"You cannot stop talking about palliative care:" Perspectives and Learnings from Providers on Communicating about Home-based Palliative Care to Patients and Physicians.

BACKGROUND: Home-based palliative care (HBPC) programs are proliferating across the U.S, yet face significant, documented challenges in promoting uptake of services and sustaining sufficient patient referrals. There is a huge need to understand effective methods for engaging physicians, patients, and caregivers in palliative care. Thus, the purpose of this study was to elicit successful practices on how to best communicate about HBPC to both healthcare providers and patients/caregivers. METHOD: Focus groups with nine California-based HBPC organizations were conducted between January and April 2020. Discussions lasted approximately 54 minutes, were guided by a semi-structured protocol, audio-recorded, and transcribed verbatim. Thematic analysis was used to identify themes and codes from the data. RESULTS: Twenty-five interdisciplinary HBPC staff members participated in a focus group. Most identified as white (76%), female (76%), and working in their current position for 5 years or less (56%). Three themes were identified from the data: (1) value of relationships; (2) communication do's and don'ts; and (3) need for education. Participants discussed actionable recommendations for each theme. DISCUSSION: Study findings highlight several successful practices for HBPC programs to communicate- and foster relationships with healthcare professionals and patients/families about palliative care, with education at the crux. Lessons learned about key words and phrases to say and to avoid are particularly valuable for budding HBPC programs. Our results suggest that HBPC providers exert enormous efforts to increase patient referrals and enrollment through strategic, continuous outreach and education to physicians, patients, and their caregivers; however, palliative care educational interventions are needed.

Identifying Paths Forward: Expanding Palliative Care to Low-Income Patients in California.

Multiple studies demonstrate most consumers do not know about palliative care. And, since January 2018, California's Medi-Cal Managed Care patients have been eligible for palliative care services under Senate Bill 1004 (SB 1004). Yet, the uptake of palliative care services was underwhelming. The purpose of this study was to explore patient-centered barriers to palliative care. We recruited 27 adult Medicaid managed care patients from community-based sites in Los Angeles and conducted semi-structured qualitative interviews. Each participant was asked questions to elicit their knowledge about, and perspectives on, palliative care as well as their preferred communication approaches for receiving a referral to palliative care. The interviews were audio-recorded and transcribed verbatim. We used a grounded theory approach to guide our analysis of primary themes. Our findings indicated that the barriers to palliative care referrals among this population included lack of knowledge about palliative care and available services; the reliance on, and trust in, primary care physicians for information; language and cultural barriers; housing instability; and patient believing they are neither old enough nor sick enough to need palliative care. These findings emphasize the critical role primary care physicians play in advocating for low-income patients and the necessity for culturally sensitive education about palliative care. Promoting knowledge and understanding of palliative care among both primary care physicians and consumers is critical to ensuring access to care.

A Tale of Two Trials: A Comparative Case Study of Successful versus Terminated Home-Based Palliative Care Trials.

Background: In 2007 we published a trial of home-based palliative care (HBPC) conducted in a managed care organization (MCO) that found significant improvements in patient satisfaction with health care, rates of home deaths, and reductions in health care use and costs. A decade later, we undertook a similar trial of HBPC within accountable care organizations (ACOs) funded by the Patient-Centered Outcomes Research Institute. This trial tested the same model using similar eligibility criteria and recruitment strategies as the earlier trial, yet it failed to achieve its enrollment targets. Objectives: To understand key differences in the trials that contributed to the success of one and failure of the other. Methods: We conducted a comparative case study of the original MCO HBPC trial and the subsequent ACO HBPC trial. Two researchers familiar with both trials reviewed both quantitative and qualitative data obtained from previous analyses and publications to develop a rich, in-depth understanding of each study. Results: We identified four differences that explain in large part why the ACO trial failed while the MCO trial succeeded. These differences center on the trials' setting, target populations, outreach strategies, and providers' understanding of palliative care. Discussion: Our findings demonstrate the challenges in conducting research in complex health care systems and how physician and setting structures along with target population and lack of general palliative care knowledge can influence the success of research. Conclusion: Future HBPC trials must consider the strengths and weaknesses of trial design factors when partnering with multiple health care organizations. ClinicalTrials.gov Identifier: NCT03128060.

Home-Based Palliative Care Organizations Struggle to Survive and Thrive in a Competitive Market.

