This cross-sectional study examines the association of profit status with family caregivers’ reports of hospice care experiences and the factors that may be associated with observed differences in care experiences.
Key Points
Question
Is hospice profit status associated with family caregivers’ reports of care experiences?
Findings
In this cross-sectional analysis of national Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from 653 208 caregiver respondents, reflecting care received from 3107 hospices, family caregivers reported worse care experiences at for-profit hospices compared with not-for-profit hospices. Almost one-third of for-profit hospices scored 3 or more points below the national hospice average; in contrast, only one-eighth of not-for-profit hospices scored that poorly.
Meaning
Family caregivers reported poorer care experiences in for-profit hospices, but reported quality of care varied among both for-profit and not-for-profit hospices; public reporting of hospice quality data is critical for identifying high-quality hospices.
Abstract
Importance
Expansive growth in the US hospice market has been driven almost exclusively by an increase in for-profit hospices. Prior research found that, in contrast to not-for-profit hospices, for-profit hospices focus on delivering care to patients in nursing homes, provide fewer nursing visits, and use less skilled staff. However, prior studies have not reported on the associations of these differences in care patterns with hospice care quality. Patient- and family-centeredness is a core element of hospice care quality that is measured through surveys of care experiences.
Objective
To examine whether differences in profit status are associated with family caregivers’ reports of hospice care experiences and assess factors that may be associated with observed differences in care experiences by profit status.
Design, Setting, and Participants
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from 653 208 caregiver respondents, reflecting care received from 3107 hospices between April 2017 and March 2019, were used for a cross-sectional examination of hospice care experiences by profit status. Data analysis was performed from January 2020 to November 2022.
Main Outcomes and Measures
Outcomes were case-mix–adjusted and mode-adjusted top-box scores for 8 measures of hospice care experiences, including communication, timely care, symptom management, and emotional and religious support, as well as a summary score averaging across measures. Linear regression examined the association between profit status and hospice-level scores, adjusting for other organizational and structural hospice characteristics.
Results
There were 906 not-for-profit and 1761 for-profit hospices with mean (SD) time in operation of 25.7 (7.8) years and 13.8 (8.0) years, respectively. Mean (SD) decedent age at death was 82.8 (2.3) years, similar for not-for-profit and for-profit hospices. The mean proportion of patients who were Black, Hispanic, and White was 4.9%, 0.9%, and 91.4% for not-for-profit hospices and 9.0%, 2.2%, and 85.4% for for-profit hospices, respectively. Family caregivers reported worse care experiences at for-profit hospices than at not-for-profit hospices for all measures. Significant differences in average hospice performance by profit status remained after adjusting for hospice characteristics. However, for-profit hospice performance varied, with 548 of 1761 (31.1%) for-profit hospices scoring 3 or more points below the national hospice average of overall performance and 386 of 1761 (21.9%) scoring 3 or more points above the average. In contrast, only 113 of 906 (12.5%) not-for-profit hospices scored 3 or more points below the average, and 305 of 906 (33.7%) scored 3 or more points above the average.
Conclusions and Relevance
In this cross-sectional study of CAHPS Hospice Survey data, caregivers of patients receiving hospice care reported substantially worse care experiences in for-profit than in not-for-profit hospices; however, there was variation in reported experiences among both types of hospices. Public reporting of hospice quality is important.
