Patients and families generally love hospice care. The nurses and social workers who are the most frequent providers of hospice care are usually highly enthusiastic as well. So are there any issues with this beloved process? Let’s look at a few aspects of hospice care and the agencies that provide it. First let’s define hospice.

“Hospice got its start in the 1960s as a social movement. Volunteers, often meeting in schools and church basements, organized care so patients could die at home with loved ones, instead of at the hospital laced with tubes. Dame Cicely Saunders, the pioneering English physician who opened St. Christopher’s Hospice in London in 1967, fought traditional methods of unconditional resistance to death, and brought the concept to U.S. shores” (Waldman).

According to Jeanne Dennis, Director of Visiting Nurse Service of New York Hospice Care, “Hospice is a program that provides care for the terminally ill at home or in a facility. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient, as well as providing bereavement support to the family. Hospice, which is covered by Medicare and commercial insurance, is available when the patient’s physician determines that further treatment will not cure or reverse the disease, and that the disease at its current stage typically claims life within six months. The care that hospice provides is palliative, focusing on relieving pain and other symptoms but not seeking to cure the disease.”

Beginning as a charity work, hospice has through the evolution of third-party payers and Medicare, developed a for-profit business model. Peter Waldman said, “As hospice care has evolved from its charitable roots into a $14 billion business run mostly for profit, patients like Covington and their families have paid a steep price, according to lawsuits and federal investigations. “ The Covington family is suing a for-profit hospice with charges of elder abuse and neglect. Other for-profits have been accused of paying bounties for referrals and of rewarding employees for finding patients with longer expected survival times.

“The average for-profit patient costs the government $12,609, 29 percent more than a non-profit patient, because the for-profits find people who live longer, frequently at nursing homes … Of the hospices with two-thirds or more of their patients in nursing homes, 72 percent are for-profits.  … Patients stay an average of 98 days in for-profit hospices versus 68 days at non-profits, which have a 0.2 percent profit margin, according to Medicare. The margin at for-profits is 50 times higher at 10 percent. ”

“Medicare’s reimbursement system may spur [for-profit hospice] companies to select patients who need “fewer skilled services” or longer hospice stays because the federal insurance program for the elderly and disabled pays a fixed daily rate, regardless of the services patients need,” cited Molly Peterson.

That for-profit hospice companies are attracted to the bottom-line appears widely accepted. A recent OIG report states, “Medicare currently pays hospices the same rate for care provided in nursing facilities as it does for care provided in other settings, such as private homes.  … The current payment structure provides incentives for hospices to seek out beneficiaries in nursing facilities, who often receive longer but less complex care. To lessen this incentive, the OIG recommends that CMS reduce Medicare payments for hospice care provided in nursing facilities … “ (Levinson).

Commenting on the role of the non-profit hospice service, Amy Ziettlow said, “The Glasswing Butterfly comes from Central America and is often found in regions spanning from Mexico to Panama. It’s quite common in its zone, but it is not easy to find because of its transparent wings. Rainforest ecologists say that the presence of this rare tropical gem is an indication of high habitat quality; its demise alerts them of ecological change. … As a non-profit hospice provider, we free our staff to serve unnoticed, to be transparent butterflies. Our local community profits when our non-profit hospice serves it well. The existence of a non-profit hospice, like the existence of the Glasswing Butterfly, indicates a high habitat quality in our community.”

Ziettlow speaks like a prophet singing the praises of a worthy activity blessed by the spirits.  But like the dinosaur and due to competition from the for-profit hospice, might the lovely and high flying non-profit hospice service fade away? And would that indicate ecological change towards a lowered habitat quality in our community?


Dennis, Jeanne. Hospice Straight Talk: Myths Meet Reality. Huffington Post, July 28, 2011.

Levinson, Daniel R., DHHS Office of the Inspector General. Medicare Hospices That Focus on Nursing Facility Residents, OEI-02-10-00070, July 21, 2011.

Peterson, Molly. For-Profit Hospice Companies May Gain on Fewer Cancer Patients. Bloomberg, February 1, 2011.

Waldman, Peter. Preparing Americans for Death Lets Hospices Neglect End of Life. Bloomberg, July 21, 2011.

Ziettlow, Amy. Non-Profit Hospices: On the Road to Extinction? Hoffington Post, February 10, 2011.