Abstract
Context
Medicare’s per diem payment structure may create financial incentives to select patients who require less resource-intensive care and have longer hospice stays. For-profit and nonprofit hospices may respond differently to financial incentives.
Objective
To compare patient diagnosis and location of care between for-profit and nonprofit hospices, and examine whether number of visits per day and length of stay vary by diagnosis and profit status.
Design, Setting, and Patients
Cross-sectional study using data from the 2007 National Home and Hospice Care Survey. Nationally-representative sample of 4705 patients discharged from 1,036 hospice agencies.
Main Outcome Measures
Diagnosis and location of care (home, nursing home, hospital, residential hospice, or other) by hospice profit status. Hospice length of stay and number of visits per day by various hospice personnel.
Results
For-profit hospices, compared to nonprofits, had a lower proportion of patients with cancer (34.1% [29.9–38.6%] vs. 48.4% [45.0–51.8%]) and a higher proportion of patients with dementia (17.2% [14.1–20.8%] vs. 8.4% [6.6–10.6%]) and other non-cancer diagnoses (48.7% [43.2–54.1%] vs. 43.2% [40.0–46.5%]) (adjusted P<.001). After adjustment for demographic, clinical, and agency characteristics, there was no significant difference in location of care by profit status. For-profit hospices, compared to nonprofits had a significantly longer length of stay (median 20 [6,88] vs. 16 [5,52] days, adjusted P=.01) and were more likely to have patients with stays >365 days (6.9% [5.0–9.4] vs. 2.8% [2.0–4.0]) and less likely to have patients with stays <7 days (28.1% [23.9–32.7%] vs. 34.3% [31.3–37.3%]) (adjusted P=.004). Compared to cancer patients, those with dementia or other diagnoses had fewer visits per day from nurses (0.58 [0.34,0.94] vs. 0.38 [0.19,0.65] and 0.41 [0.26,0.79], adjusted P=.002) and social workers (0.15 [0.07, 0.31] vs. 0.07 [0.04, 0.21] and 0.11 [0.06, 0.24], adjusted P<.001).
Conclusion
Compared with nonprofit hospices, for-profit hospices had a higher percentage of patients with diagnoses associated with lower skilled needs and longer lengths of stay.
Over the past 10 years, there has been substantial growth in the for-profit hospice sector.1 From 2000 to 2007, the number of for-profit hospices more than doubled from 725 to 1,660, while the number of nonprofit hospices remained essentially the same 1,193 in 2000 and 1,205 in 2007.2 Overall, for-profit hospices have significantly higher profit margins than nonprofit hospices, varying from 12% to 16% between 2001 and 2004, compared to −2.9% and −4.4% for nonprofit hospices. 2 This rapid growth of the for-profit hospice sector and the differential profit margins have raised questions about potential financial incentives in hospice reimbursement.
Medicare payment policy is a key determinant of hospice reimbursement. Medicare beneficiaries comprise 84% of patients on hospice3 and about 40% of Medicare decedents use hospice annually.2 Medicare reimburses hospices a per diem rate ($142.91/day in 2010) for routine care, which can be provided at home or in a nursing home.3 This capitated rate is fixed regardless of the care needs of individual patients or the services that they receive, and may create a financial incentive to select patients requiring less resource-intensive services. Moreover, experts generally believe that longer stays are more profitable than shorter stays,2, 4 and emerging evidence suggests that hospice costs tend to be U-shaped with considerable fixed costs at the time of enrollment and again near death.5–8 Thus hospices can lower their average daily costs by attracting patients with longer lengths of stay.7, 9 Some data suggest that for-profit hospices are less likely to admit patients with shorter expected lengths of stay,10 while other data suggest no difference in mean length of stay between for-profit and nonprofit hospices.11 The Balanced Budget Act of 1997 relaxed the previous 210 day cap on Medicare hospice coverage, allowing for an unlimited number of 60-day periods, provided patients are recertified (i.e., deemed to have 6 months or less to live if their disease runs its normal course).2 This policy change allowed for longer reimbursable stays in hospice, and may have contributed to the rise of for-profit hospices.
In this context, we compared patient diagnosis and location of care between for-profit and nonprofit hospices, and examined whether length of stay and the number of visits per day by hospice providers vary by diagnoses and by profit status.
