Private Equity Is Gobbling Up Hospice Chains And Getting Involved In The Business Of Dying

One private-equity-led hospice chain has thousands of seniors in its care and millions of dollars in government revenue. The owner's identity is a mystery.
Private equity is gobbling up small hospice providers at breakneck speed. Who ultimately profits is often a mystery.
Private equity is gobbling up small hospice providers at breakneck speed. Who ultimately profits is often a mystery.
Illustration: Rebecca Zisser/HuffPost; Photos: Getty

A few weeks ago, Julie McFadden, a nurse in California, admitted an elderly woman into hospice care. The woman was dying, but her family longed to gather for one more Thanksgiving dinner. McFadden’s job as a hospice nurse was to make that possible: to order medications, teach her family how to monitor for signs that their mother’s health might be worsening and to reassure them that some symptoms which looked frightening were normal. “Sometimes when a family member is dying, I think people want to hush-hush it away,” she said. “So I love when families don’t do that and see it more as a celebration.”

Big holidays are a surreal time of year to work in hospice, which provides end-of-life care to people who are dying of terminal illnesses. At its most basic, hospice gives people the care they need to die with some degree of comfort: pain medication, supplemental oxygen, help with walking, bathing, eating. Ideally, this takes place in their homes or in a residential facility so they can avoid spending their last days in a hospital. McFadden, though, believes her role is about more than simply dispensing drugs: it’s to help families imagine what is still possible in the final months of life and to make that a reality. The sublime can coexist with the scary.

“They can spend Christmas in a cabin, they can make their famous pie they make every year, open presents with their grandkids and still get breathing treatments,” she said. Every family’s experience should be personalized. “In general people can do whatever they want, and that’s the point.”

Lots of hospice workers describe their occupation this way — as being uniquely beautiful. From its grassroots origins in the 1960s, modern hospice care has always been a part of the medical field and yet distinct from it. Hospice care accepts the ultimate limitations on life instead of fighting them, and it openly embraces the emotional and spiritual needs of patients.

But for the past several years, hospice has grown to resemble the rest of the health care industry in one crucial aspect: Private equity is gobbling up an alarming share of the market.

Today, private equity firms are acquiring American hospices at an astonishing rate. From 2012 to 2019, the number of hospices owned by private equity companies tripled. The pace of acquisitions seems to have only gotten faster during the COVID-19 pandemic. Industry brokers who have never before put together a deal involving private equity say they now field calls from private equity buyers multiple times a week. Tempted by a wave of retiring baby boomers, the-sky’s-the-limit Medicare payments, the mom-and-pop nature of the industry and a lack of regulation that is pretty startling even by U.S. standards, private equity now accounts for three out of every five new hospice acquisitions.

One of the most active companies has been Traditions Health, whose owner is a private equity firm called Dorilton Capital. In the past three years, Traditions Health has acquired more than a dozen hospice, palliative and home care businesses, expanding its footprint to 18 states and allowing Traditions Health to boast that it is one of the fastest-growing private companies in the U.S. According to data provided by PitchBook, as measured by the number of deals, Dorilton is the most active private equity investor in elder care in the country.

Dorilton is not the kind of fast-turnaround, make-a-quick-buck private equity firm that piles debt onto its new acquisitions only to sell them a few years later. Even so, former workers at hospices acquired by Traditions described undue pressure to maximize profit — cost-cutting, staff reductions and an aggressive pursuit of more patients.

In late 2019, for example, the company acquired a hospice provider in Round Rock, Texas, that typically enrolled 15 to 20 new patients per month. Traditions gave the two-to-three-person marketing team a new monthly quota of 10 patients per marketer, meaning 20 patients was the new bare minimum. “It turned into a numbers game,” said a former clinical employee. The marketing team referred some patients to her with few or no medical records, leaving her with no idea of what equipment or medications to order. Other patients were “a stretch.” Hospice patients are supposed to have not only a prognosis of six months or less to live but also a medical need for hospice, such as symptom management. These new patients had a qualifying diagnosis, such as cancer or dementia, but there were signs that they didn’t have hospice needs; they could breathe without supplemental oxygen or could remember to take all their medications. Marketers who exceeded their monthly quota got a bonus.

