Last Friday I went with a chum to see the heavy metal band Converge. We had glorious good fun.

I have listened to metal since I was 11 years old when a fellow boy scout lent me a Judas Priest cassette tape. I still love its energy, rebellion, the chugging guitars and the thunderous drums. The music on Friday was loud and raucous and generated quite a sizable mosh pit in the crowd, which was packed in like sardines.

I turn 50 in August and consider myself a little too old for mosh pits, so my chum and I found a perch in a balcony where we had a great view of the band and a good vantage point for watching the fray below as the crowd churned.

So I looked down into the audience and caught sight of a man wearing a red T-shirt. Across the back it said in capital letters, “I HOPE I DIE HERE.”

I wasn’t sure how I felt about this. Part of me was intrigued; part of me was a little offended at first. To be fair, I never saw the front of the shirt, which maybe would have provided a little more context into what that statement on the back was about.

I wondered what he meant by those words — “I hope I die here.” Did he literally mean there, in the Concord Music Hall in Chicago? Where else had he worn the shirt? Did he want to die there too? The words were bold, but smacked of insincerity.

The offended part of me thought that the shirt was being a little flippant towards death. What would the man’s loved ones say about his apparently thoughtless declaration? What does it say to the many people in this world who are grieving? Is this making light of them?

But then it struck me, despite whatever statement the man was trying to make with his shirt, this is what many patients are effectively saying when they elect hospice. “I want to die here.” Usually, this means at home.

More than 56% of the 1.9 million patients who enrolled in hospice in 2024 received care in their private residence, according to the National Alliance for Care at Home. This was followed by assisted living facilities at 21%, which also could be considered a patient’s home.

For patients, this can be empowering. We don’t get to choose how we die in most cases. We don’t get to choose when we die. But some of us have the opportunity to decide where we die, who is with us when it happens, and whether our care goals are honored.

Hospice gives patients a choice, not only of where they want to die, but how they want to live in their final days. That choice must be honored with high quality care and the rooting out of fraudulent operators who betray patients and compromise that care.

When my time comes, I hope that I get to say, “I want to die here.”

We’ve all had a busy week unpacking the 2027 proposed hospice rule that the U.S. Centers for Medicare & Medicaid Services (CMS) released on April 2.

As expected, the proposed rule contained a welcome but woefully inadequate hike to the hospice base rate at 2.4%, which doesn’t quite cover inflation and leaves providers contending with labor costs that continue to rise.

Moreover, hospices continue to compete for new hires with better capitalized health care settings like hospitals that can offer higher wages. Meager payment increases complicate hospices’ ability to remain competitive in the labor marketplace.

However, the proposal contains some potentially beneficial regulatory changes. One is the extension of hospice’s ability to do re-certifications via telehealth through Dec. 1, 2027. This update through the rulemaking process would be separate from any legislative action on the issue.

Since the pandemic, hospices have depended on telehealth re-certifications to build efficiency, free up physician time and to reach far-flung patients in rural areas, where telemedicine is particularly important due to distances between patients.

Finalizing this aspect of the rule could give hospices some peace of mind for at least a year and a half or so.

Additionally, the rule proposes regulatory changes allowing both a physician designee and the physician member of the interdisciplinary group — along with the hospice medical director — to discharge a patient from hospice care. This would give hospices a little more flexibility and could speed care transitions when appropriate, though the question remains as to whether this would result in increased live discharges, a regulatory red flag.

Another regulatory change is a little more complicated. As part of its efforts to bolster hospice program integrity, CMS is introducing a new, publicly available hospice scoring system that uses indicators of potential inappropriate utilization, quality of care and compliance concern to identify “suspicious” providers. The proposed new system is called the service and spending variation index (SSVI).

CMS maintains that nearly all care and services for individuals nearing the end of life should be delivered within the hospice setting, except in rare or unusual circumstances. However, the agency has observed a continued rise in non-hospice spending for terminally ill individuals in recent years.

To address this, CMS has developed the SSVI, which assigns hospices a score based on metrics derived from hospice claims data. These metrics include, among others:

• Non-hospice spending

• Percentage of beneficiaries discharged after a length of stay of 180 days or more

• Average minutes of care per routine home care day

• Percentage of live discharges in which beneficiaries return to the same hospice within seven days

CMS indicated that the SSVI is not a direct measure of fraud, waste or abuse, but that a higher score may indicate an elevated level of concern, potentially signaling program integrity risks or inappropriate utilization and warranting further oversight.

CMS plans to publish provider-level data and each facility’s SSVI score on its Hospice Center webpage. While most hospices are expected to receive low scores, those with higher scores may be subject to additional review to evaluate potential compliance or program integrity issues.

The agency is right to step up its work to root out fraud and poor quality providers. Consider that just one day after CMS issued the proposed rule, the DOJ announced eight people had been arrested for alleged involvement in a $50 million hospice-related fraud in – you guessed it – California. The same week, the California Attorney General lodged charges against 21 suspects in a $267 million scheme. Such news is obviously becoming all too common.

