PRIVATE EQUITY FIRMS HOLD A GROWING OWNERSHIP OF HOSPICES
- Kaiser Health news published “Hospices Have Become Big Business for Private Equity Firms, Raising Concerns About End-of-Life Care.” The article explores the overall growth of for-profit hospices in general, and the growth of private firms owning hospices in particular.
- According to the article, “Many hospice veterans [are] worried that the original hospice vision may be fading, as those capital investment companies” demand for return on investment, and the debt load they force hospices to bear are hurting patients and their families. Physician and researcher Joan Teno, who has been focused on end-of-life care for many years, expresses concern that both patients and families may not be getting adequate care, and says, “Many of these transactions are driven by the motive of a quick profit.”
- An article in JAMA, in May 2021, reported that ownership of hospice agencies by private equity firms grew from 106 in 2011 to 409 in 2019. That is out of a total 5,615 hospices nationally. Of the hospices that were acquired by these private equities, 72% were non-profits. “And those trends have only accelerated into 2020.”
- The article notes some reasons why this is happening, saying, “Hospice is an easy business to start, with most care provided at home using lower-cost workers.” Because private equity firms are backed by “deep-pocketed investors,” they acquire small hospices and create a chain of hospices, “before selling to an even larger chain or another private equity firm.”
- Steve Larkin is CEO of Charter Healthcare, “a hospice chain owned by the private equity firm Pharos Capitol Group,” which is a private equity firm. Larkin also notes that not everyone who enters this hospice market do so with the best of intentions. Larkin says, “‘It is a little scary. There are people that have no business being in health care’ looking to invest in hospice.’”
- The article then goes in to a basic primer about hospice expenditures, notes that oversight is limited, and says, “the industry is at high risk for exploitation.” The author explores ways that staffing might be different between for-profit and nonprofit providers. A 2019 Milliman study reported that for-profit hospices employ fewer registered nurses and more LPNs. A 2019 GAO report analyzed federal data from 2014 to 2017, and found “that patients in for-profit hospices were less likely than patients in nonprofit hospices to have received any hospice visit in the last three days of life.” Teno adds that the most common way of increasing profits is to decrease visits.
- A March 2022 report from MedPAC noted that, in 2019, for profit hospices received Medicare hospice profit margins of 19%, while nonprofit hospice margins were 6%. The article asserts that for-profit hospices seek patients that will be in hospice for longer periods of time. It also reports that dementia patients are “particularly profitable.”
- Teno says the for-profit providers have fewer cancer patients, saying, “It is a very simple business model. Go to assisted living facilities and nursing homes, and it’s one-stop shopping.” According to the article, for-profit providers counter that nonprofits have “cornered the market on cancer patients and that they are expanding access by serving patients with other diagnoses.” The 2019 Milliman report found that 31% of patients in non-profit agencies had cancer, and 15%% had dementia. For-profits hospices reported that cancer patients were 22% of their service, and 22% had dementia. The article continues with a number of other comparisons between for-profit and nonprofit providers.
- National Hospice Analytics’ Cordt Kassner reports a national 13% rate of hospice being owned by private equity. Though not a huge difference, he says, “Equity-backed firms scored lower than average on self-reported quality metrics. “The article says that non-profit providers are perceived by many nonprofits as “giving the industry a bad name.” Larkin notes that quality metrics have not made the progress needed and that quality concerns are not limited to “private equity-backed or even for-profit hospice providers.”
- The link to the article at Kaiser Health News is the first link below. It was also published in Fortune, and the second link directs readers to that article. (Kaiser Health News, 7/29, https://khn.org/news/article/hospices-private-equity-firms-end-of-life-care/; Fortune, 7/27, https://fortune.com/2022/07/27/hospices-private-equity-firms-for-profit-end-of-life-care/)
CMS issued a final rule that updates payment for hospice services for FY 2023. The change takes effect on October 1, 2022, and provides a 3.8% increase (“an estimated increase of $825 million in payments from FY 2022.”) In addition, the rule provides a lasting mitigation policy designed to “smooth the impact of year-to-year changes in hospice payments related to changes in the hospice wage index.” It also offers updates to the Hospice Quality Reporting Program, and shares about the Hospice Outcomes and Patient Evaluation (HOPE) tool. Other features of the rule, as well as a complete copy, may be found on the links below. The first link is a fact sheet from CMS and the second is the entire rule at the Federal Register. (CMS, 7/27, https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2023-hospice-payment-rate-update-final-rule-cms-1773-f; Federal Register,7/29, https://www.federalregister.gov/documents/2022/07/29/2022-16214/medicare-program-fy-2023-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting)
New York Senator Michelle Hinchey’s bill, S8205A “ requires the NYS Department of Health to develop an advance care planning campaign educating New Yorkers about the benefits and availability of hospice and palliative care services to ensure that individuals, and their families, are aware of the healthcare available to them and their right to have their end-of-life medical decisions honored. The bill was signed into law by Governor Kathy Hochul, with the hope is that the bill will also “help close disparity gaps in care and ensure all New Yorkers have access to critical end-of-life services.” Hospice and Palliative Care Association of New York State’s president, Jeanne Chirico, expressed the organizations thanks to Hinchey and other champions for supporting the needs of patients and the work of hospice. (Hudson Valley Press, 7/27, https://hudsonvalleypress.com/2022/07/27/ny-governor-hochul-signs-senator-hinchey-bill/)
