we do state that there will be an exception to the standard need formula for particular groups, and in this state, and looking at the demographics you night have seen, we probably have more Native Americans and Asians then Spanish speaking, even the African Americans, and at least looking at the national data, their numbers are at least as bad if not worse, do you feel that a general exception like that is going to respond what you’re here to ask us for today? Cristi: Absolutely because I think the exception, it doesn’t matter which race you’re talking about the plan is still the same, right, you’re still going to have the same plan and strategy in place to outreach to those community members and you’re going to develop your staff to reach to those community members and to build trust so my plan would be exactly the same if I was looking at the Native American population, Asian population, I would create the same plan and it’s very successful where we’ve, the African American population where we’re located is pretty significant, so it’s more blaring and glaring for me, but I would say the exception, absolutely, we could meet the need of what the state needed, we could meet the need and looking at the population and demographics if that’s what it is you could probably actually close the gap on more than one, right, it does not have to be just one focus. It’s the same outreaching plan, I mean to think to me the number one thing to take away is that we are a community partner and we’re here to really reduce the gap of accessibility to all races. And so I think if we do a good job in hospice, we’re doing a really good job if we’re reaching out to every single race and ethnicity and until it’s all equally the same then our job’s not done yet. Gary: It’s interesting. We did an outreach to (unintelligible) community and we used about the same thing. Cristi: And how did it go? Gary: Oh very well. We tripled our numbers.

• Closing discussion of focus and quality of care; need to take hospice to “the next step,” “onestep further” and creating access.

• Provided several handouts - will provide in e-copy as well.• Cristi and Gail move to back of room to listen to exception discussion.

2. Exception Language Discussion

Kathy: I thought this would be a really good segue to talk about our proposed exception language. I am not sure that I sent this draft to everyone, I hope that I did, but on the 10th of August, Bart, Beth and I worked through subsection 12 here again, and have some language to propose to you. We didn’t receive proposed language from anyone. Last page of redlined version (of rule). Proposal is something to think about. Nancy F: (Tape, 00:46:04) The one thing that jumps out there is that I think we’ve talked a couple of times about the wording not being restricted to the demographic population and we would use the word “circumstances” and its troubling to me that down the line that could be interpreted as a group we can find in OFMs numbers where we’re really talking about other kinds of situations in which needs are not being met besides demographic groups that you can count in the census and the word we’ve settled on a couple of times is special circumstances not being addressed rather than a specific population not being served. Kathy: Did anyone see that in the consensus document? I don’t have that in front of me.

5

Beth: I was under the impression that the look back to OFM was only for the pediatrics, and everything else was, we didn’t talk about, OFM data… Nancy F: Right but all I’m saying is that if I were going to read that as staff in ten years, or a judge if this were to go to court, I think it would be really easy to argue that this group meant a demographic population and when we’ve talked about it, we’ve said special circumstances, not just identifiable groups of people. You know, they’re religious, is a religious group a population, yes, pediatrics, we would call that a population, um, but we’ve talked about a lot of situations in which a hospice, existing hospices may not be meeting current need and we left open, I mean, the applicant would have to put down their money and they’d have to pay to get their application put together, they’d have to pay the fee and argue that there is a significant need going unaddressed and I think to say specific population is narrower than we’ve ever said in this room. Gina: I don’t think we agreed on that. Frank/Kathy: That’s right. I don’t think that we agreed.1 Gina: I don’t agree with that. Nancy F: Well we can listen to the tape maybe. Kathy: I’ll send them to you. Nancy F: (Tape, 00:48:35) I don’t need to, I know what we said, I don’t need the tape. Kathy: At any rate, does anyone have any other comments with respect to the language… Nancy F: So how would we, before we move on then how would we address this? This is the draft we haven’t seen, right? Frank: Seems to me that the difficulty with exceptions is that unless we’re well defined about what those exceptions ought to be the department does not have any clear direction and the ability to be transparent and replicable with the rule. And I like the word “specific populations” because that does tie to something. If you make it significantly more generic than that, then the department does not have, I don’t think, good direction…. (Tape 00:49:23) Nancy F: Well I agree with you entirely and Frank: (tries to continue)…and I don’t think you would have consistency or transparency… Nancy F: I argued on that side that we specifically make the point that people who would like to be served by an organization that doesn’t put its religious values into the workplace and (unintelligible) would allow for death with dignity to be aggressively or at least directly offered to the hospice patient. Some have argued that death with dignity does not have anything to do with hospice, but I think that, at least in the county I live in, it was a 70% vote that death with dignity should be available. And so to tell the people in that county, if the current hospice doesn’t even let me know or if they are religious and can’t even mention that law, then there’s a significant need that 70% of the population said they want met. And Jan said, let’s don’t be specific, I want it to be vague. Now we’ve gotten specific again but in appropriately specific. So I would be happy to say that if a hospice doesn’t offer or doesn’t, you know, penalizes an employee for mentioning death with dignity or the hospice has a religious prohibitions against offering it as part of hospice, that another hospice in that county should be able to be started. But, to, Jan said we want it vague, let the applicant make the argument. Now we’ve come back around and making it specific and losing the initial need. Steve: (Tape, 00:51:090) Well, the other alternative is, there is an argument to be made under existing CoN statute and regulations, one has the ability to argue for special circumstances. The need statutory provision says that the job of the department is to determine, determines whether the population served or to be served has a need for the service to be offered, and two, whether existing providers are available and accessible to meet that need. So, frankly one option is to not have exceptional

1 See timestamped consensus document, notes and tapes from prior meetings.

6

circumstances language. Frankly, the way the regulation currently appears, one could make an argument under the existing statutory provision and the regulation tracks and language that I just cited, one can still make an argument that there are special circumstance. And let’s take a step back. I went back and looked at what the consensus was, and there was a general consensus that we would consider exceptions and as someone mentioned, one of the things we considered was, everybody seemed to agree that the pediatric population was a readily identifiable special population. But, and the language that went in to the proposed regulation, and after all, it is a proposed regulation, it’s not cast in stone, Kathy took out of, and I’m not faulting her for this, she took it out of a Florida regulation which I had done some research on, and Frank and I have research hospice regulations all over the country, and I said, well, here’s an example of what someone has done and at the time I said Providence is not suggesting that this is the way to go. The language in here is from Florida. I don’t know how that’s worked out in Florida. So I think one of the options that’s available to us is to simply leave the regulation as it is and not even include this. If you want to have something that’s broad, that would be the way to do it, allow somebody to argue under the existing statutory framework that the existing providers are not available and accessible to meet the need and just take this out. Nancy F: Well and I think to the extent that that’s what the rule says, the law says, then, and if most of our purpose of this year or so of meetings has been to clarify and to get the law and the rule and the method all to match up because there were some mismatches, so I think if we want clarity and especially guidance to staff, because they are the ones who are left to interpret this, lets recognize what the law says in the rule so then the staff can say when someone comes to sit down with them and say I have a special circumstance, I would like to create a hospice does the staff say no way you can’t ever do that or no, my guidance says that unless it’s a population I can find in OFM you’re not gonna go plunk your $30,000 down, I mean I think now is our time to get some clarity here. Kathy: (Tape, 00:54:14) What I’m hearing is that it might be a good idea to just strike section 12 altogether. Is that the general consensus? Frank, others: Yes. Nancy F: No because we just heard a very articulate argument for those precise exceptions. Kathy: Okay, and that’s your opinion, what do others feel about that? Gina: I agree with Steve. Frank: I would agree as well. Because you do have overriding CoN criteria, one of which is need, and the language in that need criterion is very clear as Steve indicated… Nancy F: So if Gail Ferguson came in and said… Frank…you can’t argue that. Kathy: Let’s let others speak. Does anyone else want to weigh in on this? Gary: Well the one thing that I take exception to, and this came up the last time we met, that there are these comments being made about hospices penalizing staff for not offering patients their opportunity to participate in this. (To Nancy F) Where? Nancy F: Well in Washington state there have been complaints filed by employees of hospices. I can get you that. Gary: Have they been recent? Nancy F: It’s in the public record. Gary: Has there been research to find out if they are true? Nancy F: All I know is that an employee filed a complaint. Gary: Yes, but it has to be researched. Nancy F: And we also have in the newspaper statements by hospices… Gary: And we know how accurate everything in the newspaper is. Nancy F: Well, okay, we also have a study by the University of Oregon and I can get you a copy… Gary: I just want to know…