However, any initiative like this must be structured in such a way that does not penalize legitimate hospices. I’m concerned that, based on some of these metrics, that may not be the case here. Some good hospices could get caught up in the dragnet.

‘First Hospice Patient in Space’

This past week I had the pleasure of interviewing Pam Harter from California who wants to be the first hospice patient in space.

Before her illness, Harter volunteered in hospice care for 15 years. She has a rare genetic condition known as pseudoxanthoma elasticum (PXE). In June 2025, she entered hospice care and is currently receiving services from Providence at Home with Compassus in Napa, California. She lives there with her husband, Todd Harter, and they have three adult children.

Pam and I talked for a while about her aspirations to enter orbit, as well as what she valued the most about the hospice care she has received. Her answer, in a nutshell, was that hospice was enabling her to continue to live as she pleases and pursue her interests and goals even in her final days.

Here are some words from Pam that didn’t make it into the Hospice News story.

“Hospice has given me the opportunity to be comfortable, to keep on living. I like to say this line: ‘I choose passports over procedures. I had an opportunity to get [a surgery]. The doctor said, ‘We can do this, but the risk is not good.’ And if I did do the surgery back then, I probably wouldn’t leave the hospital. That’s not something I wanted to do, and I’ve done such amazing things since then.”

The thing that struck me the most during our conversation was how much we laughed. Pam has a great, strong laugh that erupted several times during the interview, even though she had to preface statements about her future plans with “if I am still alive by then.” She has so much joy to share and is so full of life to this day.

I hope her dreams of voyaging to the stars come true.

Now, it’s time to report on some hospice news.

Diversity, equity and inclusion initiatives (DEI) are under attack in this country, and I urge hospices not to give up on reaching underserved populations.

While we strive to maintain objectivity and not bring our personal political stances into our coverage on Hospice News, I will risk bringing up this politically charged topic here on Inside Hospice, as I feel strongly about the issue not only as a moral matter but as a pressing issue for hospices’ business models.

It doesn’t take much to establish that the current presidential administration is vehemently anti-DEI, but some of Trump’s recent statements hammered that home.

“We will terminate every diversity, equity, and inclusion program across the entire federal government,” Trump said in a White House Fact Sheet issued last week.

Among Trump’s first actions in the White House was to sign a series of executive orders designed to root out and eliminate diversity initiatives in the federal government and beyond.

These orders intend to accomplish a wide range of objectives, including termination of all diversity, equity, and inclusion offices, positions, and programs in the federal government; elimination equity-related grants and contracts and ensuring that government contractors and grantees do have have DEI programs, and more as you as you can see on this list from The Leadership Conference of Civil and Human Rights.

Despite these pressures, hospices must stay the course to alleviate widespread and well-documented disparities in both who accesses their services and the larger health care system.

Let’s look at these numbers from the National Alliance for Care at Home:

Non-Hispanic white populations account for more than 2 million of the 2.5 million Medicare decedents nationwide who died in hospice care in 2024. Black patients accounted for 272,370. Asian and Pacific Islander patients represented 48,313, and only 60,738 of those patients were Hispanic. Native American populations had the lowest utilization at 11,682.

This is a systemic failure that signals widespread health equity problems throughout our health care system. While the trends are unsurprising, the numbers take me aback a little bit — 2 million out of 2.5 million — but even more profound and disturbing is the meaning behind the data. More people among these groups are suffering at the end of life and likely dying in hospitals.

This is a tragedy, and it should be an outrage. But at the end of the day it seems like a thing that is sometimes acknowledged, and with the exception of a few passionate advocates, largely accepted as a matter of course.

While those numbers focus on race, DEI of course goes beyond that. Other groups are also underserved by hospices, including those who have serious mental illnesses, the disabled, unhoused population and the LGBTQ+ community among others.

Hospices should devote themselves to DEI for moral reasons. However, a business case does exist. In cold financial terms, these populations represent untapped markets, and efforts to increase their utilization would likely help providers beef up their patient census and foster growth.

I know that some hospices are staying the course on DEI initiatives. We’ve spoken with them and covered them on Hospice News. I hope more will take up the banner for DEI, and I hope they will give it more than lip service or window dressing.

People are suffering. They are dying in pain. Caring for them is your mission. It’s time to fulfill that promise for everyone who is eligible for care.

Also, check out my post from last week in which I lay out while my work covering hospice is my passion and personal mission.

I’m excited to share some insights from the conference, but first, if you haven’t already please check out my most recent post on Inside Hospice. It contains my personal story of why writing about hospice care is such a passion for me.

One thing that was clearly apparent about ELEVATE was that virtually everyone in the hospice community is concerned about fraud. Attendees flocked to sessions that were addressing this issue, including our main regulatory update panel and another that focused specifically on what is happening in California.

In addition to the fraud itself and its impact on patients and families, providers are concerned that legitimate hospices may get caught up in CMS’ efforts to root out these scams.

“With the wide net that CMS is casting, certainly, good hospices are being caught up in that,” Andrew Brenton, attorney with Husch Blackwell, said at ELEVATE. “I think no one is really safe, because a lot of this is a black box; the methodology by which CMS chooses which hospices to audit or otherwise target for enforcement is kind of unknown.”

