Pinellas County's hospice began more than 30 years ago, founded by a group of volunteers with the unconventional idea that Americans deserved a better way to die.
Now Suncoast Hospice has grown into a $139 million-a-year force in the Tampa Bay area, serving more than 2,000 patients each day in their final months of life. It has become one of the largest hospices in the United States.
But this pioneering agency is facing an unprecedented challenge: competition.
Three other hospices are trying to break into Pinellas County, asking regulators to shake up what is essentially a state-sanctioned monopoly.
It's a battle that mixes the philosophy of dying with the business of dying.
Pinellas County is, for lack of a better phrase, a good market for hospice. It has nearly 1 million residents, 11,591 of whom are projected to die in 2011. And much of the marketing already has been done, because surveys show residents are better educated about hospice care than other parts of the country.
The would-be competitors include a for-profit company from Texas, plus two non-profit hospices already based in the Tampa Bay area.
This fight would have been hard to imagine in the old days, when hospice and end-of-life care were still arcane concepts waiting to gain acceptance.
The number of hospices has been regulated for a long time, but "nobody cared for years because nobody wanted to be a hospice," said Mary J. Labyak, president and CEO of Suncoast Hospice.
"That has changed drastically."
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One of the reasons Suncoast has been able to grow so dramatically over the years is that it's in a county with lots of people, especially lots of elderly people.
Here is another reason: The state hasn't let other hospices in.
This is not a free-market system. The state decides whether new hospices should be allowed to come into Florida communities, using a process that's similar to the way it decides whether new hospitals can be built.
Using surveys, formulas and other investigations, regulators look at how many people use a community's hospice, and how many people are expected to die in that community in the near future. If the numbers are too far apart, regulators allow other hospices to apply to come in.
Pinellas has one state-licensed hospice. (There is a hospice program for veterans at the Bay Pines VA Medical Center, but it is a federal facility with a different license process.)
Labyak said surveys have always shown Pinellas residents use hospice services at a high rate. But last year, she said, the numbers fell off a bit, which she said was part of a national trend of consumers using less health care services in troubled economic times.
Also, she said, Suncoast made a mistake by not counting some of the people it was providing with services. She said certain people were miscategorized, which meant the computer system did not count them.
So, on paper at least, the number of people served by the hospice looked low. As a result, the state Agency for Health Care Administration published a notice saying new hospices could apply to come into Pinellas County, the first such chance for outsiders in decades.
When Suncoast discovered its counting mistakes, it explained the situation to state regulators, who took away the right for other hospices to apply in Pinellas.
But by that time, the battle was on. Three hospices filed complaints, seeking a hearing that could lead the state to overturn its decision. The three are HPH Hospice, from Hernando, Pasco and Citrus counties; LifePath Hospice of Hillsborough County; and Odyssey HealthCare of Central Florida, whose corporate address is listed in Dallas.
Not all of them buy Suncoast's explanation that it miscounted its patients.
In its petition, LifePath objected that the state changed its mind after using "self-serving 'revised' utilization data" provided by Suncoast. But Darrell White, vice president and general counsel of LifePath, said he wasn't "claiming that anything dishonest is going on here."
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The three other hospices want to compete in Pinellas, but that doesn't necessarily mean they want unlimited competition.
The two local nonprofits, HPH and LifePath, like the current system that regulates the number of hospices. They say the system has helped them — and Suncoast — provide exceptional care.
The reasoning goes like this: In areas where there is a free-market system, hospices often have 75 or 100 patients. In the Tampa Bay area, LifePath serves more than 1,500 patients. The bigger hospices can provide more services for the entire community, including many not reimbursed by Medicare or private insurance. The largest share of hospice care is reimbursed by Medicare.
"What do you get with a larger hospice? You get a much greater scope of services," said White of LifePath, which also is affiliated with Good Shepherd Hospice in other Central Florida counties.
Labyak strongly agrees with this view. She said Suncoast has been a pioneer in providing services that are not reimbursed by Medicare or other sources, but are important to the community. Some examples: a bereavement group for parents of stillborn children and programs and camps for grieving children. A smaller, less-established hospice would not be able to have three centers in different parts of Pinellas County, plus two residential programs called hospice houses, she said.
"Our range of services is known across the nation and is really unparalleled," said Labyak. She has been at the hospice, formerly called the Hospice of the Florida Suncoast, since 1982.
So if just about everyone agrees on the closely controlled system, why do some want to modify it and come into Pinellas?
HPH already operates in Pasco County, and works with physicians and patients on both sides of the Pinellas-Pasco border, so it would be a logical extension, said Robin Kocher, spokeswoman for HPH. She called Suncoast an "absolutely wonderful" program, but said HPH could offer benefits for some.
LifePath's White said there are "a significant number of patients who reside in Pinellas County who come over to Tampa hospitals such as Moffitt (Cancer Center). … It would be a natural fit for us to provide service in Pinellas County."
The state's Division of Administrative Hearings is scheduled to hear the objections next month and issue an opinion on whether the state erred by allowing Suncoast to revise its numbers.
Curtis Krueger can be reached at email@example.com or (727) 893-8232.