7

Nancy F: Let me answer the question please. I provided it at a previous meeting. A university professor at Oregon studied the available of death with dignity because you know Oregon (had it before Washington?) and she did a topology of five kinds of hospice in Washington, those who prohibit any mention of it through a continuum of those who support it. And I think there were one or two who support it and a substantial number, about 20, who prohibit mention of it. I’d be happy to provide you a copy of that. Gary: That would be great. Steve: I just asked Kathy, I don’t want to take the floor because I’m the one who knows the least about this, but if you look at the language I was referring to just so you don’t think I am blowing smoke here, section (2)(a), criteria for the review of applications: the need of the population served or to be served by such services has for such services, (b) the availability of less costly, or more effective alternative methods, and I think we might have to go to 105, but, that’s not it. Lori: It’s not in the general need rules, 220? Or I’m sorry, 210? Frank, others: 246-310-210 Lori: You have to prove that the other providers aren’t available or accessible. Other conversation about location of rule. Steve: Yes, (1) the population served or to be served has need for the project and other services and facilities of the type proposed are not or will not be sufficiently available or accessible. So, it’s actually, you have a two-part opportunity. The population served or to be served, one could come in and say, I have a population (Tape 00:57:53) that needs to be served and someone is not sufficiently available to meet those needs, and I share Frank’s concerns. You know, I make my living fighting with the department or supporting the department, this type of provision is a lawyer’s dream, you know, a special population. Here you have the legislature saying, is there a need for a population and is need being met by the existing providers, so I think this overcomplicates this. After all, there was a big push, generally in this country, to make regulations more simple and more direct. I think the best thing to do is to keep it out. Frank: It’s also in (2), it’s very clearly in (2). Nancy F: Okay, well let me… Steve: Well yes, you are right, all residents of the service area including low income persons, regional ethnic minorities, women, dot, underserved groups. Underserved groups is pretty darn broad, so, I think, Nancy we all know your position on this and I’ve resolved not to be cranky today, but we know your concern about the death with dignity act, we know your concern about religious organizations, but I don’t think any of us, the group, is going to agree that anybody who thinks that the death with dignity, you know, who for their religious reasons does not, you know, we’re not going to go there. (See consensus and tapes on this subject). Chris: So consensus is striking 12? Kathy: Why don’t we vote on it? So let’s see a show of hands, how many people would prefer to strike the proposed subsection 12 with respect to exceptions? We have all but one person. Candace: I have a quick question just for my education. How many people historically have applied and received based on exception only without the numerical being involved? Frank: Virtually none. Beth: I’ve been with the program a year and a half and I have not seen one in a year and a half but that’s a very small snapshot. Discussion among group members at the same regarding applications submitted requesting exceptions. Many side conversations. Nancy F: Can I follow up on Steve’s point here that if the population has the need for the project and relate that to the next agenda item which is, we’ve said that a new hospice can’t be started under the method unless there are 35 people every day who are not receiving hospice in a community and we’re

8

talking about 25 people every day, so really why do we need a number, following Steve’s logic, if I can show there are 10 people a day that aren’t getting hospice, that would be a couple hundred every year that aren’t getting hospice in that county, why do I need a number, the number is meaningless if we’re going to apply this rule. Frank: Well, that’s not true because need is just one of the four criteria. Financial feasibility is another one…(unintelligible because attendee talking over Frank) Nancy F: I’m saying on the need criteria, on the need criteria we don’t need a number if it’s one… Frank: That could be… Nancy F: So I would say based on this logic we get rid of the 25 or the 35 and switch to financial feasibility as the place that we address financial feasibility. Frank: Well, financial feasibility is relatively generic in the rules here, under 236-310-220, but we put in specificity in the ADC so that we could operationalize it for the staff… Nancy F: But we’re calling it need and Steve was just arguing that we don’t need that. April/Kathy: But I think what Steve is talking about is exceptions. Nancy F: No, no, he’s not talking about exceptions, he’s saying, you can get approved if you can show your population has need. Steve: (Tape, 01:02:49) I didn’t say you could get approved, I said you can file an application and the existing regulation provides you with an avenue to make an argument for your case (many talking over Steve) I’m not saying it’s a get out of jail free card, I’m saying you have the opportunity and I’m not getting what the 25/35 has to do with exceptions. Kathy: Okay, and I’m going to bring the conversation to center, we’re talking about exceptions right now… Frank: Right… Kathy:…and just to reiterate what we’ve decided, the group consensus with the exception of the one person that didn’t vote was we want to strike… Nancy F: I’d vote if you called for a vote. Kathy…the um, we want to strike proposed section 12. Frank, others: Yes. Kathy: Okay, we’re going to conclude that part of the agenda item with that vote and move on to… Nancy F: You might let our recent guests know we just got rid of the exception that was in place…. Kathy: Thank you Nancy, that’s duly noted. Nancy F: Oh they know that?

3. WSHPCO Position Paper re ADC

Kathy: I’d like to move on to agenda item #4, and that is the presentation, or the discussion of the WSHPRO position paper, and is there someone from WSHPRO that would like to discuss that… Nancy F: I’d like to make a point of order first. Um, three months ago, I think it was when we last met, or maybe it was four months ago, Bart came to us and said, you know this has gone on long enough you guys need to recognize the decisions you’ve made, get this draft finished and out for public comment and so we drew a really hard line and said we’re not going back and revisiting the decisions we’ve already made and the only thing that is still outstanding was things like language in the draft that, and we’ve already kind of broken that guideline that we’re not going back and revisiting things today, the only thing that appeared to still be outstanding other than sources on data was length of stay which is really a matter of source (unintelligible) for most intents and purposes and so I would propose that we treat this letter as public comment it starts raising major, I mean it basically, one response to it would be to totally start over and I think I would have to agree with Bart, why are we doing this if we are going to start all over we’ve already made every decision that this responds to I think it’s legitimate public

9

comment, it’s signed by a person who I don’t think has ever been to a meeting, a lot of you are members of this organization, you are on the board of it so I think it’s really inappropriate to bring this and put this on this agenda today. If we’re going to treat these topics, they need to be put on the agenda ahead2of time so people can be prepared to reargue all of these policy decisions that have already been made and I really object to this being on the agenda today and I think if we are going to reopen four or five policy questions that are addressed there, that we start this process over. Gina: I’m okay with that. I’d rather have a good outcome that to push something through just to get it done. Nancy F: Okay, we’ll start over. Gina: I’m okay with that. Kathy: I think the group with decide if we’re going to start over again, Nancy, thank you. Gina: I think it would be silly for us to just push something through just to get it done and have one person at the table feel good about it and everybody else is going to be in the public comment process saying, I’m not okay with this…and we were at the task force meetings. Nancy F: I thought we had agreed on and decided everything. Kathy: Okay, so Leslie… Leslie: I believe that this has been a public process all along, the stakeholder process, and the comments are traditionally allowed throughout the entire stakeholder process. Kathy: That’s exactly right, thank you. Leslie: We’re not at the CR 102 phase yet… Kathy: No, we’re not. Leslie…it hasn’t been eliminated so to say that a public comment should be rejected out of hand is not accurate. Kathy: And the department agrees with you on that. We are in the developmental phase of the rule process where public comment is welcome at these workgroup meetings and so I’d like to move forward and allow WSHPRO to discuss their letter at this time, thank you… Nancy F: Well let me ask a question and I would like an answer to this question. Does this mean that we are backing away from our agreement two meeting two months ago that we cannot bring up things that have already been decided because today we’re bringing up a number of things that we’ve already decided and we’ve all kind of said tick tock the game is locked we’re not revisiting made decisions. Leslie: We just made a decision to eliminate number 12. We’re still in the public comment period. Kathy: We’re still in the rulemaking process, and we’re still developing the rules and so we’re going to allow an entity, another stakeholder, to make their position point today. Nancy F: We’re reopening the whole rule. Kathy: No, we’re still at the 101 process. Leslie: There’s been no end of the public comment period… Nancy F: I’m not talking about public comment, if I write a letter then you’ll accept my comment, but if I’m at the table you won’t, that’s what this group is saying. And I think that needs to be clarified for all of us. Steve: I don’t think so. I think that the membership of this group has been fairly constant, and some people are here and some people are not, the fact that Ms. Randal has not written a letter previously, as you said, some organization members have been here, it’s not like we’re locked in a room, we’re not a jury, but then to go a step farther, and say that, I agree that in order to make progress we try to reach consensus on some issues, but you have to consider how this unfolded. And I want the organization to give their presentation but on the particular issue of 25 versus 35, all that Frank and Mark were asked to

2 Agenda listing WSHPRO position paper as an agenda item and WSHPRO position paper provided to all attendees on September 30, 2016 by email.