On July 1, VITAS Healthcare began a “hiring and retention wellness initiative” that was created to help with staff shortages and increasing patient care. To build clinical staff, nurses will receive a one-time retention bonus after working continuously for 12 months. The bonuses will range from $2,000 to $15,000 per licensed staff. To fund the initiative, VITAS will utilize $44 million from the $80.2 million it received from the Provider Relief Funds in CARES Act dollars. More robust staffing will also improve “drops in patient days of care.” (Hospice News, 7/28, https://hospicenews.com/2022/07/28/vitas-deploys-new-retention-program-to-combat-labor-headwinds/)
PALLIATIVE CARE NOTE
Geripal posted a podcast with oncologists Jennifer Temel and Areej El-Jawahn. Temel authored of a NEJM study on the value of early palliative care for outpatients with advanced lung cancer. Areej El-Jawahri authored a JAMA article about “inpatient palliative care for patients with blood cancers undergoing stem cell transplant.” Temel’s study found that palliative care not only improved quality of life but also lead to a bit longer survival. The podcast is online at the link below, with no registration needed. (Geripal, 7/28, https://geripal.org/palliative-care-for-cancer-podcast-with-jennifer-temel-and-areej-el-jawahri /)
A post from Verywell Health offers a summary of what to expect as life nears its end. The post includes a timeline for end of life, including information about one to three months before death, one to two weeks prior death, and days and hours before death. It also includes frequently asked questions. The post is online at the link below. (Verywell Health, 7/22, https://www.verywellhealth.com/the-journey-towards-death-1132504)
A study reported by PLOS ONE explores trends in health care at the end of life. The study reports that people reported two fewer months of fair/poor health at the end of life, when compared with people dying in earlier years. The researchers say that even though life expectancy is increasing, there is no evidence that poor health and disability prior to death has been extended. They also note that “Black women and women with less than a high school degree, require extended support at the end of life.” The report is online at the link below. (PLOS ONE, 7/27, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0267551)
“A father’s wish, a bioethicist’s dilemma” appears on the John Hopkins University HUB. Travis N. Rieder, a bioethicist shares his experiences that exemplify how complex end-of-life care decision can become. Rieder, and his two sisters who are nurses, had to make healthcare decisions when their father fell and was not conscious. After twenty minutes of not breathing, the father was put on a ventilator when he arrived at the hospital. When Reider’s sister arrived, the doctor shared that her father had been “gone too long” and that he wasn’t coming back. She refused to remove the ventilator until the siblings could work together on a decision. From here, the article details the long, convoluted, and wrenching experiences of the family and their father. Though their father had told them many times that he did not want to live with diminished capacity, the challenges of the situation were extremely difficult. The story continues to share about the final decision to sign a DNR, and what happens when they don’t need it after all. (John Hopkins University HUB, 7/25, https://hub.jhu.edu/2022/07/25/travis-rieder-fathers-wish-bioethicists-dilemma/)
Rutgers School of Public Health conducted a study revealing “nearly 5400 terminally ill people in the nation have used medical aid in dying (MAID) drugs to end their lives. . .” The study, that looked back 23 years, revealed that about 70% of these decedents had cancer, Ninety-six percent were white, well-educated and in their mid-70s. Men outnumbered women, with 53.1% men vs 46.9% women. The report says, “As MAID laws mature, use of MAID increases within the state.” The article, and further details are online at the link below. (Journal of the American Geriatrics Society, 6/16, https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.17925)
GRIEF AND ADVANCE CARE PLANNING NOTES
“Advance Directives: What You Need To Know” appears in Forbes. The article says one in three U.S. adults has “an official plan in place for end-of-life care. . .” The article then offers information about advance directives. The article describe each of the documents used in advance care planning, explores the importance of advance planning, and encourages early completion. A discussion of how care might unfold without advance directives is used to further encourage people to plan. (Forbes, 7/27, https://www.forbes.com/health/healthy-aging/advance-directives/)
The House of Representatives passed H.R. 4040, a bill that extends “telehealth flexibilities” through 2024. The bill now goes to the Senate for approval. Numerous provider groups welcomed this action. (Health Care Finance News, 7/28, https://www.nhpco.org/nhpco-and-han-comment-on-final-fy23-hospice-wage-index-and-quality-reporting-rule/)
Healio News shares “Cognitive vs. emotional empathy: It’s all in your perspective.” Though we want to be empathetic, says the article, “we are not explicitly taught how to be empathetic or compassionate in our training.” The authors identify and define three types of empathy—cognitive, emotional, and compassionate. The article provides tips for nurses in best ways to express empathy verbally. Finally, the article reminds readers of the value and benefits of empathy. (Healio News, 7/27, https://www.healio.com/news/hematology-oncology/20220727/cognitive-vs-emotional-empathy-its-all-in-your-perspective)
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Hospice Analytics is the national sponsor of Hospice News Network for 2022. Hospice Analytics is an information-sharing research organization whose mission is to improve hospice utilization and access to quality end-of- life care. For additional information, please call Dr. Cordt Kassner, CEO, at 719-209-1237 or see www.HospiceAnalytics.com.