Methods
Data Source
We examined a nationally-representative sample of patients discharged from hospice, primarily due to death (84%) using the 2007 National Home and Hospice Care Survey (NHHCS).12 The 2007 NHHCS employed a stratified two-stage sampling design. First, a representative sample of US home health and hospice care agencies was selected after being stratified by agency type and metropolitan statistical area (MSA). From over 15,000 agencies, 1,545 agencies were randomly sampled from the strata with probability proportional to size. Overall, 1,461 selected agencies were eligible (95%), and 1,036 agreed to participate (unweighted 71%, weighted 59%).13 A computer algorithm randomly selected up to 10 current patients per home health agency, up to 10 hospice discharges per hospice agency, or a combination of up to 10 current home health patients and hospice discharges for a mixed agency. Hospice discharges during the 3-month period before the agency interview were eligible. Our study focused solely on the sample of 4,733 patients discharged from hospice. We excluded 28 discharges with any missing data on our main factors of interest (length of stay, diagnosis, and location of care). Our final sample consisted of 4,705 hospice discharges.
Data were collected through in-person interviews with the staff member who knew each sampled patient best; questions were answered in consultation with the patient’s medical chart or other records. No patients or family members were interviewed.
Patient Diagnoses and Location of Care
We classified patients’ primary admission diagnoses into the following 3 groups: cancer (codes 140–239), dementia (ICD-9-CM codes 290.0, 290.42, 294.8, 294.9, 331.0, 331.11, 331.4, 331.82, 331.9) and other (all remaining codes such as congestive heart failure). We categorized location of care as home, nursing home, hospital, residential hospice or other.
Hospice Length of Stay
Length of stay (LOS) was measured from date of hospice enrollment until discharge or death, whichever came first. We also assessed length of stay in categories of < 7 days, 7–30 days, 31–180 days, 181–364 days, and 365 days.
Number of Visits per Day
We measured number of visits per day by each of the following hospice providers: nurses, social workers, and home health aides. We computed each measure by dividing the total number of visits by the patient’s LOS.
Covariates
We used the following demographic characteristics: age at hospice entry (<50, 50–64, 65–74, 75–84, 85–89, ≥ 90), sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), marital status (married/partnered, not married), primary payment source (Medicare, Medicaid, private, other), and presence of a primary caregiver (yes/no). The available clinical characteristics other than diagnosis included the number of activities of daily living (ADLs) needing assistance (eating, bathing, dressing, toileting, transferring), which we categorized as (0, 1–3, 4, or all 5) and mobility impairment, which we categorized as required no assistance, required assistance with walking, and did not walk. Data were only available for two agency characteristics other than profit status, including whether the hospice agency was part of a chain (yes/no) and metropolitan statistical area defined by the Census as metropolitan, micropolitan, or “neither” (e.g., rural).
Statistical Analyses
All analyses were performed using SAS-callable SUDAAN version 10 (RTI International, Research Triangle Park, NC) to account for the complex sampling design. Data were weighted to reflect national estimates of hospice discharges. We report weighted percentages with corresponding 95% confidence intervals (CI). Statistical tests were 2-sided. We used Pearson Chi Square tests and t-tests to examine the association between profit status and patient and agency characteristics, hospice LOS, and number of visits per day. We used log transformation for our outcomes of LOS and number of visits per day to approximate normal distributions, and fit unadjusted linear regression models to examine the association between profit status and each outcome. For patients with no visits of a particular type, we imputed a visit rate of 0.5 divided by the patient’s length of stay to avoid taking the logarithm of zero. We then repeated these analyses stratifying by diagnosis to assess differences by profit status within each diagnosis group. We further assessed whether number of visits per day varied by categories of length of stay.
Next, we used logistic regression to determine whether diagnosis and location of care were independent correlates of having been in a for-profit versus nonprofit hospice after adjusting for demographic, clinical, and agency covariates. We used linear regression to examine the association between profit status and log (LOS) adjusted for all covariates including diagnosis and location of care. We used linear regression models to examine differences in number of visits per day by profit status and diagnosis after adjustment. To determine whether the association between diagnosis and number of visits per day varied by profit status, we used the Wald chi-square test to further assess the interaction between profit status and diagnosis group. We performed similar multivariable analyses to examine differences in number of visits per day by profit status and LOS categories. This study was deemed exempt by our institutional review board because we used publically available de-identified data.
Results
Patient Characteristics
Our sample of 4,705 patients represents an estimated 1.03 million patients discharged from hospice in 2007, of which 30.7% were discharged from for-profit agencies. Table 1 presents characteristics by agency profit status. Patients from for-profit and nonprofit hospices were similar except that those from for-profit hospices, compared to nonprofits were more likely to be non-Hispanic black (10.6% [7.0–15.8%] vs. 6.4% [4.7–8.7%]) or Hispanic (7.5% [4.5–12.3%] vs. 2.7% [1.8–4.1%]), P=.02. For-profit agencies, compared to nonprofits were also more likely to be part of a chain (74.0% [61.1–83.7%] vs. 5.9% [3.5–9.8%], P<.001)
Table 1.