Traditions denies unreasonable cost-cutting and says it is as eager as every other health care provider these days to retain its workers. It noted that patients, not marketers, make the ultimate decision to enter hospice. But the company does not dispute having grand plans for growth.

In an odd twist, no one outside of a small circle of executives knows who the ultimate owner of Traditions Health is — and, by extension, who benefits every time one of its hospice providers finds some minute way to increase its profit margin. The identity of Dorilton’s owner is a bona fide mystery.

Although it describes itself as an investment office for a single family, Dorilton has never, since its founding in 2009, let it slip who that family is or even how much money it has under management. The firm has a small Manhattan office inside the old AT&T Building, an Art Deco thumb that looms over a tangle of little intersections in SoHo. But it’s unclear whether the owner even lives in the United States. The mystery only deepened last summer when Dorilton acquired Williams Racing, a beleaguered British Formula One team, for nearly $198 million, leaving the world of elite racing to wonder who owns one of its most storied teams.

Dorilton is just one private equity firm of dozens that are driving this gold rush. But it exemplifies a new chapter of U.S. hospice in which a private equity company with a mysterious owner who buys race car teams can assemble one of the fastest-growing hospice and palliative networks in a matter of just a few years. And to many longtime hospice practitioners, that’s terrifying.

The modern hospice movement began as a direct challenge to the idea that death ought to be undifferentiated and systematized. Private equity is notorious for taking businesses down to the studs. It has been linked, in the health care industry, to worse care, higher prices, more unnecessary procedures and ruthless working conditions, and it has been blamed for the financial sector’s hyper-focus on short-term profits over long-term value.

Private equity has already degraded so many facets of life; now it has turned to the business of death.

A Serious Moneymaker

Until the latter part of the 20th century, people with terminal diseases often died alone in an antiseptic medical setting, typically a hospital. They were largely out of sight and out of mind. “People wouldn’t come and visit because they felt they wouldn’t know what to say and they were afraid to say the wrong thing,” said Samira Beckwith, who survived a bout with cancer in the 1970s and joined the nascent hospice movement as a social worker.

Just a few years earlier, Cicely Saunders had established the world’s first modern hospice, St. Christopher’s Hospice of London. Then, in 1969, the psychiatrist Elisabeth Kübler-Ross published “On Death and Dying,” which made the case for helping terminally ill people cope physically, mentally and spiritually with their death. (The book, an instant bestseller, is better known today for her theory of the five stages of grief.) Their message — that death can be more dignified and comfortable — inspired a massive grassroots movement of small, community hospices. Medical practitioners explored ways to deliver end-of-life care in peoples’ homes while social workers, volunteers and clergy encouraged frank and difficult conversations about death between patients and their families.

At first, many in the medical establishment resisted. Beckwith, who is now the CEO of Hope Healthcare, a hospice in Florida, recalls a doctor trying to prevent her from giving a patient ice cream because the patient was getting adequate nutrition through a feeding tube. “We would sneak peoples’ dogs in to see them,” Beckwith said. “Or their — well, sometimes cats, but mainly dogs.” Slowly, though, volunteer hospices turned into pilot programs that turned into research that won over old-school practitioners. By the 1980s, there were enough boldfaced champions — Bob Dole, Leon Panetta — that Congress authorized Medicare to pay for hospice care for people who had been given an estimated six months or less to live.

Policymakers were seduced by arguments that hospice, by replacing intense medical interventions with less-costly palliative care, would actually save the government money. They did not anticipate that hospice would become so widely adopted — and just in time to greet the “silver tsunami” of aging baby boomers. But private industry did, and for more than two decades, for-profit ownership of hospices has been on the rise.

“It is difficult to identify a health care sector more detrimentally affected by the mismatch between profit maximization incentives and quality of care than hospice.”

- Melissa Aldridge, a professor at the Icahn School of Medicine at Mount Sinai

From 2000 to 2012, the share of for-profit hospices doubled, to 60%. Then, about a decade ago, private equity began to get more and more interested in the health care sector. It has recently come to dominate fields including dermatology and dentistry and impose steep profit demands, practitioners say, at the expense of patient care.

