Despite the Hype, Quality is the Issue over Tax Status

A recent “opinion piece” in the Journal of Law, Medicine and Ethics, purporting to distinguish between for- and not-for-profit hospice care, falls short on several points. The article, in fact, fails to make its point: a clear distinction between for- and not-for-profit hospice care. Throughout the article, the authors note that there is a scarcity of research that shows a difference in quality of care, based on the tax status of the hospice provider. Here at the NHPCO Hospice Action Network, we have consistently stated that we believe the quality of care that a hospice provides should be the central issue that separates the good programs from the ‘bad apples.’ As a result, we were a little uncertain about the point that the authors were trying to make.

There are those individuals who feel that virtually any capitalist participation in the health care field is suspect. Let’s acknowledge that. And, everyone is certainly entitled to their opinions. But, let’s face a basic fact. The entire American health care system is made up of a mix of for- and not-for- profit providers, and other healthcare sectors have flourished under this model, with quality care being provided to all. It doesn’t look like the provider mix is going to change anytime soon.

So, what is the point of trying, in a veiled fashion, to paint a significant part of the hospice community as “bad players,” citing a trivial example of a hospice provider handing out pens and coffee cups to nursing home staff? Are the authors suggesting that a patient referral, once removed from the actual patient and family, can be bought with a $.43 ball point pen or $1.37 mug?

Health care delivery systems, including the hospice community, are shaped by the requirements of the care that they are asked to deliver and the adequacy of their reimbursement, not by the tax code. I am not aware of a single health care professional that consults the Internal Revenue Service Code to determine a course of treatment or intervention for a patient. Each tax status has its own relative benefits and burdens. There is “no free lunch” for either type of tax status. Indeed, the tax code places clear and significant responsibilities on both for-and not-for-profit entities.

So, from an institutional framework, both tax structures have very real financial and legal obligations to fulfill. But, the professional caregivers have a more important obligation, and that is serving the patient. Based on the overwhelming feedback we have received, over the past ten years, from surveys of family members, all types of hospices are delivering on those promises of high quality, patient-focused and compassionate care- irrespective of tax-status.

To me, the frustrating part about the article is that it relies on quasi-sensational headlines to draw the reader to a set of opinions, which I feel are lacking in substantive foundation. While articles such as this might make for good entertainment, they can do real and lasting damage to hospice’s image on Capitol Hill. We here at the Hospice Action Network have talked about the important role that the news media play in influencing your elected officials. For example, a story about the value of hospice can make the difference in a Senator singing on to the HELP Hospice Act. Conversely, a story like the one mentioned above can make a Member of Congress have second thoughts about moving the bill in the House. It’s important to note that elected officials tend to look at the industry as a whole- with the current debt crisis, two wars, and the looming 2012 election cycle on their plates, they don’t have time to play ‘referee’ in the hospice industry- they look to us to work together to be a model of quality, cost-efficient care, across the board. Divisive articles, or even murmurs or finger-pointing from within our community, that are based on loose assumptions only serve to lower their opinion of the whole industry, regardless of tax status.


As a result, we have to take the time to debunk the innuendoes, false assertions and thinly veiled references to unethical and possibility illegal behavior. One of the biggest resources that the Hospice Action Network has at its disposal is good will- who could be against quality care for those facing the end of life? Stories like this, that unnecessarily cast hospice in a bad light, cut into that resource. The energy that NHPCO and HAN have to take to walk back these types of stories take time and energy away from more pressing and important issues, like protecting the integrity of the Medicare hospice benefit and assuring expanded access for the increasing number of patients and families seeking a coordinated and seamless end of life care experience. Our resources are finite and I think you’ll agree that we’d much rather be spending them championing the model of care that hospice represents instead of having to play defense dispelling myths and incorrect assumptions.

So, perhaps a more constructive focus might be found around urging both Medicare beneficiaries and their families, with guidance from their health care professionals to be engaged in ongoing and informed conversations about their desires for care at the end of life. The product of these discussions should then be shared with family members, health care providers and others. If we focus on this, quality programs will win the day, whether they are for-profit or non-profit.

Time is precious. We know that. Let’s focus our efforts on the here and now, and not some theoretical arguments and a stalking horse for a larger agenda. We believe that high quality patient and family care should always get our undivided attention- it’s what’s good for the industry, and ultimately it’s what’s best for the patient and their family.

