Health Care/Joan Retsinas

An Insider Tip: Hospice

Golly Gee Whillikers! Roto-rooter does hospice. Along with unclogging drains, Roto-Rooter tends to the dying and comforts the bereaved.

Roto-Rooter, which bought Vitas in 1993, isn't the only corporate behemoth to enter this market. Other corporations have followed suit: Olsten, which provides temporary office help, owns Olsten Kimberly Quality Care Hospice; HCR Manor Care owns Heartland Hospice. About 30% of all hospices are for-profit. In Florida, they compete for "market share."

Jimmy Olsen, the Daily Planet cub reporter who was surprised at everything, would gape. So would Dame Cecily Saunders, the woman who founded the first teaching hospice at St. Christopher's Hospital in London. And the legions of caregivers who throughout the years have donated their time, energy and compassion to ease others' pain would wonder at the tentacles of capitalist fervor: Do people make money off every human endeavor? Even dying?

Adam Smith, who lauded the efficiency of capitalism, would answer "yes." Why not include dying as part of the Gross Domestic Product -- one addition to the Wealth of the Nation?

Within the past five years, hospice has joined up in the army of capitalism -- one more listing on the Dow-Jones. It is not a bad investment. Since the ultimate mortality rate is 100%, hospice is assured a stream of customers. People, moreover, die at home -- no expensive hospital tab. And insurers will pay. Thirty years ago Medicare crafted a hospice benefit: If patients with "terminal" illnesses abandoned expensive and futile heroic medical wizardry, Medicare would pay for all the palliative care the patient might need -- including nursing care, physicians, medications and homemakers. Medicare money was a boon to struggling hospices, forced to rely on family donations and the volunteer labor of scores of people.

While Medicare money eased hospices' financial straits, the money also introduced a business modus operandi. Hospices had to do the same accounting as any other "vendor" that does business with Uncle Sam. They had to balance their books, matching expenses against income. While they still encouraged and trained volunteers, they hired more staff, paying them competitive salaries. Hospice segued from being a religious or charitable mission-drive organization to a "non-profit." This non-profit remained committed to easing the pain of patients and comforting bereaved families -- but it had started to morph into a market product.

The transformation from "non-profit" to "for-profit" is not so momentous. "Reserves" become "profits." Hospitals have made the leap -- even hospitals founded with a religious mission. Insurers are now an odd amalgam of for-profit and non-profit entities. A non-profit Blue Cross plan may have a few for-profit subsidiaries. The nursing home industry has always divided into non-profits and for-profits. As for home care, forty years ago the non-profit Visiting Nurses dominated -- but, with Medicare reimbursement making this market more attractive, the profit-driven agencies, particularly the mega-chains, rushed in.

The sometimes Jesuitical distinction between for-profit and not-for-profit does not necessarily signal poor care. One study comparing for-profit and not-for-profit hospices faulted the latter -- but, anecdotally, patients have not registered complaints. The staff at both kinds of hospices -- the physicians, nurses, social workers and chaplains -- hold dear their professional commitment to patients.

Yet in the long run this one last step in the capitalization of health care is troubling. The hospice model is built on teams of caregivers. Will accountants now sit at the table, discussing the costs of the medications or the time-cards of home health aides?

Certainly accountants sit at the corporate tables. The point of a for-profit entity is to make a profit. If revenue slips in a hospice, will Roto-Rooter sell that "product line"? When HMOs found that Medicare reimbursement did not pay enough for over-age-65 enrollees, some HMOs restricted benefits and increased co-payments. Others simply dropped the "product," cutting thousands of elderly enrollees adrift.

Right now I suspect that the hospices are betting on more federal money. After all, to ease enrollees' drug costs, Congress passed a pharmaceutical bonanza that will enrich the pharmaceutical companies. This emergent hospice industry can hire well-connected lobbyists; they may reap the same windfall. But if the economy cycles down and Congress retrenches (as it did when it passed the Balanced Budget Act -- a decision that slashed home care, nursing home and hospital revenues), some hospices will follow their red ink out the door, abandoning their communities' dying patients. And if a for-profit hospice has aggressively captured "market share," the community will have no non-profit hospices to fall back on.

Someday the cheerleaders for the "ownership society" will need comfort and care. They may rue their enthusiasm for this addition to the gross domestic product.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

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