Let’s Talk More About Death: Hospice Becoming a For-Profit Business

Currently, occupational therapists do not play that much of a role in death and dying it seems. Could it be because meaningful occupations are in conflict of the reality of death? Many occupational therapists seem to discharge their services when it has been determined that the patient and their families decide to go on hospice.

I would argue that occupational therapists have a major role that they can play in hospice, along our allied health nursing colleagues. Sure they can manage the IV drip and the pain, but we also know how to manage pain. They can help with physical comfort, but we also know how to do that. They could help with making the environment more therapeutic. Do we as OTs know how to do that? Yes!

What inspired me to write this article is a KHN piece titled, “Hospices Have Become Big Business for Private Equity Firms, Raising Concerns About End-of-Life Care“. Traditionally, hospice (and the spirit of it) was run by non-profits. In 2011, for profit hospices and their entities comprised 3.4% of the market, but in 2019, it more than doubled to 7.3%.^[1]Braun RT, Stevenson DG, Unruh MA. Acquisitions of Hospice Agencies by Private Equity Firms and Publicly Traded Corporations. JAMA Intern Med. 2021;181(8):1113–1114. … Reference List Although we only have two data points here, it’s pretty obvious where the trend is going.

So is for-profit a good thing in the hospice world? And more importantly, what are the future implications for OT?

Private equity investors now have their eye on hospice. “It is a little scary,” he said. “There are people that have no business being in health care” looking to invest in hospice. Those in favor of for-profit for hospice argue that it expands their services in an area which non-profits have focused primarily on cancer. I don’t know if I agree with this statement.

Personally, I think bad things happen when healthcare goes private. The KHN article states that for-profits typically provide fewer visits to the patient and their families. Instead of RNs, they see licensed practical nurses, who are less skilled and they also provide nurse aides to cut down on costs. Staff who work for-profit hospices are also expected to see more clients in the same amount of time. Capitalism. This is all probably to save on the bottom line.

What is also kind of disgusting is their length of services and who they have seemed out for their clients. For-profit will typically prefer patients who are somewhere in the middle of not taking to long to die, but won’t die too quickly either — in time for the companies to conduct their expensive screens, assessments, and visits. But not so long that they become unprofitable.

“That makes dementia patients particularly profitable. Doctors have a harder time predicting whether a patient with Alzheimer’s disease or another form of dementia has less than six months to live, the eligibility criterion for enrollment. For-profit hospices enroll those patients anyway…and stand to profit the longer those patients live. They tend to enroll fewer cancer patients, whose prognosis is generally more predictable but who usually die sooner.”

“Patients in nonprofits had more nursing, social worker, and therapy visits. For-profit hospices, the report found, had longer lengths of stay by patients, discharged more patients before death, and had profit margins nearly seven times higher.”

Then there’s safety, quality of services, training, oversight — the concerning list of for-profit gets more and more concerning.

Sure there are good companies and bad companies, but when you have investors expecting a profit, I think decisions kind of get made based on this pressure…and it usually doesn’t end up in the best interest for those receiving these services.

What does this have to do with occupational therapy? As more for-profits take on clients with chronic conditions that also meet eligibility such as dementia (which OTs work with a lot in skilled nursing facilities), perhaps OTs may get involved in the world of death and hospice.

But is it in the best interests of the patient and their families?

We may not even get this far, as OTs may possibly be perceived as “too expensive” a profession for these business models. So sadly, I think our chances of occupational therapy as a profession to get involved and have a scope of practice that is reimbursed for death and hospice will become even more slim.

But hopefully I am wrong. Because I can see the potential and benefits of having OT in death and hospice. If I was on my deathbed and on hospice, I would love to have a qualified nurse AND an occupational therapist on my caseload alongside my close family and friends. This sounds morbid, but would be kind of awesome. The OT can help set up my environment to be therapeutic, make sure I am comfortable besides pharmacology from the RN, provide mental health interventions, and help meet my goals whatever they will be at that time.