BACKGROUND: New opportunities to expand home-based palliative care (HBPC) highlight the need for novel data that explores how HBPC providers currently navigate this nascent business. OBJECTIVES: To investigate how HBPC providers and their organizations sustain their operations in a rapidly evolving market. STUDY DESIGN: This was an exploratory, qualitative study. SETTING: We conducted focus groups with staff of nine HBPC organizations that held provider contracts with a large California insurance provider. MEASUREMENT: A research team member experienced in qualitative methods conducted semi-structured focus group interviews with HBPC agency staff who were knowledgeable about their agency's patient recruitment and enrollment processes. Interview sessions of roughly an hour long were audio-recorded and transcribed verbatim. We used thematic analysis procedures to identify codes and themes. RESULTS: We identified seven themes: market competition, market diversity, HBPC reimbursement, service standardization, hiring practices, marketing, strategic enrollment processes, and outcomes monitoring. The participants called for more standardization in their field. In discussing key business operations-hiring, marketing, patient enrollment, outcomes monitoring-they demonstrated inventiveness and willingness to innovate in order to succeed in a complex healthcare sector. CONCLUSION: Our study expands on the literature by providing a glimpse of the challenges encountered by HBPC providers and their organizations and the myriad strategies they undertake to navigate a health-service area that lacks standardized practice and payment guidelines. Our findings suggest that HBPC agencies will continue to struggle in the absence of standardization in practice, payment, and quality oversight.

Home-Based Palliative Care Team Perspectives on Challenges in Patient Referral and Enrollment.

CONTEXT: As funding for home-based palliative care continues to expand, there is an increasing need to understand barriers to patient referral to and acceptance of home-based palliative care. OBJECTIVES: The aim of this study was to elicit perspectives of home-based palliative care administrators and providers on barriers encountered in identification, referral, and enrollment of patients eligible for home-based palliative care. METHODS: We conducted a qualitative study employing focus groups of nine home-based palliative care agencies across California. Focus groups were audio-recorded and transcribed. Using thematic analysis, researchers independently coded the transcripts and identified themes from the codes. RESULTS: A total of 25 HBPC staff participated in the nine focus groups. Participants included both clinicians (n = 17) and administrators (n = 8). Our analysis revealed 13 themes that fit under four major thematic categories: 1) lack of formal payment structures (few HBPC payors and variation in payment and services among payors), 2) agency structure barriers (limitations of electronic medical records and multiple lines of business), 3) patient- and family-level barriers (misconceptions and/or lack of palliative care knowledge, uninformed of the referral and/or no warm hand-off, reluctance to have strangers in the home, overwhelmed with health issues and related services, HBPC service refusal/unresponsive to outreach), and 4) physician-level barriers (misconceptions and/or lack of palliative care knowledge, variability in HBPC payment and services, lack of time, patient ownership). CONCLUSION: HBPC providers identified a myriad of barriers that preclude patient access to HBPC. With growing provision of HBPC services, greater efforts to overcome these barriers are needed.

Reluctance to Accept Palliative Care and Recommendations for Improvement: Findings From Semi-Structured Interviews With Patients and Caregivers.

BACKGROUND: Despite some insurance plans now paying for home-based palliative care, recent reports have suggested that insurance coverage for palliative care may be insufficient in expanding patient access to home-based palliative care. AIM: To identify patients' and caregivers' perceived barriers to home-based palliative care and their recommendations for overcoming these barriers. DESIGN: We conducted a qualitative study using semi-structured individual interviews. Our interview protocol elicited participants' perspectives on home-based palliative care services; positive and negative aspects of the palliative program explanation; and suggestions for improving messaging around home-based palliative care. SETTING/PARTICIPANTS: Twenty-five participants (patients, proxies, and their caregivers) who were eligible for a randomized controlled trial of home-based palliative care were interviewed by telephone. RESULTS: Themes related to home-based palliative care referral barriers included reluctance to have home visits, enrollment timing, lack of palliative care knowledge, misconceptions about palliative care, and patients' self-perceived health condition. Themes related to recommendations for overcoming these obstacles included ensuring that palliative care referrals come from healthcare providers or insurance companies and presenting palliative care services more clearly. CONCLUSION: Findings reinforce the need for additional palliative care education among patients with serious illness (and their caregivers) and the importance of delivering palliative care information and referrals from trusted sources.