10

do was to test the validity of the 35. They came back, and the numbers go over my head, but they came back and said you could make an argument for 25, but that’s a number, let’s face it, the 25 versus 35 is a policy determination. You could, based on Mark’s and Frank’s numbers, one could reach the conclusion that a hospice is profitable or could make money at 25. I’m not competent to say that. But, ultimately, it’s a policy issue and if you go back and look at the consensus document, yes, and I know you refer to this, we reached a consensus on 25. Well, we reached “consensus” at a time when we didn’t know the impact of the 25 versus 35 on the calculation of the regulation and we didn’t even have a draft regulation in front of us, and we reached that conclusion in April, and the draft regulation came out in July or late June or something. Now we understand, and again, it’s a draft regulation, it’s not cast in stone, now we’re making policy decisions, we just made a policy decision and its’ not, by the way, the policy decision that night ultimately be adopted by the department, it’s not me or us who is going to make the determination, this the department’s job, we’re giving our point of view (emphasis added). It’s perfectly acceptable to say, well, in light of what we’re seeing, the organization is certainly entitled to offer a policy opinion on the 25 versus 35. Nancy F: Well my issue is a matter of process. We’ve had month after month of agendas with certain topics on the agenda so you can prepare on both sides of the matter. I came prepared at the meeting where we talked about 25 or 35 to give my presentation but Mark and Frank said 25, there’s no problem with 25 and I accepted that and I didn’t spend your time making my presentation with the understanding, and Bart having laid down the law no more discussion and we’re moving on everything you’ve decided is decided I did not see this letter as notice to those of us who want to be part of the deliberative conversation about 25 or 35 being prepared to make the argument today. And so I’m just arguing for a matter of process in which we know ahead of time what the agenda items are, which policy matters are we discussing this month and because we said everything is closed I did not see this letter as something that we’d take seriously as a reason to go back and reconsider these decisions that have been made. I can make my presentation but not today. And so if we’re going to go back and open up the entire rule, have at it and let’s have an agenda ahead of time so that know what’s on the agenda, that’s only fair. Kathy/Frank: And the agenda was handed out a week ago, the agenda was passed out some time ago, with the letter and the attachments3…. Nancy F: But but but we had said no more changes. Kathy: Right, and we’re going to go forward and allow WSHPRO to make their presentation at this time consistent with the agenda. We’ve heard your position, Nancy, thank you, we’re going to move forward now, okay? So, who from WSHPRO… Barb: Dixie was unable to be here today due to some stuff… Dixie: But she’s on the phone listening to the conversation… Barb: Yes, Dixie would you like to talk about the letter or do you want Gina as past-president or other members… Dixie: With the crud that I have I’d rather have somebody else speak about that. Gina: I don’t know that we have a formal presentation and Lori feel free to chime in, but I think that we really felt concerned about viability and that we’d never really determined what constituted a viable threshold, and break even doesn’t seem real viable from my standpoint, I’m happy for you guys to chime in on this, but I think there’s concern on the part of those of us who have spent some time on this that an ADC, an organization with an ADC of 25 would struggle, and that patients could potentially receive marginal care as a result of that. It was also concerning to us that it could impact existing providers in terms of their stability because with a threshold of 25 in some areas, in some service areas,

3 Original email to workgroup members, dated September 30, 2016, containing agenda and attachments. One of the attachments was the WSHPRO letter.

11

there would be room for multiple providers to start up, and more organizations, you guys feel free to chime in. Lori: And one of the other things I noticed in the draft rules is that it does say that by the third year you need to be financially feasible, and that’s not defined, I don’t know how that would be evaluated, and I do know in the past certificate of need in different kinds of projects, the department has said that there can be, they’ve denied projects when they couldn’t determine the financial feasibility even when there was a need, because if something happened and actually had the opposite – what if this agency got up and going and then they had to close? I mean, what happens to patients? I think we want to make sure that whatever threshold we have for financial feasibility is reasonable in a community and in a particularly, in a large urban community I think an ADC of 25to me seems really small to be financially feasible, so I think before we rush forward 25, 35, whatever that number is, I think we just want to make sure that we have a number that will allow the department to determine financial feasibility and will allow an agency to be successful if it’s approved. Frank: And when we looked at the correlation of financial feasibility, we looked at operating margin and ADC, the data were equivocal. When you look at an ADC of 35 versus an ADC of 25, and that’s what Mark and I found, but clearly, other things equal, if you have an ADC of 35 versus 25, the chances are financial feasibility will be much more likely to be met at 35 than 25, I mean that’s clearly true. And so, other things equal, if you want to better insure financial viability, as the Association suggests in their letter, 35 would do that much more likely than 25, there’s no question about that. Chris: I have some practical experience. As an agency who did go through the census of 30s, it’s a very big stretch on the organization, because what we’re talking about is 24/7 care, and when you’ve got an agency that’s, and when we talk about viability, I’d hate for us to think about the minimum viability that would sustain a program, because when we went through the 30s, it was a very big stretch for staff to cover the 24/7 on the weekends and everything that’s required for hospice to take care adequately those people, so even the low 30s was a stretch and by the time you get to a more, I mean, a better number, like for us it was 50, you can stabilize, you can supplement the staff that was weekended so that they weren’t feeling burned out but at 35, at 25 it seems that having been through that process I don’t know how you could say that’s a viable program to give good care day in and day out. 35 was much closer to it. Nancy F: Was that financial or staff stress? Gina/Chris: Financial, yes and yes. Nancy F: In terms of cash flow it’s an issue. Chris: Cash flow to sustain the staff. Others: Quality of care for the patients, that’s what is most important. Chris: That’s just a factual experience of what we went through, and we were in 2009, we did hit census, I’ve still got it on my little board, 33, 34, 35…. Nancy F: If you had been a department of a hospital would that have been the same situation? Chris: I can only speak to what we did and we weren’t. So I don’t know… Gina: And you know, one of the things that Gail mentioned in that previous presentation – CaADD pumps – and that’s not curative care, that’s palliative care. That’s making sure people have what they need, and we’ve drawn staff from organizations in other communities who come from small, real small programs, and they’re like, how do you, it’s that easy to get a CADD pump? And we’re like, what do you mean? You mean you just ask for the order and you get it? And we’re like, I don’t what you are talking about. They had to go through layers of the approval process to get what a patient needed… Barb:…to justify the expense… Gina:…because they stuck with what was PO and it was the minimum. April: I agree. When Evergreen was tiny, and I had been with Evergreen for 25 years, and we were little, and we could not provide the kind of quality of care to our patients that we are able to today, because

12

we didn’t have the financial ability to do that, nor did we have the staff to be able to provide that kind of 24 hour care the way we do now, and we are associated with a hospital and so, it didn’t matter. We just didn’t have the ability to do it. We are in much better shape now, we have the quality and the staffing to take care of our patient needs. Catherine: I can’t even imagine trying to operate with a census of 25 for the financial reasons, for the staffing reasons, I mean, you’ve got two nurses that are covering 24 hour, 7 days a week shifts [attendees speaking at once] and then the burnout, and the fact that we’re covering more and more medications, and you need that larger base to (unintelligible) your costs so that you can afford the really costly treatments for some of the patients. Gina: And you know manpower is going to become more of an issue, and we’re going to be paying more and more to hire nurses and to… Gary: What is interesting having worked for a large corporate provider, we had close to 150 branches across the country and this is more than 15 years ago, and at that point we didn’t have nearly the regulation or cost structure that we have today, we even had a service company model where the accounting and services were at the consolidated level We used a threshold of 25 back then. I can only imagine what that threshold is today. Nancy F: Well I can share some data from MedPac from the March report 2016 MedPac and what it says, and you can look at the pages, actually this is from NHPCO and the margin data is from the March 2016 MedPac report for hospice services, according to NHPCO 23.4% of all the hospices in the country have a census below 25 so 25… Gina:..but are they part of a larger? Nancy F: No, this is their total census… Others all at once: I don’t think you are able to get that from that report, that includes other things like home health, part of a corporate chain, they each have their own number… Nancy F: No, this is average daily census 10.3% of all hospices have 1 – 9 average daily census, that’s national from NHPCO, 13.4% have 10 – 25 patients average daily census so that’s a total of 23.4 which is nearly a quarter of hospices in the country based on NHPCO statistics operated this size. Now I’ll have to say that the context for this interesting change is one that Steve pointed out which is now that the numbers have run, and the existing hospices see the rule change permitting some additional competition, then the policies have to be reconsidered. That’s clearly what’s going on. Gina: I brought up my issue before we saw the outcome. And you can look at the record. Others: Agree with Gina’s statement. Nancy F: I remember you being concerned about it. Now let me talk a little bit about margins, this was broken down into quintiles meaning every 20%, this is all Medicare, only Medicare hospices, and these, I’ve got quintiles here and quintiles here [referring to a document out of a report or article no one else in group has and was not distributed to group] and the numbers don’t quite match up, the lowest quintile under MedPac in 2013 lost .3% margin or had .3% margin, that doesn’t include any donations so clearly the tiny size works against. The next quintile had a 6% margin, which means up to and a census of about 35, the next quintile made 9.4, the fourth was 11.2, and the highest, that was the highest, the largest 20% of hospices had a smaller margin at 8.3. Now overall, the average hospice size in the country is 55. The average in Washington is 600. The only state that has a larger… Gina and others: No, that’s not accurate. Nancy F: Admissions. The only, Washington has second largest hospices in the country and the certificate of need states are those that have the largest hospices, the only state that has larger hospices than Washington is Florida and in Florida, to get in you actually have to sue the other hospices, you don’t sue the department, you have to sue the other hospices, so you have to go to court in Florida so given that our hospices, and I don’t have that graph, I’d have to look through my (unintelligible) our hospices are ten times the national average in size, and to be concerned about the new rule threatening