Introduction
Hospice care began as a community-based service, largely provided by volunteers, aiming to transform end-of-life care to holistically meet the needs, preferences, and goals of dying people and their families. Since the inception of the Medicare Hospice Benefit, “any willing provider” has been permitted to participate, regardless of profit status.1 This was vigorously debated: some argued that expansion of for-profit hospices was needed, while others argued that profit incentives could threaten quality of care. Hospice use has grown substantially: approximately half of Medicare decedents received hospice services in 2020, compared with fewer than one-fourth in 2000.2 Since 2000, for-profit hospices have more than quintupled in number,2,3 with increasing acquisition of hospices by private equity firms.4 The proportion of hospices that are for-profit rose from 30% in 2000 to 73% in 2020.2,3
Prior research reported that care processes differ between for-profit and not-for-profit hospices, with for-profit hospices having higher rates of live discharge,5,6 hospitalizations and emergency department visits,7,8 and delivering a narrower range of services,9 including fewer nursing visits, using fewer and less-skilled staff.10,11,12 For-profit hospices exceed annual hospice payment caps 5 times as often as not-for-profit counterparts (22% vs 4%),13 perhaps because for-profit hospices enroll more patients without cancer who have longer lengths of stay5,14,15 and more often reside in nursing homes5,15 or assisted living facilities.13 Care patterns and populations vary substantially by hospice size and chain affiliation, as well.5,16 Despite these notable findings, to our knowledge, no research has examined differences in reported quality of care between for-profit and not-for-profit hospices.
Since 2015, the Centers for Medicare & Medicaid Services (CMS) has required eligible hospices to collect data on patient and family experiences of hospice care using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey. These data, routinely collected by thousands of hospices across the US, offer the opportunity to systematically measure and compare the patient- and family-centeredness of care, a core element of hospice care quality. We used CAHPS Hospice Survey data to examine differences in reported care experiences by profit status and the extent to which these differences persist after adjusting for other structural/organizational characteristics of the hospice.
Methods
Study Sample
We analyzed CAHPS Hospice Survey data from caregivers of hospice patients who died between the second quarter of 2017 and the first quarter of 2019, prior to the onset of the COVID-19 pandemic. The CAHPS Hospice Survey is completed by a decedent’s primary caregiver (the family member or other person most knowledgeable about the hospice care received by the decedent, as identified by the hospice). Caregivers are eligible for inclusion if the decedent was 18 years or older; died at least 48 hours after last admission to hospice care; and had a caregiver of record with a US or US territory home address who was not a nonfamilial legal guardian. Analyses were restricted to 653 208 caregiver responses from the 3107 hospices not in Puerto Rico that had 20 or more completed surveys and at least 11 completed surveys for each quality measure during the 8-quarter period and with known profit and chain status. These hospices represent 62% of all active hospices in the first quarter of 2019 and provided care to 97% of all Medicare decedents who received hospice care in 2018. Caregiver scores were aggregated within each hospice after adjustment for case mix and mode of survey administration, with analyses conducted at the hospice level. This data analysis was approved by the RAND Corporation Human Subjects Protection Committee, which provided a waiver of documented informed consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.
Survey Instrument, Outcomes, and Scoring
The CAHPS Hospice Survey contains 47 items, including questions about care experiences and sociodemographics of the decedent and the caregiver respondent. Responses are used to calculate 8 hospice quality measures: 6 composite measure scores (Hospice Team Communication, Getting Timely Care, Treating Family Member with Respect, Getting Emotional and Religious Support, Getting Help for Symptoms, Getting Hospice Care Training) and 2 global measures (Rating of Hospice and Willingness to Recommend). Survey items that compose each of these measures are listed in eTable 1 in Supplement 1.
Measure scores for each hospice are calculated as the percentage of caregivers that endorse the most positive response option (eg, “Always” for most questions using a never/sometimes/usually/always response scale).17 Scores are adjusted for mode of survey administration and differences in case mix using the following variables: decedent age, payer for hospice care, 20 primary diagnoses, including Alzheimer or other dementias and several types of cancer, among others, and length of final episode of hospice care; respondent age, education, relationship to caregiver, language spoken at home, and survey language; and response percentile (the lag time between decedent death and survey response).18,19,20 In addition to calculating adjusted scores for the 8 measures, we calculated an adjusted summary CAHPS score for each hospice by averaging each hospice’s performance across measures; in this calculation, the 6 composite measures assessing specific aspects of care experience received equal weight, while the 2 global measures each received half-weight, as they measure the same construct.
