ARTICLE EXPLORES HOW PRIVATE EQUITY FIRMS ARE ACQUIRING HOSPICES IN U.S.
“Private Equity Is Gobbling Up Hospice Chains And Getting Involved In the Business of Dying” is written my Molly Redden, Senior Politics Reporter for HuffPost. The sub-title of the article is “One private-equity-led hospice chain has thousands of seniors in its care and millions of dollars in government revenue. The owner’s identity is a mystery.”
From the dramatic title and subtitle, the article opens by giving a glimpse of hospice care from a professional caregiver’s point of view. It is a portrayal of hospice at its best. “Hospice care accepts the ultimate limitations on life instead of fighting them,” writes Redden, “and it openly embraces the emotional and spiritual needs of patients.”
But, says the article, “hospice has grown to resemble the rest of the healthcare industry in one crucial aspect. Private equity is gobbling up an alarming share of the market.” The rate of acquisition, says Redden, “is astonishing.” During 2012 and 2019, “the number of hospices owned by private equity companies tripled.” And the pace of this growth seems to have only grown during the pandemic. Brokers who help put these deals together say they now hear from “private equity buyers multiple times a week.” Redden says, “Private equity now accounts for three out of every five new hospice acquisitions.” Buyers, says the article, see the rising numbers of seniors, the reimbursements offered by Medicare, “and a lack of regulation that is pretty startling even by U.S. standards.”
Redden particularly focuses on Traditions Health, which is very active in acquisitions. Traditions is owned by a private equity firm, Dorilton Capital. In just three years, “Traditions Health has acquired more than a dozen hospice, palliative and home care business, expanding its footprint to 18 states and allowing Traditions Health to boast that it is one of the fastest-growing companies in the U.S.” Dorilton Capital, Reddin says, is not a company that offers fast buys and quick resales. Dorilton “is the most active private equity investor in elder care in the country.
Former employees of hospices already acquired by Traditions Health, however, “describe undue pressure to maximize profit – cost cutting, staff reductions and an aggressive pursuit of more patients.” Redden describes what happened in one hospice that was acquired. With normally a 15-20 patient census, efforts to increase patients “‘turned into a numbers game.’” Marketing staff members, says one former clinical employee, turned over patients with inadequate records and she had no idea what medical equipment to order. Meanwhile, the “marketers who exceeded their monthly quota got a bonus.” Traditions denies that there is “unreasonable cost-cutting,” and observes that the patients –not the marketers—make the decision to enter hospice.
Redden examines Dorilton, which was founded in 2009, and says the owner is a mystery. It self-describes itself “as an investment office for a single family.” But no one knows who this family is. Nevertheless, Dorilton is one of “dozens that are driving this gold rush.”
Redden then enters a brief historical description of hospice, with hospice’s beginnings emerging from grassroots efforts. Between 2000 and 2012, for-profit hospices grew to 60%. Then, private equity groups began to get increasingly engage and now also dominates fields such as dermatology and dentistry.
“By 2019, there were more than 300 private-equity-owned hospices providing care to more than 112,000 Medicare recipients, according to Tyler Braun, a health policy researcher at Weill Cornell Medical College.” While this is a “modest share of the total number of Medicare hospice patients,” this is still a 328% increase of patients in private equity hospices since 2012.
Redden continues, by offering a litany of concerns about quality of care in for-profit hospices, tracing the financial history of Vitas, and lightly exploring fraud allegations. She observes, “It’s still not entirely clear yet how hospices owned by private equity companies will differ from the rest of the industry.” The article continues with some educated observations about where the changes in hospice ownership might lead.
Traditions Health didn’t respond to a list of questions given to it. But David Klementz, their CEO, did talk with Redden “in broad strokes.” She covers Klementz’s response to her questions. And she gives an overview of Dorilton’s history as well. By mid-2021, says Redden, Traditions cared for more than 5,000 patients per day in 18 states.
