The latest Consumer Reports takes on end-of-life care and recommends that families steer away from newer, for-profit hospices. The move is sure to rattle the hospice industry, much of which consists of, well, newer, for-profit outfits.
But some experts say the influential magazine is mistaken to advise against for-profits.
“I’m an old hippie but honestly, the for-profits are not the bogeymen. I’ve seen hospices of both types with some bad practices,” said Dale Lupu, an associate research professor at George Washington University and the former chief executive of the American Board of Hospice and Palliative Medicine.
Even as the industry has come to define the end-of-life experience for about half of older Americans, it's hard to know how to shop for a hospice. While the federal government publishes consumer data about the quality of other health-care companies, including hospitals, nursing homes and home health agencies, it provides no such information about hospices.
It may not be until 2017, at the earliest, before government provides such data about hospice companies.
Consumer Reports, one of the nation's most read consumer advice magazines, states in its December issue that people should look for a hospice that has “not-for-profit status and 20 or more years of experience.”
“We are not prepared to say there’s no such thing as a good for-profit hospice, but there have been problems with them,” Nancy Metcalf, senior health editor at Consumer Reports, said in an interview. “We think this checklist will give people a better chance of finding a hospice that will give them the care that they need at the end of their lives.”
Last week, The Washington Post published a consumer guide to the nation’s hospices that is meant to fill the void of public information about the growing hospice industry. But how to use the information offered in the guide - and which statistics best measure quality - provoked a variety of opinions.
In compiling the statistics for the guide, The Post sought expert opinion on what information, among that which could be gleaned from arcane Medicare reports, would be useful for consumers.
The guide provides information about agencies around the country, including, among other things:
- the hospice’s age
- its size
- its accreditation
- what it spends on nursing per patient
- whether the operation is for-profit
- whether it has provided at least some patients with “crisis care,” meaning either continuous nursing care or general inpatient services.
The experts generally favored hospices that are older, not tiny and those which have provided at least some “crisis care."
“If a hospice has a longer track record, there’s a greater chance that it’s doing a decent job,” Metcalf said.
Lupu said she would look for hospices that are at least 10 years old and serve at least 50 patients at a time.
“Smaller hospices unfortunately may not have to the scale to offer robust back up,” said Lupu, who offered a detailed analysis of the data in her post about The Post’s consumer guide in Pallimed, a palliative medicine blog. “And while not every patient is going to need crisis care, you want to know that it’s there.”
To varying degrees, experts consulted by The Post favored hospices that have been accredited by outside groups.
“The first thing I would look at is whether it is accredited by an outside organization,” Lupu said. “If you are not accredited, you haven’t opened yourself up to outside scrutiny.”
Hospices that have been accredited generally face inspections more often - once every three years. The federal government, partly due to funding shortfalls, has inspected hospices only once every six years or so, though recent legislation is supposed to make them more frequent.
Other experts, including some from a panel convened by MedPAC, Congress’s watchdog over Medicare, suggested that a statistic showing how many people leave the hospice alive - known as the “live discharge rate” - is a good reflection of quality. It is included in the Post’s guide, too.
The reason live discharge rate is useful may be a bit counter-intuitive. In some cases, of course, leaving hospice alive is a good thing - because it means survival. But experts say that a live discharge rate much over 25 percent might be viewed as a warning because it may mean that the hospice is discharging patients when they need more care, or maybe more commonly that they are enrolling patients who aren’t near death.
Finally, the Post’s guide includes data on how much the hospice spends per patient on nurses, doctors and therapy.
These spending items have stirred the most debate.
“There are real risks associated with use of unaudited hospice cost report data -- and hospice cost report data generally -- as it has numerous flaws and could lead to faulty calculations,” said Theresa M. Forster, a vice president for hospice policy at the National Association for Home Care & Hospice, an industry group.
The numbers, however, come directly from the reports that the hospices file with Medicare. The guide asks any hospice that believes their information is incorrect to contact the Post.
The guide, moreover, should probably just mark the beginning of the shopping process. Experts advised interviewing hospices about their services, too. A list of questions suggested by the American Hospice Foundation may be found here.