| All Hospices (n=4,705) | For-profit Hospices (n=1,087) | Nonprofit Hospices (n=3,618) | P Value | ||||
|---|---|---|---|---|---|---|---|
| n | weighted % [95% CI] | n | weighted % [95% CI] | n | weighted % [95% CI] | ||
| Patient Characteristics | |||||||
| Age,y | .20 | ||||||
| <50 | 175 | 3.5 [2.7–4.5] | 39 | 4.1 [2.5–6.6] | 136 | 3.2 [2.4–4.4] | |
| 50–64 | 638 | 13.6 [12.1–15.3] | 147 | 12.1 [9.6–15.2] | 491 | 14.3 [12.5–16.3] | |
| 65–74 | 785 | 14.8 [13.0–16.7] | 168 | 12.8 [9.7–16.9] | 617 | 15.6 [13.6–17.8] | |
| 75–84 | 1459 | 29.6 [27.3–32.0] | 323 | 29.9 [25.7–34.6] | 1136 | 29.4 [26.8–32.2] | |
| 85–89 | 828 | 19.5 [17.7–21.6] | 185 | 18.5 [15.3–22.2] | 643 | 20.0 [17.8–22.4] | |
| ≥ 90 | 820 | 19.0 [17.0–21.2] | 225 | 22.6 [18.8–26.9] | 595 | 17.5 [15.1–20.0] | |
| Female Sex | 2600 | 54.9 [52.1–57.6] | 627 | 57.4 [52.7–62.0] | 1973 | 53.8 [50.4–57.1] | .22 |
| Race/Ethnicity c | .02 | ||||||
| Non-Hispanic white | 4080 | 86.4 [83.8–88.7] | 845 | 79.6 [73.5–84.6] | 3235 | 89.4 [86.9–91.5] | |
| Non-Hispanic black | 310 | 7.7 [6.0–9.9] | 135 | 10.6 [7.0–15.8] | 175 | 6.4 [4.7–8.7] | |
| Hispanic | 147 | 4.2 [3.0–5.9] | 55 | 7.5 [4.5–12.3] | 92 | 2.7 [1.8–4.1] | |
| Other | 79 | 1.7 [1.2–2.6] | 25 | 2.2 [1.1–4.5] | 54 | 1.5 [0.9–2.4] | |
| Marital Status c | .06 | ||||||
| Married/Partnered | 2045 | 45.3 [42.2–48.5] | 419 | 40.1 [33.3–47.4] | 1626 | 47.7 [44.4–51.0] | |
| Not Married | 2497 | 54.7 [51.5–57.8] | 638 | 59.9 [52.6–66.7] | 1859 | 52.3 [49.1–55.6] | |
| Primary Payment Source c | .36 | ||||||
| Medicare | 3816 | 82.6 [80.6–84.4] | 875 | 82.0 [78.6–84.9] | 2941 | 82.8 [80.3–85.1] | |
| Medicaid | 190 | 4.0 [3.1–5.2] | 52 | 5.7 [1.2–3.7] | 138 | 3.4 [2.5–4.5] | |
| Private Insurance | 354 | 9.3 [7.9–11.0] | 57 | 8.2 [6.0–11.2] | 297 | 9.8 [8.0–11.9] | |
| Other | 222 | 4.1 [3.1–5.4] | 50 | 4.2 [2.5–7.0] | 172 | 4.0 [2.9–5.5] | |
| Has a Primary Caregiver c | .10 | ||||||
| Yes | 4328 | 91.5 [89.3–93.2] | 1027 | 93.8 [89.6–96.4] | 3301 | 90.4 [87.8–92.5] | |
| No | 365 | 8.5 [6.8–10.7] | 59 | 6.2 [3.6–10.4] | 306 | 9.6 [7.5–12.3] | |
| Number of ADLs Needing Assistance c | .11 | ||||||
| 0 | 441 | 9.4 [7.6–11.7] | 83 | 6.7 [3.7–12.0] | 358 | 10.6 [8.5–13.2] | |
| 1–3 | 614 | 13.1 [11.1–15.4] | 137 | 12.6 [9.0–17.5] | 477 | 13.3 [11.0–15.9] | |
| 4 | 1003 | 19.6 [17.1–22.4] | 223 | 17.3 [13.1–22.6] | 780 | 20.6 [17.6–23.9] | |
| 5 | 2097 | 57.9 [54.2–61.5] | 543 | 63.3 [55.9–70.2] | 1554 | 55.5 [51.3–59.6] | |
| Mobility | .14 | ||||||
| No assistance needed | 721 | 15.1 [12.8–17.6] | 134 | 11.6 [8.1, 16.3] | 587 | 16.7 [13.9–19.8] | |
| Needs assistance | 1970 | 50.0 [45.7–54.4] | 517 | 51.4 [42.2–60.4] | 1453 | 49.4 44.6–54.2] | |
| Doesn’t do | 1431 | 34.9 [30.6–39.4] | 332 | 37.0 [28.7–46.2] | 1099 | 34.0 [29.1–39.2] | |
| Agency Characteristics | |||||||
| Metropolitan Statistical Area | .11 | ||||||
| Metropolitan | 1722 | 87.3 [85.5–88.9] | 479 | 91.0 [86.9–94.0] | 1243 | 85.6 [83.1–87.8] | |
| Micropolitan | 1749 | 9.1 [7.8–10.6] | 352 | 6.6 [4.2–10.1] | 1397 | 10.2 [8.4–12.3] | |
| Neither | 1234 | 3.6 [2.9–4.5] | 256 | 2.4 [1.2–4.7] | 978 | 4.2 [3.3–5.3] | |
| Chain | <.001 | ||||||
| Chain | 894 | 26.8 [20.9–33.7] | 587 | 74.0 [61.1–83.7] | 307 | 5.9 [3.5–9.8] | |
| Non-Chain | 3811 | 73.2 [66.4–79.1] | 500 | 26.0 [16.3–38.9] | 3311 | 94.2 [90.2–96.6] | |
Abbreviations: ADLs, activities of daily living;
n indicates sample size and percentages are weighted to reflect national estimates
