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Original Investigation
Health Care Reform
April 2014

National Hospice Survey Results: For-Profit Status, Community Engagement, and Service

Author Affiliations
  • 1Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York
  • 2Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
  • 3Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 4Geriatric Research, Education, and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
  • 5John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, Connecticut
JAMA Intern Med. 2014;174(4):500-506. doi:10.1001/jamainternmed.2014.3

Importance  The impact of the substantial growth in for-profit hospices in the United States on quality and hospice access has been intensely debated, yet little is known about how for-profit and nonprofit hospices differ in activities beyond service delivery.

Objective  To determine the association between hospice ownership and (1) provision of community benefits, (2) setting and timing of the hospice population served, and (3) community outreach.

Design, Setting, and Participants  Cross-sectional survey (the National Hospice Survey), conducted from September 2008 through November 2009, of a national random sample of 591 Medicare-certified hospices operating throughout the United States.

Exposures  For-profit or nonprofit hospice ownership.

Main Outcomes and Measures  Provision of community benefits; setting and timing of the hospice population served; and community outreach.

Results  A total of 591 hospices completed our survey (84% response rate). For-profit hospices were less likely than nonprofit hospices to provide community benefits including serving as training sites (55% vs 82%; adjusted relative risk [ARR], 0.67 [95% CI, 0.59-0.76]), conducting research (18% vs 23%; ARR, 0.67 [95% CI, 0.46-0.99]), and providing charity care (80% vs 82%; ARR, 0.88 [95% CI, 0.80-0.96]). For-profit compared with nonprofit hospices cared for a larger proportion of patients with longer expected hospice stays including those in nursing homes (30% vs 25%; P = .009). For-profit hospices were more likely to exceed Medicare’s aggregate annual cap (22% vs 4%; ARR, 3.66 [95% CI, 2.02-6.63]) and had a higher patient disenrollment rate (10% vs 6%; P < .001). For-profit were more likely than nonprofit hospices to engage in outreach to low-income communities (61% vs 46%; ARR, 1.23 [95% CI, 1.05-1.44]) and minority communities (59% vs 48%; ARR, 1.18 [95% CI, 1.02-1.38]) and less likely to partner with oncology centers (25% vs 33%; ARR, 0.59 [95% CI, 0.44-0.80]).

Conclusions and Relevance  Ownership-related differences are apparent among hospices in community benefits, population served, and community outreach. Although Medicare’s aggregate annual cap may curb the incentive to focus on long-stay hospice patients, additional regulatory measures such as public reporting of hospice disenrollment rates should be considered as the share of for-profit hospices in the United States continues to increase.