For-profit Hospices Research Articles

California Hospice Ownership Changes From 2018-2020: A Spatial Analysis and Case Illustration.

Hospices in California have undergone significant and complicated ownership changes in recent years. Little is known about the impact of these ownership changes on hospices. The purpose of our longitudinal, retrospective descriptive study was to describe the ownership changes impacting hospices 2018 to 2021 in California. Using descriptive statistics, we measured characteristics of hospices with and without ownership changes employing public data from the California Home Health Agencies and Hospice Annual Utilization Report. Ownership change characteristics were measured via publicly available hospice provider and facility data. Spatial characteristics were additionally measured via latitude and longitude publicly available data. Our findings showed that ownership changes were significant and complicated. An influx of for-profit organizations into the California market was primarily responsible for these changes. Additionally, lack of corporate financial public disclosure and voluntary hospice accreditation, certification, and reporting result in a lack of free, publicly available, definitive comprehensive data on for-profit hospice ownership. This hinders information gathering on and provider/familial choice-making regarding hospices. Our study provides critical insight into the impact of ownership changes and lack of definitive, free, publicly available information on adult hospices in California caring for children and has important clinical, research, and policy implications.

Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice

Transitions in care settings following live discharge from hospice care are burdensome for patients and families. Factors contributing to risk of burdensome transitions following hospice discharge are understudied. To identify factors associated with 2 burdensome transitions following hospice live discharge, as defined by the Centers for Medicare & Medicaid Services. This population-based retrospective cohort study included a 20% random sample of Medicare fee-for-service beneficiaries using 2014 to 2019 Medicare claims data. Data were analyzed from April 22, 2023, to March 4, 2024. Live hospice discharge. Multivariable logistic regression examined associations among patient, health care provision, and organizational characteristics with 2 burdensome transitions after live hospice discharge (outcomes): type 1, hospice discharge, hospitalization within 2 days, and hospice readmission within 2 days; and type 2, hospice discharge, hospitalization within 2 days, and hospital death. This study included 115 072 Medicare beneficiaries discharged alive from hospice (mean [SD] age, 84.4 [6.6] years; 71892 [62.5%] female; 5462 [4.8%] Hispanic, 9822 [8.5%] non-Hispanic Black, and 96 115 [83.5%] non-Hispanic White). Overall, 10 381 individuals (9.0%) experienced a type 1 burdensome transition and 3144 individuals (2.7%) experienced a type 2 burdensome transition. In adjusted models, factors associated with higher odds of burdensome transitions included identifying as non-Hispanic Black (type 1: adjusted odds ratio [aOR], 1.47; 95% CI, 1.36-1.58; type 2: aOR, 1.70; 95% CI, 1.51-1.90), hospice stays of 7 days or fewer (type 1: aOR, 1.13; 95% CI, 1.06-1.21; type 2: aOR, 1.71; 95% CI, 1.53-1.90), and care from a for-profit hospice (type 1: aOR, 1.78; 95% CI, 1.62-1.96; type 2: aOR, 1.32; 95% CI, 1.15-1.52). Nursing home residence (type 1: aOR, 0.66; 95% CI, 0.61-0.72; type 2: aOR, 0.47; 95% CI, 0.40-0.54) and hospice stays of 180 days or longer (type 1: aOR, 0.63; 95% CI, 0.59-0.68; type 2: aOR, 0.60; 95% CI, 0.52-0.69) were associated with lower odds of burdensome transitions. This retrospective cohort study of burdensome transitions following live hospice discharge found that non-Hispanic Black race, short hospice stays, and care from for-profit hospices were associated with higher odds of experiencing a burdensome transition. These findings suggest that changes to clinical practice and policy may reduce the risk of burdensome transitions, such as hospice discharge planning that is incentivized, systematically applied, and tailored to needs of patients at greater risk for burdensome transitions.

