1. Originally presented April 2009

2. PURPOSE To utilize hospice penetration as a metric for access tocare To identify those states with high and low levels, on arelative basis, of hospice penetration To compare and contrast various market factors, at thestate level, to understand differences between high andlow penetration states 3. AGENDA Background Identification of High and Low Penetration States Market Factors Influencing Penetration Conclusions 4. SPEAKER BACKGROUND BA Lehigh University Mathematics, MBA MIT SloanSchool Marketing and planning positions with Fortune 100companies, with emphasis of consumer products 20+ years in all aspects of home care with for-profitand non-profit organizations President, Healthcare Market Resources, a localmarket competitive intelligence firm 5. DATA SOURCES Medicare hospice claims files Medicare reports Center for Disease Control publications Department of Commerce, Census Bureau State Departments of Health websites 6. RESEACH APPROACH Regression Analysis See if hospice penetration is dependent on a givenvariable Utilizes entire set of state data Very high or very low correlation can be relied upon High/Low Penetration Identify high and low penetration states & see if thesegroups results mirror top 10 or bottom 10 performers forthat indicator Better able to identify factors that enhance or inhibitpenetration 7. HOSPICE PENETRATION METRICPatients ServedMedicare Eligible = Hospice Penetration 8. PENETRATION BY STATE 20064.00%3.50%3.00%2.50%2.00%1.50%1.00%0.50%0.00%AL AK AZ AR CA CO CT DE DC FL GA HI ID 9. PENETRATION BY STATE 20074.00%3.50%3.00%2.50%2.00%1.50%1.00%0.50%0.00%AL AK AZ AR CA CO CT DE DC FL GA HI ID 10. PENETRATION BY STATE 20063.50%3.00%2.50%2.00%1.50%1.00%0.50%0.00%IL IN IA KS KY LA ME MD MA MI MN MS MO 11. PENETRATION BY STATE 20074.00%3.50%3.00%2.50%2.00%1.50%1.00%0.50%0.00%IL IN IA KS KY LA ME MD MA MI MN MS MO 12. PENETRATION BY STATE 20064.00%3.50%3.00%2.50%2.00%1.50%1.00%0.50%0.00%MT NE NV NH NJ NM NY NC ND OH OK OR PA PR US 13. PENETRATION BY STATE 20074.00%3.50%3.00%2.50%2.00%1.50%1.00%0.50%0.00%MT NE NV NH NJ NM NY NC ND OH OK OR PA 14. PENETRATION BY STATE 20064.00%3.50%3.00%2.50%2.00%1.50%1.00%0.50%0.00%RI SC SD TN TX UT VT VA WA WV WI WY US 15. PENETRATION BY STATE 20074.00%3.50%3.00%2.50%2.00%1.50%1.00%0.50%0.00%RI SC SD TN TX UT VT VA WA WV WI WY US 16. HIGH PENETRATION STATES 2006OKLAHOMAARIZONAALABAMA UTAHMISSISSIPPI FLORIDAIOWAGEORGIANEW MEXICOTEXAS 17. HIGH PENETRATION STATES 2007ARIZONA FLORIDAUTAHIOWAOKLAHOMADELAWAREARIZONA TEXASMISSISSIPPI MISSOURI 18. LOW PENETRATION STATES 2006ALASKA HAWAIIWYOMINGNEW YORKDISTRICT OFPUERTO RICOCOLUMBIAVERMONTSOUTH DAKOTAMAINEWEST VIRGINA 19. LOW PENETRATION STATES 2007ALASKA WYOMINGHAWAII NEW YORKDISTRICT OFVERMONTCOLUMBIASOUTH DAKOTA KENTUCKYWEST VIRGINA MAINE 20. PENETRATION GROWTH 2006100.00%98.20%90.00%80.00%70.00%60.00%48.00% 51.20%50.00% 40.00%40.00%30.00%20.00%10.00% 0.00%HIGH LOWLOW w/o AK AVG 21. PENETRATION GROWTH 2007100.00%97.26%90.00%80.00%70.00%60.00%56.38%55.21%50.00% 47.56%40.00%30.00%20.00%10.00% 0.00%HIGH LOWLOW w/o AKAVG 22. HIGH GROWTH STATES 2006ALASKA MAINEDELAWARE RHODE ISLANDSOUTH DAKOTA IDAHOMISSISSIPPIALABAMAKANSAS