Hospice Characteristics
Our main independent variable was profit status, derived from a September 2019 list of CMS active agencies and the March 2019 CMS Provider of Services (POS) file. To better understand observed differences between for-profit and not-for-profit hospices, we also examined other organizational characteristics known to be associated with differences in health care patterns and quality,5,6,21,22 including chain status, geographic region, years in operation, size, and rurality, derived from the CMS Certification Number, March 2019 POS file, 2018 Medicare hospice claims, and documentation submitted by hospices to CMS when authorizing a CAHPS Hospice Survey vendor. For-profit hospices operating with more than 1 active Medicare provider number in 1 to 3 states were deemed state or regional chains; hospices operating in 4 or more states were deemed part of a national chain. Not-for-profit hospices with more than 1 active Medicare provider number were deemed “affiliated” hospices; these include hospices that are part of integrated health systems and those that have a common parent hospice organization.
We characterized the patients served by hospices, including the mean decedent age at death, percentage of patients discharged alive, percentage of patients living in a nursing home, mean length of stay, percentage of patients receiving hospice care with given primary diagnoses, and percentage of patients of various races or ethnicities receiving hospice care, using 2018 Medicare hospice claims data.
Statistical Analysis
We tested differences in hospice characteristics by profit status using analysis of variance and χ2 tests. We used linear regressions to test differences in the 8 individual CAHPS scores and the summary CAHPS score by hospice characteristics (including profit status). To further examine differences in hospice quality by profit status, we fit an initial linear regression model in which the summary CAHPS Hospice Survey measure score or individual measure score was the outcome and profit and chain status was the only predictor (model 1). We then assessed the extent to which differences in hospice care experiences by profit and chain status persisted after adjusting for other hospice organizational characteristics by adding hospice years in operation, rurality, geographic region, and size as predictors (model 2). Finally, we categorized hospices as “low” performers if their scores were 3 percentage points or more below the national hospice average, “average” if they were within 3 percentage points of the average, and “high” if they were 3 percentage points or more above the national hospice average. For CAHPS measures, differences of 3 points on a 0 to 100 scale are considered to be of medium effect size; differences of 1 point and 5 points or more are considered small and large, respectively.23 We performed the statistical analyses from January 2020 to November 2022 using SAS, version 9.4 (SAS Institute Inc). Two-sided t tests of linear regression coefficients, analysis of variance, and χ2 tests were conducted, using an α level of .05.
Sensitivity Analyses
To better understand observed differences in case-mix–adjusted CAHPS scores between for-profit and not-for-profit hospices, we conducted sensitivity analyses that adjusted for additional factors that, while not appropriate for adjustment when comparing hospice performance, might help to explain the mechanisms underlying the observed differences. The sensitivity analyses adjusted for the following factors known to differ by profit status: (1) processes of care under control of the hospice (the percentage of decedents who received general inpatient care or continuous home care in the last 7 days before death and the percentage of decedents in routine hospice care who received visits by professional hospice staff in the last 2 days before death, derived from the 2018 Medicare hospice claims file); (2) geographic markets or regions; and (3) the proportion of nursing home patients cared for by the hospice.
Results
The overall response rate was 32.2% (30.0% among caregivers of decedents who received care from for-profit hospices and 34.3% among those from not-for-profit hospices). Of the 3107 hospices included in our analyses, 1761 (56.7%) were for-profit hospices, 906 (29.2%) were not-for-profit hospices, and 440 (14.2%) were either government-run hospices or hospices that identified themselves to CMS as being in an unspecified “other” category. Forty-two percent of for-profit hospices (n = 748) were part of a national chain, and 21% (n = 378) were part of a state or regional chain. For not-for-profit and for-profit hospices, mean (SD) time in operation was 25.7 (7.8) years and 13.8 (8.0) years, respectively. Mean (SD) decedent age at death was 82.8 (2.3) years, similar for not-for-profit and for-profit hospices. The mean proportion of patients who were Black, Hispanic, and White was 4.9%, 0.9%, and 91.4% for not-for-profit hospices and 9.0%, 2.2%, and 85.4% for for-profit hospices, respectively. The distributions of organizational and patient characteristics of hospices by profit status appear in Table 1 and eTable 2 in Supplement 1. Compared with not-for-profit hospices, for-profit hospices were more likely to be newer, care for fewer patients, and to be in the South and in urban areas.