13

some competition I think is problematic we’ve just admitted that one person a day is need and based on Steve’s argument that we don’t need exceptions, and so I suggest that we look at these numbers from MedPac, I mean, they are responsible for setting what the hospices are going to be paid every year, so I think they do some pretty good research, so I propose that we move this whole number into financial feasibility because that’s what the issue is, it’s not need and look at what size of hospice makes sense in Washington, 25 or 35, put it in financial feasibility, but if you are an existing hospice in a large city, say you are in Spokane, and you want to go to Colville, do you have to have 35 out there to add a county? Gina: (Tape 01:25:28) The other thing we can talk about is two different numbers, one for rural and one for urban. Nancy F: And we’ve been around that and decided not to twice. Gina: The other thing though, is like Leslie said, this hasn’t gone through the process and we don’t have to have a bad outcome because we’re going to push something through. We can decide that we are going to readdress this… Nancy F: But what makes it a bad outcome? Gina: I’m just saying it’s not something we can’t re-discuss. Is it? Nancy F: How is it going to be any different? Steve: The organization has offered their view, as I understand it, that using a number of 25, and I’ve heard it from everybody who runs hospices that 35 is a more accurate number… Nancy F: No we’ve heard a feeling and a sense and there’s staffing stress… April: It’s based on experience Others: There are quite a few operators here Nancy F: We need to look at some numbers Steve: Here’s what I suggest and I don’t want to take over the department’s responsibility, but Nancy’s raised a “process point.” We’re not going to finish today, I for one would like, and I’ve heard a couple of gentlemen say, well, what exactly does that number say, because we’ve had the experience before of stuff being hauled out and saying, you know, when you get down into the details it might not really say that [refer to prior meeting notes and recordings], so I think we’d like to, and again, I’m not trying to take over the department’s role… Kathy: I agree with you…. Steve:…if Nancy wants to make a presentation at the next meeting of 25 versus 35, my view (unintelligible) but so be it, let’s get everything to us that you’re going to present, let’s not pull one graph out of a 30-page article that doesn’t define what the categories are, let’s distribute that article to everybody before the next meeting, and again, I defer to the department, and if the department feels that you can make a presentation on 25 versus 35, that’s fine with me. Nancy F: I don’t want to do that. I mean I have other things going on in my life it’s not my responsibility to create a financial feasibility standard for hospice. If Mark and Frank want to work with me, and look at these numbers and come back to you Mark is saying he’s not comfortable with the (data?) he saw before, I know Frank’s excellent at this, if the three of us come back to you with a number on the financial feasibility side I’d be happy to do that but I’m not going to stand up and be shot down… Steve: Actually we’re talking about the number as it’s applied within the methodology not within financial feasibility. Nancy F: Well I would argue against even having a number there based on what you just had us change that anybody can demonstrate need, if it was one then I could make an application. Steve: Nancy, don’t misconstrue my words, please. Nancy F: Well don’t ask me to make an argument for something else. Gina: The other thing, though, is if you guys look at that, because I’m looking back at some of Gail’s presentation, you know, massage therapy, music therapy, some of the things that we offer, I want to

14

look at what is being provided. I think it’s fair to include that in the equation. Because I think there’s a big difference between what, you [Nancy F] think being big is a bad thing, I think it’s a good thing. Nancy F: Pardon me? There’s big and then there’s huge. Other attendees speaking at once… Nancy F: There’s big and then there’s asking to be protected from new entrance and that’s my concern. I don’t mind anything about being big. Gina: I just want to… Nancy F: I object when you’re big and don’t want someone small coming into the same town. Gina: But is it fair not to include some of that. Mark: I think that’s the problem that we had when we were doing the analysis, we had no idea of quality of service, rural versus urban, depth and breadth of services, we didn’t have any of that and actually I think we even questioned whether the entire population was represented in the data. Frank: I don’t think it was. Mark: Yeah, we’re pretty sure it wasn’t. Frank: Hospital based services weren’t in there. Nancy F: We didn’t see it, so we wouldn’t... Attendees speaking at once… Frank: There were 2400 agencies included in the CMS database that were reported, but there were certain agencies that weren’t included, and certainly… Nancy F: But this was CMS cost report data… Frank: Yes Nancy F: Well that should be pretty… Frank: Yes, and it’s very different from what was just quoted, very different. We had very different findings from what was just quoted. (Tape 01:29:53) Nancy F: CMS is everybody and this was just Medicare. Frank: Well no, this was CMS but it was private agencies, it wasn’t hospital based agencies. We had a universe of 2400 agencies. Nancy F: Well that makes a big difference, hospital based has, hospitals add $20 a day in expense that’s allocated from the organization so hospital ones with small volumes do have a harder time. Frank: But our findings from the CMS study were very different than what you just quoted, very different. Nancy F: Maybe we could dig down into this MedPac, I mean to me, MedPac is pretty much the gold standard. Gina: But what about the providers at the table who have the experience? I’ve been doing this for 22 years, Mark you’ve been doing it for like way longer than that… Others: 31, 25, 25, a couple centuries or more in this room… April: And I think she (Nancy F) was throwing out numbers that were very specific numbers but they’re not in context. When you look at the average daily census on the NHPCO summary of care for 2014, and you start comparing year to year, you see that there were more of them than the smaller and there are not as many of them, and you see agencies closing across the nation because they are not viable. And I think when you look at the agency ownership and the number of agencies, you see a decrease in the number of hospices… Others trying to speak…. Nancy F: What MedPac is saying is that if you are in the lower 20% in 2000, ten years ago, you had a minus 8% margin, now you have a minus .3 so they’re saying if you’re in that lower quintile you’re in rough shape. Mark: But see, that graph, and I can see enough of it to see that it doesn’t correlate to agency size, so… Attendees talking all at once…

15

Steve: (Tape, 01:32:01) So at this point I would just ask the department, you know given the agenda today, I think the organization has had their opportunity to present their view on this, I think I’m authorized to say for Providence that we agree with the organization’s view, so the question is from the department, I guess at this point, is we can either hold a vote or we could defer to Nancy’s point of process, although she appears to maybe not want to anymore, do we want Nancy, and again, not speaking for the department, but do we want to give Nancy an opportunity at the next meeting to give her argument as to why 25 rather than 35 should be used as the threshold in the actual need calculation. Kathy: Nancy (Tyson) is saying let’s hold a vote. So with respect to the issue at hand, 25 versus 35, show of hands for 35? Returning to 35? Lori: Or financially feasible at at least 35. Kathy: Or 35ish? [Majority raise hands] Steve: Well, is the vote over? I haven’t talked to my client about this, but in light of, I’m just a lawyer again, I’m hearing the century’s worth of experience or more, and I don’t want to open the proverbial can of worms, but given what Lori just said, not demeaning what the group did twelve years ago, and does the group, and I know we may get an objection that we’re going back, but does the group want to open up the question of is 35 the appropriate number? I mean, having said that, we voted for 35, and I don’t want to undo that… Kathy K.: That’s what our two choices were, 25 or 35 (many speak at once) Steve: And I’m not suggesting that that’s necessarily a topic for the day, that would be maybe a case of Mark and Frank going back to their data and maybe when Nancy wants us to, considering this MedPac report and understanding what that says, that’s just a thought. Candace: Well, I didn’t vote because 25 or 35, that was the option and I’m not saying that’s the best. I know as a company, and of course we’re a larger company that can support, 25 is a challenge, I will say that. But, is it possible maybe to set a threshold for the startup with the trust that this is going to grow. You know, somebody staying at 25 forever, that isn’t feasible which we’re going to be assessing in three years anyway, is that a thought? Would it be better to use a different number? We have found and that’s why I was so supportive of your numbers, we did find that 23 was a break even for a lot of places… Gina: But they are part of a bigger whole… Candace: And that’s what I’m saying, they are part of a bigger whole, but this is looking individually, this is not putting money into it from the global picture, the global company, this is independent viability. Kathy K: But was administration happening from financial (unintelligible)…. Candace: No, that is pulled out, overhead is paid by that unit… Gary: As a percentage Candace: Yes, as a percentage, it’s not perfect, I’m saying that was viable. It does not mean I would ever want, having been an administrator for a lot of years, to stay there. But as an organization setting rural or whatever, and the desire to have some rural access for people in some areas where those numbers may be hard to reach, would a compromise be to say lower the starting number from 35 but have that feasibility that has to be proved somehow later so that there is a chance for entrance but also success as well. Nancy F: But we’re still three years out because the target year is three years. Frank: (Tape, 01:36:30) Well, the difficulty though is that it’s not really a threshold for just the new entities, it’s a threshold that’s perceived to be reasonable for all of the existing providers as well. And so, if you have a threshold of say, 25 or 35, separate and apart from that, you still have to demonstrate financial feasibility in the out years as an applicant and so I wouldn’t recommend going to 25 given what I’ve heard today, as opposed to say, 35. 35 would be a much safer threshold to better ensure financial viability across the marketplace.