Early Termination of a Palliative Care Trial: Perspectives of Multiple Stakeholders on Barriers to Palliative Care and Research.

Background: Although payment for home-based palliative care (HBPC) is slowly spreading, there remains significant challenges in engaging patients and physicians in palliative care programs and research. This challenge was illustrated in our previous HBPC trial that failed to identify and enroll eligible patients in both the study and in HBPC services. Objectives: The objective of this study was to determine challenges to participation in HBPC and in research among patients, caregivers, primary care physicians, HBPC providers, and accountable care organizations (ACOs). Design: We conducted a qualitative study employing individual interviews and focus groups. Setting/Subjects: We recruited patients (n = 17), caregivers (n = 8), primary care providers (n = 31), home-based care providers (n = 25), and ACO administrators and leaders (n = 12) from California, United States. Measurements: We used semistructured interview protocols to elicit perceived barriers to HBPC services and research. Results: We identified four overarching themes related to barriers to HBPC and palliative care research. These themes included: (1) limitations of patient recruitment strategies; (2) timing of stakeholder engagement; (3) lack of palliative care health literacy; and (4) novelty of the HBPC market. Conclusion: These findings point to factors that contributed to the failure, and subsequent closure, of the original randomized controlled trial. Our findings may inform the further development of HBPC and, more generally, palliative care practice and policy. ClinicalTrials.gov Identifier: NCT03128060.

Patient and physician perspectives on engaging in palliative and healthcare trials: a qualitative descriptive study.

BACKGROUND: Researchers are encountering increasing challenges in recruiting participants for palliative and healthcare research. This paper aims to understand challenges to and methods for engaging physicians and seriously ill patients and their caregivers in research studies. METHODS: Between October 2019 to July 2020, we conducted qualitative interviews with 25 patients, proxies, and caregivers participants who were eligible for a randomized controlled trial of home-based palliative care and 31 physicians from participating accountable care organizations. Using thematic analysis, we analyzed participants' responses to identify concepts and key ideas within the text. From these initial concepts, core themes around barriers to research and preferred research recruitment approaches were generated. RESULTS: Themes from patient and caregiver interviews included time constraints, privacy concerns, lack of research familiarity, disconnect with research institution, self-perceived health status, and concerns with study randomization. Physician-identified barriers focused on time constraints and study randomization. Patient and caregiver recommendations for study recruitment included in-person recruitment, recruitment at healthcare providers' offices, recruitment via mail, additional study information, and frequent calls. Physician recommendations were related to placement of flyers at clinics, financial incentives, and formal events. CONCLUSIONS: Findings demonstrated that although patients and caregivers prefer that their physicians recruit them for health-related research studies, physicians identified time constraints as a consistent barrier to research involvement.

What Consumers Say About Hospices in Online Reviews.

Background: Until recently, consumers have had limited resources to assess quality of hospices agencies, contributing to growing numbers of consumers turning to online review sites, such as Yelp. However, little is known about the content of hospice Yelp reviews and how these relate to recently available Center for Medicare and Medicaid Services' Hospice Compare (HC) site data. Objective: To better understand what consumers report on Yelp about hospice care and explore how these areas relate to HC data. Design: We examined 692 consumer Yelp reviews of 67 hospices in California and compared identified themes with quality measures presented on the HC site. Setting/Subjects: We used a purposive sample of California Hospice's with Yelp reviews. Measurements: Qualitative consumer comments about their experience with hospice care were analyzed by using a grounded theory approach. Results: We found that overall Yelp comments were positive, however Yelp themes were more extensive and diverse than those on HC. Conclusion: We recommend that consumers consider both HC and online review sites such as Yelp when evaluating a hospice.

Theory-driven role model stories improve palliative care knowledge among a diverse older population.