Table 1. Organizational Characteristics of Hospices by Profit Statusa.
| Characteristicb | Hospices, No. (%) | ||
|---|---|---|---|
| All (n = 3107)c | Not-for-profit (n = 906) | For-profit (n = 1761) | |
| Years in operation, mean (SD)d,e | 18.1 (9.7) | 25.7 (7.8) | 13.8 (8.0) |
| Hospice size, mean (SD)d,f | 493.8 (851.5) | 703.5 (943.6) | 394.0 (818.5) |
| Rural locationd,g | 537 (17.3) | 230 (25.4) | 196 (11.1) |
| Census divisiond,h | |||
| New England | 137 (4.4) | 77 (8.5) | 44 (2.5) |
| Middle Atlantic | 253 (8.1) | 104 (11.5) | 124 (7.0) |
| East North Central | 461 (14.8) | 193 (21.3) | 216 (12.3) |
| West North Central | 342 (11.0) | 131 (14.5) | 138 (7.8) |
| South Atlantic | 456 (14.7) | 145 (16.0) | 238 (13.5) |
| East South Central | 209 (6.7) | 38 (4.2) | 126 (7.2) |
| West South Central | 554 (17.8) | 56 (6.2) | 432 (24.5) |
| Mountain | 309 (9.9) | 54 (6.0) | 208 (11.8) |
| Pacific | 386 (12.4) | 108 (11.9) | 235 (13.3) |
Data from 2018 Medicare hospice claims files, March 2019 Provider of Services Files, September 2019 Active Agency List, and documentation submitted by hospices to CMS when authorizing Consumer Assessment of Healthcare Providers and Systems Hospice Survey vendors.
Missing categories not shown; χ2 tests were used for categorical variables and an analysis of variance was used for continuous variables to test across profit status categories; tests were performed among nonmissing categories only.
All hospices column includes 440 hospices that were either government-run or that identified themselves to Centers for Medicare & Medicaid Services (CMS) as being in an unspecified “other” category. Due to the heterogeneity of hospices with “other” profit status, characteristics are not shown for this group.
P < .001.
Hospice years in operation was derived from the March 2019 Provider of Services file and was calculated as of March 31, 2019.
Hospice size was obtained from the 2018 Medicare hospice claims files and was defined as the number of patients, including decedents, live discharges, and patients under care.
Hospices were defined as rural if more than 80% of patients in the 2018 Medicare hospice claims files lived in a rural zip code and the March 2019 Provider of Services file indicated that the hospice was rural.
Geographic region was determined using each hospice’s CMS Certification Number.
Caregivers whose family members received care from a for-profit hospice reported significantly poorer experiences than those whose family members received care from not-for-profit hospices for the summary measure and all 8 CAHPS Hospice Survey measures (Table 2). Reported care experiences by other hospice characteristics and by chain status are presented in eTables 3 and 4 in Supplement 1, respectively. For the summary measure, 548 of 1761 (31.1%) for-profit hospices were “low performers,” scoring 3 or more points below the national hospice mean (Figure 1); in contrast, just 113 of 906 (12.5%) not-for-profit hospices scored that poorly. Among for-profit hospices, 386 of 1761 (21.9%) were “high performers,” scoring 3 or more points above the national hospice mean on the summary measure; in contrast, 305 of 906 (33.7%) not-for-profit hospices achieved that high level of performance. Across all 8 individual measures, a substantially higher proportion of for-profit hospices than not-for-profit hospices were in the low-performing category (eFigure in Supplement 1). However, the performance of both for-profit and not-for-profit hospices varied; for example, on the summary measure, there was a 6.7-percentage-point spread between the bottom and top quartiles of for-profit hospices (25th, 75th percentile: 77.6, 84.3); among not-for-profits, this spread was 5.0 points (80.7, 85.7).
