A recent study suggesting some newer for-profit hospice programs have accepted patients too early and discharged others when the costs of caring for them rose is receiving mixed reaction from end of life experts.

Nearly 20 percent of U.S. hospice patients are discharged before death, and not-for-profit and government-run hospices have lower rates of discharge than newer for-profit programs, according to findings published in the Journal of Palliative Medicine.

“When you have a live discharge rate that is as high as 30 percent, you have to wonder whether a hospice program is living up to the vision and morality of the founders of hospice,” lead researcher Dr. Joan Teno told The Washington Post. “One part of the reason is some of the new hospice providers may not have the same values — they may be more concerned with profit margins than compassionate care.”

Patients in nonprofit programs were less likely to be discharged while alive than those in similar for-profit programs: 15 percent to 22 percent. More mature programs (those 21 years and older) had lower rates of discharge than those in operation for 5 years or less: 14 percent to 27 percent.

“There has been a striking increase in the number of hospice providers with the fastest growth coming from for-profit providers,” the researchers write.

Hospice volunteer Loretta Downs, past president of the Chicago End-of-Life Care Coalition, told Life Matters Media she found the findings alarming.

“Death is truly unpredictable, and older hospices seem to have more experience with predicting it,” Downs said. “I think hospice care should be nonprofit. Because of the nature of the care, this should not be a profit-making business.”

Downs, who has volunteered in both nonprofit and for-profit programs, recommends that terminally ill patients enter local, reputable nonprofits.

“I noticed a higher patient load for the staff and a little more marketing in a for-profit,” she offered. “They had an in-patient unit which had double-bed rooms, which is inappropriate.”

Dr. Timothy McCurry, medical director of Illinois-based Rainbow Hospice and Palliative Care, echoed Downs’ concerns.

“As the study mentions, uncertainties in prognoses means that a certain level of live discharge is both expected and appropriate. That said, there is certainly evidence of some companies, especially for-profits, focusing on a bottom line over appropriate criteria for hospice admissions,” McCurry told LMM.

The study, emphasizing the need for more stringent government regulations to help identify companies abusing the Medicare hospice benefit, is a positive step forward, McCurry said. Rainbow is a registered nonprofit organization.

“While it’s reassuring to see that the study shows Illinois averaging lower than what might be considered abusive levels, it does highlight the opposite issue in our state: that often times patients and families don’t find their way to hospice soon enough,” he said.

Hospice care is designed to help comfort the seriously ill near the end of life, and it has become increasingly popular in recent years – reaching nearly $14 billion in payments during 2011. The Medicare hospice benefit, established in 1982 to help patients pay for care, is usually provided only to those with a life expectancy of six months or less. All Medicare hospice discharges between January and December 2010 were analyzed.

Dr. Martha Twaddle, senior vice president for Medical Excellence and Innovation at Illinois-based Journeycare, is skeptical of some of the claims gleaned from the study.

“I don’t want to polarize the bigger issue around what a live discharge represents. With older for-profits and nonprofits there wasn’t that same type of disparity. It’s not nonprofit or for-profit, it’s how they’re being managed,” Twaddle told LMM.

Many hospices in poorer, rural areas report higher discharge rates because of their commitment to patients and their communities, Twaddle said. Connecticut had the lowest rate of live discharge (13 percent), and Mississippi had the highest (41 percent).

“What we found in Mississippi, our poorest state, is that their social services are anemic at best,” she added. “Hospices were using the hospice benefit to get care to people who had no other resource for care. That’s why their live discharges were so high. That doesn’t excuse it, but there is a bigger socioeconomic or societal issue that needs to be addressed. It’s not for lack of values.”

Lisa Hunt, executive director of Allegiant Hospice, a new for-profit program headquartered in Mesa, Arizona, said their mission is to help promote quality of life for the seriously ill.

“As for the nonprofit versus for-profit argument, I believe there are some agencies who seek nonprofit status and do it in an effort to avoid taxes. I feel if we earn money, we should be taxed on it,” Hunt told LMM. “There’s a notion out there that nonprofits don’t make any money and for-profits are big, bad businesses making a buck. Neither is true. All of us must be good stewards of the Medicare monies we receive in order to stay in business to serve patients.”