Maggie recently wrote about a MedPAC decision aimed at stopping for-profit hospices from purposefully keeping patients under their care for extended periods of time in order bill Medicare for more days of service. Medicare’s concern that the hospices might be bilking the system raises a larger question: should we be worried that so many of today’s hospices are for-profit?
The short answer is “yes,” and at the very least, we should be giving them—and hospices in general—more attention. Hospices play a bigger role in our health care system than ever before. In 2005, hospices cared for 1.2 million patients, and one-third of Americans who passed away that year did so under hospice care. According to the National Hospice and Palliative Care Organization (NHPCO), hospice admissions are rising rising at a rate of almost 10 percent a year.
The fastest growing segment of the hospice industry is—you guessed it—for-profit hospices. Between 1994 and 2004, the number of for-profit hospices in the US increased nearly 4-fold, growing more than 6 times faster than nonprofit hospices. According to industry estimates, for-profit hospice programs now care for about 35% of hospice patients, versus a mere 9% in 1990 (today, nonprofit groups care for 56% and the government and other types of organizations care for the remaining 9%). Little wonder, given that there’s so much money to be made in the industry: Medicare reimbursement for hospice care has grown from $68.3 million in 1986 to $8.3 billion in 2005 and is expected to hit a whopping $45.6 billion by 2030.
The bad news is that, in their quest for Medicare dollars, for-profit hospices don’t provide all the care that they should in order to fulfill the hospice mission of maximizing patients’ quality of life. In fact, a 2004 Medical Care study of 2,080 patients enrolled in 422 hospices across the country found that “terminally ill patients who receive end-of-life care from for-profit hospice providers receive a full range of services only half the time compared with patients treated by nonprofit hospice organizations.” That’s because for-profit hospices like to keep costs low by skimping on services, particularly so-called “non-core” services like medications and personal care (How these are classified as “non-core” services I don’t know—they seem pretty important to me—but there you go). For example, families of patients receiving care from a for-profit hospice received counseling services, including bereavement counseling, only [45% as often] as those in a nonprofit hospice. Translation: when researchers controlled for differences across patients, sicknesses, and conditions, those at for-profit hospices were only half as likely to get the same support provided at nonprofit hospices. A 2005 follow-up study confirmed that for-profit patients receive a “narrower range of services” than nonprofit patients.
Given these results, the senior author of both studies, Dr. Elizabeth Bradley of Yale, concludes that “for-profit hospices…might not be as strongly rooted in…[the]…traditional hospice philosophy” of “psychosocial support, spiritual care, the use of volunteers and family, and symptom management” as their nonprofit counterparts.