Columns may not add to 100% because of rounding
Data were unknown or missing for race/ethnicity (n=89), marital status (n=163), primary payment source (n=123), caregiver status (n=12), number of ADL’s needing assistance with (n=550), mobility (n=583)
Relationship of Profit Status to Diagnosis and Location of Care
Table 2 demonstrates that diagnosis and location of care both varied by profit status. Compared to nonprofit hospices, for-profit hospices had a lower proportion of patients with cancer (48.4% [45.0–51.8%] vs. 34.1% [29.9–38.6%]) and higher proportions of patients with dementia (8.4% [6.6–10.6%] vs.17.2% [14.1–20.8%]) and other diagnoses (43.2% [40.0–46.5%] vs. 48.7% [43.2–54.1%]). These differences remained significant after adjustment (P<.001). Compared to nonprofit hospices, for-profit hospices also had a higher proportion of patients residing in nursing homes (23.1% [20.4–26.1%] vs. 34.2% [27.9–41.0%]) and a lower proportion residing at home (57.1% [53.5–60.7%] vs. 51.5% [44.6–58.3%]). However, there was no independent association of location of care with profit status after adjustment for all covariates, most notably diagnosis.
Table 2.
Diagnosis and Location of Care of Patients By Hospice Profit Status a
| All Hospices (n=4,705) | For-profit Hospices (n=1,087) | Nonprofit Hospices (n=3,618) | Adjusted Odds Ratio of For-profit Status (95% CI) b | ||||
|---|---|---|---|---|---|---|---|
| n | weighted % [95% CI] | n | weighted % [95% CI] | n | weighted % [95% CI] | ||
| Diagnosis c | |||||||
| Cancer | 2092 | 44.0 [41.2–46.9] | 364 | 34.1 [29.9–38.6] | 1728 | 48.4 [45.0–51.8] | 1.0 (referent) |
| Dementia | 462 | 11.1 [9.4–13.1] | 150 | 17.2 [14.1–20.8] | 312 | 8.4 [6.6–10.6] | 2.32 (1.44–3.72) |
| Other | 2151 | 44.9 [42.1–47.7] | 573 | 48.7 [43.2–54.1] | 1578 | 43.2 [40.0–46.5] | 1.62 (1.17–2.24) |
| Location of Care d | |||||||
| Home | 2834 | 55.4 [52.1–58.7] | 655 | 51.5 [44.6–58.3] | 2179 | 57.1 [53.5–60.7] | 1.0 (referent) |
| Hospital | 393 | 10.3 [7.8–13.4] | 69 | 8.4 [5.3–12.9] | 324 | 11.1 [8.0–15.3] | 0.72 (0.30–1.75) |
| Nursing Home | 1201 | 26.5 [23.7–29.6] | 319 | 34.2 [27.9–41.0] | 882 | 23.1 [20.4–26.1] | 1.32 (0.88–1.96) |
| Hospice Residence | 240 | 6.7 [5.2–8.6] | 40 | 5.6 [3.2–9.5] | 200 | 7.2 [5.5–9.5] | 0.73 (0.34–1.58) |
| Other | 37 | 1.1 [0.5–2.3] | 4 | 0.4 [0.1–1.4] | 33 | 1.4 [0.7–3.1] | 0.27 (0.05–1.58) |
n indicates sample size and percentages are weighted to reflect national estimates
Adjusted odds ratio and 95% confidence intervals were derived from a single model that adjusted for age, sex, race/ethnicity, primary payment source, having a primary caregiver, # ADLs needing assistance, mobility, and metropolitan status
P<.001 for unadjusted comparison by profit status. P <.001 for adjusted comparison by profit status
P=.01 for unadjusted comparison by profit status
Hospice Length of Stay
Table 3 presents the median length of stay in hospice with corresponding 25th and 75th percentiles by profit status of all patients and stratified by diagnosis. Median length of stay was 4 days longer in for-profit as compared to nonprofit hospices (20 [6,88] vs. 16 [5,52] days, P=.002). The unadjusted length of stay was 41.0% [95% CI 13.5–75.1%] longer in for-profit than nonprofit hospices. After full adjustment, length of stay remained significantly longer in for-profit hospices compared with nonprofit hospices (95% CI 26.2% [4.9–51.9%]) (P=.01). A model adjusting for only diagnosis and location of care was nearly