Jon Keyserling is the Executive Director of the Hospice Action Network and Senior Vice President of the Office of Health Policy at the National Hospice and Palliative Care Organization.

3 thoughts on “Despite the Hype, Quality is the Issue over Tax Status

  1. While Quality is an important component of value (the ultimate goal) it is only one component. The other component is Integrity. Integrity is actaully more important than Quality. If for example, Hospice A operates in a manner that lacks integrity, that hospice may enjoy an averege lenght of stay (ALOS) of 110 days. The vast majority of their patients will have lower acuity and be less costly to care for. Hospice B operates with more integrity and has an ALOS of 60 days. This hospice will be working harder and creating more value for patients, families and society in general than Hospice A. Hospice B may actually be providing better quality care but will most likely have more quality concers because of the higher acuity of its patient mix. It could be that because of the higher acuity in Hospice B, Hospice A may appear to have fewer qualty concerns. Hospice B could be working much harder, spending more of its resources on pateint care but still appear, on some measures, to be providing lower quality care than Hospice A.
    Hospice A’s behavior, however, will cause payors to create more regulations and complex reimbursement structures in order to offset the Integrity concerns. This tightening will effect all hospices as the reimbursement to hospices will decline. This decline in reimbursement will have a negative impact upon the ability all hospices have to provide high quality care.
    That is why Integrity is the primary driver of both quality and value.

  2. I am wondering if such evidence as was presented in the May 2004 issue of Medical Care can be included in your “lacking in substantive foundation” argument? This research found that for-profit hospice patients received the full range of services only half the time that nonprofit patients did. In our area, for-profit hospices have almost twice the caseload expectations for their staff that our nonprofit does. How can it be that these facts can be somehow imagined to have no impact on quality? I think it may be a good argument that objective measures of the differences in the patient experience in these two instances are lacking, but to pretend that a difference in quality does not exist because it can’t yet be measured is wrong.
    I know that there are a significant number of us who believe that there is a difference, and it is a growing concern that our National Trade Organization is increasingly being seen as the apologists for for-profit hospice. Let’s examine the differences openly and honestly and take action to address the very real threat to the integrity of hospice that so many do, and yet too many refuse, to see.
    I get that we must all speak with one voice to impact legislators on important issues, but at what point do we acknowledge that very real differences exist in core principles and values? Hopefully this can happen before the soul of hospice has been sold for the sake of unity between those who consider hospice to have a focus on patient and family, and those who have their hospice focus on a business plan.

  3. Doug’s response to my initial post raises several interesting points and I certainly appreciate the engagement. My reading of the 2004 Medical Care article that Doug cited seems to distinguish between the types of services that a small group of hospices, both FP and NFP, provided, but did not address an assessment of the quality of care delivered by either. Also, I believe the research indicated that for core hospice services, there was little if any distinction between FP and NFP providers. It was only when the researchers looked at “other” services were there differences. I do not recall the authors noting if one set of service offerings, when taken together, was better than the other.

    With respect to the second point, referencing local staffing practices, NHPCO has recently released staffing guidelines that, instead of using set ratios for staff allocations, uses a flexible approach based on patient needs. Different staffing ratios might reflect operating efficiencies, care protocols, patient demographics and/or approaches to service delivery. Case load is not necessarily an indicator of quality. But, let’s be clear, the goal of all providers (and their national organization) is to deliver the highest possible level of quality care to their patients and families.

    Tim’s post focusing on integrity couldn’t be more relevant. In fact, NHPCO is about to release a position statement and commentary, approved by the NHPCO Board of Directors that reinforces the need for ethical behavior and the highest standards care for the patients and families served by the hospice community. As Don Schumacher, President of NHPCO as said, “The highest ethical practices and standards are necessary from every single provider in the hospice community — with no exceptions.”

    As a representatives of the largest and oldest national organization representing the hospice community, we have to be very careful about how we portray the various divisions and differences within the hospice community. That includes rural and urban providers, as well as large and small providers. And, yes, even for profit and not for profit providers. The hospice community is akin to all other areas of health care in that we have a broad mix of provider types. Our core guide is and will remain assuring that the highest level of quality care will be delivered to every patient and family needing end of life care.

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