untitled ORIGINAL CONTRIBUTION Association of Hospice Agency Profit Status With Patient Diagnosis, Location of Care, and Length of Stay Melissa W. Wachterman, MD, MPH Edward R. Marcantonio, MD, SM Roger B. Davis, ScD Ellen P. McCarthy, PhD, MPH D URING THE PAST 10 YEARS, the for-profit hospice sec- tor has increased substan- tially.1 From 2000 to 2007, the number of for-profit hospices more than doubled from 725 to 1660, while the number of nonprofit hospices re- mained essentially the same—1193 in 2000 and 1205 in 2007.2 Overall, for- profit hospices have significantly higher profit margins than nonprofit hos- pices, varying from 12% to 16% be- tween 2001 and 2004, compared with −2.9% and −4.4% for nonprofit hos- pices.2 This rapid increase in the for- profit hospice sector and the differen- tial profit margins have raised questions about potential financial incentives in hospice reimbursement. Medicare payment policy is a key de- terminant of hospice reimbursement. Medicare beneficiaries compose 84% of patients in hospice,3 and about 40% of Medicare decedents use hospice annu- ally.2 Medicare reimburses hospices a per diem rate ($142.91/d in 2010) for routine care, which can be provided at home or in a nursing home.3 This capi- tated rate is fixed regardless of the care needs of individual patients or the ser- vices that they receive and may create a financial incentive to select patients requiring less resource-intensive ser- vices. Moreover, longer hospice stays are thought to be more profitable than shorter stays,2,4 and emerging evi- dence 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 re- duce their average daily costs by at- tracting patients with longer lengths of Author Affiliations: Division of General Medicine and Primary Care (Drs Wachterman, Davis, and McCarthy), Divisions of General Medicine and Primary Care and Gerontology (Dr Marcantonio), Department of Medi- cine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Corresponding Author: Melissa W. Wachterman, MD, MPH, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02115 (mwachter@bidmc .harvard.edu). 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 hospice. 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 (1087 discharges from 145 agencies), compared with non- profit hospices (3618 discharges from 524 agencies), had a lower proportion of patients with cancer (34.1%; 95% CI, 29.9%-38.6%, vs 48.4%; 95% CI, 45.0%-51.8%) and a higher proportion of patients with dementia (17.2%; 95% CI, 14.1%-20.8%, vs 8.4%; 95% CI, 6.6%-10.6%) and other noncancer diagnoses (48.7%; 95% CI, 43.2%- 54.1%, vs 43.2%; 95% CI, 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 with nonprofit hos- pices had a significantly longer length of stay (median, 20 days; interquartile range [IQR], 6-88, vs 16 days; IQR, 5-52 days; adjusted P = .01) and were more likely to have patients with stays longer than 365 days (6.9%; 95% CI, 5.0%-9.4%, vs 2.8%; 95% CI, 2.0%-4.0%) and less likely to have patients with stays of less than 7 days (28.1%; 95% CI, 23.9%-32.7%, vs 34.3%; 95% CI, 31.3%-37.3%; P = .005). Com- pared with cancer patients, those with dementia or other diagnoses had fewer visits per day from nurses (0.50 visits; IQR, 0.32-0.87, vs 0.37 visits; IQR, 0.20-0.78, and 0.41 visits; IQR, 0.26-0.79, respectively; adjusted P = .002) and social workers (0.15 visits; IQR, 0.07-0.31, vs 0.11 visits; IQR, 0.04-0.27, and 0.14 visits; IQR, 0.07-0.31, respectively; adjusted P � .001). Conclusion 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. JAMA. 2011;305(5):472-479 www.jama.com 472 JAMA, February 2, 2011—Vol 305, No. 5 (Reprinted) ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 stay (LOS).7,9 Some data suggest that for-profit hospices are less likely to ad- mit patients with shorter expected LOS,10 while other data suggest no dif- ference in mean LOS between for- profit and nonprofit hospices.11 The Bal- anced Budget Act of 1997 relaxed the previous 210-day cap on Medicare hospice coverage, allowing for an un- limited number of 60-day periods, provided patients are recertified (ie, 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 pa- tient diagnosis and location of care be- tween for-profit and nonprofit hos- pices and examined whether LOS and the number of visits per day by hos- pice personnel vary