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

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.

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.

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.