In the United States there has been a huge influx of for-profit companies into what was started as a humane, civilised way of leaving this world in a caring, kindly way.  Profiting from death was the last thing the founders of St. Christopher’s hospice in London thought of when they established the first hospice in the mid-’70s.  But a Washington Post analysis of hundreds of thousands of U.S. hospice records indicates that, as for-profit companies, financed by Wall Street, transformed the movement once dominated by community and religious organizations into a $17 billion industry, patient care suffered along the way.

Between 2000 and 2012, the number of for-profit hospices tripled to 2,196, according to federal figures, compared with about 1,500 nonprofit hospices, including those run by local governments.   In 2012, Medicare spent more than $15 billion on hospice care,

On several key measures, for-profit hospices as a group fall short of those run by nonprofit organizations:

• For-profit hospices had a smaller proportion of registered nurses than non-profits; patients at for-profit hospices received a narrower range of services; and  for-profit hospices were more likely to restrict enrollment of patients with potentially high-cost care.
•  For-profit hospices spend less on nursing per patient –  $30 a day per patient on nursing visits, compared with $36 per day for non-profits.
•  For-profits are less likely to have sent a nurse to a patient’s home in the last days of life.  A typical patient at a for-profit hospice is 22 percent less likely to have been visited by a nurse during this window than a patient at a nonprofit hospice.
•  For-profits are less likely to provide more intense levels of care for patients undergoing a crisis in their symptoms. Nonprofits offered about 10 times as much of this per patient-day as did for-profits.
•  For-profits have a higher percentage of patients who drop out of hospice care before dying. 22 percent of  patients leave a for-profit hospice, while only 14 percent leave  nonprofits. High rates of dropout are often viewed as a sign that patients were pushed out of hospice when their care grew expensive, left dissatisfied or were enrolled for hospice even though they were not close to death.

The quality of individual hospices varies widely. In some cases, for-profit hospices provide service at levels comparable to nonprofits, according to the review. But the data analysis, based on hundreds of thousands of Medicare patient and hospice records from 2013, shows that the gap between the for-profits as a whole and nonprofits is striking and consistent. There is a pressure to cut costs and  sparse government oversight.  Hospices are paid a flat daily fee by  Medicare for each of their patients, and this means that the fewer services they provide, the wider their profit margin.

On the plus side for-profits can more easily raise money for investments in equipment and expansion, achieve a size that offers them economies of scale, and are maybe more efficient.  A large hospice can, in theory, afford to lose money on some patients who may need extraordinary care.

My own observations, necessarily limited, suggest that care homes and hospices are run by poorly paid and barely-trained people, often imported from developing countries, with no experience and sometimes poor English.   Serving in such homes is for the staff, unsurprisingly, a temporary expedient before finding a better-paid job.  The care can be rough and casual, the food pretty dreadful, the patients drugged, and the TV permanently on. This is how we push the elderly out of sight and out of mind.

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