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Key Message Points

JAMA Article - Key Message Points for NHPCO Members
February 2, 2011

The February 2 issue of the Journal of the American Medical Association includes an article, “Association of Hospice Agency Profit Status, With Patient Diagnosis, Location of Care, and Length of Stay.” NHPCO offers the following thoughts to members.

More than 1.5 million dying Americans receive hospice care every year. Ultimately, the most important measure or consideration is the quality of care provided to patients at the bedside.  Nothing in the article indicates that tax status is a reflection of quality.  NHPCO calls for all providers to comply with and exceed NHPCO’s Standards of Practice for Hospice Programs, participate in its Quality Partners initiative, and fully comply with all industry regulations.

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Hospice patients deserve quality care.

  1. NHPCO is committed to the provision of the highest quality hospice and palliative care, regardless of provider structure, and works to support access to quality care for all patients and family caregivers coping with serious, life-limiting illness in all settings.

    a)  NHPCO’s “Standards of Practice for Hospice Programs” provides a comprehensive set of standards regarding the provision of care to which all providers are encouraged to comply.
    b)  A tenet of hospice is to bring care and services to patients at home – wherever they are. This includes private residences, nursing homes, assisted living and long-term care facilities.
    c)  One in four Americans die in nursing homes and they deserve the compassionate care that hospice professionals are skilled in providing.
    d)  Communities across the nation are different and hospice organizations reflect the range of needs in their service areas.
    e)  The JAMA article reminds readers that for-profit hospices serve a greater number of African-American and Latino patients.


  2. Quality is more than a measure of visit numbers or length of stay:  Quality metrics are vitally important and should reflect perceptions of quality care from the patient and the family caregivers.

    a)  The article in JAMA notes that the reported study does not differentiate between types of visits; furthermore, the study does not reflect indicators such as visit length or quality of visit – which NHPCO feels is essential in looking at quality care.
    b)  NHPCO offers a collection of outcome measure tools to help providers collect important data they can use as part of a comprehensive quality improvement process.  These measures include:  Family Evaluation of Hospice Care (FEHC), Family Evaluation of Bereavement Services (FEBS), National Data Set, Survey of Team Satisfaction (STAR), Quality Partners Self- Assessments and others.
    c)  The JAMA article brings up issues that have been previously mentioned by MedPAC and NHPCO takes this opportunity to remind the field of the importance of having quality measures as a component of research.

Tax status is not a reflection of quality.

  1. NHPCO research shows that patients served by for-profit hospices (just like non-profit hospices) receive high quality care from the nation’s hospice.  
    a)  NHPCO’s comprehensive survey, the Family Evaluation of Hospice Care shows no difference in family caregivers’ evaluation of quality of care.
    b)  Any business model – for-profit, non-profit or governmental – that provides greater access to quality hospice care is good for the nation’s healthcare system and good for patients and families.
    c)  Over the past decade the increased numbers of for-profit providers parallels increased numbers of Americans served by hospice.
    d)  For-profit organizations contribute to the financial well-being of the states and communities they serve through the taxes they pay.

  2. Hospice has evolved from an all-volunteer model to become an important component of the healthcare delivery system.  

    a)  Hospice began as a volunteer-driven, grassroots movement in the US in the late 1970s. Hospice has since moved beyond the all-volunteer organization and now the make-up of the industry includes a mix of profit, for-profit and governmental entities similar to other healthcare sectors in the US.
    b)  The federal hospice Conditions of Participation are the same for all providers, tax-structure is not a factor.
    c)  There are variations in for-profit organizations and variations in non-profit organizations – and within each area a range of diverse providers can be found.

Hospice is beneficial to those dying from a range of illnesses and in all settings.  

  1. For many years NHPCO has been encouraging hospices to care for a full range of patients in the last months of life including non-cancer patients, such as those with dementia.  Hospices representing all profit structures have worked to address the needs of such populations, including those who reside in nursing homes and they provide a very important and essential need in this country.

a)  In 2009, less than 44% of patients had cancer diagnoses, which reflects increased access to those with other illnesses.
b)  The care of patients with dementia can be unpredictable and not as straightforward as a cancer diagnoses and providers admitting dementia patients run a greater risk of having admits questioned and claims denied.
c)  The study authors seem to conclude that dementia patients are ‘lower skill’ – the implication being that their care needs are minimal.  This reflects a fundamental misunderstanding of the important unmet needs for persons dying from dementia. A person dying from dementia may still experience pain.
d)  One in four Americans will die in a nursing home – they deserve access to quality hospice care.
e)  Research has shown that the availability of hospice care in nursing homes raises the level of care for all residents.

While increased access to hospice care has resulted in increased Hospice Medicare Benefit expenditures, overall hospice care saves Medicare money.

  1. Annual Medicare expenditures are about $11 billion – dollars that are spend to provide the most comprehensive, patient-centered care for a person at the end of life.
    a)  While Medicare’s hospice expenditures have risen since 2000, it was estimated that many hospice appropriate patients did not receive this interdisciplinary, compassionate care as they died. For every person who received hospice, at least two more would have benefited and did not get it.
    b)  It’s about the best care at end of life; however, research shows that hospice saved Medicare money.  A study out of Duke University found that hospice saved Medicare $2,300 for every beneficiary that received hospice care.
    c)  Lead author of the Duke study, Don H. Taylor, Jr., wrote, “Given that hospice has been widely demonstrated to improve quality of life of patients and families...the Medicare program appears to have a rare situation whereby something that improves quality of life also appears to reduce costs.”

NHPCO’s Belief

It is NHPCO’s position that research should move the entire industry forward by analyzing which hospice interventions enhance the quality of care provided and which demonstrate the efficacy of hospice care in all settings and for all hospice patient populations.

Furthermore, NHPCO calls for all providers, regardless of profit status, to meet and exceed NHPCO’s Standards of Practice for Hospice Programs, participate in its Quality Partners initiative, and fully comply with all hospice regulations.