16

Candace: Then I’m going to say why 35 and why not 100? I mean of course, 100 is going to be more viable too, and I’m trying to think of what number is going to be best for starting reality to create access for our rural populations… Nancy F: Is this per county or by agency? That’s always been an issue. Candace: And we’re just going with agency, units… Nancy F: Okay, so maybe Steve the attorney can tell us… Many people speaking at once, many side conversations…part of our discussion has been concern about rural access and rural healthcare… Nancy F:…everything is reopened now, so if the law allows us to review the entire entity instead of county by county, and Jan has always said, oh no we have to go county by county, that’s what’s hurting us because we’ve got an added county to a perfectly healthy organization that unless they can show 35 they, we can’t add that county. Is it really true that the law prohibits us to look at an agency as a multi-county agency because the early law allowed us to and the interpretation… Steve: The existing regulation does not (unintelligible) Nancy F: It does say that you can’t because originally it did Steve: No it’s silent… Nancy F: Well the redraft is silent, but the early draft that we started with, it was allowed, you were able to have a multi-county agency. Steve: I’m sorry I don’t recall that. I’m not saying it’s not true Nancy F: We took it out in this group Leslie: There have been discussions about rural versus urban... Nancy F: well, so what is… Leslie: Actually, Nancy (F) I’m still talking. Nancy F: Well I was already talking… Leslie: Well, but you cut off Candace earlier and she didn’t get to finish her discussion about access for rural hospices… Nancy F: well I was trying to help her… Leslie: So could we please continue, let her finish Kathy: No, let her (Candace) finish her conversation. Nancy F: Alright. Candace: I think I pretty much got it across, you know, and maybe having a different number for rural versus urban would be the way to go, maybe when you say 25 or 35, I don’t feel that 35 may be the number maybe it’s shoot for the middle, I don’t know, I don’t have the data to really support choosing a particular number, as a hospice administrator do I want to stay at 25, staffing, all that, you know, but do I want that to be what people have to prove to enter and perhaps maybe provide the heart centered care for a rural population that needs it, that’s asking for it? Maybe we do need two different numbers. Leslie: Are there any statistic with OFM that defines what a rural versus an urban area is? Other attendees wonder the same thing. Kathy: So I think what I’m hearing is we are not fully cooked on this particular issue, we thought we were, but we’re not, and it looks like we need to do some additional research and vetting and that kind of thing, is that, that’s kind of what I’m hearing. Leslie: Pat Justus here at the department health is running the rural health care and she’s doing a session next week on rural palliative care, so she probably has statistics about that, and that would be something we could bring to the next meeting, and that is, what would be a good cutoff for rural folks, rural counties, rural populations, where we could draw a line that perhaps might make sense for rural areas. Gina: I mean I think that it’s fair to say that under 25 is not reasonable so 25 in my mind for rural, I mean feasibility is the issue.

17

Frank: I think based on your own actual data in the methodology, 25 or 35 isn’t going to matter for the rural counties. Barb: I have the OFM definition up here on their website. Frank: It’s not going to matter; if you set it at 35, it’s not going to matter for the rural counties versus setting it at 25. You’d have to drop it significantly below that for the rural counties based on the data. Barb: So a rural county is defined as a county with a population density of less than 100 persons per square mile, and it’s a county smaller than 225 square miles. Kathy: Barb, can you shoot me the link to that… Nancy F: I think we might consider this like a corridor, that if you are between 25 and 35 you have some additional financial, in other words, you’ve got to show where your other money is coming from. So it moves over to financial feasibility so we could say, at 35 we accept the feasibility, we’re willing to go with need at 25 but you have an extra burden to show that either you are part of a larger entity or you are endowed with a million dollars, or something. Beth: No matter what, if you’re not financially feasible, you’d have to demonstrate financial feasibility not matter how you demonstrate it, it doesn’t matter if you succeed at every other criteria, if you fail financial feasibility, your application fails…(01:42:31) Nancy F:..and that’s what I’m saying… Beth:…so what you’re saying is no different than any other applicant, any applicant has to show that… Nancy F: No, because we’ve got the, we’re conflating need and financial feasibility in this one number that’s the last column in the need method and what we have done in our draft that’s in place is we set the need at 25, meaning there is need, you can document need at 25 but what the letter says is we don’t think you can make it financially at 25 so we’re saying, historically we’ve accepted 35 maybe it needs to be 50 or 100 I don’t know but between 25 and some other number you have to go an extra step, in other, your volumes, (to Beth) no let me finish, your volumes aren’t enough to convince us that you are financially feasible and so to deal with the rural aspect, if you’re part of a rural hospital that’s going to support you then 25 yes, but you have to show something else or you’re part of a larger hospice and they’re going to float your cash flow for the first x years you’ve got to show if you’re between 25 and x some additional financial feasibility and put this where their bringing it up is in financial feasibility not need. Gina: That’s what you believe… Nancy F: I’m proposing. Beth: What I was going to say is if an applicant comes to us and let’s say, and I’m making up a fake applicant, I’m not modeling this on anybody’s business model, let’s say they come to us and say we expect to have an ADC of 25, great, you told me that, you’ve been up front with that, and I’ll look at their financial projections and I’ll take a look at where they are getting those numbers, I’m going to see if those numbers are reasonable, and if it comes to the bottom line that they show me they are losing $300,000 a year, my question as an analyst is, how are you going to be sustainable into the future and if they can’t answer that question, it’s a denial. If they can answer that question and show me in the future how are you going to be sustainable, if they can answer that question, you can get there. Frank: Well I think the simpler answer is that historically the department has always said, at the third year, if you don’t have a positive bottom line, you fail. And that’s the simple answer. Beth: Yes, but I guess what I’m saying, when we get that application and we’re looking at it, it’s not just this, oh I see that you’ve said this, it’s a denial, we’re going to ask you, we’re going to give you opportunities to… Nancy F: So you’re saying that that concerns addressed in this letter that they can’t get approved if they are not financially feasible so we don’t need to change our draft Beth: I’m not expressing an opinion on 25 versus 35, I am saying that 25 versus 35 doesn’t have an effect on how I’m going to measure an applicant’s financial feasibility.

18

Steve: Let’s just clarify that what Beth said is exactly correct. Frank made the good point that the role of the 35 in the numerical need methodology is both with respect to the existing, it’s a system –wide number in terms of financial feasibility for the system, it’s not being used to evaluate financial feasibility. It performs a threshold role in the need methodology. The draft we have for financial feasibility, we specifically removed any numerical element of the, unless I’m working off, I’m working off the 8/28[16] draft that says, “an applicant must demonstrate financial feasibility by the end of the full third year of operation.” We took out, it used to say, “an applicant must demonstrate that they can meet a minimum average daily census of 35” we changed that o 25, got rid of that too, so the only issue we’re talking about in terms of 25 versus 35 is this role in the methodology. We’ve taken a vote on that, the vote is done, but I raised the issue and maybe I should have kept my mouth shut, is, does the group based upon your experience which I have none of, feel that in the methodology, not for financial feasibility because financial feasibility is not based on any number, it ought to be 41 or 37 but… Nancy F: But if it’s financial feasibility there isn’t a number. Gina: We’re not talking about financial feasibility, we’re talking about need. Nancy F: Okay, let me talk as a hospital administrator here which I was for many years and I’m published on the subject of hospital occupancy rates. We used to use a thing called a plasson distribution to determine what occupancy levels you want for a hospital or for a unit. And it was based on random occurrence of demand, and how many people do you want to turn away, if you turn away people 1% of the days, then you’ve got 3.4, 3.6 days a year that somebody can’t get in the hospital that’s 1%. Okay. If you look at hospice, what we’ve said, if you take the idea of the occupancy rates that we would apply to hospitals, which is like 80% for a big hospital and 90% for a big hospital, we use the percent that we’re turning away and it’s very low for hospitals (Tape, 01:47:51) you know we don’t want to turn 10 people away a year, for OB we don’t want to ever turn anyone away, so if you take that thought process of random occurrence and it’s even more random in hospice because you don’t have the surgeons are all skiing this week and so there’s changes in demand, so this science on how you set occupancy rates has been around for like 40 years, Frank probably remembers it from the old days, if you take that same thought, for hospice, and you say, what percent of people who aren’t accessing this system is acceptable, and if we took the same thought process from hospitals which is ten people a year, five people a year, we would not have an average daily census of 35 people every day of the year going without hospice we would have five or ten people all year we would be five or ten admissions a year would trigger need. Chris: Can I comment on that… Nancy F: No let me finish. So the disparity between what we’ve said for hospitals where we’re building capital and it’s very expensive, we spend a lot to make sure we don’t turn people away from hospitals, yet on hospice we have people never going to have another chance they’re dying (Tape, 01:49:14) it’s a very difficult cultural situation and we’re letting 35 people every day of the year go without care. This is the discrepancy that is hard for me to grasp. April: Do you have the numbers to prove that? Nancy F: Pardon me? Many in group speaking at once. Frank: Your analogy is so imperfect. Kathy: Chris would like to comment on that. I’d like to open the floor to Chris right now, thanks. Chris: I think that the thing that helps me is that there is a world of difference between turning away and what we’re suggesting the numbers indicate for hospice. Has anyone that has ever worked in a hospice ever said no to somebody? Many in group speaking at once: No. Nancy F: That’s laughable (Tape, 01:49:54)