Other key insights from Elevate included updates on the Hospice Outcomes and Patient Evaluation (HOPE) tool implementation process which began last October with the start of the 2026 fiscal year. The transition is going smoothly to date for most providers, which is welcome news considering many were concerned at the end of last year that most hospices did not have sufficient time to prepare.

Speakers at ELEVATE also asserted that as more health care providers and payers adopt risk-based models, interest in palliative care is likely to grow due to those services’ potential for reducing health care costs and improving patient outcomes.

“Organizations are starting to take on more risk, and what we all have known historically is that palliative care is helpful,” Dr. Nelia Jain, medical director for palliative care at Thyme Care, told us at ELEVATE. “Palliative care decreases utilization. Palliative care improves quality of life and patient experience. But now that organizations are being held accountable for meeting some of those outcomes, there’s an increased interest in really integrating palliative care along the serious illness care journey, rather than a discrete entity in episodic care, particularly later in life.”

Of course this is only a handful of the great insights that we heard at the event. It was difficult to choose which to highlight. Keep your eyes on Hospice News – and Inside Hospice – for more coverage of what our speakers had to say at ELEVATE.

Key GIP Trends

I had to flag this story by Hospice News Senior Reporter Holly Vossel because she did such a great job on it. In “Sustaining the ‘Rare Species’ of Inpatient Hospice Services,” Holly conducted an analysis of patterns in hospice inpatient center openings and closings to uncover real challenges to maintaining access to the general inpatient and respite levels of care.

No one is currently tracking any national data on inpatient facility openings, which meant Holly had to do some digging. She went through a few years of Hospice News’ coverage of new or closing centers, as well as a slew of local news reports, company press releases and social media announcements. She then proceeded to contact each organization to verify the information she collected.

This leg work resulted in an excellent story, and I hope you’ll give it a read.

Ongoing Research Into Hospice Care for CHF

Hospice utilization is relatively low for congestive heart failure patients, who often have specific and complex needs.

Dr. Sarah E. Chuzi, cardiologist at Northwestern Medicine’s Bluhm Cardiovascular Institute, is conducting research into the ways hospices can better serve those individuals, including their policies and approaches to therapies like inotropes, left-ventricular assistive devises, internal defibrillator management and other types of treatment.

Providers can participate in the research by taking this survey.

On a final note, I would like to assure you all that Holly and I did not plan to wear perfectly matching outfits at the ELEVATE opening reception. It just happened by coincidence. Black-and-while polka dots for the win!

Writing about hospice, death and dying isn’t just a job for me, it’s a mission. This is why.

We launched Hospice News in 2019, and over the years many people have asked me how I got into this work and why I do it. So I thought I would take a moment to share my story. As people who work in the field often say, we all have a story.

First, I have to admit that in my young adulthood I never planned to become a journalist, and I never spent a day in journalism school. I studied for my original ambition, to teach English at the college level. I studied at the University of Chicago. But — because one semester of graduate school there cost more than my entire undergraduate education — I never finished my Ph.D.

So I fell back on journalism and soon fell in love with it. I am grateful in many ways for the direction my professional life has taken.

I started working in magazines covering legislation and regulation related to transportation safety, emergency response, counter-terrorism and homeland security. After about seven years of this I moved into health care when I worked at the publishing arm of The Joint Commission. In addition to working on a diverse range of books and periodicals, I edited the accreditation manuals for hospice and home health agencies. That was the first professional work I did in the hospice space. I stayed there for 11 years.

But when I saw a LinkedIn post about a forthcoming new digital publication focused entirely on hospice, I jumped at it. I really wanted this job. It felt like a personal mission before I was even hired.

First, I was knowledgeable about hospice from my work at The Joint Commission and hold a strong admiration for people who have the courage and compassion to care for the dying.

I also had personal experience with hospice care, seeing my cousin pass away from cancer in her 70s after receiving excellent hospice care. My beloved nephew Joshua also died peacefully in hospice care at age 14 after a brief lifetime of suffering from cerebral palsy and other chronic conditions.

Also, about 10 years ago I stayed with a friend’s family in Texas for a few weeks to help care for her mother while she received hospice. Here I saw hospice’s profound benefits and also its limitations. On one awful day, the patient’s medication delivery was delayed and she literally screamed for about eight hours.

But the real reason that this work is so dear to my heart is that death seemed to shadow my steps as I grew up on the South Side of Chicago, in a neighborhood where violence was everywhere. During my formative years I saw a lot of people die, through illness and age, through disease, through accidents and even violence.

In one incident, I saw two men open fire into a pizza restaurant, killing one 19-year-old man and injuring two other people.

But few things have shaped my life more profoundly or dramatically than the day I found my little brother’s body after he was shot and killed. Danny was 12-years-old. In fact, he was three days away from his 13th birthday when he died. I was 15. My mother and I had gone to a bakery to pick up his cake and came home to find that he was gone.

I will spare you the horrible details of what went on that night. But I will say this. These events left me with complex post-traumatic stress disorder and a feeling of unending grief. Later in life, I found a great therapist who has helped me tremendously to work through this and manage it.