From 2011 to 2019, private equity ownership of hospices tripled. By 2019, there were more than 300 private-equity-owned hospices providing care to more than 112,000 Medicare recipients, according to Tyler Braun, a health policy researcher at Weill Cornell Medical College. That is a modest share of the total number of Medicare hospice patients — 1.46 million in 2019 — but it still works out to a soaring increase in the number of people spending their final days in the care of private equity: a 328% jump since 2012.

Hospice can be a serious moneymaker. In general, Medicare pays hospice providers the same rate per day per patient visit, no matter how complicated or expensive that person’s medical needs — meaning a nurse who spends an hour administering pain medication for a cancer patient nets the same reimbursement as a lower-paid certified nursing assistant who spends a half hour helping a dementia patient eat a meal. Medicare also pays the same rate no matter where a patient is located — in their home, where the next closest patient is many miles away, or in an elder care facility, where the next closest patient is right down the hall.

“So you can imagine what the incentive is,” said David Stevenson, a professor of health policy at the Vanderbilt University School of Medicine.

For-profit hospices offer fewer services, hire staff with less training and enroll more patients who have less-complicated needs and spend a longer time in hospice. Enrolling patients with dementia — who may go many months without declining and may primarily need an aide to help them eat and bathe — can be especially lucrative, while enrolling patients with cancer — who may need a suite of expensive medications and someone trained to dispense them — can be a money loser. A 2019 study of Medicare billing data found that one of the chief differences between nonprofit and for-profit hospices is that for-profits enroll more patients with diagnoses other than cancer.

“The opportunities for profit maximization are pretty ripe,” Stevenson said.

Some of the first hospices in the United States have now transformed into giant profit-generating enterprises. Today, the nation’s largest provider of hospice is Vitas, originally a small nonprofit that Don Gaetz, the father of Rep. Matt Gaetz (R-Fla.), founded at the outset of the hospice movement. By 2004, Vitas had operations in 18 states and was sold for $400 million to Chemed, the Ohio corporation that owns Roto-Rooter.

Vitas recently paid $75 million, the largest-ever settlement in the hospice industry, to resolve claims that the company systematically defrauded Medicare for more than a decade by billing for patients who weren’t eligible for hospice care or for hospice care that never took place. In one case, Vitas claimed it was providing a patient with crisis care ― acute care for when a patient’s symptoms suddenly worsen, which is worth hundreds of dollars more in reimbursements than routine hospice care on days she was playing bingo. Although the alleged fraud began in 2002, two years before he sold the company, Don Gaetz denied any wrongdoing took place on his watch, and Vitas did not admit wrongdoing as part of the 2017 settlement. The year before the settlement, Vitas reported $1.12 billion in revenue, almost all of it from Medicaid and Medicare.

The arrival of private equity spells an even more intense wave of consolidation. Still, it’s not entirely clear yet how hospices owned by private equity companies will differ from the rest of the industry. Early research has linked private equity ownership of a hospice with lower-quality care and higher government spending, although Braun cautioned that we don’t know if that’s because private equity funds tend to buy hospices that are already cutting corners. There are things that private equity does well that could benefit hospices, said Braun: consolidate back-office operations, buy bulk supplies at better prices or provide growth capital that small, independent hospices might not be able to access on their own.

“There are good private-equity firms and bad private-equity firms,” he said, and it’s hard to tell who’s who in the middle of a historic upheaval. “This has never happened before in hospice.”

Longer hospice stays are not automatically a bad thing, said Melissa Aldridge, a professor at the Icahn School of Medicine at Mount Sinai. “I don’t see it as bad for patients and families when they’re enrolled ‘too early,’ although it has been a way for a hospice to make more money.” Too often, she said, people don’t get enough time in hospice. Many patients would thrive longer if they entered hospice earlier rather than hold off until they can no longer endure aggressive treatments.

If private equity groups help the hospice industry expand, the question is whether they will serve more patients with expensive nursing needs who would benefit from more care or simply seek out patients who are comparatively cheaper to provide with care.

Even with those caveats, Aldridge is broadly pessimistic about the consequences of private equity muscling its way into hospice care. For-profit ownership already creates pressure for hospices to dole out profits rather than reinvest them. The arrival of private equity groups, which eventually try to sell their portfolio companies for a huge profit, just turns up the pressure. Good hospice care requires long-term investments in training and staff. And in an ideal world, it’s about more than pills and intravenous drips.

