Maryland lawmakers, who are used to seeing fights over the rules on who can offer lucrative health services such as open-heart surgery, this year are witnessing one over a service that loses money - hospice care for the terminally ill.
Maryland Community Hospice, part of a larger organization based in the District of Columbia, is trying to beat back a bill - passed 41-0 by the state Senate on Saturday - that would restrict its ability to operate statewide.
Sen. Thomas M. Middleton, chairman of the Finance Committee and a Senate sponsor, said the bill is designed to protect small, community-based hospice programs against "a big out-of-state entity" that threatens them.
He said the name "Maryland Community Hospice" was "confusing to people," who might make donations thinking they were helping a small organization in their community.
Erwin Abrams, president of Hospice of the Chesapeake, which operates in Anne Arundel and Prince George's counties, said the bill is needed to assure "the survival of hospices that subsist on community volunteers and fund raising."
Loss of even a fairly small number of patients could jeopardize the viability of small hospice programs, said Abrams, who is also chairman of the public-policy committee of the Hospice Network of Maryland, a trade group that supports the legislation.
James Elmslie, who runs Maryland Community Hospice, which is a part of the Washington Home and Hospice, said his nonprofit organization, which has been expanding, has not hurt the smaller hospices, and that opposition to growth by his program is "based on a fear factor of the future and what we might do."
The story begins, in a sense, in 1888, when what was then called the Washington Home for Incurables was founded to treat terminally ill patients.
Washington Home maintains a nine-bed inpatient hospice unit on its Northwest Washington campus, where it also has a large nursing home. In recent years, hospice care has focused on providing nursing and counseling to terminally ill patients at home.
In 2001, Washington Home bought the hospice unit of MedStar Health, a system that operates hospitals and other health services in the Baltimore-Washington area. Last year, Washington Home formed an affiliation under which it provides hospice services to Johns Hopkins patients.
The MedStar acquisition put Washington Home in an unusual position in terms of Maryland regulatory requirements. Barbara McLean, executive director of the Maryland Health Care Commission, said the state requires new hospice services to get a "certificate of need."
Her commission develops a state health plan in which it projects need for various services. For example, it would only authorize a new nursing home if the health plan shows it is needed.
Certificates of need for hospice services are limited to a single county, she said, but when the certification process was extended to hospice services about 15 years ago, existing programs were "grandfathered" and allowed to continue to operate without geographic restriction.
When Washington Home bought MedStar's hospice program, "they essentially bought the grandfathering," McLean said.
Middleton's bill would end that, limiting Washington Home to counties it served in 2001.
Elmslie said it is not clear what counties, if any, would lose service from his organization if the bill passes. The bill would, however, block it from serving additional counties, a right it says it now has.
McLean said her commission supports the intent of the bill, and had been considering developing regulations that would prevent "grandfathered" hospice agencies from opening in new areas without a certificate of need. She said the current health plan shows there is no unmet need for hospice services.
Elmslie, however, said that part of the plan was developed in 1997 and doesn't adequately measure current need for the service. He predicted demand would grow as his organization does "outreach" to make people more familiar with hospice care.
Gary Alexander, a lawyer and lobbyist for Washington Home, said, "This is a tough fight, and it shouldn't be." He said it should be "inconceivable" that the legislature would revoke the statewide authority Washington Home already has.
Large health systems such as MedStar and Hopkins, he said, want to contract with a statewide agency to provide service.
Middleton said the small, community hospices, which he believes are threatened by Washington Home, are providing excellent service. He said Hospice of Charles County is "one of the most respected nonprofits in my community."
"When my Dad was brought home to die," he said, "every afternoon, that hospice volunteer was there."