Private Equity and the Damage Done

“Hospices owned by private equity firms yield higher profit margins and spend fewer dollars on direct patient care," a new study in Health Affairs found. For the study, researchers examined revenue and expense data among providers using four types of ownership models: PE-backed, publicly traded companies, other for-profit entities, and nonprofits. PE-owned agencies reported the highest profits and lowest spending on patient care. 

"Our findings suggest that PE-owned hospices may follow distinct operational strategies, emphasizing nursing facility-based care and administrative efficiency while limiting direct patient-care investments,” the study indicated. "Reduced spending on patient care may compromise hospice quality and shift costs to other areas of the healthcare system."

Health Affairs is absolutely correct that PE-owned hospices are hurting end-of-life care. The report goes on to suggest that policymakers should consider revising the hospice payment model to address this inequity in payments. Unfortunately, the report merely suggests tweaking the existing per diem model - this solution will not work. The manipulation of coding and cherry-picking patients while skimping on care is the for-profit operating strategy.

We need a payment model that doesn’t reward cherry-picking patients or encourage coding manipulation for payment. The entire payment model for hospice is designed to create these outcomes, and tweaking it will not solve the problem. The fact is that hospice services are neither complex nor that expensive.

In this sector of healthcare services, a simple cost-based reimbursement model would be ideal. It would also eliminate any difference in profit margin and focus competition on the quality of care. Go to my book, The Journey’s End, to learn more about how and why this payment model should be adopted by policymakers. www.thejourneys-end.org.

From Rock Legend to End‑of‑Life Reflection: What Ozzy Osbourne’s Last Rites and The Journey’s End Teach Us About Legacy and Dignity

I came across this article in the Wall Street Journal about Ozzy Osbourne’s memoir Last Rites, which offers a raw look at the final chapters of his life. What struck me most wasn’t just the drama of his health battles or the weight of his public persona—but rather how Osbourne confronts mortality.

That resonated with me because it echoes many of the ideas in The Journey’s End.

Here’s what these two works teach us about life, death, and how we carry ourselves in between:

1. Facing the inevitable with honesty

Osbourne does not shy away from admitting mistakes and frailties. He reflects on health crises, family dynamics, and what it means to come to terms with decline.

The Journey’s End argues that our culture overemphasizes “fighting to the last breath,” often at the cost of dignity and meaning. Instead, it encourages readers to accept life’s limits and make intentional decisions about how we die. 

Together, they suggest that courage isn’t only in defiance, but also in surrendering to what’s beyond one’s control.

2. Legacy is not what we build—but how we end

Ozzy’s memoir is, in part, an effort to shape how he’ll be remembered—warts, triumphs, humor and all.

The Journey’s End emphasizes the importance of “death literacy” (knowing one’s options, putting one’s wishes in writing) so that one’s final act aligns with one’s values. 

The intersection is powerful: we rarely get to control how long our story runs, but we can influence its final pages.

3. The cost of over-medicalizing life’s final chapters

Ozzy’s memoir recounts invasive surgeries, complications like sepsis, and repeated recoveries—an experience many in the public eye might fear or conceal. 

The Journey’s End critiques the U.S. system’s over-reliance on aggressive care near death, often because of payment models and cultural expectations to “do everything.” 

In both, there’s tension between extending life and living it well in one’s last chapter.

🤔 What can we take into our own lives?

Encourage conversations about end-of-life wishes and respect that sometimes the bravest decision is not to push further, but to step back.

Recognize that a narrative is unfinished until its close—and that how we approach that closure matters as much as how we began.

In closing, I’d love to hear how Last Rites or The Journey’s End (or both) shifted how you think about endings in life.

Why do we spend 6% of healthcare dollars on renal dialysis—but only 4% on primary care?

Both renal dialysis and primary care provide critical services, but the magnitude of their benefits is vastly different. Dialysis serves a relatively small population—many of whom are frail elderly patients, for whom the intervention may offer limited or even futile benefit. By contrast, primary care serves the entire population and is well-documented to improve quality of care while reducing overall healthcare spending.

This disparity in funding is both irrational and costly. Why does it persist?

The problem lies in our healthcare payment system. Fee-For-Service (FFS) payment, combined with diagnosis-based coding, rewards procedure-intensive services like dialysis while undervaluing cognitive, relationship-based services like primary care. As a result, funding for primary care has declined for decades, even as the costs for dialysis have grown exponentially.

We now face a serious crisis. More than 25% of Americans have poor access to primary care. Even more troubling is the rapid decline in the number of physicians choosing to enter the field. This shortage is worsening just as our aging population creates even greater demand for primary care services.

To reverse this trend, we need swift, targeted health policy reform. Two straightforward changes would have an immediate impact:

1. Require a palliative care consultation before starting dialysis.This ensures patients and families fully understand the risks, burdens, and alternatives—particularly in cases where dialysis may not improve quality of life.

2. Eliminate Fee-For-Service payment for primary care and shift to salaried compensation.This would allow primary care providers to focus on long-term patient health, prevention, and care coordination—without being penalized for taking time with patients.

Both changes would encourage more thoughtful use of dialysis and provide the support primary care needs to thrive. Without such reforms, we risk further weakening the foundation of our healthcare system.

For more on how these solutions can be implemented, visit:www.thejourneys-end.org