Writing in 2021 in response to Braun’s discovery of how fast private equity had grown, she wrote: “It is difficult to identify a health care sector more detrimentally affected by the mismatch between profit maximization incentives and quality of care than hospice.”

A Volume Business

At Guiding Hospice, a hospice care provider in Round Rock, Texas, that Traditions Health took over in late 2019, one of the clearest signs that the new owners would do things differently arrived with the COVID-19 pandemic.

Already the medical team had been clashing with the marketing team, with its new quotas and bonus incentives, according to a former worker on the clinical side. The influx of new patients with scant medical records forced nurses to sometimes probe family members for medical records of their dying loved one ― or even to ask, “What’s he dying of?” If a hospice nurse questioned any of the new admissions, one former employee said, the marketers would go straight to the medical team at Traditions headquarters, who would chew out the nurse’s boss.

The coronavirus, of course, posed a unique danger to health care workers and elderly people living in group settings, and it wasn’t long before one of Traditions’ patients had all the telltale symptoms: fever, trouble breathing, a relentless cough. The patient was in an assisted-living facility — one that publicly claimed to have weathered the first wave of the coronavirus pandemic without any residents or staffers contracting COVID-19. When a doctor for Guiding Hospice ordered the patient to be tested, the assisted-living facility was faced with the possibility of detecting its first COVID-19 case, and it refused to perform the test.

“It turned into a numbers game.”

- A former Guiding Hospice employee

For a for-profit hospice, an assisted-living facility is an attractive place to find patients because hospice staff can visit multiple patients relatively quickly. That may be why, when this likely COVID case resulted in a standoff between a member of Guiding Hospice staff and the assisted-living facility, Traditions Health executives sided with the facility. A Traditions executive told the director of clinical services at Guiding Hospice not to make a notation of the facility’s refusal to test in the woman’s medical chart but to let it go. “Part of the justification was this is one of our main accounts,” recalled the former clinical director, who requested anonymity so as not to hurt her future employment. “We need to keep them happy.” The director would not budge — failing to write down the order could have put her medical license at stake — and Traditions wrote her up.

Traditions did not respond to a list of detailed questions about its operations, including the allegations made by the former employees of Guiding Hospice. But David Klementz, a genial health care executive who became Traditions’ CEO in April, agreed to talk about the company in broad strokes.

Tradition Health’s profitability is thanks to its scale, he said, not staff cuts, spending cuts or tinkering with the patient population. Dorilton, he noted, tends to hold on to its portfolio companies for many years, not the three- to five-year window that was typical of private equity groups in the past. (Overall, the average length of time that private equity groups hold on to their acquisitions is increasing.) “I worked for a private equity firm a long time ago, and I really didn’t have a desire to go back,” he said.

He changed his mind because Dorilton doesn’t intend to make a quick buck; it intends to invest for the long run, he said. The goal of Traditions’ recent acquisition spree was to establish itself in as many states as possible, with a focus on states where the population is aging and that don’t have the kind of regulations which make it difficult for a new company to enter the health care market. Its goal now is to scale up and expand in those states, either by grabbing more market share or adding the number of services it can offer to the same patient, Klementz said. A home care patient could later become a hospice patient.

Another reason why Traditions acquired so many businesses in the past three years is because of the opportunities presented by the COVID-19 pandemic: Solo operators are struggling while baby boomers are increasingly seeking home care versus inpatient care for post-acute treatment.

Klementz said he couldn’t speak to many of the changes that former employees said they experienced in 2019 and early 2020, before his time. (Traditions didn’t make anyone available who could; Dorilton, Klementz mentioned offhand, had discouraged him from responding to me at all.) But he said their claims weren’t representative of how the business operates today.

Many of the claims made by former employees hearken back to when Traditions was merely a hospice provider, not the sprawling network of post-acute home care, palliative care and hospice providers it is today, Klementz said.

“In 2019, we were a much smaller organization. We were about a tenth of the size we are now.” And if takeovers used to entail staff reductions or wage cuts, Klementz said, the opposite became true during the pandemic, which made staff retention harder than ever. “If we’re talking about volume, we need more clinicians, not less,” he said. “You have to really do some self reflection on your compensation levels to be competitive.”