But back in the day, I dealt with all of this almost completely alone — because no one could handle talking about it. My parents were too devastated themselves to offer much support at the time, and friends and other family members just didn’t know what to say and found it difficult to listen to talk about the uncomfortable subjects of death and grief.

So, now, I have made it my mission to talk about it. To foster conversations about death and dying both professionally and in my personal life. If someone I know is bereaved, I show up for them. I talk to people in my life about what the future may hold, how we feel about it and how we prepare for it. I am a surrogate health care decision maker for several friends; the list goes on.

I am also kind of a walking memento mori. I tend to wear mostly black, fill my home and wardrobe with skulls and wear earrings shaped like coffins, among other things. These are small gestures. but I hope in some small way that it makes people think, helps them remember what we all have to face.

I continue to grieve for my brother. But I am OK with that. Grief is the price we pay for loving, and it’s a way to stay in relationship with our departed loved ones. We are connected in our grief, with them and with each other.

My work at Hospice News — and at inside Hospice — is an extension of this drive. I have been blessed with a very large soapbox from which I can help inform and educate people about the end of life and the people who stand ready to care for them when their time comes.

It is my mission, and it is my honor.

I’m coming to you live from the Hospice News ELEVATE Conference in Charlotte! If you’re going to be there, please be sure to say hello, and thank you for being a part of the ELEVATE community.

ICYMI: Recent Inside Hospice posts

• A Counterintuitive Take on Palliative Care Telehealth with Empassion CEO Robin Heffermen

• My 3 Takeaways from the Enhabit-Kinderhook Transaction

The Risks That Come With Growth

Today I read a fascinating piece posted on LinkedIn by Tonia Barrier, a registered nurse and chief clinical officer of Cadre Hospice.

The article, “Scaling Hospice Growth Without Increasing Compliance Risk,” looks at the risks that can arise in tandem with expansion and success.

Barrier highlights the changes that the hospice market has undergone over the past five years, including heightened demand, census expansion, regulatory scrutiny, workforce shortages and financial pressures.

“Sustainable growth in hospice is not simply a function of referral volume. It requires deliberate alignment between admission pacing, documentation infrastructure, workforce capacity, and quality oversight,” Barrier wrote. “Organizations that expand census faster than their operational systems can absorb often experience early signs of risk: delayed clinical documentation, variability in length-of-stay patterns, productivity instability, and heightened vulnerability in audits or survey activity.”

Barrier proposes a framework for more responsible, risk-avoidant business growth rooted in regulatory compliance and operational readiness.

I thought the piece included some remarkable insights that would prove useful for hospice leaders.

“In today’s environment, the most successful hospice organizations will be those that recognize safe growth as a leadership discipline grounded in foresight, structure, and measurable accountability,” Barrier wrote.

In my conversations with hospice executives over the years, I’ve seen that some organizations do adopt a similar approach. A frequent theme is they don’t want to “grow just to grow,” but want to expand in a way that most benefits patients, ensures compliance and fosters greater access to care. I salute leaders who prioritize being a better hospice, rather than the biggest.

The Return of the Hospice CARE Act

In the news this week, a congressional representative and a senator both re-introduced companion versions of the Hospice Care Accountability, Reform, and Enforcement (Hospice CARE) Act, designed to modernize the Medicare Hospice Benefit, fight fraud and expand access to care.

The bill features a mix of program integrity provisions and payment reforms intended to “strengthen” the benefit, according to the lawmakers. It would bake in new anti-fraud guardrails and enhance government oversight of hospices. The legislation also proposes re-structured reimbursement methodologies designed to incentivize high-quality care.

A previous version of the bil was first introduced by former Rep. Earl Blumenaur (D-Ore.). We were deeply honored that Blumenaur chose to announce the legislation as Hospice News’ ELEVATE conference in 2024.

I first met Blumenaur during a visit to Capitol Hill, also in 2024. He was considerate enough to step out of a committee meeting to speak with me for about 10 minutes, and I was able to invite him to speak at ELEVATE.

Some aspects of the bill, I believe, are essential. One key example would be the development of a new payment model to support high-acuity palliative services like chemotherapy, blood transfusions, radiation and dialysis. Too many patients are denied access to these types of palliation, which could foster greater quality of life in their final days.

Moreover, many patients decide to forgo hospice care altogether because they fear they will lose access to those services. This is a serious problem.

I think payment reforms would serve hospices well. The Medicare Hospice Benefit has changed little since its 1982 inception and could use an update. However, some stakeholders have said that the specific proposed changes to payments for traditional services like Routine Home Care could cause adverse disruptions.

As this bill courses through Congress, I think it will prompt — and indeed require — a robust series of conversations about what the future of hospice care will look like. Personally, I do hope some version of this bill, even a revised one, will pass.

Hospice Fraudsters Strike Again

Hospice fraud is real, despicable and rampant. Recent developments include the discovery of 197 hospices that were operating out of the same location in Los Angeles County, California.