identical, suggesting that these two factors account for most of the variation in LOS. Compared to nonprofit hospices, median length of stay in for-profit hospices was similar for patients with cancer (16 [6,39] vs. 15 [6,44] days) and longer for patients with dementia (26 [6,135] vs. 43 [10,161] days) and other non-cancer diagnoses (14 [4,70] vs. 23 [6,100] days). In adjusted analyses, dementia patients had longer median LOS than patients with cancer and other diagnoses (35 [7,161] vs. 16 [6,40] and 17 [4,85] days, respectively, P < 001). Compared to patients in nonprofit hospices, patients in for-profit hospices were more likely to have stays >365 days (2.8% [2.0–4.0%] vs. 6.9% [5.0–9.4%]) and were less likely to have stays < 7 days (34.3% [31.3–37.3%] vs. 28.1% [23.9–32.7%]), P =.005.
Table 3.
Hospice Length of Stay by Profit Status
| All Hospices (n=4,705) n (weighted % [95% CI]) |
For-profit hospices (n=1,087) n (weighted % [95% CI]) |
Nonprofit hospices (n=3,618) n (weighted % [95% CI]) |
P-value | |
|---|---|---|---|---|
| Overall Hospice LOS Categories | ||||
|
|
||||
| Stays < 7 days | 1375 (32.4 [29.9–34.9]) | 245 (28.1 [23.9–32.7]) | 1130 (34.3 [31.3–37.3]) | .005 a |
|
|
||||
| Stays 7–30 days | 1442 (30.5 [28.4–32.7]) | 311 (27.9 [24.4–31.8]) | 1131 (31.6 [29.2–34.2]) | |
| Stays 31–180 days | 1340 (26.7 [24.3–29.2]) | 342 (30.4 [26.3–34.8]) | 998 (25.0 [22.2–28.1]) | |
| Stays 181–364 days | 323 (6.4 [5.1–8.0]) | 99 (6.7 [4.3–10.3]) | 224 (6.2 [4.8–8.1]) | |
|
|
||||
| Stays ≥365 days | 225 (4.1 [3.2–5.2]) | 90 (6.9 [5.0–9.4]) | 135 (2.8 [2.0–4.0]) | |
|
| ||||
| Median LOS [Q1, Q3] | ||||
| Overall | 17 [5, 62] | 20 [6, 88] | 16 [5, 52] | .002 b |
| Stratified by Diagnosis | ||||
| Cancer | 16 [6, 40] | 15 [6, 44] | 16 [6, 39] | |
| Dementia | 35 [7, 161] | 43 [10, 161] | 26 [6, 135] | |
| Other Diagnoses | 17 [4, 85] | 23 [6, 100] | 14 [4, 70] | |
| Profit Status c P=.01 | ||||
| Diagnosis c P <.001 | ||||
Comparing length of stay categories between profit and nonprofit hospices using a chi-square test
Outcome was log transformed; unadjusted model based on 1-unit increase in log (LOS)
P-values are based on a single model that also adjusts for age, location of care, sex, race/ethnicity, type of insurance, primary caregiver, # ADLs needing assistance, mobility, and MSA status
Number of Visits per Day
Table 4 presents the median number of visits per day by nurses, social workers, and home health aides overall and stratified by diagnosis. Overall, for-profit and nonprofit hospices provided similar numbers of nursing visits per day (0.45 [0.27,0.82] vs. 0.45 [0.28,0.83]). However, for-profits, compared to nonprofits provided fewer social work visits per day (0.12 [0.06,0.25]) vs. 0.15 [0.07,0.34], P=.03) and more home health aide visits per day (0.33 [0.15,0.50] vs. 0.25 [0.07,0.45] P=.02). Compared to cancer patients, those with dementia or other diagnoses had fewer visits per day from nurses (0.58 [0.34,0.94] vs. 0.38 [0.19,0.65] and 0.41 [0.26,0.79], P=.002) and social workers (0.15 [0.07, 0.31] vs. 0.07 [0.04, 0.21] and 0.11 [0.06, 0.24], P<.001). No significant interaction was observed between diagnosis and hospice profit status for any of the type of visits examined. Table 5 presents the median number of visits per day by each provider type, stratified by LOS categories. While patients with stays < 7 days had more visits per day by nurses and social workers than patients with longer stays, this did not differ by profit status.