OBJECTIVE: To test the effectiveness of theoretically driven role model video stories in improving knowledge of palliative care among a diverse sample of older adults. METHOD: We developed three 3-4 min long theoretically driven role model video stories. We then recruited cognitively intact, English-speaking adults aged 50 and older from senior centers, assisted living, and other community-based sites in the greater Los Angeles area. Using a pretest-posttest study design, we surveyed participants using the 13-item Palliative Care Knowledge Scale (PaCKS) and also asked participants about their intentions to enroll in palliative care should the need arise. Participants first completed the pretest, viewed the three videos, then completed the posttest comprised of the same set of questions. RESULTS: PaCKS score improved from an average of 4.5 at baseline to 10.0 following video screening (t(126) = 12.0, p < 0.001). Intentions to enroll oneself or a family member in palliative care rose by 103% (χ2 = 7.8, p < 0.01) and 110% (χ2 = 7.5, p < 0.01), respectively. Regression analysis revealed that participants who believed the role models are real people (ß = 2.6, SE = 1.2, p < 0.05) significantly predicted higher change in PaCKS score. Conversely, participants with prior knowledge of, or experience with, palliative care (ß = -5.9, SE = 0.8, p < 0.001), non-whites (ß = -3.6, SE = 0.9, p < 0.001), and widows (ß = -2.9, SE = 1.1, p < 0.01) significantly predicted lower changes in PaCKS score. SIGNIFICANCE OF RESULTS: This study suggests that theoretically driven role model video stories may be an effective strategy to improve palliative care knowledge. Role model video stories of diverse palliative care patients provide one way to mitigate health literacy barriers to palliative care knowledge.

Health Care Provider Barriers to Patient Referral to Palliative Care.

OBJECTIVE: The purpose of this study was to explore healthcare provider-perceived challenges to HBPC patient referral and elicited providers' feedback for overcoming these challenges. METHODS: We conducted a qualitative study using semi-structured interviews with 25 Medicaid managed care providers (primary care physicians, nurse practitioners, and care managers) working in the greater Los Angeles area. Our interview protocol elicited providers' knowledge and awareness of palliative care; perceived barriers to HBPC referral; and suggestions for overcoming these barriers. We analyzed verbatim transcripts using a grounded theory approach. RESULTS: Themes related to referral barriers included providers' lack of palliative care knowledge and clarity regarding referral processes, provider reluctance to refer to HBPC, and provider culture. Providers also identified patient-level barriers, including financial barriers, reluctance to have home visits, health literacy, cultural barriers, and challenges related to living situations. Themes related to methods for overcoming challenges included increased HBPC education and outreach to providers, specifically by HBPC agency staff. CONCLUSIONS: Findings from this study underscore the need for additional palliative care education for Medicaid healthcare providers. They point to the need for novel strategies and approaches to address the myriad barriers to patient identification and referral to HBPC.

Challenges in Using Insurance Claims Data to Identify Palliative Care Patients for a Research Trial.

BACKGROUND: Little is known about strategies for enrolling patients in home-based palliative care programs despite the need to conduct effectiveness studies of this emerging industry. PURPOSE: We used medical claims data from Accountable Care Organizations in California to identify patients for a randomized controlled trial of home-based palliative care. We report outcomes from this strategy and the implications for future research. RESULTS: Claims data identified 1357 patients. Research assistants could not reach 986 patients (72.7%), usually because the phone calls went unanswered (38.5%) and many patients' phone numbers were missing or incorrect (16.3%). Of 371 patients reached, 163 opted out. Of 208 patients screened, 177 were ineligible for the trial. Just 10 patients were enrolled. RECOMMENDATIONS: Our findings suggest that medical claims data may not be useful for engaging patients potentially eligible for palliative care research trials. We recommend that alternative identification and recruitment strategies be considered.

In Search of Hospice Information: Consumer Information Available on Hospice Compare and Yelp.

Background: The hospice industry has expanded in recent years with limited oversight and few consumer-facing resources to assist consumers in selecting hospice agencies to care for their family members. Objectives: To better understand the availability of consumer-facing hospice information and how hospices are evaluated by these websites, this study examined two websites with national reach-the Centers for Medicare and Medicaid Services' Hospice Compare (HC) website and Yelp.com. We described Yelp hospice ratings and caregiver-reported ratings on HC and compared conceptually related HC ratings to each other. Methods: We collected hospice ratings from Yelp and hospice- and caregiver-reported quality indicators (QIs) from HC for all California hospices. We conducted descriptive statistics for all variables and conducted chi-square to examine differences in proportions for categorical variables. We conducted Pearson's correlation coefficient (r) to test the strength of the association between the hospice-reported pain assessment QI and the caregiver-reported indicators on HC. Results: Among our sample of 1040 California hospices, HC reported QIs for 200 (19.2%) hospices for the caregiver-reported QIs ranging to 448 (43.1%) hospices for the hospice-reported QIs. Just 236 hospices (22.7%) had a Yelp review. Hospice ratings on both Yelp and HC were fairly high. For-profit hospices were less likely to show HC QIs or to be rated on Yelp. Caregiver-reported HC ratings for pain and symptom management were significantly lower than conceptually related HC hospice-reported QIs. Conclusions: More research is needed to understand the lack of hospice representation on HC and investigate the usefulness of hospice-reported HC measures.