Table 2. Adjusted CAHPS Hospice Survey Measure Top-Box Scores by Profit Statusa.
| Measure | Mean (95% CI) | ||
|---|---|---|---|
| All hospices in analysis (n = 3107)b | Not-for-profit (n = 906) | For-profit (n = 1761) | |
| Summary measure | 81.8 (81.6-81.9) | 83.1 (82.8-83.3) | 80.8 (80.6-81.1)c |
| Willingness to recommend | 84.4 (84.2-84.6) | 87.3 (86.9-87.6) | 82.6 (82.3-83.0)c |
| Rating of hospice | 80.8 (80.6-81.1) | 82.7 (82.3-83.0) | 79.6 (79.3-79.9)c |
| Getting timely care | 78.0 (77.7-78.2) | 79.4 (79.0-79.8) | 76.8 (76.5-77.2)c |
| Getting hospice care training | 75.5 (75.3-75.8) | 76.8 (76.4-77.2) | 74.5 (74.1-74.8)c |
| Hospice team communication | 80.6 (80.5-80.8) | 81.9 (81.6-82.2) | 79.8 (79.5-80.0)c |
| Getting help for symptoms | 75.3 (75.1-75.5) | 76.2 (75.8-76.5) | 74.5 (74.2-74.8)c |
| Treating family member with respect | 90.6 (90.4-90.7) | 91.5 (91.3-91.7) | 90.0 (89.8-90.2)c |
| Getting emotional and religious support | 89.8 (89.7-90.0) | 90.8 (90.7-91.0) | 89.2 (89.0-89.4)c |
Abbreviations: CAHPS, Consumer Assessment of Healthcare Providers and Systems; CMS, Centers for Medicare & Medicaid Services.
Compares for-profit and not-for-profit hospices based on results of linear regression models that tested differences in the 8 individual CAHPS scores and the summary CAHPS score by profit status (including hospices with an “other” profit status). Scores were adjusted for mode of survey administration and differences in case mix using the following variables: decedent age, payer for hospice care, primary diagnosis, and length of final episode of hospice care; respondent age, education, relationship to decedent, language spoken at home, and survey language; and response percentile (reflecting the lag time between decedent death and survey response).
All hospices column includes 440 hospices that were either government-run or that identified themselves to CMS as being in an unspecified “other” category. Due to the heterogeneity of hospices with “other” profit status, adjusted means are not shown for this group.
P < .001.
Figure 1. Distribution of For-Profit and Not-for-Profit Hospices’ Performance on the CAHPS Hospice Survey Summary Measure.
Percentages are calculated as the proportion of not-for-profit and for-profit hospices, respectively, that are low performers (scores at least 3% below the national mean), average performers (scores within 3% of the national mean), and high performers (scores at least 3% above the national mean) on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey summary measure. Summary measure scores are calculated as a weighted average of the hospices’ case-mix–adjusted and mode-adjusted scores for 8 individual measures of hospice care quality. The national mean was calculated including hospices with an “other” profit status; proportions of hospices in the “other” profit status that fall into each category of performance are not shown due to the heterogeneity of the “other” profit status group.
Multivariate model results indicate significantly poorer care experiences for the summary measure and all individual measures for for-profit hospices than not-for-profit hospices (eTable 5 in Supplement 1). Though the pattern varied somewhat by measure, caregivers whose family member received care in a not-for-profit hospice reported the best care experiences, generally followed by those who received care in a for-profit independent hospice. Those who received care in a for-profit state/regional chain or a for-profit national chain reported the worst care experiences.
Adjusting for other organizational and structural characteristics of the hospice slightly decreased the magnitude of some of the differences by profit and chain status; however, these differences remained largely similar and statistically significant. Figure 2 illustrates the poorer quality of care for the summary measure and 8 individual measures for for-profit hospices compared with not-for-profit hospices, adjusting for organizational/structural hospice characteristics. For the summary measure and 7 of the 8 individual quality measures, the adjusted differences between for-profit hospices and not-for-profit hospices were between 1 and 3 points (small to medium differences); for the remaining measure—Willingness to Recommend—the adjusted difference was between 3 and 5 points (medium to large difference).
