Advocates of the trend say it has the potential to hold down health costs and improve quality of life for the dying.
ST. LOUIS - Breathing has become increasingly difficult for Jeanne Lampe, who spends her days hooked to an oxygen tank.
Lampe, 79, has "end stage" emphysema but still lives at home in a south St. Louis apartment. She's visited twice a week by a nurse from Hope Hospice Inc., which also provides a massage therapist, a social worker, a chaplain and workers to help with showers and chores -- all paid for by Medicare.
When the end comes, she's resolved to die at home, on her own terms.
"Death itself doesn't bother me, but emphysema is a crappy death. You're basically gasping for breath," she said. "When I'm ready to go, I want morphine and a margarita."
Lampe is among a fast-growing number of patients who are choosing hospice, which seeks to provide comfort rather than a cure. Advocates say the trend holds great potential to hold down runaway U.S. health costs by steering end-of-life patients away from more expensive and aggressive hospital care. But the industry's rapid growth also presents regulatory challenges to federal authorities concerned about unethical recruitment of patients and the cherry-picking of less complex but more profitable cases.
The number of hospice patients on Medicare doubled to 1.1 million between 1998 and 2008, according to the federal Centers for Medicare & Medicaid Services. Another estimate of hospice patients this year, from the National Hospice & Palliative Care Organization, put the number at 1.6 million.
"With the aging population and many people suffering from chronic illnesses, the number of people choosing hospice has exploded," said Melissa D.A. Carlson, an assistant professor at Mount Sinai School of Medicine in New York. "As people understand hospice, they want more and more to stay at home with their family."
And more and more health care providers want to get into the burgeoning market. About 58 percent of Americans still die without hospice care, says the National Hospice & Palliative Care Organization, leaving ample room to grow the business.
A decade ago, hospice care was a niche dominated by nonprofits. And about 80 percent of Medicare-certified hospice providers entering the market between 2000 and 2009 were for-profit firms, according to a study published in June by Health Affairs, a Bethesda, Md.-based policy journal.
"There's obviously money to be made," said Carlson, who co-authored the study.
Advocates say hospice offers more quality of life and dignity in death -- at much lower cost. By contrast, hospitalization in an intensive care unit can cost upward of $10,000 a day, including drugs, equipment and staffing.
"It is a phenomenal benefit to the family members and the patient as well as the health care delivery system," said Judy Alexander-Weber, president and chief executive of the Visiting Nurse Association of Greater St. Louis, a nonprofit whose hospice workers visit residences and nursing homes. "It's the most cost-effective way to manage end-of-life care."
Costs aside, many hospice patients choose that option out of a more fundamental desire to control their destiny and manner of dying.
Benny Davenport, 84, a former flight engineer and auto mechanic, resides in St. Charles County, Mo., with his wife Martha -- and wants to keep it that way until his death. SSM Hospice is helping his wife take care of him as his lung cancer spreads through his body.
"I want to clone my nurse," Davenport said. "I'm as happy as I can be."
Greater use of hospice by terminally ill patients, advocates say, would improve quality of life and help save Medicare funds for future generations.
A study published last year in the Journal of the American Medical Association found that for-profit hospice providers were more likely to have patients who require less complex, less costly care -- but stay longer in hospice.
The study found, for instance, that for-profit firms have a higher proportion of patients residing in nursing homes. These patients are more likely to have dementia, which means they probably will live longer but have fewer needs than cancer patients.
Another study, published in 2010 by the Journal of Palliative Medicine, found that for-profit hospices often employ lower proportions of more highly qualified staff than do nonprofit hospices.
The national hospice association has proposed federal legislation that would require states to perform surveys, or periodic inspections, of hospice providers every three years.