TENNESSEE High Penetration-Bold; Low Penetration-Italics 23. HIGH GROWTH STATES 2007ALASKAMAINEDELAWARERHODE ISLANDIDAHO SOUTH DAKOTASOUTH CAROLINA NORTH DAKOTATENNESSEE IOWA High Penetration-Bold Low Penetration-Italics 24. LOW GROWTH STATES 2006KENTUCKY COLORADOHAWAII NEVADAILLINOIS MICHIGANFLORIDAOREGONWASHINGTON MARYLAND High Penetration-Bold Low Penetration-Italics 25. LOW GROWTH STATES 2007KENTUCKY COLORADONEVADA ILLINOISOREGON HAWAIIWYOMINGMARYLANDNEW YORK FLORIDA High Penetration-Bold Low Penetration-Italics 26. CON STATES PENETRATION 2006 2.50% 2.25%2.29%2.19% 2.00% 1.82%1.71% 1.50% 1.00% 0.50% 0.00%CONCONNon-CON Natl WghtNatl States States w/o StatesAvg UnwghtFLAvg 27. CON STATES PENETRATION 20073.00%2.43%2.41%2.50%2.30%2.00% 1.92% 1.82%1.50%1.00%0.50%0.00%CON States CON States Non-CONNatl Wght Natl Unwght w/o FLStates AvgAvg CON States - 25% of Total 28. ACCESS IN CON STATES 2006(Hospices per Counties) 3 32.5 21.51.41.281.17 10.95 0.82 0.8 0.82 0.790.680.63 0.71 0.60.5 0.33 0.23 0AR DC FL HIKY MD NY NCSC TNVT WA WV US AVG 29. ACCESS IN CON STATES 2007 (Hospices per Counties)3.50 3.003.002.502.00 1.601.481.50 1.17 1.021.000.81 0.820.820.650.710.680.64 0.600.500.330.23 -AR DC FLHIKY MD NY NC SC TN VT WA WV US AVG 30. HIGH PENETRATION STATES 2006CON STATES IN BOLDOKLAHOMAARIZONAALABAMA UTAHMISSISSIPPI FLORIDAIOWAGEORGIANEW MEXICOTEXAS 31. HIGH PENETRATION STATES 2007CON STATES IN BOLDARIZONA FLORIDAUTAHIOWAOKLAHOMADELAWAREARIZONA TEXASMISSISSIPPI MISSOURI 32. LOW PENETRATION STATE 2006CON STATES IN BOLDALASKA HAWAIIWYOMINGNEW YORKDISTRICT OFPUERTO RICOCOLUMBIAVERMONTSOUTH DAKOTAMAINEWEST VIRGINA 33. LOW PENETRATION STATE 2007CON STATES IN BOLDALASKA WYOMINGHAWAII NEW YORKDISTRICT OFVERMONTCOLUMBIASOUTH DAKOTA KENTUCKYWEST VIRGINA MAINE 34. LOW GROWTH STATES 2006CON STATES IN BOLDKENTUCKY COLORADOHAWAII NEVADAILLINOIS MICHIGANFLORIDAOREGONWASHINGTON MARYLAND 35. LOW GROWTH STATES 2007CON STATES IN BOLDKENTUCKY COLORADONEVADA ILLINOISOREGON HAWAIIWYOMINGMARYLANDNEW YORK FLORIDA 36. HOSPICE PENETRATION (Hospice Deaths as % of Anticipated Deaths)50.0% 45.3%44.4%45.0%40.0% 33.6%35.0%30.0%25.0% 20.1% 20.4%20.0%15.0%10.0% 5.0%0.0%Top 10 High Pent Bottom 10 Low Pent Natl Avg 37. METRIC COMPARISON BY STATEHigh Death % High Penetration % Low Death %Low Penetration %ArizonaOklahoma Alaska AlaskaUtah ArizonaDist of Columbia HawaiiAlabamaAlabamaHawaii WyomingFloridaUtah WyomingNew YorkMississippiMississippiPuerto RicoDist of ColumbiaColorado FloridaNew York Puerto RicoNew Mexico Iowa VermontVermontOklahoma GeorgiaSouth Dakota South DakotaOregon New Mexico North Dakota MaineIowa TexasMaineWest Virginia 38. HOSPICE GROWTH(% Change in Hospice Penetration % 2002-6)80.0%79.9%70.0%60.0% 51.0%50.0%48.0%40.0%40.0%30.0% 23.1%20.0%10.0% 0.0%Top 10 High Pent Bottom 10 Low Pent Natl Avgw/o AKw/o AK 39. HOSPICE GROWTH(% Change in Hospice Penetration % 2002-7)100.0% 92.6%90.0%80.0%70.0%60.0%56.4% 55.2%47.6%50.0%40.0%30.0%27.3%20.0%10.0% 0.0% Top 10 w/o High Pent Bottom 10 Low Pent Natl AvgAK w/o AK 40. POPULATION DENSITYPopulation per Square Mile 700 604.57 600 500 400 300 200 100 92.9 90.283.8 14 0 Top 10 High Pent Bottom 10 Low Pent Natl Avg w/o