by diagnoses and by profit status. METHODS We examined a nationally representa- tive 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 used a stratified 2-stage sampling design. A representative sample of US home health and hos- pice care agencies was selected after being stratified by agency type and met- ropolitan statistical area. From more than 15 000 agencies, 1545 agencies were randomly sampled from the strata with probability proportional to size. Overall, 1461 selected agencies were eli- gible (95%), and 1036 agreed to par- ticipate (unweighted, 71%; weighted, 59%).13 A computer algorithm randomly se- lected 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 dis- charges for a mixed agency. Hospice discharges during the 3-month period before the agency interview were eli- gible. Our study focused solely on the sample of 4733 patients discharged from hospice. We excluded 28 dis- charges with any missing data on our main factors of interest (LOS, diagno- sis, and location of care). Our final sample consisted of 4705 hospice dis- charges. Data were collected through in- person interviews with the hospice staff member who knew each sampled pa- tient best; questions were answered in consultation with the patient’s medi- cal record or other records. No pa- tients or family members were inter- viewed. This study was deemed exempt by the Beth Israel Deaconess Medical Center institutional review board be- cause we used publicly available deiden- tified data. Hospice profit status was obtained from the agencies’ administrators. The agency was considered for-profit if it was owned by an individual, partner- ship, or corporation and nonprofit if owned by a nonprofit organization, re- ligious group, or government agency. Patient Characteristics We classified patients’ primary admis- sion diagnoses into the following 3 groups using codes from the Interna- tional Classification of Diseases, Ninth Revision, Clinical Modification: cancer (140-239), dementia (290.0, 290.42, 294.8, 294.9, 331.0, 331.11, 331.4, 331.82, and 331.9), and other (all re- maining codes, such as congestive heart failure). We categorized location of care as home, nursing home, hospital, resi- dential hospice, or other. Length of stay was measured from date of hospice en- rollment until discharge or death, whichever came first. We also as- sessed LOS in categories of less than 7 days, 7 to 30 days, 31 to 180 days, 181 to 364 days, and 365 days or longer. We measured number of visits per day by each of the following hospice person- nel: nurses, social workers, and home health aides. We computed each mea- sure by dividing the total number of vis- its by the patient’s LOS. W e u s e d t h e f o l l o w i n g d e m o - graphic characteristics as covariates: age at hospice entry (�50 y, 50-64 y, 65-74 y, 75-84 y, 85-89 y, �90 y), 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 NHHCS collected race/ ethnicity data using predetermined cat- egories through interviews with the hospice staff members who knew the participants. The available clinical characteristics other than diagnosis included the number of activities of daily living needing assistance (eating, bathing, dressing, toileting, transferring: cat- egorized as 0, 1-3, 4, or all 5) and mobility impairment (required no assistance, required assistance with walking, and did not walk). Data were only available for 2 agency characteris- tics other than profit status: whether the hospice agency was part of a chain (yes/no) and metropolitan statistical area, defined by the US Census as met- ropolitan (at least 1 urban area with a population �50 000), micropolitan (an area with a population of 10 000- 49 999), or “neither,” eg, rural (did not meet criteria for metropolitan or micropolitan). Statistical Analyses All analyses were performed using SAS-callable SUDAAN version 10 (RTI International, Research Triangle Park, North Carolina) to account for the complex sampling design. Data were weighted to reflect national estimates of hospice discharges. We report weighted percentages with corre- sponding 95% confidence intervals (CIs). Statistical tests were 2-sided. We used Pearson �2 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 HOSPICE AGENCY PROFIT STATUS AND PATIENT CARE ©2011 American Medical Association. All rights reserved. (Reprinted) JAMA, February 