When families compare hospices, they usually compare the things that are easy to see: the website, the brochure, how kind the person on the phone sounded. Ownership structure almost never comes up.
It probably should. Not because one category is good and the other is bad, but because ownership shapes the pressures a hospice operates under, and those pressures show up in staffing, visit frequency, and which patients a provider is willing to take. Here’s what the research actually says, and what to do with it.
The short answer
How American Hospice Changed
Hospice in the United States started as a volunteer movement. In 1990, roughly 5% of hospices were for-profit. Today that figure is around 75%, and much of the growth has come from private equity acquisitions and multi-state chains.
That shift wasn’t an accident. Medicare pays hospices a flat daily rate per patient, regardless of how many visits the patient receives. A provider is paid about the same whether a nurse visits twice a week or once every ten days. For any operator, the economics of that model are obvious, and they reward efficiency in a way that doesn’t always align with what a dying patient needs.
Most for-profit hospices deliver good care. But the payment model creates a temptation, and research suggests that on average, the two ownership types respond to it differently.
What the Research Shows
A 2024 study published in JAMA, along with earlier work from RAND, found that nonprofit hospices consistently rate higher on family-experience measures, including the CAHPS Hospice Survey that Medicare uses to collect feedback from bereaved families.
Across the broader literature, a few patterns appear repeatedly:
| What researchers measure | The general pattern |
|---|---|
| Family-reported experience (CAHPS) | Nonprofits score higher on average, including on communication and whether families felt they got timely help. |
| Visit frequency near death | Nonprofits tend to provide more nursing and aide visits in the last days of life. |
| Higher levels of care | Continuous home care and general inpatient care are offered more often by nonprofits. Both cost the hospice far more per day than routine home care. |
| Live discharge rates | For-profit hospices show higher rates of discharging patients before death, which can disrupt care for complex or long-stay patients. |
| Complex or expensive patients | Nonprofits more often accept patients needing costly medications, IV symptom management, or care in remote areas. |
| Charitable and community services | Grief camps, community education, and care for uninsured patients are more common among nonprofits, which fund them through donations. |
Two cautions before you treat this as a scoring system. First, these are averages across thousands of providers. A well-run for-profit hospice routinely outperforms a poorly run nonprofit, and both exist in every metro area. Second, some differences reflect patient mix rather than provider behavior; a hospice serving a high proportion of long-stay dementia patients will look different on paper than one serving mostly cancer patients, whatever its ownership.
Why live discharge rates matter more than they sound
Live discharge is the measure families should understand best, because it’s the one most likely to affect them directly. A discharge can be entirely appropriate when a patient stabilizes and no longer meets criteria. But when the rate is unusually high, it can also mean patients are being taken on early, or discharged as they approach the Medicare aggregate cap, which limits total payment per beneficiary.
What usually happens in practice is that the family discovers the problem at the worst moment: care stops, equipment is picked up, and they have to re-enroll somewhere else while their loved one is declining. If you’re comparing providers, ask directly how often it happens and why. A hospice comfortable with its own numbers will answer without hedging.
What Ownership Doesn't Tell You
Ownership is a proxy, and proxies fail at the individual level. Here’s what it can’t tell you about the hospice you’re actually considering:
Whether a nurse answers the phone at 2 a.m. Both types are required to provide after-hours access. Whether that means a registered nurse who can change orders and send someone out, or an answering service that takes a message, varies provider to provider. This is the single biggest predictor of whether a family feels supported. See 24/7 on-call nursing.
How many patients each nurse carries. Ten to twelve patients per nurse is a healthy benchmark. Fifteen to twenty means shorter, rushed visits regardless of who owns the company.
Whether the hospice holds voluntary accreditation. Medicare certification is mandatory for any hospice that bills Medicare, so it isn’t a distinction. Accreditation from a body such as CHAP or The Joint Commission is voluntary, and it means the provider invited outside review of its clinical records and practices. Plenty of for-profits pursue it and some nonprofits don’t. See certifications and accreditations.
How fast admissions actually happen. A hospital discharge on a Friday afternoon is the real test. Ask what happens then.
Whether they know your loved one’s diagnosis. Dementia, heart failure, and ALS each have different trajectories. Experience with the specific condition matters more than ownership. See the conditions we serve.
How to Check a Hospice Yourself
Most of this information is public, and it takes about fifteen minutes.
1. Look up the provider on Medicare Care Compare
Medicare’s Care Compare tool publishes ownership type, quality measures, and CAHPS family-survey results for every certified hospice. Compare the family-experience scores against the state and national averages rather than reading them in isolation.
2. Ask the four questions that actually separate providers
Who answers the after-hours line, and can they send a nurse tonight? How many patients does each nurse carry? Do you provide continuous home care and general inpatient care, and how often did you use them last year? What’s your live discharge rate, and what drives it?
The answers matter, but so does the reaction. A provider that treats these as reasonable questions is telling you something. One that gets vague is telling you something too.
3. Read reviews for patterns, not scores
A single angry review means little. Repeated comments about calls not being returned, aides not showing up, or medications arriving late are a pattern worth taking seriously. Our full framework is in how to compare hospice providers in Detroit.
4. Ask about the transition you're most afraid of
Whatever worries you most, ask how they handle it. If your father is at home and his pain becomes uncontrollable at midnight, what happens? If your mother lives in a nursing facility, who coordinates with the staff? Concrete scenarios get more honest answers than general questions about philosophy.
If You've Already Chosen and It Isn't Working
Families often assume the first choice is permanent. It isn’t. Medicare allows a patient to change hospice providers once per benefit period without losing coverage or restarting the benefit.
The practical steps and the timing are covered in switching hospice providers in Michigan. If visits are being missed, calls aren’t returned, or symptoms aren’t controlled, raise it with the hospice first. If nothing changes, switching is a normal thing to do.
Frequently Asked Questions
On average, nonprofit hospices score higher on family-experience measures and provide more of the costlier levels of care. But the variation within each category is wider than the difference between them, so the individual provider matters far more than the label. Use ownership as one signal among several.
No. Medicare pays every certified hospice the same daily rates regardless of ownership, and the Medicare Hospice Benefit covers care almost entirely either way. Families pay up to $5 per prescription for symptom-related drugs and about $24 a day for respite care, capped at five days.
Medicare's Care Compare tool lists ownership type for every certified hospice. You can also ask the provider directly. Nonprofits are typically organized as 501(c)(3) organizations.
Yes. Medicare permits one change of hospice provider per benefit period without losing coverage. See switching hospice providers in Michigan.
Yes. Advanced dementia qualifies. Eligibility is usually judged with the FAST functional scale (stage 7a or beyond) along with a complication such as recurring infections, difficulty swallowing, or significant weight loss. A patient can also qualify through another condition, such as heart failure. See what dementia symptoms qualify for hospice.
Nurse caseload, who answers the after-hours line and what they can do, whether the hospice actually provides continuous and inpatient care, voluntary accreditation, admission speed, and experience with your loved one's specific diagnosis.
The Practical Takeaway
Ownership is worth knowing, and it’s a reasonable place to start. It just isn’t where the decision should end. The providers families are happiest with tend to share traits that cut across ownership: manageable caseloads, a real nurse on the phone after hours, willingness to take complex patients, and straight answers to uncomfortable questions.
St. Marie’s Hospice is Medicare-certified and CHAP-accredited, serving families across Wayne, Oakland, and Macomb counties. We’re glad to answer every question in this article about our own program, including the ones about caseloads and discharge rates.
No comment