19

Chris: It’s a huge part of the point. We don’t have, you mentioned surgeons going skiing, there’s never a question of, we’ve served 95 people late in December of this last year, we served 142 very recently, we’ve said no to zero people. And so, my parents have been through it. And to suggest that this methodology indicates that we’re turning people away, I think it is… Nancy F: I’m not saying… Chris: If I can finish, please. I do think I heard you say turning away, and the concept is night and day they don’t apply together… Nancy F: I said it for hospitals, but I said it for not accessing the system for hospice. Gina: I think that in states that have higher penetration rates and by and large they are non CoN states, what you have to keep in mind is some of those small organizations are possibly admitting people who are not appropriate because they are trying to keep their doors open. Nancy F: I’m not talking about other states, Washington hospice… Gina: I’m just saying, essentially the way we calculate need in this state is to take the state’s average and compare it to a county’s average. Is that not the spun-down kind of version? Nancy F: No. Gina: If, and you’re talking about turning people away, we don’t turn people away, I’m just saying that you’re proposing that more is better, more organizations is better, and big is not good and the thing I would have you know is that I think that in probably in some of the states that have (???) issues, that have the microscope of the OIG they’re admitting people who are not appropriate. They’re not discharging people who no longer meet the criteria. Nancy F: Okay, we can raise these issues of high quality and size, and I can remind you that Washington experiences the worst (Tape, 01:51:51) record in the country for people who are routine home care not getting a visit in the last two days of life. One out of five of your patients are not being seen in the last two days of their life, that’s 20% Wisconsin has 5% Washington has 20% it’s the highest in the county. April: I believe that when new numbers come out, more current data, it will be significantly different. Nancy F: That’s great but size has not been fixing it yet. Barb: Many other states require a nurse to pronounce death, the patient isn’t dead until the nurse pronounces it, therefore there’s a visit made. Nancy F: Well I don’t know the technical aspects of it…. Gary: Procedure makes a big difference. Nancy F: But size, there’s a limit to economies of scale. Steve: And Nancy, the report you continually cite on that topic, you cite that bullet point, if you read that article, which I went and did, after you kept holding up that one graph, I asked Kathy to get a, I need to see the whole article, and the article says at the beginning, this article does not conclude that size has anything to do with the amount of visits in the last five days of life. Nancy F: I didn’t say it had to do with size, I said if we’re great because we’re big, it’s not holding true for some of the key measures that MedPac and CMS are using. Kathy: So I’d like to just table our conversation because we have one more agenda item to get to. It sounds to me, again, like we haven’t fully cooked this issue. I’m going to listen to the tape again and kind of come up with some ideas about how we can move forward this this, not ready to make a decision at this time but if that’s okay with everyone I’d like to move on. I’m sure you want to present, Nancy, correct? Nancy F: Well I’m [not?] happy to I’ve been asked to (Tape, 01:53:43) Kathy: Okay, then we’ll move on to Nancy’s presentation. Does everybody have the handout for that? Does anybody need a quick bio-break before we start? ** BREAK***

20

4. Average Length of Stay Presentation – Nancy Field Kathy: (Tape, 01:54:17) Alright, so recording has started again. Before we get started with this next segment, we have folks that need to leave a little bit early, so I want to kind of stop at 3:40 and talk about a couple of things before we close, that is scheduling the next meetings, those kinds of things because holiday season is approaching, blah blah blah, and people might have stuff going on, so before people that have to leave, leave, I want to have that conversation so they know what’s going to happen next. So at 3:40, we’re stopping and doing that. And then we can move on. Okay, so Nancy [F], you have the floor. Nancy F: You may remember we’ve talked a little bit about this length of stay and this isn’t all about what it ought to be, this is only about when the methodology is run where do we get that CMS average length of stay that it calls for. So I’m not lobbying for anything one way or the other, it’s a matter of sourcing that CMS number. And that’s gotten, and Beth will tell you, that’s gotten harder because the sources have been changing over time. For the first ten years or so, eight years at least, CMS, we didn’t have a CMS length of stay, the department wasn’t accessing either cost report or CMS data and so we were using the survey and just doing the old way of doing it which is called out in the method, we divide total days by admissions. Well then because of some court cases we quit asking data three years back and ALOS couldn’t be calculated in the same way. So a new source was found, and Bob Russell was the first who found it, and he found a report which is shown here on your last two pages and it’s called the, it’s a statewide hospice utilization and it shows days per patient per year. And I was concerned about that at the time because it was instead of our rule where you use deaths and admissions, it was using patients. And it wasn’t real clear what’s a patient and what’s an admission and that argument kind of disappeared for a while but it’s really come to a head now because they’re not publishing this table anymore, and we need a CMS average length of stay for the rule. And I’m not proposing we don’t use the CMS average length of stay, I’m saying where do we get that CMS average length of stay. So about three or four years ago when Bob and I first started talking about this, I called a gal named Maria Dafogena [Diacongiannis], I think that’s how you say it, and she’s the head of data distribution from CMS and in particular the hospice numbers and as it turned out, when Beth started looking for this data this year and she found out that this table isn’t being published anymore, we were using, I think the department was using 2011 for two or three years but really got kinda old… Beth: It was 2013. Nancy F: Oh 2013, okay, but it was getting kinda old and we weren’t finding a new version of it. So Beth in her wisdom started looking for how am I going to get this data and she wrote to the people, she found the people to ask, and as it turned out, I had also called the same people so luckily we don’t have Joe Schmo and Suzie Smith giving us two different numbers, we’re actually talking, without knowing it, were talking to the same people. Maria and a gal that works for her named Stephanie. And what Stephanie did after we talked with her on the phone, she wrote an email to us, that’s this page here (note: refers to page 6 of handout containing non-original email content cut and pasted into handout. Email addressed only to Nancy Field; department not copied or otherwise included in email string) in which she described the two possible sources that Washington can use for its Medicare average length of stay that’s put into the methodology on, at that at step, I don’t know the steps anymore because we’ve added steps, but it’s the old step 6, right, average length of stay gets put in there and that’s what we calculate, we multiply the projected admissions times the projected average length of stay to get total days, and then we divide to get the average daily census that is the 25 or 35 or whatever we’re going to put there. So it’s key and Beth can’t run the numbers, and nobody can run their numbers without something to put in there. What Stephanie was kind enough to lay out was the discussion about the differences between the old table that’s been used in the past from 2013 and a new number that

