Political Economy of Hospice Care

Vast, but disparate, literatures study hospice care, but none explains how government policy affects the dying experience of terminally ill patients and their families. This topic is of the utmost significance as there are important unanswered questions that fall under the purview of public administration, and may be in conflict with its principles of truth, efficiency, effectiveness and equity. This dissertation is formatted as three related essays in the area of hospice care. The first essay informs government policy in end-of-life care with insights from government policy in child care. The methodology consists of trend analysis in order to better understand the elder care choices of adult children who have elderly parents or relatives that need hospice care. The methodology is focused on married households and the data was extracted from the Current Population Survey (CPS). The study finds that married households in the middle income bracket are less likely to bring their elderly relatives into their homes as long as the Medicare hospice benefit remains a viable alternative to the demands that hospice care at home may impose on household income and in labor participation. Trend analysis of median household income and Child and Dependent Tax Credit demonstrate that the tax code can be an effective tool in promoting hospice care at home. The second essay studies how the Medicare Hospice Program affects the financial viability of the hospice organization, and in turn, affects the survival of terminally ill patients. The methodology consists of Panel-Corrected Standard Errors regression technique and focuses on the organizational effects rather than on the individual effects on length of stay. The study finds that the liquidity of the hospice organization and investment in human capital in the form of nurses influence how long a patient stays in hospice care. The assessment of the hospice organization's financial health is a novel development as well as beachhead for extending the theory of non-profit financial management into hospice care. The third and final essay analyzes whether government policy on aging has an effect on the distribution of firms, non-profit or for-profit, offering hospice care. The essay analyzes hospice care organizations from a population ecology perspective and tests a resource-partitioning model in order to explain the interorganizational relationships between generalist and specialist organizations. The methodology applied is fixed effects regression and the essay links the resources in the environment with the organization and patient outcomes. The study finds that the age of the generalist form of hospice organization providing core services increases the length of stay. This finding runs counter to the literature that promotes dying at home as the way to increase survival time during hospice care. The three essays share the goal of better understanding the effect that Medicare hospice policy has on the end of life. The end outcome of the essays show that government policy in the form of the Medicare hospice benefit may in fact undermine the hospice care philosophy or self-determination and dying in our own terms. This dissertation is the first to consider that government policy in the form of hospice care may have evolved into a health program that counters rather than supports the axioms of the hospice philosophy.