Other evidence arose that seriously ill seniors were being abused and starved at a care home operated by a fraudulent hospice. Nearby residents alerted authorities after hearing their cries for help. This is as disgusting as it is heartbreaking.

Check out Holly Vossel’s great reporting on these events and the ways regulators are fighting back.

After receiving an unexpected and sad phone call from New Day Healthcare last Thursday evening, I found myself publishing the unfortunate news that company CEO G. Scott Herman had died from cancer at age 61.

I have always enjoyed working with Scott and the New Day team. He was always willing to make himself available to Hospice News for interviews, webinars and podcasts and was particularly forthcoming about his company’s growth strategies and plans. I wish his family, friends and coworkers all the best during this difficult time.

New Day on March 9 named Co-Founder and Chief Operating Officer Kathy Poland as its interim CEO. She brings several decades of home-based care leadership experience to the role, according to a statement from the company.

A transformational legal landscape

Also this past week, another great collaborator with Hospice News announced her forthcoming retirement — Meg Pekarske, partner at the law firm Husch Blackwell. Meg spoke with Hospice News reporter Holly Vossel about top regulatory issues in the space and how the industry’s legal landscape has changed in recent years.

I was struck by Meg’s perspective on the “double-edged sword” of the hospice community’s growth and becoming more mainstream in health care. While greater access to care is a good thing, this has come with some growing pains, she told Holly.

“When I started doing this work, hospice was still sort of in a grassroots evolution and wasn’t as mainstream as it is now. That movement into the mainstream came at a great cost. Hospices [are] reaching more lives, but that comes with challenges …,” Meg said in the interview. “The mainstream nature has probably been one of the biggest changes I’ve seen. It’s sort of a double-edged sword, because there is more access and because we’re in the infancy of some regulatory changes in hospice care. Not everyone is doing it the same way and not all four levels of care are available to everyone in all settings. Regulation is important to setting basic standards that would be good to see in the future of hospice.”

Stat of the Week: Staffing shortages hospices’ No. 1 Worry

Ongoing workforce constraints continue to represent hospice leaders’ top concerns in 2026. Nearly 40% of respondents to Hospice News 2026 Outlook Survey cited staffing as the greatest challenge for providers this year. This is up from 35% year over year.

The staffing issue led the pack by a wide margin. The workforce problem was followed by changing payment dynamics (16%) and public awareness and education of hospice’s value (15%).

Results reflect the perspectives of 103 professionals who report working for organizations that provide hospice services. Among respondents, 61% hold executive leadership roles—including C-suite positions, vice presidents, and directors—offering an informed outlook on the state of the hospice industry in the year ahead. Thirty-four percent represent organizations with an average daily census of 300 or more, and 96% report that hospice care is included among their service lines.

Meanwhile, concern over regulatory changes and oversight declined significantly, dropping from 21% — the second-most cited challenge in 2025 — to 12%, ranking sixth in 2026.

Download the full report here.

Palliative care’s impact on payer star ratings

I also had a great conversation this week with Empassion Health’s CEO Robin Hefferman. Much of the discussion focused on the ways that palliative care can impact a payer’s Medicare star ratings and how that is driving investment.

However, due to the length of the Hospice News article I had to omit a portion of the interview that focused on the effectiveness of telehealth-based palliative care. You can find that additional material here.

Now, I think it’s time to pour more coffee and get going reporting today’s news!

I recently had a great conversation with Empassion CEO Robin Heffernan, which resulted in this Q&A on Hospice News.

But here, I want to share her valuable take on telehealth. I had to cut this from the Hospice News article due to length, but Robin takes an interesting stance: Doing nothing for a patient is often better for them than providing the type of telehealth that is available.

If you’re interested in the impact of palliative care on payer quality measures, be sure to check out the piece on Hospice News..

What are you seeing in terms of the integration of telehealth and palliative care these days?

We’re seeing folks that have tried telehealth models in palliative care. I think the results have been quite minimal, to be honest. You would intuitively think, well, something is better than nothing.

But in fact, I’m not sure that the telehealth models are even better than doing nothing on the patient, and I think that’s largely because if you think about like, what is palliative care supposed to be doing, it’s supposed to be understanding where is the patient truly at in their disease progression. How are they and family members dealing with this emotionally? What other factors are influencing it?

Oftentimes we’ll go do an initial assessment, and the home environment is very telling about how the patient is navigating through. Do they live by themselves? Do they actually have family support? Do they have food in their fridge? Do they need home modifications? All of these things are sort of very hard to assess on the phone.

The other main point of palliative care is to provide additional education to the patient and family about the likely progression of this disease. Let’s think ahead. Would you want to be intubated? Would you want to be resuscitated? Would you want to have these medical interventions if something happened?

That’s just hard to do on the phone with someone and to gain their trust around it. And ultimately, you need to get goals-of-care documented from the patient, so that if they do have an acute event and they go to the hospital, the hospital actually knows what the patient wants done. And so if you haven’t built trust with the patient, you don’t have those documents, then they end up having a shortness of breath episode, they call 911.