2, 2011—Vol 305, No. 5 473 Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 type, we imputed a visit rate of 0.5 divided by the patient’s LOS 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 cat- egories of LOS. We used logistic regression to deter- mine whether diagnosis and location of care were independent correlates of having been in a for-profit vs non- profit hospice after adjusting for demo- graphic, clinical, and agency covari- ates. We used linear regression to examine the association between profit status and log(LOS) adjusted for all co- variates, including diagnosis and loca- tion of care. We used linear regression models to examine differences in num- Table 1. Characteristics of Hospice-Discharged Patients and Hospice Agencies by Hospice Profit Statusa All Patients (N = 4705) Patients From For-Profit Hospices (n = 1087) b Patients From Nonprofit Hospices (n = 3618) b P ValueNo. Weighted % (95% CI) No. Weighted % (95% CI) No. Weighted % (95% CI) Age, y �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) .20 75-84 1459 29.6 (27.3-32.0) 323 29.9 (25.6-34.6) 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 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) .02 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 Married/partnered 2045 45.3 (42.2-48.5) 419 40.1 (33.3-47.4) 1626 47.7 (44.4-51.0) .06 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 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) .36 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 Yes 4328 91.5 (89.3-93.2) 1027 93.8 (89.6-96.4) 3301 90.4 (87.8-92.5) .10 No 365 8.5 (6.8-10.7) 59 6.2 (3.6-10.4) 306 9.6 (7.5-12.3) No. of ADLs needing assistance c 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) .11 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 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) .14 Not mobile 1431 34.9 (30.6-39.4) 332 37.0 (28.7-46.2) 1099 34.0 (29.1-39.2) Agency characteristics MSA 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) .11 Neither 1234 3.6 (2.9-4.5) 256 2.4 (1.2-4.7) 978 4.2 (3.3-5.3) Chain status Yes 894 26.8 (20.9-33.7) 587 74.0 (61.1-83.7) 307 5.9 (3.5-9.8) �.001 No 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; CI, confidence interval; MSA, metropolitan statistical area. a No. indicates sample size, and percentages are weighted to reflect national estimates. Columns may not add to 100% because of rounding. b Discharges were from 145 for-profit agencies and 524 nonprofit agencies. c Data were unknown or missing for race/ethnicity (n = 89), marital status (n = 163), primary payment source (n = 123), caregiver status (n = 12), No. of ADLs needing assistance (n = 550), and mobility needs (n = 583). HOSPICE AGENCY PROFIT STATUS AND PATIENT CARE 474 JAMA, February 2, 2011—Vol 305, No. 5 (Reprinted) ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 ber of visits per day by profit status and diagnosis after adjustment. To deter- mine whether the association be- tween diagnosis and number of visits per day varied by profit status, we used the Wald �2 test to further assess the interaction between profit status and di- agnosis group. We performed similar multivariable analyses to examine dif- ferences in number of visits per day by profit status and LOS categories. All statistical testing was 2-sided. Our 3 main factors of interest (profit sta- tus, diagnosis, and location of care) were defined a priori, and our study was considered hypothesis generating rather than definitive testing. However, we did calculate a Bonferroni-corrected criti- cal value of P � .017, given our 3 fac- tors of interest. RESULTS Our sample included 4705 patients discharged from hospice in 2007, of which 1087 patients (30.7%) were discharged from 145 for-profit agen- cies and 3618 patients (69.3%) were discharged from 524 nonprofit agen- cies. Our sample was representative of an estimated 1.03 million patients discharged from hospice in 2007. 