Expanding Access to Home-Based Palliative Care: A Randomized Controlled Trial Protocol.

Introduction: Studies show that home-based palliative care (HBPC) improves participant outcomes and satisfaction with care while also decreasing hospitalizations and emergency department visits. U.S. health care payment reforms create financial opportunities to offer HBPC. Consequently, more HBPC programs are emerging, heightening the need to evaluate their effectiveness. Methods: This randomized, controlled trial is comparing the effectiveness of an evidence-based model of HBPC and enhanced usual primary care for participants who receive primary care from medical groups and clinics organized under an accountable care organization or Medicare Advantage plan. Palliative care services are reimbursed by our partnering health plan provider. The five-year trial will enroll 1155 seriously ill participants (and ∼884 of their caregivers) with heart failure, chronic obstructive pulmonary disease, or advanced cancer. We are collecting data via telephone surveys with participants at baseline and one and two months postenrollment and with caregivers at baseline, one and two months postenrollments, and following the death of a loved one. We are collecting participant-reported outcome measures of pain, symptoms, anxiety, depression, participant-provider communication, and hope. Caregiver outcome measures include caregiver burden, communication with providers, anxiety, and depression. Additional outcomes are participant survival time and participants' emergency department visits and hospitalizations. Study Implementation: Challenges and Contributions: Our research team has encountered several significant challenges in early study implementation. These include engaging primary care providers in the study and coordinating logistics with a health plan. Both challenges have contributed to a lag in participant enrollment. Despite these challenges, our study holds tremendous promise to accelerate adoption and spread of an evidence-based HBPC model across the country.

Home-Based Palliative Care: Toward a Balanced Care Design.

Background: Palliative care for seriously ill adults is spreading rapidly, giving rise to a fast-growing business sector: the home-based palliative care (HBPC) industry. These programs offer services common to most palliative care programs; what distinguishes them is that services are delivered to patients in their homes. Research shows these programs hold promise for improving patient outcomes at lower cost than usual care. Given this, growth in the HBPC business is likely fueled partly by the sector's money-making potential. As in many emerging industries, there are concerns that HBPC benefit may not be enjoyed equitably by patients and other stakeholders. Objective: To safeguard HBPC quality, we take stock of where quality problems may manifest and discuss strategies to forestall these problems. Methods: We examine HBPC trends with significant implications for care quality and cost, including HBPC payment, patient enrollment, staff management, and patient visits. Results/Conclusions: Recommendations pertain to quality metrics, patient disclosures, and further research.

What Consumers Say About Nursing Homes in Online Reviews.

Background: Although patient-centered care is an expressed value of our healthcare system, no studies have examined what consumers say in online reviews about nursing homes (NHs). Insight into themes addressed in these reviews could inform improvement efforts that promote patient-centered NH care. Research Design and Methods: We analyzed nursing home (NH) Yelp reviews. From a list of all NHs in California, we drew a purposeful sample of 51 NHs, selecting facilities representing a range of geographical areas and occupancy rates. Two research teams analyzed the reviews using grounded theory to identify codes and tracked how frequently each code was mentioned. Results: We evaluated 264 reviews, identifying 24 codes, grouped under five categories: quality of staff care and staffing; physical facility and setting; resident safety and security; clinical care quality; and financial issues. More than half (53.41%) of Yelp reviewers posted comments related to staff attitude and caring and nearly a third (29.2%) posted comments related to staff responsiveness. Yelp reviewers also often posted about NHs' physical environment. Infrequently mentioned were the quality of health care provided and concerns about resident safety and security. Discussion and Implications: Our results are consistent with those from related studies. Yelp reviewers focus on NH aspects that are not evaluated in most other NH rating systems. The federal Nursing Home Compare website, for instance, does not report measures of staff attitudes or the NH's physical setting. Rather, it reports measures of staffing levels and clinical processes and outcomes. We recommend that NH consumers consult both types of rating systems because they provide complementary information.

Ratings game: an analysis of Nursing Home Compare and Yelp ratings.