Changes in Diagnoses and Site of Care for Patients Receiving Hospice Care From Agencies Acquired by Private Equity Firms and Publicly Traded Companies

Private equity firms and publicly traded companies have been acquiring US hospice agencies; an estimated 16% of US hospice agencies are owned by private equity (PE) firms or publicly traded companies (PTC). To examine the association of PE and PTC acquisitions of hospices with Medicare patients' site of care and clinical diagnoses. This cohort study of US hospice agencies used a novel national database of acquisitions merged with the Medicare Post-Acute Care and Hospice Public Use File for 2013 to 2020. Changes in sites of care and patient characteristics for hospice agencies acquired by PE or PTCs were compared with changes for patients in nonacquired for-profit hospice agencies. Private equity and publicly traded company acquisitions. This study used a difference-in-differences approach within an event-study framework to examine the association of PE and PTC acquisitions of hospice agencies with changes in patient diagnoses and sites of care. Dependent variables were annual hospice-level measures of the Hierarchical Condition Category (HCC) score and proportion of patients diagnosed with cancer or dementia. Sites of care included the proportion of patients receiving hospice care in their personal home, nursing home, or assisted living facility. A total of 158 hospice agencies acquired by PEs, 250 acquired by PTCs, and 1559 other for-profit hospice agencies were included. Preacquisition, hospice agencies that would later be acquired by PE or PTC served a mean (IQR) 30.1% (12.0%-44.0%) and 29.4% (13.0%-43.0%) of their patients in nursing homes respectively, a greater proportion compared with the 27.1% (8.0%-43.8%) served by for-profit hospices that were never acquired. Agencies acquired by PE between 2014 and 2019 saw a significant relative increase of 5.98% in dementia patients (1.38 percentage points; 95% CI, 0.35-2.40 percentage points; P = .008). In PTC-owned hospices, the proportion of patients receiving care at home increased by 5.26% (2.98 percentage points; 95% CI, 1.46-4.51 percentage points; P < .001), the proportion of dementia patients rose by 13.49% (3.11 percentage points; 95% CI, 2.14-4.09 percentage points; P < .001), and the HCC score decreased by 1.37% (-3.19 percentage points; 95% CI, -5.92 to -0.47 percentage points; P = .02). These findings suggest that PE and PTCs select patients and sites of care to maximize profits.

Hospice—The Time Is Now for Additional Integrity Oversight

This JAMA Forum discusses the concerning trend of for-profit hospice programs in the US, the current issues and problems with hospice care, and the need for increased oversight to ensure and improve quality for patients.

Association of Hospice Profit Status With Family Caregivers’ Reported Care Experiences

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. 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. 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. 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. 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. 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.

A national study of disenrollment from hospice among people with dementia.

People with dementia (PWD) are at high risk for hospice disenrollment, yet little is known about patterns of disenrollment among the growing number of hospice enrollees with dementia. Retrospective, observational cohort study of 100% Medicare beneficiaries with dementia aged 65 and older enrolled in the Medicare Hospice Benefit between July 2012 and December 2017. Outcome measures included hospice-initiated disenrollment for patients whose rate of decline ceased to meet the Medicare hospice eligibility guideline of "expected death within 6 months" (extended prognosis) and patient-initiated disenrollment (revocation). Hospice, regional, and patient risk factors and variation were assessed with multilevel mixed-effects logistic regression models. Among 867,695 hospice enrollees with dementia, 70,945 (8.2%) were disenrolled due to extended prognosis and 43,133 (5.0%) revoked within 1-year of their index admission. There was substantial variation in hospice provider disenrollment due to extended prognosis (10th-90th percentile 4.5%-14.6%, adjusted median odds ratio (MOR) 1.86, 95% confidence interval (CI) 1.82, 1.91) and revocation (10th-90th percentile 2.5%-10.1%, MOR 2.09, 95% CI 2.03, 2.14). Among hospital referral regions (HRR), there was more variation in revocation (10th-90th percentile 3.5%-7.6%, MOR 1.4, 95% CI 1.34, 1.47) than extended prognosis (10th-90th percentile 7.0%-9.5%, MOR 1.23, 95% CI 1.18, 1.27), with much higher revocation rates noted in HRRs located in the Southeast and Southern California. A number of patient and hospice characteristics were associated with higher odds of both types of disenrollment (younger age, female sex, minoritized race and ethnicity, Medicaid dual eligibility, Medicare Part C enrollment), while some were associated with revocation only (more comorbidities, newer, smaller, and for-profit hospices). In this nationally representative study of hospice enrollees with dementia, hospice disenrollment varied by type of hospice, geographic region, and patient characteristics including age, sex, race, and ethnicity. These findings raise important questions about whether and how the Medicare Hospice Benefit could be adapted to reduce disparities and better support PWD.

