Community support has been key in keeping hospice services locally run.
Hospice of the Northwest of Mount Vernon stands out among a growing tide of nonprofit hospices and palliative care facilities that have been bought out by for-profit companies in the past two decades.
When the nonprofit received an out-of-the-blue acquisition offer in 2020, some locals raised alarm bells.
The prospective buyer, national for-profit chain Bristol Hospice, stood in stark contrast to Hospice of the Northwest, which is locally run. Some community members worried the sale would result in reduced services.
“The community certainly rallied together to support Hospice of the Northwest,” said the organization’s spokesperson, Carrie McBride. Ultimately, the organization’s officials “realized that keeping Hospice of the Northwest a locally owned and operated hospice provider was the best option.”
‘Really lucky’
At the turn of the century, a majority of hospices were nonprofit. But by 2020, 70% of the country’s 5,200 hospices had for-profit ownership, according to the Centers for Disease Control and Prevention.
Hospice is relatively new, with the first founded in 1967 in England. As the hospice movement migrated to the U.S., it was largely supported by volunteers and donations. That began to change in the ’80s when Congress passed bills authorizing Medicare to cover hospice benefits and, eventually, increasing the per diem reimbursement rate — the fixed daily rate Medicare pays providers for a patient’s stay.
“Hospice in general is moving in a more for-profit company direction,” McBride said. “So to still have a locally owned and operated hospice is becoming rare.”
The main drivers of the shift? Publicly traded companies and private equity firms. In fact, the majority of hospices acquired by those kinds of entities between 2011 and 2019 were nonprofits.
As for-profit hospices have risen, so have complaints of fraud and concerns that profits are being put before care. Studies have shown that for-profit hospices offer fewer services, have higher discharge rates for still-living patients and employ less skilled staff. Family caregivers also reported worse experiences with for-profit hospice, according to a 2023 study.
Proponents of for-profit hospices argue that the businesses’ higher access to capital offers better financial stability than their nonprofit counterparts and that those financial resources can be used for things like new technology and facilities.
Northwest Washington as a region is “really lucky” when it comes to hospice care, said McBride. Hospice of the Northwest, PeaceHealth Whatcom Hospice and WhidbeyHealth Hospice are all nonprofits.
“Because we’re not looking to make a profit, we’re able to use more of our funding for actual patient care,” McBride said. “We’re just able to do a lot of things that the for-profit providers aren’t able to do, especially since we have a foundation that pays for uncompensated care and unique treatments or equipment that people might need that are above and beyond what Medicare would cover.”
That difference, she added, equates to things like short-term dialysis to help a woman live long enough to see her granddaughter graduate high school or purchasing noninvasive alternatives to catheters.
Hospice of San Juan is another part of the local hospice ecosystem. It is one of only a handful of all-volunteer hospices in the U.S. and serves between four to seven patients at any given time.
Unlike paid hospice organizations, which can be both for-profit or nonprofit, all-volunteer hospices offer free services and aren’t reimbursed by insurance, Medicare or Medicaid.
That gives the organization a lot more flexibility when it comes to the care volunteers can offer, said executive director Mariluz Villa.
Unlike most volunteers for paid hospices, Hospice of San Juan volunteers aren’t just limited to providing companionship and other non-medical assistance. A handful of the organization’s volunteers are nurses, for example, and can provide care that they are licensed and insured to offer through their day jobs. That ranges from things like wound care to ostomy.
Volunteers with the organization can also stay with patients even when no caregiver or hospice worker is present — something volunteers for paid hospice often aren’t allowed to do.
“Our volunteers, who are trained, can go into a home and they can say to the caregiver, ‘You may go out of the home now and take care of yourself. Go for a walk on the beach, run errands, get your free time that you need’,” Villa said. “So it’s a lot more beneficial for the caregiver who’s associated with the care recipient to have our volunteers come in, versus volunteers from a hospice that receives payment.”
New players?
Washington is one of 35 states with a certificate of need program, which requires certain providers to obtain approval before building new facilities or expanding services.
The state approves a specific number of hospices in each county based on estimated demand. Washington State Department of Health, or DoH, spokesperson Frank Ameduri said the state has not noticed an increase in demand and that applications for new hospice facilities and services are down, along with most other facility types.
Since 2021, the DoH has received four applications for new hospice providers across Skagit, Whatcom and San Juan Counties, according to its website. Only one of the applications — from Eden Hospice, a for-profit in Whatcom County — was approved.
Hospice of the Northwest has served Island, San Juan, Skagit, Whatcom and Snohomish counties for decades. But recently, McBride said the organization has seen more competition from national, for-profit hospices.
“There’s definitely some hospices in the area that are sort of chomping at the bit to get into our market and do business here,” she said, “so we have had to continue to sort of fight to stay more exclusive, particularly in Skagit County, which is something we hadn’t really dealt with before.”
Although Bristol Hospice’s bid to expand into Skagit County was unsuccessful, it has since opened a location in Snohomish County, its first in Washington. The for-profit chain has 60 locations across 22 states.
Demand trends
Both Hospice of the Northwest and Hospice of San Juan reported fairly steady demand levels over the past five years.
But that’s not necessarily the case in other parts of the state, according to the Washington State Hospice and Palliative Care Organization.
“The Pacific Northwest is no different from the rest of the country in that hospice numbers took a dip during COVID and just began rebounding back to their previous levels in 2024,” executive director Barb Hansen said. “Many programs are reporting that they’re as busy as they’ve ever been, so that’s a good trend.”
Although Hospice of the Northwest didn’t see an increased demand due to COVID, McBride said there have been other lasting impacts, including an increase in patients who are unhoused or have mental health problems or substance use disorders.
“Some of those things that really sort of heightened during COVID, we’re continuing to see the impacts of that in terms of patients’ needs,” McBride said.
The organization has also continued to use telehealth to help free up additional time for doctors and to allow social workers and spiritual counselors to work with patients remotely if needed.
“It’s nice to have that option, whereas before we did not have considered doing that,” McBride said. “Depending on that person’s desire to have someone in their home or not, we try to be in person as much as possible.”
As hospices across the state look to the future, Hansen said staffing is a big issue, with providers looking at measures like increasing pay rates and new recruitment and retention techniques.
“I think some programs have tried to be more flexible in their staffing, but that’s, of course, limited by what you’re able to do, because you do need your patients to be seen,” Hansen said. “As the baby boomer generation grows, there will be an increasing need for hospice care, and hopefully hospices in the state will be able to meet that need.”
— By Sydnee Chapman
Also read in Salish Current:
• Commentary: Loss of palliative care is a community’s loss, May 19, 2023
• Commentary: Outpatient palliative care program unfortunately unsustainable, May 19, 2023
• Proposed changes to state’s Death with Dignity Act spark debate, Feb. 16, 2023
• Possible hospice sale sparks concerns in San Juans, Nov. 13, 2020
• Commentary: The coronavirus pandemic adds new twists to the ‘good death’, June 4, 2020