Table 4.
Median Visits per Day by Hospice Providers by Profit Status, Overall and Stratified by Diagnosis
| For-profit hospices (n=1,087) Median [Q1, Q3] |
Nonprofit hospices (n=3,618) Median [Q1, Q3] |
||
|---|---|---|---|
| Overall a | |||
| Nursing visits | 0.45 [0.27, 0.82] | 0.45 [0.28, 0.83] | P=.75 |
| Home health aide visits | 0.33 [0.15, 0.50] | 0.25 [0.07, 0.45] | P=.004 |
| Social worker visits | 0.12 [0.06, 0.25] | 0.15 [0.07, 0.34] | P=.006 |
| Stratified by Diagnosis | |||
| Nursing Visits | |||
| Cancer | 0.58 [0.34, 0.94] | 0.50 [0.31, 0.83] | |
| Dementia | 0.38 [0.19, 0.65] | 0.36 [0.23, 0.89] | |
| Other | 0.41 [0.26, 0.79] | 0.41 [0.25, 0.78] | |
| Profit Status b P=.78 | |||
| Diagnosisb P=.002 | |||
| Social Work Visits | |||
| Cancer | 0.15 [0.07, 0.31] | 0.15 [0.09, 0.30] | |
| Dementia | 0.07 [0.04, 0.21] | 0.12 [0.05, 0.37] | |
| Other | 0.11 [0.06, 0.24] | 0.15 [0.07, 0.37] | |
| Profit Status b P=.03 | |||
| Diagnosis b P=.0001 | |||
| Home Health Aide Visits | |||
| Cancer | 0.26 [0.05, 0.55] | 0.19 [0.05, 0.42] | |
| Dementia | 0.39 [0.24, 0.57] | 0.30 [0.08, 0.44] | |
| Other | 0.37 [0.21, 0.50] | 0.26 [0.12, 0.49] | |
| Profit Status b P=.02 | |||
| Diagnosis b P=.80 | |||
Outcome was log transformed; unadjusted model based on 1-unit increase in log (visits/day)
Outcome was log transformed; model based on 1-unit increase in log (visits/day). P-values are based on a single model that also adjusted for age, sex, race/ethnicity, location of care, primary payment source, having a primary caregiver, # ADLs needing assistance, mobility, and MSA status
Table 5.
Median Visits per Day by Hospice Providers by Profit Status, Stratified by Length of Stay
| For-profit hospices (n=1,087) Median [Q1, Q3] |
Nonprofit hospices (n=3,618) Median [Q1, Q3] |
|
|---|---|---|
| Nursing Visits | ||
| Stays < 7 days | 1.09 [0.74, 1.41] | 1.07 [0.71, 1.43] |
| Stays 7–30 days | 0.58 [0.36, 0.83] | 0.49 [0.36, 0.73] |
| Stays 31–180 days | 0.32 [0.22, 0.43] | 0.29 [0.21, 0.40] |
| Stays 181–364 days | 0.19 [0.15, 0.33] | 0.20 [0.15, 0.28] |
| Stays ≥365 days | 0.19 [0.15, 0.27] | 0.19 [0.14, 0.28] |
| Profit Status a P= .56 | ||
| Length of Stay a P <.0001 | ||
| Social Worker Visits | ||
| Stays < 7 days | 0.37 [0.26, 0.63] | 0.43 [0.27, 0.73] |
| Stays 7–30 days | 0.16 [0.12, 0.25] | 0.16 [0.16, 0.27] |
| Stays 31–180 days | 0.07 [0.04, 0.10] | 0.07 [0.05, 0.11] |
| Stays 181–364 days | 0.04 [0.03, 0.07] | 0.05 [0.03, 0.08] |
| Stays ≥365 days | 0.04 [0.03, 0.05] | 0.04 [0.03, 0.07] |
| Profit status a P=.19 | ||
| Length of Stay a P <.0001 | ||
| Home Health Aide Visits | ||
| Stays < 7 days | 0.37 [0.17, 0.66] | 0.25 [0.14, 0.56] |
| Stays 7–30 days | 0.36 [0.16, 0.55] | 0.21 [0.04, 0.43] |
| Stays 31–180 days | 0.33 [0.05, 0.45] | 0.22 [0.02, 0.37] |
| Stays 181–364 days | 0.29 [0.11, 0.43] | 0.11 [0.00, 0.32] |
| Stays ≥365 days | 0.29 [0.07, 0.36] | 0.30 [0.12, 0.40] |
| Profit status a P=.006 | ||
| Length of Stay a P <.0001 | ||
Outcome was log transformed; model based on 1-unit increase in log (visits/day). P-values are based on a single model that also adjusted for age, sex, race/ethnicity, location of care, primary payment source, having a primary caregiver, # ADLs needing assistance, mobility, and MSA status
COMMENT
The recent growth in the for-profit hospice sector raises critical questions about potential financial incentives in hospice reimbursement. Using nationally-representative data, we found notable differences in the types of patients enrolled in for-profit compared to nonprofit hospices. For-profit hospices had a disproportionate number of patients with non-cancer diagnoses, dementia in particular. For-profit hospices also had a greater proportion of patients with prolonged lengths of stay (LOS ≥ 365 days). In turn, we found that patients with non-cancer diagnoses and those with prolonged lengths of stay received fewer visits per day from skilled providers (i.e. nurses and social workers). Despite these differences in case mix, we found that patients received similar rates of nursing visits regardless of hospice profit status. On the other hand, patients in for-profit hospices received fewer social work and more home health aide visits per day than those in non-profits as would be expected given the observed case-mix differences. Our findings have important implications both for clinicians taking care of patients at the end of life, and for policymakers in the area of Medicare hospice payment.