Hospice Glassdoor and CAHPS® Scores-Glassdoor Scores and Hospice Financial Characteristics Predict Hospice Consumer Assessment of Healthcare Providers and Systems Scores.

Recent public data transparency on both decedent caregiver satisfaction and employee satisfaction is impacting the three most essential needs of any hospice, admitting hospice enrollees, attracting hospice professionals and delivering on quality. Explore the relationship between Glassdoor hospice employee recommendation data, hospice financial characteristics, and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) scores among the 50 largest US hospices. Retrospective data with multivariate regression analysis. Provider CAHPS hospice survey data from 2019-2020 and Glassdoor employee recommendation data. Glassdoor Composite and CAHPS Composite were positively correlated (r = .469, p < .01). Glassdoor scores, profit status, and acquisition status predicted Hospice CAHPS scores and explained 44% of the variation in CAHPS Composite. Being a large, for-profit hospice in acquisition status each predicted lower CAHPS scores. Non-profit hospices had significantly higher Glassdoor and CAHPS scores than for-profit hospices. CAHPS Composite and CAHPS Star Rating have potential as global indicators to inform customers of a given hospice's overall quality on the Hospice Compare website of CMS. Hospice leaders seeking improvements in CAHPS scores are encouraged to seek feedback on whether their own employees would recommend their hospice to a friend. Communication and responsiveness were the strongest indicators of overall hospice quality. Skelton hospice staffing models must give way to realistic models that value company culture and employee satisfaction. Hospice quality and hospice profits are not necessarily mutually exclusive. Future research should explore the difference in themes emerging from positive and negative online caregiver reviews.

Bereavement Support Services in a National Sample of Hospices: A Content Analysis

Although the Medicare Hospice Benefit mandates that hospices provide bereavement services to families for 1 year following death, it does not stipulate what services should be offered or how. Thus, this study aimed to explore the range of hospice bereavement services. This study stems from Cagle et al.’s (2020) prior study surveying 600 randomly selected agencies, stratified by state and profit status. Most participants (N = 76) worked as clinical supervisors or directors of patient services (41.6%) for medium-sized (53.2%), for-profit hospices (50.6%). Responses to “What types of bereavement support does your hospice provide to families?” were content analyzed. Analyst triangulation and peer debriefing enhanced trustworthiness. Four domains emerged: timing of support, providers of support, targets of support, and formats of support. Each domain reflected substantial variability. All hospices offered postdeath bereavement support. A minority described offering predeath support, often through bereavement risk assessment and supportive services targeting those at risk. Providers frequently included trained bereavement counselors, social workers, and chaplains. Less often, hospices leveraged familiar members of the decedents’ care team to encourage family participation. Although bereavement services predominantly targeted surviving adult family members of deceased hospice patients, services tailored to children and hospice-unaffiliated community members also emerged. The format of bereavement services demonstrated the widest variability. Commonly reported formats included written materials, support groups, and phone calls. Most hospices employed multiple formats. Although findings are consistent with prior research, the variability in each domain complicates rigorous investigation of which aspects offer the greatest benefit to bereaved family members.

Frequency and Characteristics of Patients Prescribed Antibiotics on Admission to Hospice Care.