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 with non- profit hospices were more likely to be non-Hispanic black (10.6%; 95% CI, 7.0%-15.8%, vs 6.4%; 95% CI, 4.7%- 8.7%, respectively) or Hispanic (7.5%; 95% CI, 4.5%-12.3%, vs 2.7%; 95% CI, 1.8%-4.1%; P = .02). For-profit agencies compared with nonprofit agencies were also more likely to be part of a chain (74.0%; 95% CI, 61.1%-83.7%, vs 5.9%; 95% CI, 3.5%- 9.8%, respectively; P � .001). TABLE 2 demonstrates that diagno- sis and location of care both varied by profit status. Compared with non- profit hospices, for-profit hospices had a lower proportion of patients with can- cer (48.4%; 95% CI, 45.0%-51.8%, vs 34.1%; 95% CI, 29.9%-38.6%, respec- tively) and higher proportions of pa- tients with dementia (8.4%; 95% CI, 6.6%-10.6%, vs 17.2%; 95% CI, 14.1%- 20.8%) and other diagnoses (43.2%; 95% CI, 40.0%-46.5%, vs 48.7%; 95% CI, 43.2%-54.1%). These differences re- mained significant after adjustment (P � .001). Compared with nonprofit hospices, for-profit hospices also had a higher proportion of patients resid- ing in nursing homes (23.1%; 95% CI, 20.4%-26.1%, vs 34.2%; 95% CI, 27.9%- 41.0%, respectively) and a lower pro- portion residing at home (57.1%; 95% CI, 53.5%-60.7%, vs 51.5%; 95% CI, 44.6%-58.3%). However, there was no independent association of location of care with profit status after adjust- ment for all covariates, most notably diagnosis. Reasons for discharge among for- profit hospices and nonprofit hos- pices were, respectively, death (77.7% vs 87.3%), condition stabilized or im- proved (6.7% vs 4.3%), obtained more aggressive therapy (7.7% vs 3.2%), moved to a different geographic re- gion (2.3% vs 1.6%), and other rea- sons (5.2% vs 3.5%). Also, for-profit hospices had a higher proportion of dis- charges based on readmissions than nonprofit hospices (9.3% vs 5.5%, re- spectively). TABLE 3 presents the median LOS in hospice with corresponding 25th and 75th percentiles by profit status of all patients and stratified by diagnosis. Me- dian LOS was 4 days longer in for- profit hospices as compared with non- profit hospices (20 days; interquartile range, [IQR], 6-88, vs 16 days; IQR, 5-52; P = .002). The unadjusted LOS was 41.0% longer (95% CI, 13.5%-75.1%) in for-profit hospices vs nonprofit hos- pices. After full adjustment, LOS re- mained significantly longer in for- p r o f i t h o s p i c e s c o m p a r e d w i t h nonprofit hospices (26.2%; 95% CI, 4.9%-51.9%; P = .01). A model adjust- ing for only diagnosis and location of care was nearly identical, suggesting Table 2. Diagnosis and Location of Care of Patients by Hospice Profit Statusa All Patients (N = 4705) Patients From For-Profit Hospices (n = 1087) Patients From Nonprofit Hospices (n = 3618) Adjusted OR of For-Profit Status (95% CI) bNo. Weighted % (95% CI) No. Weighted % (95% CI) No. 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 [Reference] 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 [Reference] 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) Abbreviations: CI, confidence interval; OR, odds ratio. a No. indicates sample size and percentages are weighted to reflect national estimates. b Adjusted ORs and 95% CIs were derived from a single model that adjusted for age, sex, race/ethnicity, primary payment source, having a primary caregiver, No. of ADLs needing assistance, mobility needs, and metropolitan statistical area. c P � .001 for unadjusted comparison by profit status. P � .001 for adjusted comparison by profit status. d P = .01 for unadjusted comparison by profit status. HOSPICE AGENCY PROFIT STATUS AND PATIENT CARE ©2011 American Medical Association. All rights reserved. (Reprinted) JAMA, February 2, 2011—Vol 305, No. 5 475 Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 that these 2 factors account for most of the variation in LOS. Compared with nonprofit hospices, median LOS in for-profit hospices was similar for patients with cancer (16 days; IQR, 6-39, vs 15 days; IQR, 6-44, respectively) and longer for patients with dementia (26 days; IQR, 6-135, vs 43 days; IQR, 10-161) and other non- cancer diagnoses (14 days; IQR, 4-70, vs 23 days; IQR, 6-100). In adjusted analyses, patients with dementia had longer median LOS than patients with cancer and other diagnoses (35 days; IQR, 7-161, vs 16 days; IQR, 6-40, and 17 days; IQR, 4-85, respectively; P � .001). Compared with patients in nonprofit hospices, patients in for- profit hospices were more likely to have stays longer than 365 days (2.8%; 95% CI, 2.0%-4.0%, vs 6.9%; 95% CI, 5.0%- 9.4%) and were less likely to have stays less than 7 days (34.3%; 95% CI, 31.3%- 37.3%, vs 28.1%; 95% CI, 23.9%- 32.7%; P = .005). TABLE 4 