“Federal quality control of hospices is almost nonexistent,” says Redden. She shares that legislators have interest in addressing concerns they have about hospice quality. And she says there are some fixes to current problems. She suggests compliance tools, and a presidential order allowing “Medicare inspectors to use data they already have on file to identity dangerous hospices.”
Melissa Aldridge, a professor at the Icahn School of Medicine at Mount Sinai, is a critic of private equity in hospice care. She is concerned because “for-profit ownership creates pressure for hospices to dole out profits rather than reinvest them.” Aldridge wrote, in another article, “‘It is difficult to identify a health care sector more detrimentally affected by the mismatch between profit maximization incentives and quality of care than hospice.’” (HuffPost, 12/21, https://www.huffpost.com/entry/hospice-private-equity_n_61c0f858e4b061afe39659ea)
HOW DO OUR BRAINS DEAL WITH GRIEF?
NPR explores “How your brain deals with grief, and why it takes time to heal.” Mary-Frances O’Connor, an associate professor of psychology at the University of Arizona, “studies what happens in our brains when we experience grief.” Grief is a form of learning, says O’Connor, “one that teaches us how to be in the world without someone we love in it.” Her book, “The Grieving Brain,” will be out soon. In it, O’Connor examines what scientists have learned about “how our minds grapple with the loss of a loved one.”
We know the pain of grief—of coming to understand we will never again spend time with someone we have loved. “‘What we see in science is, if you have a grief experience and you have support so that you have a little bit of time to learn, and confidence from the people around you, that you will in fact adapt.’”
In an interview with O’Connor, NPR explores the grieving process and the difference between grief and grieving. Grief “just knocks you off your feet and comes over you like a wave.” “Grieving is what happens as you adapt to the fact that our loved one is gone, that we are carrying the absence of them with us.” The range of emotions in grief include panic, anxiety, sadness, and yearning. But it is also difficult to concentrate, and there is confusion about what to do next. And these emotions are intense.
Though there is no much known, O’Connor talks about imaging studies done of grieving brains. What we do know, she says, is that there are many brain functions that help us recall memories, remember others, increase heart rates, and experience pain. Prolonged grief, which O’Connor says used to be called complicated grief, happens in less than 10% of people.
O’Connor offers ideas for supporting grieving people. Listening is critical, as is just being there for them. Tell them you can imagine a future where they will not suffer so much, she advises, and do not try to cheer them up. Those who lost loved ones to COVID face special challenges as they were often unable to observe the worsening physical conditions and to be with loved ones as they die. (NPR, 12/20, https://www.npr.org/sections/health-shots/2021/12/20/1056741090/grief-loss-holiday-brain-healing)
* There are lethal dangers for consumers when hospice fraud occurs, says a recent article in Vermont’s Barre Montpelier Times Argus. The article notes the importance of hospice, and warns readers of the down side of hospice fraud. Sometimes, a fraudulent hospice may certify a person who is not terminally ill. Patients may be offered gifts, be billed at a rate of care higher than they actually receive, and/or experience “incomplete or inadequate” services. (Barre Montpelier Times Argus, 12/18, https://www.timesargus.com/features/weekend_magazine/cove-the-lethal-dangers-of-hospice-care-fraud/article_3281bf15-28fc-5596-a474-1bda1f05ebca.html)
* Florida’s Agency for Health Care has approved five new hospices to open in January, 2023– one more than expected. The decisions can still “be challenged in state administrative court and therefore are not final.” The process and approvals are described in the online article in the first link below. The second link shares the official state announcement of all new facilities announced. (Florida Politics, 12/20, https://floridapolitics.com/archives/481384-state-gives-initial-approval-for-five-new-hospice-programs/; Florida’s Agency for Health Care Administration, https://www.flrules.org/Gateway/View_notice.asp?id=25374247)