Background: Little is known about antibiotic prescribing on hospice admission despite known risks and limited evidence for potential benefits. Objective: To describe the frequency and characteristics of patients prescribed antibiotics on hospice admission. Design: Cross-sectional study. Subjects: Adult (age ≥18 years) decedents of a national, for-profit hospice chain across 19 U.S. states who died between January 1, 2017 and December 31, 2019. Measures: The primary outcome was having an antibiotic prescription on hospice admission. Patient characteristics of interest were demographics, hospice referral location, hospice care location, census region, primary diagnosis, and infectious diagnoses on admission. We used multivariable logistic regression to quantify associations between study variables. Results: Among 66,006 hospice decedents, 6080 (9.2%) had an antibiotic prescription on hospice admission. Fluoroquinolones (22%) were the most frequently prescribed antibiotic class. Patients more likely to have an antibiotic prescription on hospice admission included those referred to hospice care from the hospital (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.00-1.29) compared with an assisted living facility, those receiving hospice care in a private home (aOR 3.85, 95% CI 3.50-4.24), nursing home (aOR 3.65, 95% CI 3.24-4.11), assisted living facility (aOR 4.04, 95% CI 3.51-4.64), or hospital (aOR 2.43, 95% CI 2.18-2.71) compared with inpatient hospice, and those with a primary diagnosis of liver disease (aOR 2.23, 95% CI 1.82-2.74) or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (aOR 3.89, 95% CI 2.27-6.66) compared with those without these diagnoses. Conclusions: Approximately 9% of hospice patients had an antibiotic prescription on hospice admission. Patients referred to hospice from a hospital, those receiving care in a noninpatient hospice facility, and those with liver disease or HIV/AIDS were more likely to have an antibiotic prescription. These results may inform future antimicrobial stewardship interventions among patients transitioning to hospice care.

Main Referral Sources Based on Hospice Organizational Structure Variances in the United States

Background and Aim: Referral contracts are an avenue for understanding the organizational structure of different hospice organizations. The aim of the study is to determine whether an organization’s type and ownership impact patient referral patterns. Methods: A cross-sectional retrospective study was conducted among a nationally weighted representative sample of 620 hospice agencies in the United States. The survey responses were collected using a stratified, multi-stage probability design. Results: The data supported that hospice referral sources are impacted by organizational variations in ownership status. The data showed that 101(23.5%) of for-profit hospitals reported a hospital as their main referral source. Approximately 167(68.5%) of respondents reported hospitals which were the main referral sources, were part of a chain. For-profit hospice agencies were 7.82 times and 4.21 times more likely to have nursing homes and physicians’ offices as the main patient referral source. Not-for-profit hospices were 42% (adjusted odds ratio = 0.58; 95% confidence interval = 0.36–0.9) less likely to have administrators with a master’s administrator than those with a bachelor’s degree. Not-for-profit hospices were 4.42 times and 1.72 more likely to be part of a change and have no formal contracts with outside sources. Conclusions: Hospice care is a comprehensive interdisciplinary approach to end-of-life care for patients. The referral sources are impacted based on their ownership status- es. Proper knowledge of hospice and hospice services delivery is essential to provide effective referrals. The data presents that internal and external factors play critical roles in the overall referral sources of hospice organizations.

Content Analysis of Negative Online Reviews of Hospice Agencies in the United States