He did not deny that marketers have patient recruitment quotas. “Sales folks, their compensation is going to be tied to their level of performance,” he said. The sales targets are not arbitrary — “We don’t go in and juice up their targets” — but they are exacting. They are based on an estimate of how many potential patients live in the region based on how many people are already enrolled in hospice care and the number of local competitors.

All patients are properly certified for hospice, he said, and Traditions advises doctors who refer patients on what counts as an appropriate hospice admission, decisions that are routinely reviewed by a compliance team.

In so many words, Klementz was saying that Traditions’ owners are not the vulture capitalists that the words ‘private equity’ conjure. “They’re not coming in to say, ‘You’ve got a 5% margin. In one year you need to get it to 20%,’” he said. They have invested significantly in a sustainable company. “We haven’t even begun to accomplish what I think we can accomplish.” Is the goal to keep growing? “Absolutely.”

Klementz also said he doesn’t know the identity of who actually owns Traditions and Dorilton: “Nope, no idea. It’s not really relevant to me running a business.”

‘Treated As Family’

Dorilton bought Traditions Home Health Care for an undisclosed price in 2011, and for almost a decade that was just about its only venture into elder care. Then, starting in early 2019, Dorilton (doing business as Traditions) went on a buying spree that expanded its operations in Arizona, California, Georgia, Illinois, Indiana, Kansas, Louisiana, Missouri, Oklahoma, South Carolina and other regions of Texas. The exact size and structure of these deals is not clear, although a person close to the company said Dorilton does not load up its new acquisitions with steep debt that those businesses, including the hospices, then have to pay off.

This buying spree is why Dorilton popped up on our radar. There are giant private-equity groups buying giant hospice networks, and there are mid-sized private-equity firms doing the yeoman’s work of consolidating smaller hospices into those large networks. Dorilton belongs to the latter category, and its network is one of the fastest-growing in the country.

By mid-2021, Traditions was in charge of care for more than 5,000 patients in 14 states, according to its website, although in our recent conversation, Klementz said it was operating in 18 states and that it has acquired several large hospices of up to 1,500 patients each. Its busiest stretch was December 2020 to January 2021 — the peak of the coronavirus pandemic, when many hospices were struggling to keep people on staff, keep patients safe and afford protective gear for workers.

“Their practices are definitely questionable, and it sounds like you are already aware of the cost-cutting and staff-cutting they do,” a former employee of another hospice acquired by Traditions, who was offered anonymity in order to speak freely, wrote to me. “When it came to our hospice, prior to them acquiring it, it was a wonderful team and a great place to work. It all definitely changed as soon as they took over.”

In 2018, 14% of patients at hospices operated by Traditions had cancer as their primary diagnosis, compared to a national average of 20.6%, and 25.4% of Traditions patients had dementia as their primary diagnosis, compared to a national average of 17.5%. (HuffPost calculated these averages by using Medicare data that licensed hospices are required to report to the federal Centers for Medicare & Medicaid Services. We found data for roughly half of the 50-plus businesses owned by Traditions; the other half may be primarily licensed as home health providers and follow different reporting requirements.)

Klementz said Traditions hospices enroll a smaller share of dementia patients and only patients with very late-stage dementia, but he did not provide exact numbers.

Because 2018 is the most recent year for which Medicare has released hospice data, it’s not possible to see whether the mix of patients has changed at the 10 hospice companies, including Guiding Hospice, that Traditions has acquired since the start of 2019. But those hospices — even before they were taken over by Traditions — also reported enrolling a smaller share of cancer patients and a larger share of dementia patients than the average hospice nationally.

Former Guiding Hospice employees said that as the founders prepared to sell the company to Traditions, one of them brought in a relative’s consulting company to identify ways to reduce costs and boost the company’s profitability. In awkward one-on-one meetings, some employees described their jobs to the consultants and then re-interviewed for those jobs on the spot. The company let several people go and reassigned their tasks.