Figure 2. Differences in Reported Hospice Care Experiences Between For-Profit and Not-for-Profit Hospices, After Adjusting for Hospice Organizational Characteristics.
Squares indicates the mean, and error bars indicate the 95% CI, of the difference in top-box scores between for-profit hospices compared with not-for-profit hospices. Models adjust for the following organizational characteristics: years in operation, size, census division, and rural/urban location. Hospice years in operation was derived from the March 2019 Provider of Services file and was calculated as of March 31, 2019. Hospice size was obtained from the 2018 Medicare hospice claims files and was defined as the number of patients, including decedents, live discharges, and patients still under care. Geographic region was determined using each hospice’s Centers for Medicare & Medicaid Services Certification Number. Hospices were defined as rural if more than 80% of patients in the 2018 Medicare hospice claims files lived in a rural zip code and the March 2019 Provider of Services file indicated that the hospice was rural. Missing values for all hospice characteristics (with the exception of profit status) were imputed with the overall mean for the given characteristic across all hospices.
Sensitivity analyses showed that differences in reported hospice quality by profit and chain status: (1) remained significant after adjusting for 2 care processes; (2) were similar across geographic regions; and (3) do not significantly vary by the proportion of a hospice’s patients who reside in a nursing home (results not shown).
Discussion
The Medicare Hospice Benefit reimburses hospices using a capitated daily payment for the provision of holistic care for dying people and their families. Hospices are paid this daily rate regardless of whether hospice staff visit the patient or provide other services; this creates a financial incentive for hospices to find efficiencies in how they deliver care by, for example, reducing the number of professional staff visits provided, having fewer staff available for visits after normal business hours, and concentrating care in nursing home or assisted living facilities, in which they can visit numerous patients consecutively with no added travel time. The US Department of Health and Human Services Office of the Inspector General has highlighted concerns about variation in hospice care processes that results from payment systems that may inadvertently incentivize hospices to minimize services or pursue patients with fewer needs.24,25 These concerns are particularly pressing given the striking growth of for-profit hospices, which have profit maximization incentives that may be reasonably expected to affect hospice care patterns.26
Dame Cicely Saunders, founder of the modern-day hospice movement, noted the “importance of patients’ own views of what they need” as an important marker of the quality of care.27 Caregiver reports of care experiences provide critical insight into the degree to which hospices are providing person- and family-centered care. 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. These findings are robust and are not explained by the geographic region in which the hospices operate or the proportion of their patients that reside in nursing homes.
Differences in hospice performance by profit status remained significant after adjusting for key care processes identifiable in our data, such as professional staff visits in the last days of life, suggesting that survey responses may be capturing additional consequences of for-profit hospices’ behavior beyond those attributable to specific clinical indicators. Further research is needed to understand the root causes of differences in reported care experiences and to identify what poorer-performing hospices can do to improve. Prior research provides some hypotheses regarding factors that may differ between lower- and higher-performing hospices. For example, employees of not-for-profit hospices rate their hospices as better working environments than employees of for-profit hospices28; work environment ratings may reflect differences in organizational culture, compensation, and workload, among other considerations. In online reviews of hospices, families frequently mention characteristics of hospice staff, such as professionalism, knowledge, and skill,29 which vary across hospices, and express concerns when staff seem overworked, the hospice is understaffed, or there are high rates of staff turnover.30 Online hospice reviewers report marked differences in communication between for-profit and not-for-profit hospices, with reviewers reporting higher rates of “promises made but not kept” and poorer responsiveness to telephone inquiries at for-profit hospices than at not-for-profit hospices.30 Finally, not-for-profit hospices are more likely than for-profit hospices to have open-access policies that allow patients to receive treatments, such as blood transfusions and palliative radiation therapy, that address symptoms or improve the quality of life but are usually not provided by hospices due to their cost; not-for-profit hospices have more flexibility to offer these unreimbursed services than for-profit hospices, which must be attentive to their profit margins.31
While a greater proportion of for-profit than not-for-profit hospices perform substantially worse than the national hospice average, it is important to note that some for-profit hospices (between 15.8% and 31.1% across measures) perform substantially better than the national average. These findings indicate that it is possible for for-profit hospices to provide excellent patient and family care experiences; that high-performing hospices can serve as models for improvement for lower-performing hospices; and that choice of a hospice should not assume that profit status is a proxy for quality, but should be guided by the reported care experiences and other quality indicators for a particular hospice.