* MedPAC’s December 9, 2021, report by the Payment Advisory Commission is now posted online. The transcript of the entire presentation appears at the first link below. The transcript of the hospice presentation begins on page 200 of that document. On page 210 is the recommendation made by MedPAC regarding hospice. “For fiscal year 2023,” says MedPAC, “the Congress should eliminate the update to the fiscal year 2022 Medicare base payment rates for hospice and wage-adjust and reduce the hospice aggregate cap by 20 percent.” The report also notes the lack of date on hospice telehealth because hospices are not required to report these visits. This leads to a recommendation that requires hospices to report telehealth visits and enable MedPAC to better “monitor beneficiary access to care during the PHE.” The PowerPoint of Kim Neuman’s presentation on hospice is found at the second link below. (MedPAC, https://www.medpac.gov/wp-content/uploads/2021/09/Dec21_MedPAC_Meeting_Transcript_SEC.pdf; https://www.medpac.gov/wp-content/uploads/2021/09/Hospice-update-MedPAC-Dec-2021.pdf)
* The Pancreatic Cancer Action Network shares “When the ‘H’ Word Means Gratitude: Hospice the Right Decision for Mom to Live Life to the Fullest.” Lauren Postyn shares about her role as caregiver to her mother, and her appreciation for the care that hospice offered –in spite of her concern that accepting hospice would feel like defeat and giving up. Instead, her mother found herself better able to truly live. (Pancan, 12/22, https://www.pancan.org/stories/when-the-h-word-means-gratitude-hospice-the-right-decision-for-mom-to-live-life-to-the-fullest/)
* A new hospice in Nashville is focused on serving Black families. Heart and Soul Hospice is owned by Black citizens who will serve everyone, but focus on Black patients. Nashville’s population is 27% black, but only 19% of hospice patients are Black. Two of the three investors “started a Black-focused hospice agency in Michigan and have plans to replicate the model in other states.” (NPR, 12/28, https://www.npr.org/sections/health-shots/2021/12/28/1064096741/black-owned-hospice-seeks-to-bring-greater-ease-in-dying-to-black-families)
* The Elizabeth Kubler-Ross Foundation offers “Understanding Hospice.” Veteran hospice leaders Barbara Karnes and Gabby Jimenez lead the event. The presentation, offered on January 4 from 1:00 to 2:30 p.m. EST, will be posted on the Elizabeth Kubler-Ross Youtube channel. There is no fee but registration may be required. (Eventbrite, https://www.eventbrite.com/e/understanding-hospice-with-barbara-karnes-rn-gabby-jimenez-tickets-224793372027)
END-OF-LIFE AND PALLIATIVE CARE NOTES
* End of Life University offers the podcast “The Legacy of Elizabeth Kubler-Ross with Ken Ross.” Ken Ross, Elizabeth’s son, talks about his life with his mother, her focus on death and dying, and the controversies she faced in her life. (End of Life University, 12/20 https://eolupodcast.com/2021/12/20/ep-330-the-legacy-of-elisabeth-kubler-ross-with-ken-ross/?mc_cid=c7d98084d6&mc_eid=d0771da91c)
“Illness and Death Are Not Just Medical Issues,” says Sonya Dolan, COO of Mettle Health and past administrator at Hospice by the Bay, in a Forbes article. In an interview, Dolan speaks with Sophie Okolo and talks about “a critical dissection of dying and death in America and how Mettle Health is changing the end-of-life conversation. (Forbes, 12/27,https://www.forbes.com/sites/sophieokolo/2021/12/27/mettle-healths-sonya-dolan-illness-and-death-are-not-just-medical-issues/?sh=5d6bda8a75be)