The current Medicare Hospice Benefit reimburses hospices at a fixed per diem rate that does not consider patient’s diagnosis, location of care, or hospice length of stay. Under this system, profit can be maximized by caring for patients with certain diagnoses that require fewer skilled services, patients residing in nursing homes, or patients with longer hospice stays.2, 4, 6, 14,10 While others have found that patients with non-cancer diagnoses were significantly more likely than cancer patients to be in for-profit hospices,10, 11 we further examined the subset of patients with dementia and found that they were even more likely to be enrolled in for-profit hospices. Our findings indicate that approximately two-thirds of patients in for-profit hospices have dementia and other non-cancer diagnoses, whereas only about half of patients in nonprofit hospices have these diagnoses. We further found that these diagnoses are associated with longer stays in hospice, which are known to be more profitable, and that overall patients with these diagnoses had fewer visits per day by skilled providers (nurses and social workers), which again can be financially advantageous for hospices under a capitated reimbursement system. For-profit hospices were also less likely than nonprofit hospices to have patients enrolled for fewer than 7 days, and these patients had more visits from skilled providers, which is costly for hospices. Our findings build upon previous research that has shown that length of stay in hospice and services delivered correlate with patients’ terminal diagnoses.7, 15, 16
Previous studies examining the association of profit status or diagnosis with length of stay or care intensity have used proprietary data7 or data limited to a single state.11, 17 Lorenz and colleagues used 1997 California data to show that 46% of patients in for-profit hospices had non-cancer diagnoses, compared to 28% in nonprofits. We find a similar difference, though of smaller magnitude which may be partially due to the fact that our 2007 data show a substantial increase in non-cancer diagnoses in both for-profit and nonprofit hospices, compared to their 1997 study.11 Our study also examined dementia specifically and demonstrated an even stronger association between profit status and dementia. Another study,18 which used an earlier version of the NHHCS, could only document whether patients had ever received services from a given type of provider because it lacked information on the frequency of visits. Our study, using the most recent NHHCS, expands upon prior work by quantifying the number of visits per day delivered by core members of the hospice team, and thus provides an improved, albeit imperfect, measure of care intensity. Our study also builds on a study of nursing home patients in a for-profit hospice that found that cancer patients received more visits than non-cancer patients.5
For-profit hospices had significantly more patients with stays exceeding 365 days and fewer patients with stays less than 7 days. While hospice is intended for patients with a prognosis of less than 6 months, research demonstrates19–22 that it is difficult for clinicians to prognosticate, especially for patients with non-cancer diagnoses. Therefore, stays that exceed 6 months may have been appropriate at the time of enrollment. While it is unknown whether hospice patients with stays of exceeding one year were enrolled inappropriately early in the course of their illnesses, these admissions can be particularly lucrative for hospices in a per diem reimbursement system because, as we found, they receive fewer visits per day from skilled hospice providers.