Our findings are consistent with those in other settings of care, in which not-for-profit organizations have been shown to outperform for-profit organizations with regard to quality measures assessing both clinical processes and patient care experiences.32,33,34,35 In the hospice context, poor quality care has been associated with complicated family grief and poorer bereavement adjustment,36,37 so this quality gap, combined with the growing dominance of for-profit hospices, is of particular concern.
Strengths and Limitations
Strengths of our study include national data from hospices that serve the overwhelming majority of patients receiving hospice care and assessment of hospice outcomes that are most important to patients and families. Nonetheless, there are also important limitations. Because the smallest and newest hospices in the country are not required to participate in the CAHPS Hospice Survey, our data do not include younger, smaller for-profit hospices that have a higher rate of live discharges than older, not-for-profit hospices,38 which may slightly understate the difference between for-profit and not-for-profit hospices (eTable 6 in Supplement 1 compares characteristics of hospices included in and excluded from our analysis). The 32% response rate is similar to other national patient experience surveys39 and is largely driven by hospices’ selection of the lowest-cost mail-only mode of administration, which has a lower response rate than the available mixed mode (mail with telephone follow-up).18 There is potential for nonresponse bias if characteristics associated with nonresponse are also associated with reported care experiences in a way that differs by profit status. While one could consider patient-level nonresponse weighting to mitigate nonresponse bias, evidence from other CAHPS surveys suggests that adjusting for factors associated with response propensity, as done in this study, reduces nonresponse bias with less variance inflation than would be obtained with patient-level nonresponse weighting.40,41 Studies of nonresponse to this survey19 provide no evidence of threats to the validity of case-mix–adjusted comparisons between for-profit and not-for-profit hospices.
Conclusions
In this cross-sectional study of CAHPS data, 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. Continued oversight of hospice quality performance and refinement to payment incentives are needed as the hospice market continues to expand.
eTable 1. CAHPS Hospice Survey Measures and Component Survey Items
eTable 2. Additional Hospice Characteristics by Profit Status
eTable 3. Adjusted CAHPS Hospice Survey Measure Scores (95% confidence intervals) by Hospice Characteristics
eTable 4. Adjusted CAHPS Hospice Survey Measure Top-Box Scores by Profit and Chain Status (with 95% confidence intervals)
eTable 5. Differences in CAHPS Hospice Survey Measure and Summary Measure Top-Box Scores by Profit and Chain Status, Relative to Not-for-Profit Hospices
eTable 6. Characteristics of Hospices in the Analysis
eFigure. Distribution of For-Profit and Not-for-Profit Hospices’ Performance on the 8 CAHPS Hospice Survey measures
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. CAHPS Hospice Survey Measures and Component Survey Items
eTable 2. Additional Hospice Characteristics by Profit Status
eTable 3. Adjusted CAHPS Hospice Survey Measure Scores (95% confidence intervals) by Hospice Characteristics
eTable 4. Adjusted CAHPS Hospice Survey Measure Top-Box Scores by Profit and Chain Status (with 95% confidence intervals)
eTable 5. Differences in CAHPS Hospice Survey Measure and Summary Measure Top-Box Scores by Profit and Chain Status, Relative to Not-for-Profit Hospices
eTable 6. Characteristics of Hospices in the Analysis
eFigure. Distribution of For-Profit and Not-for-Profit Hospices’ Performance on the 8 CAHPS Hospice Survey measures
Data Sharing Statement