21

she has described as more appropriate to what we’re trying to do which is each person only has one of these in other words like we have the deaths at step one, every person only has one death, every person in our model, every person only has one admission, we know that’s, there’s technical issues with that but we’ve kind of agreed every person has one admission (Tape, 02:00:01) meaning every person has one episode and the word they use is episode, so and in the language, a single episode had started being used as unduplicated patient is a single episode so what Stephanie and Maria did was provide some clarification for this group I asked her to write this for this group, and show the difference between how they are constructed. And what happens when you use this table here, is that the total number of days for the year are being divided by every person who had any care for that year. Now if your length of stay is 60 days, you’re going to have a lot of people who were seen in the prior year and this year. Or this year and the next year. So the longer your length of stay, the more people are getting counted twice. They’re being counted, there’s a little picture here that shows how this works, it’s the one with the colored boxes on it, and I can walk you through that, where is that, this one here. What our goal is and the language and this isn’t a change, we’ve accepted this language from workgroup from 12 or 13 years ago, that we’re looking at admissions, and what this does is just kind of do a diagram in another universe where everybody’s stay is 60 days, and this hospice only gets, it’s got really bad census because it only gets one admission a month, so each person is theoretically dying at the end of their 60 days, and you can see the difference in the calculation here, if you divide the total days of the year by patients, you’ve got an extra patient because you’ve got one that stayed over from the year before. But if you divide by admissions, or episodes, you get the correct length of stay. (Unintelligible). And I finally came up with a (chart?) that I think shows that. And so that’s all we’re saying, and this is a picture of what Stephanie and Maria have said to us about the data they publish. They said essentially, don’t use this table because it understates the length of stay because we’re throwing people in from other years when we divide the days by “patient” because patient means anybody who had any service that year and you know, again, the longer your length of stay the worse that gets. So, as a result, because this wasn’t really clear the way the rule was written before, and it’s right the way it was written it just wasn’t clear, I propose just some the red underlined language would help kinda (see?) that definition all the way through it’s written correctly right up at the front, but then it kind of drifts off without a good enough reference back to the definition as we go further into the document. So this is not changing any standards, it’s only changing where in the bureaucracy do we get this number as that changes over the years. We didn’t know that report was being discontinued until Beth went to look for it we couldn’t find it and we don’t know what will happen in the next year or the year after that, so it was important to put language in here that makes it really clear that in the future, where ever we look for a number, even if we have to do it ourselves, this is per episode, per admission, and it matches up with our death rate which is the basis of our demand, and this language just clears that up and I thought we had kind of tied that down but it’s kind of an in the weeds kind of thing and so I thought I’d be happy to present on it just so everybody kind of had an opportunity to at least if you have a mind that likes this stuff to you know kind of get your brain wrapped around it and see what we’re doing here. April: So my question would be… Nancy F: So I made a recommendation on page 5 that we adopted this that changed language (Tape, 02:04:51), that we start accessing the CMS episode average length of stay that Stephanie has offered actually I talked to Maria and Stephanie at length and they have been doing this every couple of years for the national, there’s a big national health status report, they haven’t done it every year but they have the number and they have it from a couple of years ago so they ran it for us and they have committed to run it for Washington every year and it’s off the Medicare database and it’s based on individual patients and their experience of care which we’re calling episode or admission. So I don’t know if we put that in the language or not but that would be the guidance we’d be giving future staff. I think it’s really important and I think we’ve said one of our guidelines is that any data that’s used be

22

available to the public and so if this has to be ordered by the department of health each year that it be ordered as soon as CMS can get it to the department so the department can make it public because people who are doing feasibility studies I don’t know whether they want to start up a new hospice in Washington they don’t wait until July or August they’re thinking about it a year ahead of time. So the sooner we can get an accurate length of stay available to the public and to the department I think the (unintelligible) we might as well as for it as soon as we can get it. And that, um, what do I want to say here… Attendees speaking at once, somebody had a question over here. April: Well I just, my question was for you [Beth] was it, so were you using the average lifetime length of stay calculation from CMS, is that what you were using? Beth: It was from, I apologize I don’t have it exactly in my head, I know the label for it was average days of covered care per person. That was the label for it. Nancy F: It was this table here. Beth: This looks a little different than the one I looked at, I’m not disputing you, I’m just saying I don’t have the one I used in front of me, so I can’t support for it, can’t verify it. April: And I know we talked about it last time when we met, but there was, you know, there’s a standard average length of stay which is calculated using only deaths and discharges and not actually still live clients because then it’s more accurate and then you do that whole stay. Beth: And where would we get that? April: So, NHPCO, it’s what NHPCO uses, which is total number of clients who died and their days of care and you divide that. Nancy F: Days of care over any year? April: Yes, over any year because it gives you an actual length of stay for their whole episode. Nancy F: That would be the same. Frank: Yes, that would be unduplicated. Mark: That’s what I’m not clear on if it would be the same because one calculation that she’s referring to is the people who have died, or have been discharged so it’s only the days for those episodes, you’re disregarding the patients that are currently on and this is saying episode could be a full, live patient. Nancy F: The thing is, I let my hands be tied by the fact that it said CMS I wasn’t going to rock that boat it said CMS length of stay per 15 years and I didn’t want to argue that we shouldn’t have a CMS average length of stay so I left it that we would look for a better CMS or any CMS average length of stay because they had quit publishing this one that had been used the last three or four years. But Mark’s point is right that based on deaths wouldn’t necessarily work. This number from Stephanie and Marie would include, it’s only Medicare, that would be the only issue. Mark: It’s only Medicare and somebody could be admitted on December 31st, and it does say in future years, if they live all of the next year and they live into the next year, in that middle year they would be counted... Nancy F: And we talked about that. There would be a handful of people that were admitted in 14 and died in 16 and never show up in this number. But that’s a little error on the high side, and I didn’t think I wanted to get that far into the detail I thought it would give Washington a good enough average from CMS to (unintelligible) so I thought they’re willing to provide it, it meets the CMS rule, it fits with our death and episode unduplicated. Frank and I talked about this a little bit, Frank do you have any comments? Frank: No, I think what you said is correct, we want episodic lengths of stay with unduplicated counts, and it appears that the number that we’re currently using isn’t giving us that. Kathy: Any other comments? (Tape, 02:10:44) Mark: Did you ask, the number you mention was from NHPCO but I would think that CMS could provide that same number for us.

23

April: All you would need is days of care and number of deaths for those people who… Mark: Deaths [under?] live discharges… April: Yes, days of care for those specific deaths… Nancy F: Well they’d be getting there [from that?] CMS, CMS could get it…a different count, is that what you are suggesting? Mark: Yes Nancy F: We could ask. Beth: Nancy I have a question. So I noticed in the email about the episode average length of stay, they mention that they have 64 days in 2014 and 66 days in 2015, I don’t necessarily expect you to know, but did they happen to mention when the earliest time that the data would be available? Nancy F: I didn’t ask them what they [unintelligible – what they had for cycles?]. I think they could do it for any time you know just like this little chart here, you could do it for two months or 25 months… Beth: No, um…. Nancy F: They’re willing to give it, what they said would be a period would be, we don’t know how long you’ve been in until you’re out so the period would be people who were discharged during the subject year. Beth: But what I meant… Nancy F: No matter how far back you went. Beth: But what I’m asking is, so let’s say I asked for the 2015 numbers in April of 2016. Would the number be available then or I can see this was August 22, is that conceivably the earliest when this would be available? Nancy F: I don’t know that. Beth: I didn’t necessarily expect you to… Nancy F: And that’s why I kinda said ask us as you can and I think, you know, the time you would find out what that reasonable time would be. If you’re asking for the most recent year what our rule calls for is the most recent so if we’re gonna stick to calendar years, and you know, we don’t know when the hospice cycle is going to be, we don’t know if it’s going to be October like it is now, if it were to move to March or February, and this is 2016, you may not be able to get 15, you’d have to use the 14 average length of stay that’s the most recent CMS average length of stay for Washington state. So we’ve been using two or three year lag time all along… Beth: (Tape 02:13:11) But I guess what I’m saying is, it’s 2016 now and they were able to give you 2015 data and that’s very atypical of hospice CMS data so I’m just asking a question. I’m well aware of the lag… Nancy F: I didn’t ask the timing of it, but I think that’s, I’m not sure how technical to get into about that sourcing to get into here. I know, I know we said that once we finished all this we would have a session where we talk about sourcing for everything and the sourcing issues, like, you know, this whole vital statistics thing, of having to wait until November to get the deaths. Does that mean that the cycle should be earlier in the year I don’t know, but our group said, well we’ll deal with sourcing what we know what it is we’re trying to source. And I think that would be one of the questions, is what is the timing on the sourcing of the sources that we recommend to future applicants and staff? Kathy: I have some questions to your recommendations. You recommend that we adopt the proposed language and unfortunately, there are definitions in there that we haven’t defined. You’ve used language that isn’t defined anywhere else in the rule, such as, and I’m just thinking about the kind of push back we’re going to get from our regulatory affairs manager on this language you’ve proposed, such as “an individual’s entire stay.” What is individual? What does “entire stay” mean? What does “complete episode” mean? When we say “recognizing,” what does that mean? That’s in subsection, let’s see, this first proposal right here. As to this proposal here in 4, looks like (1)(b), again we’ve got “patient episode of care” without a definition, I don’t know, if the group decides to go with that concept we’re