DCw/o DC 41. ACCESS TO CARE(Hospices /10K Medicare Eligible) 21.981.81.61.491.41.21 0.840.8 0.730.60.40.360.2 0Top 10High Pent Bottom 10 Low Pent Natl Avg 42. GEOGRAPHIC ACCESS TO CARE(Hospices per 1K Sq Miles)6 5.8354.734321.2810.61 0.81 0.280Top 10 High Bottom LowLowNatlex DC Pent 10 ex Pent Pent ex AvgAK AK, DC, PR 43. NON-WHITE PATIENTS(% Non-White Discharges)35.0%32.5%30.0%25.0% 20.1%20.0%15.0%14.7%12.1%10.0%5.0%2.0%0.0%Top 10 High Pent Bottom 10 Low Pent Natl Avg 44. NON-WHITE HOSPICE PENETRATION(% Non-White Discharges/% Non-White Population) 70.0%67.5% 60.0% 50.0%41.0%42.4% 40.0% 36.5%31.3% 30.0% 20.0% 18.1% 10.0%0.0% Top 10 HighBottom LowLowNatlPent10 PentPent ex Avg DC, HI 45. DISEASE MIX(% Non-Cancer Hospice Deaths)70.0%67.2% 60.0%61.9%60.0% 53.8% 54.8%50.0%40.0%30.0%20.0%10.0%0.0%Top 10High Pent Bottom 10Low PentNatl Avg80+% Correlation between Hospice Penetration & Non-Cancer Hospice Deaths 46. ALZHEIMERS IMPACT(% Alzheimers/Dementia Deaths of Total Deaths)35.0% 30.9%30.0%25.0%19.9%20.0% 16.9% 14.8%15.0%10.0%7.1%5.0%0.0%Top 10 High Pent Bottom 10 Low Pent Natl Avg 47. FOR-PROFIT PRESENCE(FOR-PROFIT MEDICARE REVENUES/TOTAL MEDICARE REVENUES) 80.0%77.4% 70.0%63.0% 60.0% 50.0% 49.4% 40.0% 30.7% 30.0%25.0% 20.0% 10.0% 9.7%0.0% Top 10 HighBottom LowLowNatlPent10 PentPent ex Avg AK 48. LENGTH OF STAY(Days per Discharge)100 99.891.7 90 80 69.8 7064.5 60 53.2 50 40 30 20 100Top 10 High Pent Bottom 10 Low Pent Natl Avg 49. LONG STAY PATIENTS(% Patients w/LOS>180 days)18.0%17.0%16.0%15.4%14.0%12.0% 10.8%10.0%9.2%8.0%7.2%6.0%4.0%2.0%0.0%Top 10 High Pent Bottom 10 Low Pent Natl Avg 50. LONG STAY PATIENTS(% Patients w/LOS>90 Days)30.0%28.6% 26.7%25.0% 19.7%20.6%20.0% 15.1%15.0%10.0%5.0%0.0%Top 10 High Pent Bottom 10 Low Pent Natl Avg 51. NURSING HOME MARKET On currently available claims data, there is no data onplace of service; must infer Claims data has place of death; if patient dies in a medicalfacility, it is either a hospital or a skilled nursing facility If patient dies in a hospital, they were likely there toreceive inpatient services So if a patient dies in a medical facility and has noinpatient days on the last claim, we infer that they musthave did in a SNF 52. NURSING HOME MARKET(% DIED IN MED FAC W/NO INPT DAYS)35.0% 30.9%30.0%25.0%19.9%20.0% 16.9% 14.8%15.0%10.0%7.1%5.0%0.0%Top 10 High Pent Bottom 10 Low Pent Natl Avg 53. CORRELATION SUMMARY(Hospice Penetration)INDICATOR CORREL INDICATOR CORRELHospice Growth-.265Alzheimers Impact.257Population Density-.217For-Profit Presence .477Access to Care.372 Length of Stay.597Geographic Access -.198Long Stay Patients.645Non-White Patients-.129Long Stay Patients 90+.583Non-White Penetration .017 Nursing Home Market .124Disease Mix .807 Hospice Death Penetration .949 54. CONCLUSIONS Few market factors appear to consistently influencehospice penetration(access to care) Those factors with the greatest influence Non-Cancer Hospice Deaths Length of Stay, particularly driven by 180+ day patients Presence of For-Profits CON appears to inhibit hospice penetration 55. CONTACT INFORMATIONRich ChesneyPresident, Healthcare Market Resourcesrchesney@healthmr.com215.657.7373215.657.0395(f)www.healthmr.com