To the workers, the sale to Traditions was surprising and abrupt. Guiding Hospice used to advertise that it was the area’s “only family owned and operated facility and patients are treated as family.” But the growth of private equity in the industry has enticed a lot of entrepreneurs to start up independent hospices that they plan to sell in a few years’ time, said Joan Teno, a professor of medicine at Oregon Health Sciences University and a longtime expert in hospice care. Startup-to-sell is where a lot of hospice horror stories take place, she said, because the founders have a single-minded focus on growth. “If they can get it to a certain census, [they can] sell it for a lot of money,” Teno said. It’s possible the founders of Guiding Hospice always intended to find a deep-pocketed buyer. An early employee’s LinkedIn profile boasted that those first few years were “a rapidly growing startup phase.”

“When it came to our hospice, prior to them acquiring it, it was a wonderful team and a great place to work.”

Still, Guiding Hospice was by most accounts a good hospice and a rewarding place to work. And former employees who worked there during the sale said the quality of medical care did not suffer under Traditions.

What changed, they said, were the working conditions. Traditions introduced a new way to document patient visits that seemed less about ensuring consistency between visits and more about documenting down to the minute which tasks had been performed: drive time, call time, even document time — the time you spent documenting your time.

Traditions converted vocational nurses, who have less certification than registered nurses, from salaried employees to contractors who were paid only for the time they spent with patients. And that wasn’t all. Before Traditions took over, workers who made home visits had company cars they were allowed to drive home at the end of the day. After the acquisition, the company began charging employees around $200 for personal use of the company car. Workers could either put wear and tear on their own cars or drive to and from the office every day, instead of going straight to patient visits, to pick up the company car. For those who were hourly workers, the extra leg made their days even longer — Texas is big — right as their time became worth less.

It was like this, bit by bit, that the jobs became more proscribed, “more check-boxy,” in the words of one former employee. Staff who had lost wages or who felt that the new way of doing things degraded their relationships with patients and families searched for new jobs.

The community started to worry there was a difference between Guiding Hospice and Traditions, too. On an old Facebook page for Guiding Hospice, one person after another praised the company’s nurses and social workers for their compassion and patience. A woman whose husband had been in Guiding Hospice’s care recounted how the chaplain had set up a private concert for him and one of the social workers came to his funeral. The team even made it possible for him to visit his daughter in Pennsylvania before he died.

“I do not know what my family or I would have done without the wonderful people from Guiding Hospice,” another client wrote, in February 2019. “We were provided support, comfort, kindness, understanding and community, even within our own selves.”

One year later, another woman replied to the original poster asking if she would still recommend hiring Guiding Hospice now that it was part of Traditions.

“I’m looking for a hospice provider for my mother now,” she wrote. “Guiding Hospice gets rave reviews everywhere, but they were acquired by Traditions Health in December, and Traditions gets HORRIBLE reviews everywhere.”

An Uninterrupted Pipeline

Federal quality control of hospices is almost nonexistent. In contrast to nursing homes, the federal agency that runs Medicare has very few tools to identify and crack down on hospices that put profits ahead of patients. On occasions when federal inspectors can actually identify the worst offenders, they can’t fine them.

The combination of weak regulation plus the huge potential for profit has policymakers starting to worry. This summer, Sen. Ron Wyden (D-Ore.), a longtime booster of the federal hospice benefit, joined Sens. Elizabeth Warren (D-Mass.) and Sherrod Brown (D-Ohio) in opening an investigation into Kindred at Home, a giant hospice provider that has traded hands from one private equity group to another. They demanded data from the company that would show whether Kindred’s quality of care declined while it was owned by Humana health insurance company and two private equity partners.

“We are concerned that when applied to hospice care, the private equity model of generating profit on a rapid turnaround can occur at the expense of dying patients and their families,” the senators wrote.

Some of the problems facing regulators are fixable. Congress could give Medicare agencies the same compliance tools for hospices that exist for nursing homes. The president could sign an executive order freeing Medicare inspectors to use data they already have on file to identify dangerous hospices. The inspector general at the Department of Health and Human Services has been urging both of these measures since 2016, but neither Congress nor Presidents Joe Biden or Donald Trump has acted.

Ultimately, though, those are minor fixes, able to prevent more serious health violations but unlikely to impede the growth of private equity and whatever consequences that may bring.

