Wednesday, February 2, 2011

Does Hospice Agency Profit Status Affect Care Received?

(Disclaimer: I currently work for a non-profit hospice agency and have not worked for a for-profit agency)
This has been a question that many in the hospice community have asked but the research on the subject has been pretty minimal and most strongly influenced by strong anecdotal experiences from people who have worked on either side of the for-profit (FP) and non-profit (NP) divide. JAMA’s lead article this week ("Association of Hospice Agency Profit Status With Patient Diagnosis, Location of Care, and Length of Stay") is a retrospective study on the demographics of 4705 patients who discharged from hospice (16% discharged alive). (Available free online)

First let’s look at the stats before we get to what I might consider the ‘spin’ placed on this article. The authors looked at a few key variables and found FP hospices had more patients with dementia (OR 2.32) and more patients in nursing homes (OR 1.32). What understandably follows is that FP had longer Length of Stay (LOS) (Median FP – 20 vs NP – 16), not very surprising. Of note they found no difference in number of nursing visits, and more visits for social workers in NP, and more visits for home health aides in FP.

Compared with nonprofit hospice agencies, for-profit hospice agencies had a higher percentage of patients with diagnoses associated with lower-skilled needs and longer lengths of stay.
And from that the media concludes:
I think most of us in the field have seen some of the findings this article confirms. FP hospices do a good job of developing relationships with nursing homes and with more dementia patients there and the increase in efficiency from visiting multiple people in one location you could probably do better on margins. Makes good business sense to me.  So with FP hospice agencies can have margins of 12-16% compared to losses of 2.9-4.4% at NP agencies. along with the growth in FP hospices has Medicare looking into the reimbursement structure. (See chapter 8)

But I think we have to ask ourselves as a field, is this study trying to be more ambitious in its conclusions? And has the media amplified that?
We have to be very careful to examine the assumptions of this article. Nothing in this article tells us why any of the results are true. Maybe it is good to have a different mix of disciplines for patient in nursing homes or with different diagnoses? What is really the best combination for high quality hospice service to be delivered? Ask yourself what the conclusions would have been if there were a lot more SW or nurse visits for patients in a nursing home or with dementia. Would we then clamor and say ‘that is too many visits compared to a patient at home or with cancer!’

The authors note in the comments the many limitations for this study and most importantly I will highlight this paragraph since the majority of the world will stop at the summary and never even read the article:
Finally, and perhaps most importantly, we are unable to assess the relationship between profit status and quality of care. While our study improves on previous research by assessing the number of visits per day by various hospice personnel, 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 5-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 and licensed vocational nurses; past research suggests that registered nurses, who are more skilled and more expensive, deliver a lower proportion of nursing visits in for-profit hospices vs nonprofit hospices.
Now I may be wrong but I imagine there are a lot of NP hospice agencies that may use this article as evidence they will do a better job.  But I am not sure this article really supports those conclusions.  Maybe I am being cynical and no one in the US hospice world would ever draw those conclusions from this article but if the LA Times is hyping it that way, I can't be too far off.  If you are looking for more detailed info I think the MedPAC report (Chapter 8) has a lot more to say about the differences between NP and FP. 
I am not someone who will come out to defend profit making and accountability to investors as a good practice model for health services, but I also don’t want to see our field tearing itself apart over these philosophical differences because we did not read the whole article and just depended on the summary.
(UPDATE 11:35PM Here is the response from the NHPCO. Which includes this great quote: "The study authors seem to conclude that such patients are 'lower skill' – the implication being that their care needs are minimal. This reflects a fundamental misunderstanding of the important unmet needs for persons dying from dementia. A person dying from dementia may still experience pain," remarked noted researcher Joan Teno, MD, MS, of Brown University and a member of the NHPCO board.")
(By the way, I will leave a lot of leeway for comments on this article, but I ask that you be civil and support your points well.)
ResearchBlogging.orgWachterman, M., Marcantonio, E., Davis, R., & McCarthy, E. (2011). Association of Hospice Agency Profit Status With Patient Diagnosis, Location of Care, and Length of Stay JAMA: The Journal of the American Medical Association, 305 (5), 472-479 DOI: 10.1001/jama.2011.70

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