The researchers found variation in overall performance of for-profit and not-for-profit hospices, so they say decisions on selecting a hospice should be based on publicly available data.
Family caregivers say they have worse care experiences at for-profit hospices than at not-for-profit hospices, a new journal article found.
Earlier research has shown that for-profit hospices do not perform as well as not-for-profit hospices, with higher rates of hospitalizations and emergency department visits, as well as offering a narrower range of services such as less nursing visits. The percentage of hospices that are for-profit has risen significantly over the past two decades, increasing from 30% in 2000 to 73% in 2020, according to the Medicare Payment Advisory Commission.
The new research article, which was published today by JAMA Internal Medicine, examines Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data collected from 1,761 for-profit hospices and 906 not-for-profit hospices.
The CAHPS Hospice Survey includes eight measures of hospice care experiences by family caregivers: hospice team communication, getting timely care, treating family member with respect, getting emotional and religious support, getting help for symptoms, getting hospice care training, rating of hospice, and willingness to recommend a hospice. The CAHPS Hospice Survey also includes a summary measure, which is an average of a hospice's performance across the eight measures of hospice care experiences.
CAHPS Hospice Survey data was examined from April 2017 to March 2019.
The new research article includes four key findings:
- For all measures, family caregivers reported worse care experiences at for-profit hospices than at not-for-profit hospices
- For-profit hospice performance varied, with 31.1% of for-profit hospices scoring 3 or more points below the national hospice average of overall performance, and 21.9% scoring 3 or more points above the national average
- Not-for-profit hospices scored better on overall performance, with 12.5% of not-for-profit hospices scoring 3 or more points below the national average, and 33.7% of not-for-profit hospices scoring 3 or more points above the national average
- Family caregivers with patients who received care in for-profit state, regional, or national hospice chains reported the worst care experiences
"Family members and friends of patients receiving hospice care reported substantially worse care experiences in for-profit compared with not-for-profit hospices; however, there is important variation in quality among both types of hospices. Because both for-profit and not-for-profit hospices are represented among the highest-performing and lowest-performing hospices, reporting of quality results for individual hospices is critical. Publicly reported survey measure scores provide important information to guide selection of a hospice," the study's co-authors wrote.
Interpreting the data
The family caregiver survey data provides valuable information about hospices, the study's co-authors wrote. "Using national data, we find that caregivers report substantially poorer care experiences in for-profit hospices than in not-for-profit hospices, with caregivers of those in for-profit hospices nearly 5 percentage points less likely than those in not-for-profit hospices to definitely recommend their hospice."
Prior research and the new study raise serious concerns about for-profit hospices, the co-authors wrote. "In the hospice context, poor quality care has been associated with complicated family grief and poorer bereavement adjustment, so this quality gap, combined with the growing dominance of for-profit hospices, is of particular concern."
In comments to HealthLeaders, the study's lead author speculated about why caregivers report substantially poorer care experiences in for-profit hospices than in not-for-profit hospices.
"The difference in care experiences between for-profit and not-for-profit hospices is likely explained by a combination of things that for-profit hospices don't do as well, and things that not-for-profit hospices do especially well. For example, many for-profit hospices try to provide more cost-efficient care by using fewer and less skilled staff. This means that their hospice teams may be less responsive to telephone calls from patients and families, or less likely to visit patients when they need it most. In contrast, not-for-profit hospices, which have smaller profit margins than for-profit hospices, are more likely to provide services that help improve patients' quality of life but are not covered by hospice payments," said Rebecca Anhang Price, PhD, senior policy researcher at RAND Corporation.
She also speculated on why hospices in chains received the lowest care experience scores. "Chains may be particularly attentive to their profit margins, and as such, they may look to reduce the number and cost of staff, since staffing is the main expense for a hospice. But high-quality staff are key to a hospice's ability to provide high-quality care, so understaffing—in terms of either number of staff or the skills and training of that staff—can have negative effects on patient and family care experiences."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
For all nine measures of care experience examined in the study, family caregivers reported worse care experiences at for-profit hospices than at not-for-profit hospices.
Family caregivers with patients who received care in for-profit state, regional, or national hospice chains reported the worst care experiences.