Hospice quality is difficult to assess during private equity expansion because ownership changes can be hard to trace, and hospice has limited transparency and quality measures. Melissa Aldridge says those gaps make it tough to study whether ownership changes affect care. The question is whether quality improves or declines, not ownership type alone.
Ownership records can miss the timing of a change
A study needs to connect a hospice's ownership to its care and quality over time. In a GeriPal discussion, Lauren Hunt said Medicare data do not show when a hospice changed ownership, making it hard to understand variation in care. Without a clear timeline, comparing results before and after an acquisition becomes difficult.
The Medicare Payment Advisory Commission reported that ownership details in CMS's PECOS enrollment system are self reported, lack a central source for verification, and have longstanding accuracy and completeness problems. MedPAC also said CMS has not typically used PECOS to study ownership types such as private equity. These gaps make it harder to identify which hospices changed hands and when.
Few measures capture what matters to families
Aldridge said hospice has little regulation, limited transparency and very limited quality metrics. She warned that even a small difference in the incentive to make money could translate into large differences for patients and families. When measures are sparse, a change in an agency's results may be hard to detect or interpret.
A 2019 Government Accountability Office report, as summarized by the Private Equity Stakeholder Project, found that hospices with the lowest quality ratings were most likely to be for profit, while average quality was similar across ownership types. The project called this a red flag as private equity presence grows. That finding describes for profit hospices overall, so it does not establish private equity's effect.
The investment timeline can complicate comparisons
Aldridge described private equity investments as often lasting roughly three to five years, with investors changing operations, seeking a profit and then selling. She said this short horizon compresses the timeframe of the for profit motive compared with nonprofit or publicly traded ownership. Tracking quality only at one point in time may miss changes that occur during an ownership period or after a sale.
The Private Equity Stakeholder Project argues that a focus on short term profits may amplify concerns about for profit hospice ownership. That is a concern about incentives, not a measure of care at a specific hospice. Hospice leaders can make ownership changes visible and review quality measures across the transition, so a change has a clear date to compare against.
Quality is the central test
Cordt Kassner, speaking on GeriPal, described a conflict between mission and money and said the key test is whether care quality improves or declines. That framing keeps attention on patient care while allowing for the possibility that ownership arrangements differ in their effects.
Aldridge has called for ownership transparency and suggested that changes in ownership could trigger audits. Hospice owners can record ownership changes clearly and preserve quality measures across the transition.
This page is general education only. It is not medical advice. Talk with your own doctor about your health.
Frequently asked questions
How common is for profit hospice ownership?
Aldridge said research tracking hospice ownership from about 2000 to 2010 found a rising share of for profit providers. She estimated that about two thirds of the hospice market is now for profit.
What patient patterns have researchers reported after hospice acquisitions?
A study of Medicare hospice agencies found that, compared with for profit hospices that were never acquired, agencies acquired by private equity firms or publicly traded companies saw increases in patients receiving care at home and patients diagnosed with dementia. Critics cited by the study raised the possibility that owners could target patients needing less complex care or longer stays.
What can happen when someone leaves hospice alive?
Among Medicare beneficiaries discharged alive from hospice, a study found that 9% were hospitalized and readmitted to hospice, while 3% were hospitalized and died in the hospital. Black identity, short hospice stays and for profit hospice care were associated with higher odds of these transitions. For questions about an individual patient's care, talk with their doctor.
Sources
- Private Equity Gobbling Up Hospices plus Hospice and Dementia: Melissa Aldridge, Krista Harrison, & Lauren Hunt (GeriPal podcast (Mount Sinai))
- Is Hospice Losing Its Way: A Podcast with Ira Byock and Joseph Shega (GeriPal podcast (UCSF))
- Report to the Congress: Medicare and the Health Care Delivery System | June 2021 (Chapter 3: Congressional request: Private equity and Medicare) (Medicare Payment Advisory Commission (MedPAC))
- Private Equity Health Care Acquisitions, November 2023 (Private Equity Stakeholder Project)
- Leadership, Quality, and the Future of Hospice: Guests Chris Comeaux and Cordt Kassner (GeriPal podcast (Hospice Analytics))
- Changes in Diagnoses and Site of Care for Patients Receiving Hospice Care From Agencies Acquired by Private Equity Firms and Publicly Traded Companies (JAMA Network Open)
- Hospice Readmission, Hospitalization, and Hospital Death Among Patients Discharged Alive from Hospice (JAMA Network Open)
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