The incentives for private equity to enter the hospice business, meanwhile, have never been higher. Within a decade, every single baby boomer will be old enough, 65, to qualify for Medicare, which pays for the vast majority of hospice care in America. Private equity loves an opportunity to consolidate — to collapse multiple billing, marketing and accounting departments into one and to build huge referral networks — and with thousands of hospices still independently run and owned, the hospice industry is ripe for consolidation. In the South and Midwest — where many private equity acquisitions are clustered, according to Braun’s research — the laws governing who can create or take over a health care facility are extremely lax. And, as the name suggests, acquiring a home hospice does not typically involve huge real estate costs.

Like Dorilton, lots of private equity firms have invested in complementary businesses, Braun said, such as medical suppliers, home care ― a service many families use right before hospice care ― and bereavement counseling, creating one smooth, profit-optimized pipeline from illness to death. And they are not just targeting older Americans. At a 2020 conference on lending and private equity in health care, a panelist enthused that acquiring pediatric home health care businesses was “a gateway to offering patients additional services,” such as therapy and even pediatric hospice care.

Most families don’t pay for hospice out of pocket but use Medicare or private insurance. But that doesn’t mean they won’t be vulnerable to the consequences of so much upheaval.

Hospice care is uniquely hard for most people to evaluate, Aldridge points out. Many people don’t know how hospice works until they enroll. Hospice care usually lasts less than a month, and most families will use hospice only once, meaning they have no comparison point. And even if they don’t think their loved one got the care he or she deserved, it’s rare for grief-stricken families to make complaints after a loved one dies.

“It’s such a difficult time that they’re just happy to have some help,” Beckwith said. “For families who are satisfied with, let’s say, low-quality care, they don’t know they should expect better.”

The Ultimate Kaiser

As Traditions-owned hospice operations struggle with their new reality, the identity of the person holding the purse strings remains a secret. The other industries in which Dorilton has invested — machinery movers, industrial parts suppliers and a small Canadian company that makes honey-based gummy vitamins — do not exactly provide any clues.

Then, in August 2020, Dorilton purchased Williams Racing, a Formula One team that, alongside teams like Ferrari and McLaren, is a pillar of elite European racing. And journalists became determined to identify its new owner.

Forbes contributor Will Nicoll drew up a list of ultra-wealthy people who had shown an interest in buying Williams in the past: Canadian-Iranian businessman Michael Latifi, whose son is a race car driver; Russian businessman Dmitri Mazepin, whose son is a race car driver; Israeli businessman Chanoch Nissany, whose son is a race car driver; and Scottish coal scion David Matthews, whose son is married to Prince Williams’ sister-in-law Pippa Middleton (and was previously a race car driver).

Ultimately, though, Nicoll determined that Dorilton’s owner is most likely not a race car daddy but billionaire Calvin F. Lo, a Harvard-educated businessman from Hong Kong who runs a life insurance company for the ultra-rich. Nicoll reported having seen documents from the Caymans, Delaware and the United Arab Emirates linking Dorilton to Lo. Nicoll also found reports in the Cantonese business press that Lo had been interested in buying an unnamed, ailing British Formula One team — which could only mean Williams, a team that has struggled with debts and last-place finishes for years. Sources also told Nicoll that Lo is close friends with megastar Michelle Yeoh, whose partner, Jean Todt, has been president of Formula One’s racing association since 2009 and is stepping down in the coming weeks.

Lo is a private person who appears to be vastly wealthy. The business press coverage indicated that Lo “has taken measures to not be listed by Forbes, and others, on so-called ‘rich lists,’ estimating his net worth,” Nicoll wrote. Besides potentially Dorilton, Nicoll linked Lo to a maze of offshore holdings, such as a Cayman Islands fund with interests in the extraction of rare earth elements. HuffPost could not independently corroborate many of these details, in part because in the middle of Nicoll’s investigation, several of those business press articles vanished from the internet.

Lo’s main public indulgence is an Instagram account in which he photographs his meals — thousand-dollar omakase, Piedmont truffles with breakfast — his private jet travel and his Lego hobby, like this 1,300-piece James Bond Aston Martin. His nom de plume is “The Ultimate Kaiser®.

Does Lo, a jet-setter who owns the five-star Mandarin Oriental in Taipei, Taiwan, also derive some of his wealth from a chain of low-profile but lucrative U.S. hospice and palliative businesses? Like the question of who owns Dorilton, a query for Lo that I sent to the life insurance company he manages went unanswered.

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