IMPORTANCEAs online reviews of health care become increasingly integral to patient decision-making, understanding their content can help health care practices identify and address patient concerns.OBJECTIVETo identify the most frequently cited complaints in negative (ie, 1-star) online reviews of hospice agencies across the United States.DESIGN, SETTING, AND PARTICIPANTSThis qualitative study conducted a thematic analysis of online reviews of US hospice agencies posted between August 2011 and July 2019. The sample was selected from a Hospice Analytics database. For each state, 1 for-profit (n = 50) and 1 nonprofit (n = 50) hospice agency were randomly selected from the category of extra-large hospice agencies (ie, serving >200 patients/d) in the database. Data analysis was conducted from January 2019 to April 2019.MAIN OUTCOMES AND MEASURESReviews were analyzed to identify the most prevalent concerns expressed by reviewers.RESULTSOf 100 hospice agencies in the study sample, 67 (67.0%) had 1-star reviews; 33 (49.3%) were for-profit facilities and 34 (50.7%) were nonprofit facilities. Of 137 unique reviews, 68 (49.6%) were for for-profit facilities and 69 (50.4%) were for nonprofit facilities. A total of 5 themes emerged during the coding and analytic process, as follows: discordant expectations, suboptimal communication, quality of care, misperceptions about the role of hospice, and the meaning of a good death. The first 3 themes were categorized as actionable criticisms, which are variables hospice organizations could change. The remaining 2 themes were categorized as unactionable criticisms, which are factors that would require larger systematic changes to address. For both for-profit and nonprofit hospice agencies, quality of care was the most frequently commented-on theme (117 of 212 comments [55.2%]). For-profit hospice agencies received more communication-related comments overall (34 of 130 [26.2%] vs 9 of 82 [11.0%]), while nonprofit hospice agencies received more comments about the role of hospice (23 of 33 [69.7%] vs 19 of 31 [61.3%]) and the quality of death (16 [48.5%] vs 12 [38.7%]).CONCLUSIONS AND RELEVANCERegarding actionable criticisms, hospice agencies could examine their current practices, given that reviewers described these issues as negatively affecting the already difficult experience of losing a loved one. The findings indicated that patients and their families, friends, and caregivers require in-depth instruction and guidance on what they can expect from hospice staff, hospice services, and the dying process. Several criticisms identified in this study may be mitigated through operationalized, explicit conversations about these topics during hospice enrollment.

Trends in Contracting and Common Ownership Between Hospice Agencies and Nursing Homes.

In recent years, policymakers have paid particular attention to the emergence of a robust for-profit hospice sector and increased hospice use by nursing home residents. Previous research has explored financial incentives for nursing home-hospice use, but there has been limited research on nursing home-hospice partnerships and none on the extent of nursing home-hospice common ownership. To describe trends in nursing home-hospice contracting and common ownership and to identify potential tradeoffs in care provided by nursing homes and hospice agencies that share common ownership. Retrospective cohort study of nursing home-hospice patients between 2005 and 2015. Between 2005 and 2015, the number of hospice agencies and nursing homes with common ownership grew substantially, now representing almost 1-in-5 providers in each sector. Relative to individuals using hospice in nursing homes without common ownership, adjusted analyses found that individuals receiving hospice from a commonly owned agency had a greater likelihood of having stays of 90 days or more [odds ratio (OR)=1.06; 95% confidence interval (CI), 1.02-1.10], having a stay resulting in a live discharge (OR=1.06; 95% CI, 1.02-1.11), and having at least 1 registered nurse/licensed practical nurse visit during the last 3 days of life (OR=1.17; 95% CI, 1.05-1.29); these individuals also had a lower mean visit hours per day (-0.07; P=0.003). Common ownership between hospice agencies and nursing homes is an emerging trend that reflects a broader push toward consolidation in the health care sector. Our analyses highlight potential concerns relevant to Medicare payment policy and are a first step toward improving our understanding of these trends and their implications.

Live Discharge From Hospice: A Systematic Review.

Live discharges from hospice may occur because of patient choice or provider choice. However, when discharges occur before death, patients and families may feel abandoned and left to manage care needs previously provided by hospice. The purpose of this systematic review was to better understand the nature of live discharges, including frequency, patient characteristics, and hospice characteristics. Of 44 studies identified for review, 13 met inclusion criteria and were published between 2008 and 2018. Live discharge rates varied from 5% to 23%. Patients' prehospice characteristics varied widely based on diagnosis, comorbidities, gender, race, and ethnicity. Hospice characteristics indicated that the likelihood of a live discharge was increased for patients enrolled in for-profit hospices and in rural areas. Only 2 studies captured the patient/family perspective of the live discharge experience, finding that the loss of hospice support was fraught with difficulties. A need for further study of the live discharge experience and the practices of hospices with high live discharge rates was identified.