presents the median num- ber of visits per day by nurses, social workers, and home health aides over- all and stratified by diagnosis. Overall, for-profit and nonprofit hospices pro- vided similar numbers of nursing vis- its per day (0.45 visits; IQR, 0.27- 0.82, vs 0.45 visits; IQR, 0.28-0.83, respectively). However, for-profit hos- pice agencies compared with non- profit agencies provided fewer social work visits per day (0.12 visits; IQR, 0.06-0.25, vs 0.15 visits; IQR, 0.07- 0.34; unadjusted P = .006; adjusted P = .03) and more home health aide vis- its per day (0.33 visits; IQR, 0.15- 0.50, vs 0.25 visits; IQR, 0.07-0.45; un- adjusted P = .004; adjusted P = .02). Compared with cancer patients, those with dementia or other diagnoses had fewer visits per day from nurses (0.50 Table 3. Hospice Length of Stay by Profit Status All Patients (N = 4705) Patients From For-Profit Hospices (n = 1087) Patients From Nonprofit Hospices (n = 3618) Unadjusted P Value Patients by Category LOS categories, No. of patients (%) [95% CI] a �7 d 1375 (32.4) [29.9-34.9] 245 (28.1) [23.9-32.7] 1130 (34.3) [31.3-37.3] 7-30 d 1442 (30.5) [28.4-32.7] 311 (27.9) [24.4-31.8] 1131 (31.6) [29.2-34.2] 31-180 d 1340 (26.7) [24.3-29.2] 342 (30.4) [26.3-34.8] 998 (25.0) [22.2-28.1] .005 b 181-364 d 323 (6.4) [5.1-8.0] 99 (6.7) [4.3-10.3] 224 (6.2) [4.8-8.1] �365 d 225 (4.1) [3.2-5.2] 90 (6.9) [5.0-9.4] 135 (2.8) [2.0-4.0] LOS per Patient LOS, median (IQR), d Overall 17 (5-62) 20 (6-88) 16 (5-52) .002 c Stratified by diagnosis d Cancer 16 (6-40) 15 (6-44) 16 (6-39) Dementia 35 (7-161) 43 (10-161) 26 (6-135) Other 17 (4-85) 23 (6-100) 14 (4-70) Abbreviations: CI, confidence interval; IQR, interquartile range; LOS, length of stay. a No. indicates sample size and percentages are weighted to reflect national estimates. b Comparing LOS categories between profit and nonprofit hospices using a �2 test. c Outcome was log transformed; unadjusted model based on 1-unit increase in log(LOS). d P values are based on a single model that also adjusts for age, location of care, sex, race/ethnicity, type of insurance, primary caregiver, No. of ADLs needing assistance, mobility needs, and metropolitan statistical area. In analyses of LOS, P = .01 comparing profit status and P � .001 comparing diagnoses. Table 4. Visits per Day by Hospice Personnel by Profit Status, Overall and Stratified by Diagnosis Median (IQR) Unadjusted P Value All Patients (N = 4705) Patients From For-Profit Hospices (n = 1087) Patients From Nonprofit Hospices (n = 3618) Overall a Nursing visits 0.45 (0.28-0.83) 0.45 (0.27-0.82) 0.45 (0.28-0.83) .75 Social worker visits 0.14 (0.07-0.31) 0.12 (0.06-0.25) 0.15 (0.07-0.34) .006 Home health aide visits 0.26 (0.09-0.49) 0.33 (0.15-0.50) 0.25 (0.07-0.45) .004 Stratified by Diagnosis b Nursing visits c Cancer 0.50 (0.32-0.87) 0.58 (0.34-0.94) 0.50 (0.31-0.83) Dementia 0.37 (0.20-0.78) 0.38 (0.19-0.65) 0.36 (0.23-0.89) Other 0.41 (0.26-0.79) 0.41 (0.26-0.79) 0.41 (0.25-0.78) Social work visits d Cancer 0.15 (0.07-0.31) 0.15 (0.07-0.31) 0.15 (0.09-0.30) Dementia 0.11 (0.04-0.27) 0.07 (0.04-0.21) 0.12 (0.05-0.37) Other 0.14 (0.07-0.31) 0.11 (0.06-0.24) 0.15 (0.07-0.37) Home health aide visits e Cancer 0.22 (0.05-0.44) 0.26 (0.05-0.55) 0.19 (0.05-0.42) Dementia 0.35 (0.16-0.50) 0.39 (0.24-0.57) 0.30 (0.08-0.44) Other 0.28 (0.12-0.50) 0.37 (0.21-0.50) 0.26 (0.12-0.49) Abbreviation: IQR, interquartile range. a Outcome was log transformed; unadjusted model based on 1-unit increase in log(visits/d). b Outcome was log transformed; model based on 1-unit increase in log(visits/d). 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, No. of ADLs needing assistance, mobility needs, and metropolitan statistical area. c For analyses of nursing visits, P = .78 comparing profit status and P = .002 comparing diagnoses. d For analyses of social work visits, P = .03 comparing profit status and P � .001 comparing diagnoses. e For analyses of home health aide visits, P = .02 comparing profit status and P = .80 comparing diagnoses. HOSPICE AGENCY PROFIT STATUS AND PATIENT CARE 476 JAMA, February 2, 2011—Vol 305, No. 5 (Reprinted) ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 visits; IQR, 0.32-0.87, vs 0.37 visits; IQR, 0.20-0.78, and 0.41 visits; IQR, 0.26-0.79, respectively; adjusted P = .002) and social workers (0.15 