The recent series of articles in the Washington Post on the relative strengths and weakness of for-profit (FP) vs. not-for-profit (NFP) hospice has produced a lot of emotional response and some insight. However, in many people’s opinion, the Post pieces have not been the most objective and have been biased toward presenting FP hospice in a negative light. As is usually the case, bias in a report does not lead to objectivity in the discussion. There are a couple of issues to my mind that have either not surfaced or not been given enough attention.
This is not a new issue in health care. Long term care in a number of states long suffered from unscrupulous operators who took advantage of their relatively defenseless “customers” to make a profit. It should be noted that some of these operators ran FP operations and some ran NFPs. This point is not to excuse those who may take advantage of the dying in the same way but just to point out that this is not something particular to hospice.
Demonizing for-profit health care is simplistic and unhelpful to the debate. There are clearly good and bad actors on both sides. FPs who are mission driven (and there are many) often provide state of the art care as well as pay off investors. Successful companies in all fields are successful exactly because they both satisfy their customers and reward their investors. There are many NFP hospitals now owned by FP companies that have not missed a beat in continuing to provide patient-centered care. Yes, NFPs can do fund raising but, put simplistically, fund raising and raising capital are just two different ways to raise cash. Neither one is inherently good or bad. Its what the cash goes for that counts.
Even though chaplaincy is unreimbursed and not clearly a revenue generator or cost saver, I know some for profit hospices which provide the most professional, best trained (and therefore most expensive) chaplaincy and I know some NFPs that provide the cheapest and substandard chaplaincy just so they comply with regulations.
The big issue that I have heard peak its head up but not be seriously addressed is the issue of quality of care. The Washington Post has framed the debate by at least implying that the quantity of care is positively correlated with the quality of care. They strongly imply that spending less nursing time on a patient or not sending a nurse to visit over the last two days of life is substandard care just by virtue of it being less care. This claim invokes a classic US premise that More care is necessarily Better care. It is this premise that is at least partially responsible for the US spending so much on health care but having less than optimal results. We are starting to learn and palliative care is teaching how false this premise can be. Do we know that having a nurse visit in the last two days of life is “better” care? We don’t. Is this even what patients and families want and need? We don’t know. And maybe the “pain” is social or spiritual generating anxiety so maybe the visitor should be the chaplain or the social worker. We don’t know that either.
I believe that a major reason why quality is not discussed is that quality measures are not used in much of US health care and often we do not even know what a quality measure would be in a given context. We are getting better and some recent findings indicate that less care can even lead to, not only better QOL but to longer life, but we have a long way to go.
The more is better premise is also common in chaplaincy. A lot of us still work on the basis that the more we visit a patient the better without any real evidence for (1) whether the patient even wants this and (2) whether we are accomplishing anything positive. We are nice people and patients like us but do we “help” and what does help mean in this context?
It is on the basis of agreed upon quality measures that hospices ought to be compared. The only question should be does the particular hospice deliver quality care (effective and efficient), not whether it is FP or NFP. We often claim we don’t have time for quality measures and even sometimes imply that we deserve to be trusted because we are good and honorable people in this for the right reasons. But that is no longer good enough. Our patients deserve better no matter what our business model is.