* Delaware’s “Block End of Life Options Law,” opposed by some of the disability community, has enough safeguards to protect everyone, writes Vickie George, who is herself disabled. George, who has MS, served on the Governor’s Council for Health Promotion and Disease Prevention, and wrote an opinion piece in Delaware’s Bay to Bay News. She is part of the disability community and also co-founded Yes U Can USA. That program “positively impacts every participant’s life, as they realize they are able to regain control of things that they did not think they could.” (House Bill 140).” The state of Oregon, she says, has never “received a complaint that a person with disabilities was coerced or being coerced to make use of the (1994 Oregon Death With Dignity) Act.” George’s sister, she says, “died a horrific death from cancer.” And she wants the option to choose for herself. (Bay to Bay, 1/2, https://baytobaynews.com/stories/commentary-people-with-disabilities-have-diverse-opinions-on-end-of-life-care,67519)
* As Journal of Palliative Medicine (JPM) celebrates its 25th anniversary, is sharing thirty best articles of the last 25 years. The articles shared are in three categories: “most read, most cited and highest Altmetric Score.” The articles are online and available to all. (Journal of Palliative Medicine, https://home.liebertpub.com/lpages/jpm-25th-anniversary-article-collection/306 )
GRIEF AND ADVANCE CARE PLANNING NOTE
* Author Joan Didion, who died on 12/23/21, experienced and wrote about grief. After her husband died in 2003, she wrote a memoir, “The Year of Magical Thinking.” sharing her loss. The book was a finalist for a Pulitzer prize. About 18 months later, her only daughter died. From her experiences with that loss, she wrote a second memoir, “Blue Nights.” In this book, she detailed her grief and examine “mortality and aging.” “The raw emotional weight of both The Year of Magical Thinking and Blue Nights provided an unflinching look inside Didion’s otherwise steely, sophisticated exterior.” Didion wrote that we work to keep the dead alive because we want to keep them with us. But, she wrote, “‘I also know that if we are to live ourselves there comes a point at which we must relinquish the dead, let them go, keep them dead.’” (Time, 12/23, https://time.com/6131414/joan-didion-grief/?utm_medium=email&utm_source=sfmc utm_campaign=newsletter+brief+default+ac&utm_content=+++20211224+++body&et_rid=31875114&lctg=31875114)
* “‘Green burials’ can change our relationship with death – and help the Earth,” appears in Washington Post. Mallory McDuff authors the article and is also author of “Our Last Best Act.” As an environmental educator, she began to explore plans for her own future burial. She spent a year researching “options such as water cremation, home funerals, end-of-life doulas, green burial, human composting and even body farms.” She learned much “about better ways to calibrate our inevitable deaths with the needs of our planet.” Our deaths, she came to believe, “can help restore the Earth and our connections to the land.” McDuff shares from her experiences during her study, sites she visited, and burials she attended. (Washington Post, 12/17, https://www.washingtonpost.com/outlook/green-burials-can-change-our-relationship-with-death–and-help-the-earth/2021/12/16/85137994-5de5-11ec-bda6-25c1f558dd09_story.html?utm_campaign=wp_todays_headlines&utm_medium=email&utm_source=newsletter&wpisrc=nl_headlines&carta-url=https%3A%2F%2Fs2.washingtonpost.com%2Fcar-ln-tr%2F358db1d%2F61bdbf499d2fdab56bce1d6f%2F5de936e2ae7e8a73196a6d15%2F40%2F59%2F61bdbf499d2fdab56bce1d6f)
* Frank Ostaseski, co-founder of Zen Hospice Project and Buddhist teacher, talks about serious stokes he has suffered and his quick movement from caretaker to caregiver. He shares about lessons learned and still being learned. He “speaks about the loss of identity in the setting of illness and why he’s more interested in discovery, not recovery.” (End Well, https://endwellproject.org/paradox-of-vulnerability/?mc_cid=7da4e7916e&mc_eid=d67266dfca)
* Two articles, in separate publications and with separate authors, share personal views of death and dying. One author writes about getting prepared for death by settling up his business affairs. The second shares her experiences with death and her growing awareness of mortality. Links to both articles are below. (LimaOhio.com, 1/2, https://www.limaohio.com/news/491625/john-grindrod-come-the-new-year-thoughts-of-the-end; NYDailyNews.com, 1/1, https://www.nydailynews.com/opinion/ny-oped-death-alive-covid-20220101-lr2pyaota5b2bjr44mrrrbsfre-story.html)