Effect of Ownership on Hospice Service Use: 2005–2011

Abstract

Background/Objectives For-profit agencies comprise the majority of all United States hospice agencies, prompting concerns about aggressive enrollment practices and deficient care. Using detailed administrative data from 2005–2011, we sought to assess differences in patient populations and service use by hospice ownership, chain status, and agency size. Design/Participants Retrospective cohort study of 5,405,526 Medicare beneficiaries age 65+ enrolled in hospice during 2005–2011. Hospice use by ownership category (for-profit non-chain and chain, not-for-profit non-chain and chain, government) and agency size (0–50 patients, 51–200, 201–400, 401+). Mean length-of-use, stays ≤3 days, stays ending with live discharge, and decedents receiving no general inpatient care (GIP) or continuous home care (CHC) level hospice in the last 7 days of life. Results After adjusting for patient and geographic differences, for-profit non-chain and chain agencies had longer mean lengths-of-use (84.5 and 91.2 days, respectively) than other agency types (66.3–72.5 days); higher rates of live discharge (21.0% and 20.2% versus 14.6%–15.9%); and lower proportions of stays of ≤3 days (13.9% and 14.7% versus 16.6%–17.5%) (all p-values<0.001). The proportion of decedents not receiving GIP/CHC level care before death was highest among for-profit chains (75.9%) and lowest among not-for-profit non-chains (63.2%). Across ownership categories, smaller agencies had longer mean lengths-of-use, higher live discharge rates, lower rates of stays ≤3 days, and higher rates of patients receiving no GIP/CHC level care. Considerable variation in patient traits and unadjusted service use existed among the nation’s largest chains. Conclusion Although for-profit and not-for-profit hospice agencies differ along key dimensions, our results convey substantial heterogeneity within these categories, highlighting the need to consider factors such as agency size and chain affiliation in understanding variations in Medicare beneficiaries’ hospice care.

Closing the Gap in Hospice Utilization for the Minority Medicare Population

“…The finding of the positive relationship between the prevalence of for-profit hospices and racial/ethnic minority Medicare utilization is not surprising given previous research showed for-profit hospices engage in greater community outreach to racial/ethnic minorities and low-income communities than nonprofit hospices (Aldridge et al, 2014; Stevenson et al, 2016). Prior research showed that both lower income and lower education were associated with lower rates of hospice care enrollment and at-home hospice death when holding other covariates constant (Barclay, Kuchibhatla, Tulsky, & Johnson, 2013; Jenkins et al, 2011; Silveira, Connor, Goold, McMahon, & Feudtner, 2011).…”

“…One variable that relates to a greater number of racial/ethnic minorities receiving information about hospice is hospice ownership status. For-profit hospices tend to engage in greater community outreach to low-income and racial/ethnic minority communities than nonprofit hospices (Aldridge et al, 2014; Stevenson, Grabowski, Keating, & Huskamp, 2016). Stevenson et al (2016) found this relationship persisted despite its chain status.…”

“…For-profit hospices tend to engage in greater community outreach to low-income and racial/ethnic minority communities than nonprofit hospices (Aldridge et al, 2014; Stevenson, Grabowski, Keating, & Huskamp, 2016). Stevenson et al (2016) found this relationship persisted despite its chain status. With the growth in the proportion of hospices having for-profit ownership from 5% in 1990 to over 60% in 2014, it is important to compare measures such as utilization between hospices with different ownership status.…”

Pc-Facs

“…These findings substantiated previous work, suggesting that savings diminished with prolonged stay [4][5][6] and that traits and behaviors inherent to hospice agencies influenced lengths of stay. 7 The study underscored the need for providers to be proper stewards of finite healthcare resources as they continue to advocate for hospice use.…”

Quality of Hospice Care at Home Versus in an Assisted Living Facility or Nursing Home

“…The use of hospice has expanded rapidly in recent decades, with almost 48% of Medicare decedents receiving hospice care in 2014 . Variations in delivery of hospice to individuals with different diagnoses and in different settings have led to concerns about quality of care . The Affordable Care Act required the Centers for Medicare and Medicaid Services to develop a plan to publicly report quality data for hospices using standardized measures across settings .…”