24

going to have to re-work the wording in that. The same thing at page 2, referring back to a definition, that’s not going to fly with our regulatory affairs manager. We need to refer back to the WAC, not the definition section, so there is a way to write that that’s acceptable rule writing practice. So, if the group decides to go with these recommendations, we do need to re-wordsmith those sections. I think if we’re going to rely on this email that you’ve attached here, we’d like to see the original email… Nancy F: Okay, I can forward that. I think I forwarded that, did I forward that to you [Beth]. Okay, I’ll forward it. Kathy: We need to see the original email string on that. Nancy F: Okay. Kathy: On your third recommendation you say “CMS Episode Average Length of stay be made available to the public and potential applicants at earliest date available each calendar year,” Beth, is that something that we can operationalize easily? Beth: Can you show me the page, I’m sorry. Kathy: It’s on page 5. Beth: Page 5, I was looking earlier. I mean, when we have something that we’re going to make available to the public we are able to get it posted to our website within a week typically. But I don’t know if we can commit to a specific date. Nancy Tyson: We shouldn’t. Beth: No, and that‘s what I’m saying… Kathy: And that’s what I’m getting at. Beth: So there’s no reason why we wouldn’t, let’s say, because I believe in some of our earlier meetings we talked about what if we were just emailing CMS and saying can you give me this, and we would go ahead and post that email once we had it available, that still stands, that’s something we could post on our website. Kathy: And then there’s a comment at the bottom of page four, last sentence, “So this will be based on actual patient records submitted to CMS by hospices rather than the aggregate statistics reported by agencies to CMS in Cost Reports or to CON in its hospice survey.” So, are you suggesting that we’re not going to rely on the survey any more? Nancy F: No no, I believe that Jan had said in the kidney dialysis decision making there had been, maybe as you were saying regulatory person had said we need to change the wording about, I adopted this phrase from something she had said about kidney dialysis, we’re not supposed to say CMS data, we’re supposed to say reported to CMS? And then it comes back to us? Kathy: What Jan was referring to is specific sections of a dialysis facility report that we identified in the original rule set, so we were being specific about the source and the page of the report. We were advised by our regulatory affairs manager to remove that, and so we’re not proposing that in this rule set. Gina: Can I ask a question? Is this the way the national average length of stay is calculated? Kathy: I don’t know. Nancy F: You can calculate length of stay in a lot of ways. Gina: But when we look at the, you know, you provide the information for us so we can look at ourselves across the board and compare ourselves and then there’s the national average length of stay. Nancy F: It could be either way. Lots of ways. That’s the problem, that’s the whole issue is, I mean, this report has been, this one from the feds on per patient has been out there for years and being used by the department for years. It’s the legitimate average length of stay and that’s what I say here, there are a lot of ways to say it. What we want is the average length of stay per what in the what is episode and admission. A patient is somebody who is a patient in up to two years or three years like Mark said. Our specific need is to have in a length of stay per that death related person entire admission or episode or all their days attendant to their experience and there are a lot of words to use. When you say patient

25

you can be a patient in more than one year and that starts dividing the days of the year by too many people and you get two very different numbers. And that’s been the issue. And that’s why they wrote back and said don’t use that one, that is not meet your, the need of your law, we can get you this one that is more appropriate. Gina: Can we come back to this next time we meet or is it… Kathy: At this time, no we don’t have to decide today because it’s just being proposed today. Do any others have comments they want to make or questions they want to ask with respect to this? Nancy F: I’m sorry, I didn’t hear what you said, we can’t do what? Kathy/Beth: We’re not making a decision on this today. Nancy F: Because it was just proposed today? Beth: I just want to… Nancy F: I’m sorry, I thought we made a lot of decisions on things that were just proposed today. Kathy: We’re going to move forward with just discussing this. Beth? Beth: I want to point out, like Nancy (F) mentioned, we both contacted the same source with the CMS Program Statistics Division. If you have any questions about definitions I would really strongly recommend reaching out to them for definitions, they are fantastically responsive and since they are the custodians of that data they are really going to be the experts (someone asks for email address) I absolutely can, I don’t have it off the top of my head but I will grab it and I will make sure it goes out to the group. Nancy F: I have a contact too Beth: We’ll make sure that everybody gets that. As the data custodians, they are probably going to be a great resource if you have any questions or if you want to put forth any of your own proposals…

5. Conclusion: Kathy: Why don’t we take this time right here to talk about the next meetings and that kind of thing because Gina and April have to leave. I’m hearing proposals from people that maybe we have our next meeting in January because we have the holiday season coming up and it may be hard for people to get away, I know I’m out for part of the month of November. What are people’s thoughts on that? I’m seeing lots of nods. Okay, and I don’t know how the legislative session is going to be affecting folks, do we have people who are affected? Leslie: We are affected…(many group members talking at once) Kathy: And you know I will be too, that’s why I was asking. Leslie: Well it starts January 9 so conceivably you could even have the next meeting prior to session starting. Kathy: Yes, and that’s what I was thinking, so does that work for everyone? First part of January? Okay. No objections to that? We’ll do that, okay. Nancy F: Could we have an agenda that says what policy matters we’ll be discussing? Kathy: I’m not going to make a decision on the policy matters at this time, Nancy (F). Nancy F: No, I’m saying when we have an agenda, could it tell us what we will be discussing? Kathy: Yes, and like everyone else you’ll receive the agenda a week before the meeting… Nancy F: That’s all I’m asking… Kathy: And that happens every time we have a meeting, thank you. Steve: I’m sorry, were you done? Kathy: Yes, I was done. Steve: Providence has a couple of other issues that we do want to discuss at the next meeting. And I don’t know that you would prefer us to kind of, we’re not prepared to discuss them today, we could say

26

what they are, or we could present something between now and January 9 kind of outlining. They’re not… Gina: Well, and Steve I think they are the same issues that the Washington State Hospice and Palliative Care... Mark/Frank: And maybe more, there’s more. Like for sure there is. Kathy: So would you be able to provide us with, like, an issue paper or that type of thing? Steve/Frank: Yes. Could we do that? Kathy: Yes Steve: I mean, rest assured we’re not going to reinvent the wheel, just have a couple of issues and I’ll just give you a preview, like update the application forms, I mean, stuff like that, and one of them is, and this may be controversial, given the fact that there are so few applications, do we need concurrent review for hospice? It’s not reinvent the wheel, it’s just, and we have a position on the potential target year for planning purposes. Mark: We share that. Steve: And we also may have a proposal about somehow, and I think some of the organization members may have talked about this, but how do you account for the ability of existing providers to expand their capacity, I mean again, I’m not qualified to opine on this, but this is not a bricks and mortar type business where hospitals have to plan ten years down the road and spend 15million dollars to add beds, it’s staffing your own business, so those are kind of the basic issues that would be in our position paper. I wouldn’t even call it an issue paper, just an issue statement of things we’d like to discuss with the group. And if you could give us a date you’d like that by once you decide, and we would do our best to get it to you well in advance of the meeting. Kathy: Could you do it before the next meeting? Steve/Frank: Yes. Kathy: So, how about end of November, would that be okay? So you’ll provide the department with your issue paper, I’ll distribute it to the group, and then the agenda will be developed, and as always, that will be distributed a week ahead of time with any relevant materials that people have to present or I received over the course of time since this meeting. Candace: And I just wanted to add, thank you Nancy (F) for putting this together, it helps me visually but I also didn’t hear an answer for Gina’s question and I would love to hear are we talking the same language as the national. Nancy F: I can try to answer that if you tell me which national you’re referring to. Gina: I’m good to come back to it Nancy (F) Nancy F: Pardon me? Gina: I’m good to come back to it. Nancy F: I don’t mean right now, I just mean. I have one other topic that I just want to get on the list because we had just put it aside until we were more done which is sources. Kathy: Do you want to add that to the next agenda? Nancy F: No, no, no just our sort of rolling agenda of things that we’re not done with yet. For example, Beth and I discovered we’re using two different sources for our population and I think, you know, we should all be using the same (one?) because Oregon has two so if we can tie that down, which one is the right one, then we don’t go to court over it. Kathy: Okay, we’ll put it on the list. If we’re done, I’d like to offer a roundtable, so Frank, anything to add? Frank: No, we’ve said what we wanted to say. We’ll have an issues paper. Kathy: I’m looking forward to seeing that. Steve: I’ve said more than enough, I apologize. Lori/Mark: I’m fine.

27

Nancy F: I’ve (unintelligible) to say. Gary/Mark: (no further comment) Barb: I think I’ve got it on the record that I’ve been doing hospice for centuries. Kathy: And that has been absolutely duly noted and I love it, thank you Kathy K/Candace: (no further comment) Leslie: I just want to thank the DOH staff for their facilitation today and appreciate your flexibility in working with us and keeping things moving forward. Kathy: Thank you Nancy Tyson: Nothing to add but I’m looking forward to the hospice conference next week. Catherine: (no further comment) Beth: Thank you so much for being here; I love seeing a full room Gina/April: (no further comment) Kathy: I guess that concludes the meeting then and we’ll see everybody in January. **END**