vis- its; IQR, 0.07-0.31, vs 0.11 visits; IQR, 0.04-0.27, and 0.14 visits; IQR, 0.07- 0.31, respectively; adjusted P � .001). No significant interaction was ob- served between diagnosis and hospice profit status for any of the types of vis- its examined. TABLE 5 presents the me- dian number of visits per day by each personnel type, stratified by LOS cat- egories. Although patients with stays less than 7 days had more visits per day by nurses and social workers than pa- tients with longer stays, this did not dif- fer by profit status. COMMENT The recent increase in the for-profit hos- pice sector raises critical questions about potential financial incentives in hospice reimbursement. Using nation- ally representative data, we found no- table differences in the types of pa- tients enrolled in for-profit hospices compared with nonprofit hospices. For- profit hospices had a disproportionate number of patients with noncancer di- agnoses, dementia in particular. For- profit hospices also had a greater pro- portion of patients with prolonged LOS (�365 days). We also found that patients with noncancer diagnoses and those with prolonged LOS received fewer visits per day from skilled personnel (ie, nurses and social workers). Despite these dif- ferences in case mix, we found that pa- tients received similar rates of nursing visits regardless of hospice profit sta- tus. On the other hand, patients in for- profit hospices received fewer social work visits and more home health aide visits per day than those in nonprofit hospices as would be expected given the observed case-mix differences. Our findings have potentially important im- plications both for clinicians taking care of patients at the end of life and for policy makers in the area of Medicare hospice payment. The current Medicare Hospice Ben- efit reimburses hospices at a fixed per diem rate that does not consider the pa- tient’s diagnosis, location of care, or hospice LOS. Under this system, profit can be maximized by caring for pa- tients with certain diagnoses that re- quire fewer skilled services, patients re- siding in nursing homes, or patients with longer hospice stays.2,4,6,10,14 Al- though other studies have found that patients with noncancer diagnoses were significantly more likely than cancer pa- tients to be in for-profit hospices,10,11 we further examined the subset of pa- tients with dementia and found that they were even more likely to be en- rolled in for-profit hospices. Our find- ings indicate that approximately two- thirds of patients in for-profit hospices have dementia and other noncancer di- agnoses, whereas only about half of pa- tients in nonprofit hospices have these diagnoses. We also found that these diagnoses were 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 personnel (nurses and so- cial workers), which could be finan- cially advantageous for hospices un- der a capitated reimbursement system. For-profit hospices were also less likely than nonprofit hospices to have pa- tients enrolled for fewer than 7 days, and these patients had more visits from skilled personnel, which is costly for hospices. Our findings build on previ- ous research that has shown that LOS in hospice and services delivered cor- relate with patients’ terminal diag- noses.7,15,16 Previous studies examining the as- sociation of profit status or diagnosis with LOS or care intensity have used proprietary data5,7 or data limited to a single state.11,17 Lorenz et al11 used 1997 California data to show that 46% of pa- tients in for-profit hospices had non- cancer diagnoses, compared with 28% in nonprofits. We find a similar differ- ence, although of smaller magnitude— which may be partially due to the fact that our 2007 data show a substantial increase in noncancer diagnoses in both Table 5. Median Visits per Day by Hospice Personnel by Profit Status, Stratified by Length of Stay Median (IQR) a Patients From For-Profit Hospices (n = 1087) Patients From Nonprofit Hospices (n = 3618) Nursing visits b LOS �7 d 1.09 (0.74-1.41) 1.07 (0.71-1.43) LOS 7-30 d 0.58 (0.36-0.83) 0.49 (0.36-0.73) LOS 31-180 d 0.32 (0.22-0.43) 0.29 (0.21-0.40) LOS 181-364 d 0.19 (0.15-0.33) 0.20 (0.15-0.28) LOS �365 d 0.19 (0.15-0.27) 0.19 (0.14-0.28) Social worker visits c LOS �7 d 0.37 (0.26-0.63) 0.43 (0.27-0.73) LOS 7-30 d 0.16 (0.12-0.25) 0.16 (0.16-0.27) LOS 31-180 d 0.07 (0.04-0.10) 0.07 (0.05-0.11) LOS 181-364 d 0.04 (0.03-0.07) 0.05 (0.03-0.08) LOS �365 d 0.04 (0.03-0.05) 0.04 (0.03-0.07) Home health aide visits d LOS �7 d 0.37 (0.17-0.66) 0.25 (0.14-0.56) LOS 7-30 d 0.36 (0.16-0.55) 0.21 (0.04-0.43) LOS 31-180 d 0.33 (0.05-0.45) 0.22 (0.02-0.37) LOS 181-364 d 0.29 (0.11-0.43) 0.11 (0.00-0.32) LOS �365 d 0.29 (0.07-0.36) 0.30 (0.12-0.40) Abbreviations: IQR, interquartile range; LOS, length of stay. a Outcome was log transformed; model based on 1-unit increase in log(visits/d). P values are based on a single model that also adjusted for age, sex, race/ethnicity, diagnosis, location of care, primary payment source, having a primary caregiver, No. of ADLs needing assistance, mobility needs, and metropolitan statistical area. b For analyses of nursing visits, P = .56 comparing profit status and P � .001 comparing LOS. c For analyses of social work visits, P = .19 comparing profit status and P � .001 comparing LOS. d For analyses of home health aide visits, P = .006 comparing profit status and P � .001 comparing LOS. HOSPICE AGENCY PROFIT STATUS AND PATIENT CARE ©2011 American Medical Association. All rights reserved. (Reprinted) JAMA, February 2, 2011—Vol 305, No. 5 477 Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 for-profit and nonprofit hospices, com- pared with their 1997 study.11 Our study also examined dementia specifi- cally and demonstrated an even stron- ger association between profit status and dementia. Another study,18 which used an earlier version of the NHHCS, could only document whether pa- tients had ever received services from a given type of provider because it lacked information on the frequency of visits. Our study, using the most re- cent NHHCS, expands on prior work by quantifying the number of visits per day delivered by core members of the hospice team and thus provides an im- proved, 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 can- cer patients received more visits than noncancer patients.5 For-profit hospices had signifi- c a n t l y m o r e p a t i e n t s w i t h s t a y s exceeding 365 days and fewer patients with stays less than 7 days. Although hospice is intended for patients with a prognosis of less than 6 months, research demonstrates19-22 that it is difficult for clinicians to prognosti- cate, 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 exceeding 1 year were enrolled inappropriately early in the course of their illnesses, these admissions can be particularly lucra- tive for hospices in a per diem reim- bursement system because, as we found, they receive fewer visits per day from skilled hospice personnel. Our study has several important limi- tations. First, the NHHCS includes only patients who were discharged from hos- pice and therefore underestimates LOS because patients with longer LOS have a lower likelihood of having been dis- charged and are therefore underrepre- sented in the sample. Nonetheless, we found that for-profit hospices were more likely than nonprofit hospices to have prolonged LOS (ie, �1 year). This undersampling of long LOS means that our study on the whole probably un- derestimates the differences in me- dian LOS by profit status. Second, we lacked data on impor- tant agency characteristics beyond metropolitan statistical area and chain status, such as the hospices’ geo- graphic 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 com- position of hospices resulted in lower costs or greater revenue. Fourth, diag- nosis is an imperfect measure of dis- ease severity. Finally, and perhaps most impor- tantly, we are unable to assess the rela- tionship 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 assis- tance 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 research11,17 suggests that registered nurses, who are more skilled and more expensive, deliver a lower pro- portion of nursing visits in for-profit hospices vs nonprofit hospices. Clinicians caring for patients con- sidering hospice can be reassured that for-profit hospices appear to provide as many nursing visits and more home health aide visits (although fewer social work visits) than nonprofit hos- pices. However, there are important policy implications if hospice agencies differentially enroll more patients with dementia and other noncancer diag- noses, who