RAND Corp.: Families Report Better Care from Nonprofit Hospices

The families of patients who received care from nonprofit hospices give their providers higher marks on quality than those who went with for-profits, a RAND Corp. study has found.

RAND researchers analyzed Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey data from 653,208 caregivers whose family members received care from 3,107 hospices between April 2017 and March 2019.

Nonprofits scored higher across all of the assessed metrics, and families were 5% more likely to recommend their provider to others than those cared for by for-profits, according to RAND.


“Our results are not explained by the geographic regions the hospices operate in, or by the types of patients they care for,” lead author Rebecca Anhang Price, senior policy researcher at RAND, said in a statement. “These findings are particularly pressing given the striking growth of for-profit hospices, which have profit incentives that have been shown to affect how they care for patients.”

The relative value of nonprofit and for-profit providers has been a longstanding discussion in the hospice community. Nearly all hospices were nonprofit organizations at the time the Medicare benefit was established in 1982, but in terms of sheer numbers the balance has shifted toward for-profits in the intervening years.

The number of hospices operating in the United States rose to 5,058 in 2020, the most recent year for which data are available, the Medicare Payment Advisory Commission (MedPAC) reported. Of those, about 73% were for-profit companies, and 24% were nonprofits. The remaining 3% were government organizations.


These numbers reflect a 4.5% increase in the number of U.S. hospices between 2019 and 2020.

For-profit chains received the poorest ratings, according to RAND. However, this trend was not universal. A contingent of for-profits performed better than the national average.

“Not all for-profit hospices provide poor quality,” Anhang Price said. “When choosing a hospice, families and health care professionals can look at the quality metrics available for hospices in their area on Medicare’s Care Compare website.”

The RAND analysis, which appeared in JAMA Internal Medicine, examined eight quality measures: hospice team communication, timely care, help for symptoms, respectful treatment, emotional and spiritual support, caregiver education, overall rating of hospice care and the likelihood that they would recommend their provider to others. 

“Nonprofit providers of hospice care have long been standard bearers for quality care in the sector — as this research shows,” Katie Smith Sloan, president and CEO of LeadingAge. “The incredible value of mission-driven, nonprofit providers’ approach to hospice care has endured, even as the composition of the hospice sector evolves.”

Prior research by the Government Accountability Office (GAO) in 2019 found that the two types of organizations performed similarly overall on quality measures from the Hospice Item Set as well as CAHPS scores. However, disparities existed when it came to individual measures.

For example, in 2017 for-profits and nonprofits both averaged about six provider visits within the last seven days of life. However, 85% of patients with nonprofits received a visit during their last three days compared to 77% among for-profits. For-profits also had higher rates of live discharges, according to GAO.

But that same year, for-profits cared for a greater proportion of patients from underserved demographics, such as the African American, Asian and LatinX communities.

“Our review of CMS data found that for 2017, both for-profit and nonprofit hospices, on average, had similar scores on the seven quality measures that are provider-reported and that CMS currently uses to assess the quality of hospice care,” GAO indicated. “For six of the seven measures, for-profit and nonprofit hospices had average scores of 94.7% or better.”

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