Have Hospice Costs Increased After Implementation of the Hospice Quality–Reporting Program?

ContextThe Centers for Medicare & Medicaid Services Hospice Quality–Reporting Program introduced the requirement that hospices nationwide begin collecting and submitting standardized patient-level quality data on July 1, 2014. ObjectivesThis study examined whether this requirement has increased hospice total costs, general costs, and visiting services costs. MethodsWe conducted a cross-sectional study using data from the 2012 and 2014 Medicare hospice cost reports linked to hospice claims. We measured total costs per patient day (PPD), general costs PPD, and visiting services costs PPD for freestanding hospices. We estimated the incremental costs of operating in 2014 vs. 2012 using hierarchical random effects models and adjusting for year, wage index, care volume, case-mix, and hospice and market characteristics, stratified by hospice ownership type. ResultsBoth for-profit and nonprofit hospices reported higher total costs PPD and general services costs PPD in 2014 than 2012. Nonprofit hospices also reported higher general costs PPD in 2014 than 2012. In adjusted models, the total costs PPD in 2014 were $10.55 higher than in 2012 for nonprofit hospices and $6.43 higher for for-profit hospices. The increase in general costs PPD and visiting services costs PPD ranged from $3.15 to $5.87 by ownership and type of costs. Both for-profit and nonprofit hospices showed lower costs PPD for all types associated with more patients and longer length of stay. ConclusionHospice costs increased after the Centers for Medicare & Medicaid Services Hospice Quality–Reporting Program quality data collection/submission requirement. Complementary studies need to understand whether increased costs brought additional benefits.

Closing the Gap in Hospice Utilization for the Minority Medicare Population.

Background: Medicare spends about 20% more on the last year of life for Black and Hispanic people than White people. With lower hospice utilization rates, racial/ethnic minorities receive fewer hospice-related benefits such as lesser symptoms, lower costs, and improved quality of life. For-profit hospices have higher dropout rates than nonprofit hospices, yet target racial/ethnic minority communities more through community outreach. This analysis examined the relationship between hospice utilization and for-profit hospice status and conducted an economic analysis of racial/ethnic minority utilization. Method: Cross-sectional analysis of 2014 Centers for Medicare & Medicaid Services (CMS), U.S. Census, and Hospice Analytics data. Measures included Medicare racial/ethnic minority hospice utilization, for-profit hospice status, estimated cost savings, and several demographic and socioeconomic variables. Results: The prevalence of for-profit hospices was associated with significantly increased hospice utilization among racial/ethnic minorities. With savings of about $2,105 per Medicare hospice enrollee, closing the gap between the White and racial/ethnic minority populations would result in nearly $270 million in annual cost savings. Discussion: Significant disparities in hospice use related to hospice for-profit status exist among the racial/ethnic minority Medicare population. CMS and state policymakers should consider lower racial/ethnic minority hospice utilization and foster better community outreach at all hospices to decrease patient costs and improve quality of life.

Factors Associated With Hospices' Nonparticipation in Medicare's Hospice Compare Public Reporting Program.

To enhance the quality of hospice care and to facilitate consumers' choices, the Centers for Medicare and Medicaid Services (CMS) began the Hospice Quality Reporting Program, in which CMS posted the quality measures of participating hospices on its reporting website, Hospice Compare. Little is known about the participation rate and the types of nonparticipating hospices. To examine the factors associated with hospices' nonparticipation in Hospice Compare. We analyzed data from the CMS 2016 Hospice Compare. "Nonparticipants" were those who did not submit any quality measure. With the data of the Provider of Service file, the Healthcare Cost Report Information System, and the Area Health Resources File, multivariate logistic regressions estimated the association between nonparticipants and hospice and market characteristics, including ownership, size, nurse staffing ratio, and market competition intensity. Among the 4123 certified hospices subject to penalty from nonparticipation, 259 did not participate in Hospice Compare. California, New Mexico, Texas, and Wyoming had participation rates lower than 80%. Hospices that were for-profit, had no accreditation, had few nurses per patient day, provided no inpatient care, and were located in competitive markets were less likely to participate than other hospices. Hospice Compare successfully motivated hospice in participating in the quality report program in most of states. For-profit hospices, hospices with less quality, and hospices located in competitive markets were less likely to participate. Further research is warranted to examine the quality of these nonparticipants, especially in the 4 states with a lower participation rate.