require fewer visits from skilled personnel such as nurses and social workers. Patient selection of this nature leaves nonprofit hospice agen- cies disproportionately caring for the most costly patients—those with can- cer and those tending to begin hospice very late in their course of illness; as a result, those hospices serving the neediest patients may face difficult financial obstacles to providing appro- priate care in this fixed per-diem pay- ment system. Our findings are timely, comple- ment the findings of the Medicare Pay- ment Advisory Committee (MedPAC) reports,2,16 and can help inform the c u r r e n t d e b a t e a r o u n d p a y m e n t reform in the Medicare Hospice Ben- efit. 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 stan- dard payment at the time of death. Given that approximately 1 million Medicare beneficiaries use hospice each year and that the for-profit hos- pice industry continues to expand rap- idly, 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. Author Contributions: Dr Wachterman had full ac- cess to all of the data in the study and takes respon- sibility 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 in- tellectual content: Wachterman, Marcantonio, Davis, McCarthy. Statistical analysis: Wachterman, Davis, McCarthy. Obtained funding: Wachterman. Administrative, technical, or material support: Wachterman, Marcantonio, Davis, McCarthy. Study supervision: Marcantonio, McCarthy. Conflict of Interest Disclosures: All authors have com- pleted and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were re- ported. HOSPICE AGENCY PROFIT STATUS AND PATIENT CARE 478 JAMA, February 2, 2011—Vol 305, No. 5 (Reprinted) ©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 Funding/Support: Dr Wachterman received support from grant 6T32HP12706-02-01 from the Health Re- sources and Services Administration of the Depart- ment of Health and Human Services to support the Harvard Medical School Fellowship Program in Gen- eral 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, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. Previous Presentation: An earlier version of this work was presented at the national meeting of the Society of General Internal Medicine; Minneapolis, Minne- sota; April 30, 2010; and at the national meeting of Academy Health; Boston, Massachusetts; June 28, 2010. Disclaimer: The study contents are solely the respon- sibility of the authors and do not necessarily repre- sent the official views of the Department of Health and Human Services. Additional Contributions: We thank Benjamin Som- mers, 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. REFERENCES 1. NHPCO facts and figures: hospice care in America [2010 edition]. National Hospice and Palliative Care Organization. http://www.nhpco.org/files/public /Statistics_Research/Hospice_Facts_Figures_Oct-2010 .pdf. Accessed December 17, 2010. 2. Hackbarth GM. Reforming the delivery system: MedPAC report to Congress [June 2008]. http://www .medpac.gov/documents/Jun08_EntireReport.pdf. Accessed January 10, 2011. 3. Hospice facts and statistics [September 2009]. Na- tional Association for Home Care & Hospice. http: //www.nahc.org/facts/HospiceStats09.pdf. Accessed October 10, 2010. 4. 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Predicting patient survival before and after hospice enrollment. Hosp J. 1998;13 (1-2):71-87. 22. Fox E, Landrum-McNiff K, Zhong Z, Dawson NV, Wu AW, Lynn J; SUPPORT Investigators. Evaluation of prognostic criteria for determining hospice eligibil- ity in patients with advanced lung, heart, or liver dis- ease: Study to Understand Prognoses and Prefer- ences for Outcomes and Risks of Treatments. JAMA. 1999;282(17):1638-1645. In our flowing affairs a decision must be made—the best, if you can, but any is better than none. There are twenty ways of going to a point, and one is the shortest; but set out at once on one. A man who has that presence of mind which can bring to him on the instant all he knows, is worth for action a dozen men who know as much but can only bring it to light slowly. —Ralph Waldo Emerson (1803-1882) HOSPICE AGENCY PROFIT STATUS AND PATIENT CARE ©2011 American Medical Association. All rights reserved. (Reprinted) JAMA, February 2, 2011—Vol 305, No. 5 479 Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021