They go to the hospital, and all of a sudden they’re having chest compressions and MRIs and a bunch of labs. And then the family member shows up the next hour and is like, “What are you doing? My mother didn’t want all this.”

Telehealth is hard in and of itself. Where we have seen it be successful is if you have an in-home program, and so the patient is being seen on a regular monthly basis by in-home providers, and then they’re getting phone calls in between. Maybe the social workers are following back up with the patient, or you’re helping the husband, for example, figure out a meal benefit. That’s great, and that’s been really successful. Actually, some of our top providers do that religiously. But on its own, I think telehealth is pretty hard

When you say that the impact of tele-palliative care has been minimal, are you talking in terms of the impact on patient outcomes or the financial ramifications? Could you put a finer point on that?

It’s across the board. So, you can look at clinical outcomes, and it doesn’t really change those measures. Does it reduce the number of acute admissions? No. Does it reduce ED visits? No. Does it increase satisfaction of the patient and the family when you survey them? Generally not.

A lot of that is actually based on how good the hospice provider is. Then, from a financial standpoint, if you’re not reducing the admissions, and you’re not reducing the ED visits, and you’re not getting someone to hospice more often, you’re not saving any money.

I think some of those use cases are really valuable. On the other hand, if you have a palliative care program, and all that entails is someone calling the patient once a month, that’s not a good use of funds. It’s not good for the patient, certainly not good for the taxpayer dollars.

It’s more nuanced. For example, hospice recertification on a telehealth basis, that’s a good idea. That’s been proven to be effective, particularly in rural locations. That one should continue. Should you be able to do telehealth visits in between in-person visits? Yeah, that makes sense. Should you be able to do an initial palliative visit by telehealth? That’s debatable in my mind.

If you missed my post on MedPAC’s latest recommendations, check it out. Spoiler alert: I am not supportive of the commission’s recommendations for hospice rate freezes.

Jennifer Sheets’ first interview

I was honored to conduct the first interview that Jennifer Sheets did after taking the helm at the National Alliance for Care at Home. Some key takeaways from me from that interview were:

• Under Jennifer’s leadership, the Alliance is extending its programs across the home-based case continuum. For example, the We Honor Veterans program – currently designed for hospices – will soon include home health.

• Jennifer’s multifaceted experience makes her uniquely well-positioned to lead the Alliance, including her work as a bedside clinician, a hospice and home health CEO and as a board member for the Alliance and its affiliate, the Research Institute for Home Care.

Alivia Care optimism

I also recently spoke with Alivia Care CEO Susan Ponder Stansel about getting more invested in ACO models. I was struck by how optimistic she is about the potential for Alivia in new models like LEAD. The history of ACOs is full of disappointments, and it remains to be seen whether CMS is applying lessons learned here, to enable this new model to fulfill its potential – I have little doubt that Susan’s optimism is warranted. Check out the full story here.

Palliative care demand surge

A news item that caught my eye today was this announcement of palliative care expansion at Hollywood Health Systems, citing “record demand.”

I’d love to hear from anyone who also is seeing a surge in demand for palliative care, or who has any reactions to the information that Hollywood shared about the role of palliative care in an integrated continuum! Leave a comment here or shoot me an email!

Lastly, here’s a photo of what’s been keeping me warm this week in Chicago, while I impatiently await spring (my fire sword):

Hospice News Senior Reporter Holly Vossel did some excellent reporting on the recent $1.1 billion acquisition of Enhabit Inc. (NYSE: EHAB) by the private equity firm Kinderhook Industries, but I still want to add my own two cents.

The implications of the deal for the hospice and home health communities are far-reaching and multi-faceted, but I want to call out three points that struck me as I considered this news.

Independent Publicly Traded Companies Dwindling

Every year fewer standalone publicly traded companies are active in the hospice space. This is due to a series of huge acquisitions in recent years, such as the purchases of LHC Group and Amedisys by UnitedHealth Group’s (NYSE: UNH) subsidiary Optum.

Four of the 10 largest hospice providers of 2024 were publicly traded — UnitedHealth Group, Amedisys, BrightSpring Health Services (Nasdaq: BTSG) and VITAS Healthcare, which is owned and operated by the publicly traded company Chemed (NYSE: CHE). This is according to research by Hospice News and the data analysis company Hospice Analytics. As of 2025, however, Amedisys is knocked off that list due to the Optum transaction.

This reflects a larger trend in the public markets — and a shift in the balance of economic power in the hospice market towards private equity.

Since the enactment of the Sarbanes-Oxley Act in 2002, the number of initial public offerings in the United States has declined markedly. As a result, private equity — ranging from individual investors to large investment firms and venture capital groups — has become one of the limited options available to health care providers seeking capital for expansion. Moreover, the financial capacity of these investors generally surpasses that of nonprofit funding sources, which rely primarily on philanthropic contributions.

Private Equity Renews Appetite for Hospices

After a three-year lull, private equity buyers are once again hungry for hospices. The hospice M&A market has recently regained momentum after a lengthy slump. During that time, virtually no large-scale private equity hospice platform deals took place, due to a barrage of headwinds like inflation, elevated interest rates and increased regulatory pressure, as well as buyers needing time to integrate the sizable assets they acquired during the 2020–2022 surge.