Association between Hospice Spending on Patient Care and Rates of Hospitalization and Medicare Expenditures of Hospice Enrollees.

Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice. To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees. Longitudinal, observational cohort study (2008-2010). Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355). We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures. Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices. Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

Earnings management in non-public companies: the case of for-profit hospice organizations

We examine earnings management in non-publicly listed companies, with a focus on for-profit (FP) hospice organizations, and extend the accounting earnings management literature to the hospice industry. FP hospice organizations file Medicare cost reports that include complete financial statements not otherwise publicly available. Managers of FP hospice organizations have incentives to manage earnings to increase performancebased bonuses, meet or beat bond covenant requirements, or avoid public scrutiny. We find total accruals are significantly positively associated with profitability, debt, and size factors. However, discretionary accruals are significantly negatively associated with debt and size, but not profitability. Thus, monitoring and political cost factors appear to effectively mitigate earnings management in this industry sector.

Population-Based Measures from Administrative Data to Guide Efforts to Examine and Improve the Quality of Hospice Care (S711)

•Identify seven population based measures that can be calculated for Medicare claims data.•Understand how certain characteristics of hospices correspond to being an outlier on multiple measures listed in Objective 1. Medicare requires hospices to submit claims containing information that could be used to create population based measures of processes and outcomes to guide efforts to monitor hospices and improve care delivery. Identify hospices that are outliers in the provision of hospice services along seven dimensions: (1) provision of General Inpatient and Continuous Home Care days, (2) visits by nurse or social worker at the end of life, (3) long length of stays in hospice, (4) rates and patterns of hospice live discharge, (4) selective enrollment of nursing home and ALF patients, (6) infrequent hospice visits by nursing staff over the entire course of the episode, and (7) average time spent by nurse during a visit. Population based measures are calculated using 100% of Medicare hospice claims from FFY 2014. For each measure, hospices are grouped into deciles. We count how times a hospice is in the highest decile for each measure and use that count to determine outliers. 460 out of 3,453 hospices scored in the highest decile for 3 or more measures. Those hospices were in southern census region (56% vs. 38%, p <.001) and were for-profit (75% vs 55% for not-for-profit, p<.001). A multivariate ordinal logit model showed newer, smaller, for-profit hospice programs were more likely to be above the thresholds for 3 or more measures compared to larger, older, not-for-profit programs (AOR 2.52 - 95% CI: 1.86-3.42). Potential markers of poor performance can be calculated using hospice claims. Ownership and location are correlated with poor performance across multiple measures.

A Focus on the Program of All-Inclusive Care for the Elderly (PACE)

ABSTRACTFor over four decades, the Program of All-Inclusive Care for the Elderly (PACE) has been operated by nonprofit organizations. Research has demonstrated that nonprofit PACE provides quality, cost-effective community-based care to older adults who would otherwise require a nursing home level of care. Recently, the U.S. Secretary of the Department of Health and Human Services has authorized for-profit entities to operate PACE, contingent on their ability to demonstrate that they can provide care that is similar to nonprofit PACE with regard to access to care, quality of care, and cost-effectiveness. In 2013, a study was conducted to evaluate how PACE operates under for-profit versus nonprofit status. The results were presented to Congress which, in turn, authorized for-profit PACE providers. This article critiques the 2013 study, offers a comparison to for-profit hospice, and argues that at best there is not enough evidence to conclude that for-profit PACE provides the same quality of care as existing nonprofit operators.