Our study has important limitations. First, the NHHCS includes only patients who were discharged from hospice, and therefore, underestimates length of stay because patients with longer lengths of stay have a lower likelihood of having been discharged and are, therefore, underrepresented in the sample. Nonetheless, we found that for-profit hospices were more likely than non-profit hospices to have prolonged lengths of stay (i.e., greater than 1 year). This under-sampling of long lengths of stay means that our study on the whole probably underestimates the differences in median LOS by profit status. Second, we lacked data on important agency characteristics beyond metropolitan status and chain status such as the hospices’ geographic location, which may explain the observed differences in racial composition. We also do not know whether hospices were part of a larger system of care, which could facilitate coordination of and transitions in care, and thus increase hospice LOS. Third, we lacked data on costs and revenue, and therefore, we do not demonstrate that differences in the diagnostic composition of hospices resulted in lower costs or greater revenue. Fourth, diagnosis is an imperfect measure of disease severity. Finally, and perhaps most importantly, we are unable to assess the relationship between profit status and quality of care. While our study improves upon previous research by assessing the number of visits per day by various hospice providers, we lacked important information on the length of each visit and care provided. For example, we could not distinguish between a home health aide visit that consisted of a five minute “check-in” and a half-day visit providing assistance with activities of daily living. We are also unable to determine whether higher rates of home health aide visits in for-profit hospices reflect additional care or substitution of other types of unmeasured (and potentially more expensive) clinical services. We also could not distinguish between visits delivered by registered nurses (RNs) and licensed vocational nurses (LVNs); past research11, 17 suggests that RNs, who are more skilled and more expensive, deliver a lower proportion of nursing visits in for-profit than nonprofit hospices.
Importantly, clinicians caring for patients considering hospice can be reassured that for-profit hospices provide as many nursing visits and more home health aide visits (though less social work visits) than nonprofit hospices. However, there are important policy implications if hospice agencies differentially enroll more patients with dementia and other non-cancer diagnoses, who require fewer visits from skilled providers such as nurses and social workers. Patient selection of this nature leaves nonprofit hospices disproportionately caring for the most costly patients those with cancer and those tending to start hospice very late in their course of illness; as a result, those hospices serving the neediest patients may face difficult financial obstacles to providing appropriate care in this fixed per-diem payment system.
Our findings are timely, complement the findings of the Medicare Payment Advisory Committee (MedPAC) reports,2, 16 and can help inform the current debate around payment reform in the Medicare Hospice Benefit. MedPAC has recommended that, as of 2013, reimbursement rates for hospice reflect a U-shaped pattern that considers the intensity of care required at the beginning and end of hospice, with higher per diem rates during the first 30 days of enrollment and a standard payment at the time of death. Given that approximately one million Medicare beneficiaries use hospice each year and that the for-profit hospice industry continues to expand rapidly, future research is needed to understand more fully the association of profit status with quality of care and patient and caregiver experiences at the end of life.
Acknowledgments
Funding/Support: Dr. Wachterman was funded by grant 6T32HP12706-02-01 from the Health Resources and Services Administration of the Department of Health and Human Services to support the Harvard Medical School Fellowship Program in General Medicine and Primary Care.
Role of the Sponsor: The funding organization had no role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Footnotes
Author Contributions: Dr. Wachterman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Wachterman, McCarthy
Acquisition of data: Wachterman, McCarthy
Analysis and interpretation of data: Wachterman, Marcantonio, Davis, McCarthy
Drafting of the manuscript: Wachterman, McCarthy
Critical revision of the manuscript for important intellectual content: Wachterman, Marcantonio, Davis, McCarthy
Statistical analysis: Wachterman, Davis, McCarthy
Administrative, technical, or material support: Wachterman, Marcantonio, Davis, McCarthy
Study supervision: Marcantonio, McCarthy
Financial Disclosures: None reported.
Previous Presentation: An earlier version of this work was presented at the national meeting of the Society of General Internal Medicine in Minneapolis, MN, April 30, 2010, and at the national meeting of Academy Health in Boston, June 28, 2010.
Disclaimer: The study contents are solely the responsibility of the authors and do not necessarily represent the official views of the Department of Health and Human Services
Additional Contributions: We thank Dr. Benjamin Sommers, MD, PhD, Harvard School of Public Health, for his editing assistance and helpful comments on the manuscript. He did not receive compensation for the contribution.
Contributor Information
Melissa W. Wachterman, Email: mwachter@bidmc.harvard.edu, Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.
Edward R. Marcantonio, Email: emarcant@bidmc.harvard.edu, Division of General Medicine and Primary Care and Gerontology, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.
Roger B. Davis, Email: rdavis@bidmc.harvard.edu, Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.
Ellen P. McCarthy, Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA.
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