But that is changing. For years, these investors have been sitting on more than $800 billion in dry powder — but now they are returning to the hospice marketplace with guns a-blazing.

In late 2025, the private equity firm Linden Capital Partners acquired Agape Care Group, a major hospice and palliative care provider. In a separate transaction, four private equity-backed buyers each purchased segments of Traditions Health, which had previously been a portfolio company of Dorilton Capital Partners. The acquiring companies — VitalCaring, The Care Team, LifeCare Home Health Family, and Mission Healthcare — divided Traditions Health’s assets along geographic lines.

A range of other PE-backed hospices have completed smaller tuck-in deals as well, such as Choice Health at Home’s purchase of Alliant Home Health, Alliant Palliative Care and Alliant Hospice. Agape Care Group also recently picked up Community Hospice of Alabama.

Private equity investment in hospice has historically gone strong. Between 2011 and 2020, hospice transactions involving private equity increased by nearly 25%, according to an industry transaction report from The Braff Group shared with Hospice News. Roughly half of the nation’s 20 largest hospice chains are now owned by private equity firms.

Macroeconomic conditions have also played a role in the rebound. In 2024, the Federal Reserve lowered U.S. interest rates by 0.5 percentage points, followed by an additional quarter-point cut in October 2025.

Because private equity firms often rely on debt financing to fund acquisitions, interest rate shifts can significantly influence hospice merger and acquisition activity. The decline in rates, from approximately 5.5% to a range of 3.75% to 4%, reduces borrowing costs and may stimulate increased dealmaking as capital becomes less expensive.

Expect a Focus on Value-Based Care

Enhabit’s buyer, New York City-based Kinderhook Industries, has an extensive portfolio that covers numerous sectors, ranging from health care, construction, automotive, manufacturing, waste management and a slew of others.

The $1.1 billion Enhabit deal is a big one for the firm, exceeding its typical investment range. Kinderhook makes control investments in companies with transaction values stretching from $25 million to $150 million.

The firm describes its investment philosophy as “predicated on partnering with strong management teams to build market leaders through targeted growth opportunities.” Kinderhook specializes in transactions that involve entrepreneurial-owned businesses, non-core divisions of public companies and small capitalization companies that lack institutional support.

Kinderhook’s current health care portfolio includes five companies, Revere Medical, Lifeline Screening, Better Health Group, Avita Health Solutions and Absolute Care. A common thread among these diverse companies is that they are all heavily invested in value-based care models.

One can reasonably expect that value-based care will continue to be a key priority for Enhabit as it comes under Kinderhook’s wings. It’s an expectation shared by Joe Widmar, director of mergers and acquisitions at business and technology consulting firm West Monroe.

“I wouldn’t be surprised if they have value-based care aspirations for the organization beyond what they’re currently doing,” Widmar told my colleague Morgan Gonzales, associate editor of Home Health Care News. “With a sponsor as well-rooted in various platforms and services that support value-based care, I would anticipate a pretty aggressive movement in that direction and some good support from the sponsor in doing so.”

For this “aggressive movement,” the home health and hospice provider has already laid the groundwork.

To expand its referral network and increase patient volume, Barb Jacobsmeyer, president and CEO of Enhabit Inc., has emphasized the goal of positioning the company as a “full-service” provider — one with broad payer relationships and the capacity to manage a large share of a referral partner’s patients. According to Jacobsmeyer, payer innovation has been the most critical component of Enhabit’s strategy to achieve that objective.

One can also expect that Kinderhook will pursue aggressive growth for Enhabit. Like a can of Red Bull, the capital infusion could give the company “wings.”

The firm’s health care assets have been prolific in terms of roll-up deals. Revere Medical, for instance, has completed eight acquisitions in recent years. Avita has completed six transactions, and Better Health Group has closed 17.

As consolidation — and private equity dollars — continue to transform the hospice landscape, Enhabit will be an interesting company to watch, with new propellants for growth, a new ownership and capital structure and a forthcoming new CEO.

Every year, we report the latest recommendations for hospice payment updates from the Medicare Payment Advisory Commission (MedPAC). And every year, the recs make me want to slam my head against my desk.

The commission for a few years running has called on Congress to freeze payment rates for hospice providers, allowing for no increases in 2027 and perhaps beyond. While Congress to date has not acted on these recommendations, the possibility exists that they could. This would threaten the survival of many hospices.

But even if Congress never acts on MedPAC’s recommendations, the commission’s reports send a message that I believe is damaging for the industry, in the picture they paint about the state of play for hospice providers and the benefits that hospice delivers for the health care system as a whole.

MedPAC considers hospices to have a rosy financial outlook, enough to justify the elimination of payment increases in coming years. The commission reported that Medicare beneficiaries have ample access to care and that quality of care remains stable based on publicly reported metrics.

MedPAC also contends that hospices have sufficient access to capital and points to an 8% average margin as a positive indicator. However, the commission’s own data show that providers are undergoing margin compression, with nonprofits bearing the brunt.