BACKGROUND: Two strategies for rating the quality of nursing homes (NHs) in the USA are exemplified by the Nursing Home Compare (NHC) website, launched by the federal Centers for Medicare and Medicaid Services in 1998, and Yelp.com, an online consumer review site that has grown in popularity since its founding in 2004. Both sites feature a 5-star rating system. While much is known about NHC ratings, little is known about NH Yelp ratings. This study examines Yelp ratings for NHs in California and compares these ratings with NHC ratings. Understanding how these ratings relate can inform efforts to empower consumers and enhance NH decision-making. METHODS: We collected NHC and Yelp ratings for all California NHs between September and November 2016. For each NH with a Yelp review, we recorded the star rating and the total number of reviews. We also recorded the NHC 5-star rating and NHC ratings for inspections, staffing and quality measures (QMs). We conducted descriptive statistics and frequencies for these variables. We conducted correlations and tested means to compare the ratings. RESULTS: A total of 675 NHs (68.1% of the total sample of 991 NHs) had both Yelp ratings and NHC ratings. Correlations between the Yelp and NHC ratings were relatively weak. The Yelp rating was significantly lower than the 5-star NHC rating and the NHC ratings for staffing and QMs. It was significantly higher than the NHC inspection rating. CONCLUSIONS: This study found that when consumers rate NHs on Yelp, their ratings differ considerably from NHC ratings, a finding in keeping with similar studies of NH quality measurement. Further research is needed to analyse the content of Yelp reviews and compare the themes and topics consumers identify with those reported on NHC.

Ethnic Differences in Advance Directive Completion and Care Preferences: What Has Changed in a Decade?

Studies have documented ethnic differences in advance directive (AD) completion, with lower rates in minority groups. Of those with ADs, blacks are more likely than whites to prefer aggressive care, but little is known about how these differences in preferences have changed over time in ethnic groups. This nationally representative study aimed to investigate whether these differences in AD development persisted after adjusting for important confounding variables. Year of death was analyzed to see how AD completion changed over time within ethnic groups, and for those with an AD, the association between these factors and opting for aggressive care was investigated. Data from the 2000 to 2012 Health and Retirement Study (HRS) exit interviews from 7,177 decedents were used. Analyses included logistic regression to determine the relationship between ethnicity and AD completion and preferences for aggressive care and how it changed over time in ethnic groups. Forty-six percent of decedents had completed an AD (whites 51.7%, Hispanics 18.0%, blacks 15.0%). Of blacks completing an AD, 23.8% elected prolonged care, compared with 13.3% of Hispanics and 3.3% of whites. Logistic regression revealed that blacks 75% lower odds of completing an AD and Hispanics had 70% lower odds. Model covariates had a small influence on ethnic differences, although in examining the change in AD completion over time, the odds of having an AD increased with each subsequent death year for blacks and whites but not Hispanics. Additional research is needed to investigate the effect of cultural differences in AD completion rates of ethnic minority groups to ensure that preferences are honored in the clinical setting.

Who Knew? Hospice Is a Business. What that Means for All of Us.

A seasoned gerontologist whose work has explored end-of-life care, I thought I knew what I was getting into when I undertook care for my brother Jim. In April 2014, Jim, whose health was then declining rapidly due to liver cancer, moved from his apartment in Minneapolis to my house in Santa Monica. Jim had come for a liver transplant evaluation at the University of California, Los Angeles (UCLA). When the UCLA team declined to list him-his cancer was just too widespread-Jim elected to stay with my family and me, enrolling in hospice. I did my homework when shopping for a hospice provider. Colleagues in the field gave me referrals. I googled their recommendations and read the reviews. I interviewed admissions counselors. When Jim signed the admission papers, I was confident that we were in good hands with the agency we selected. For the most part, we were. Hospice is widely considered an effective program. Studies show that it prevents pain and suffering among dying patients and increases satisfaction with care. Although other health care programs are regularly pilloried in the press, hospice programs are often lauded. Indeed, they sometimes appear so mission driven that one might mistake them for charities. They are not. Whether for-profit or not-for-profit enterprises, they are businesses-and concerned about their bottom line. Through Jim's story and mine, this article highlights the implications of this business orientation for patients and providers. Methods for evaluating hospice programs nationally are critiqued. Finally, recommendations for improving the business of hospice care are offered.