The average Medicare fee-for-service margin for hospices fell to 8% in 2023, down from 9.8% in 2022 and 14.2% in 2020, according to MedPAC.

Among for-profit providers, the average 2023 margin was 13.7%, whereas nonprofits in aggregate showed a loss at -1.3%. These numbers exclude cap overpayments and non-reimbursible costs.

These declines occurred during a time of record-breaking demand. Hospice utilization in 2024 reached the highest rate it has ever seen at 53%, MedPAC reported. More than 1.8 million Medicare decedents received hospice care that year for a total of 148 million days of service.

So hospices are caring for more patients but making less money. In that scenario, the likely culprit is rising costs. Hospices and the national trade organizations are reporting that providers’ costs are going up, largely due to inflation and labor expenses. As the nation at large contends with a crisis of affordability, hospices are also feeling the squeeze.

A wide range of stakeholders insisted that the 2.6% pay raise that hospices received in 2026 was insufficient due to proliferating expenses. The falling margins support this position. Hospices are doing more with less and need greater financial support to sustain the access to care that MedPAC lauds.

Flaws and limitations also exist in the methodology that MedPAC uses to determine its recommendations.

First, the commission by necessity uses aggregated national data. This does not account for differences in hospices’ financial positions in individual markets. All health care is local, and hospices in some locales may have higher costs than others or lower rates due to wage adjustments or other factors.

The aggregated data is also skewed by outliers. Some large for-profits see higher, double-digit margins, according to MedPAC. Mathematically, this can lead to a higher average percentage that doesn’t necessarily reflect the experience of the lion’s share of providers.

Also, the data they use mostly pertains to for-profit hospices, MedPAC acknowledges in its annual reports to Congress that it lacks data on the financial performance of nonprofits, which represent a large contingent of the hospice community.

The numbers are also old. The commission applied 2023 data to make its recommendations for 2027. For 2023, they used 2019 data, and so on. The bottom line is that the numbers they are using do not accurately reflect the realities on the ground for hospices today, rather than three years ago.

Of course, it does take time to collect and analyze data, especially so much of it. MedPAC truly may not have a better option or access to more current numbers. However, this limitation spurs questions about the validity of MedPAC’s methodology.

Finally, MedPAC only has data from traditional Medicare and doesn’t reflect the activity of other payers like private insurance or Medicaid. This may have only a small impact because most of hospice’s revenue does come from the traditional Medicare benefit, but nevertheless, gaps exist in the data.

We, as a nation, do need to bring down our preposterously high health care spend. The nation’s total estimated health expenditures in 2024 saw the fastest rate of growth since 1991, the U.S. Centers for Medicare & Medicaid Services (CMS) reported.

In 2024, U.S. health care spending reached $5.3 trillion, up 7.2% year over year. In 2023, those expenditures rose by 7.4%. The 2024 amount represents a cost of $15,474 per person and represents 18% of the U.S. economy. The rate of spending in 2024 grew faster than the nation’s gross domestic product, which rose by 5.3%.

But hospice is not the place to pinch pennies.

Whether we are talking about the commission recommendations or CMS’ annual payment rates, the part that frustrates me is this: Better support for hospices would generate greater savings for the health care system.

Hospice care saves Medicare roughly $3.5 billion for patients in their last year of life, according to a joint report from the National Hospice and Palliative Care Organization (NHPCO), the National Association for Home Care & Hospice (NAHC) and NORC at the University of Chicago. NHPCO and NAHC have since merged into the National Alliance for Care at Home.

With a higher rate, hospices could hire more staff. They could care for more patients. They could generate greater savings. Slashing or freezing their payments would be counterproductive, could reduce access to care and thus push up costs.

I confess, I don’t know what MedPAC can do to address the limitations in its data. Even in my own work as a journalist, we can only act on the best information available at the time. MedPAC is not a villain, but the commission is wrong. Hospices need a payment update, and they need more than 2.6%.

Hospice care is my passion. My purpose as the editor of Hospice News is to use the skills I have cultivated as a journalist to support those who have the courage and compassion to ease a person’s suffering at the culmination of their existence.

I am excited to pursue this passion in a new way — through this Substack. Here, you will get to know me on a deeper level and consider my perspectives on the issues facing the hospice community. While Hospice News is a more traditional journalistic enterprise, this page will be a window to the nooks and crannies of my soul and the sometimes odd, sometimes provocative outpourings of my mind.

Like the salons, symposiums, taverns and soapboxes of years past, this will be a place for sharing ideas and stories that go beyond the headlines. You can expect to find:

• My in-depth analysis of hospice industry trends and news

• Behind-the-scenes looks at our journalistic process

• Opinion pieces and my personal stories

I will also probably crack a joke now and again.

Through this venue, I am excited to engage with you more directly through your comments and direct communication with me and with each other. This represents a new frontier as I work not only to inform and educate our readers, but to play a more active role in bringing together the incredible community of hospice professionals.

Let’s keep in touch. I’ll post here at least once per week and send out a weekly email to subscribers, to keep you up to date on my musings. Please subscribe and join the conversation.

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