Greetings! I am now far away from my desk in northern Michigan, camping my heart out. But I wrote this before leaving, so I wouldn’t be leaving my readers hanging for a week. Thanks again to all of you for tuning into Inside Hospice.

Today I want to talk about goals-of-care conversations. Many patients miss out on the benefits of hospice care – or come on service too late – because they lacked timely access to these discussions. Many health care providers are not training clinicians to facilitate such conversations, and for some people, these conversations can seem antithetical to their perceived mission of curing disease and staving off death.

I recently had the pleasure of speaking with Dr. Ileana Leyva, regional medical director for the large hospice provider VITAS Healthcare, for a Hospice News article on improving access to the benefit for cancer patients. But we also talked about goals-of-care conversations. Dr. Leyva gave me some tips for conducting them effectively that I thought I would share with you here.

Dr. Leyva told me this:

You have to do some prep work. I tell my docs, “You can’t wing it.” You have to do a record review. You have to know what you’re walking into. Many times, I describe it as I feel like I’m a referee with a whistle in my mouth, because I’m referencing five different physician specialties during these conversations. So, rule number one is you have to be prepared for it.

Two, you have to set the stage. You can’t just walk in and decide that we’re going to do this right now. You have to invite that conversation, plan it with the patient and whoever is most important to be present. At times patients have certain people they don’t want present, because they’re not going to be as open with you if there’s a particular person in the room.

We have to leave all our biases and judgments at the door, because it’s not our journey. It’s the patient’s journey. That can be very, very hard, because we know what that trajectory will look like for the patient and they don’t. So it’s really a conversation about helping me understand what you’ve been told and what you’ve understood of where things are, and then the conversation of what you think is happening and [based on that], guiding them to better understand their disease.

At the same time, asking the key question: What’s most important to you with regard to where you’re going to live your life? How do you want to live your life? I have patients who say, “I want to be home. I don’t want to go back to the hospital. I’m done with the tests and anything that’s invasive.” And I have had other patients who’ve told me, “If you can prop me up in the corner, and I can watch my grandkids, that to me is a good quality of life.”

So, it’s getting what’s most important for the patient and trying to then be able to implement the plan of care around what’s important to the patient and what’s feasible and viable as well. So, that’s why I say it’s also refereeing five or six other sub-specialties into not undermining what a good plan of care may look like.

It’s a long conversation, and it’s never a one and done. It’s a fluid conversation that takes place over time, and it’s important to do more listening during the goals-of-care conversation than it is to do speaking.

I really appreciated Dr. Leyva’s insights.

Hospice and palliative care providers know how to have these conversations, perhaps better than many clinicians in other settings. What are your best tips for holding them? Let me know in the comments.

I am gearing up for a week-long camping trip starting next Tuesday, so I’m in a mad scramble to write all my stories in advance as well as prepare for the excursion itself. Thus, this has been a busy week. I hope everyone out there is also taking time to enjoy the summer.

The camp out will have a Viking theme this year, complete with aligned art pieces displayed onsite, a “Brunch of the Gods,” theme-appropriate garb and an axe throwing yard made from wood and chain link that we will assemble when we get there. I am looking forward to it!

But right now I have other things to say.

In its 2027 proposed rule for home health agencies, the U.S Centers for Medicare & Medicaid Services (CMS) clarified that those providers can use certain billing codes to cover community-based palliative care.

This action by CMS could help improve access to palliative care in the United States, which is sorely needed. However this impact could be very limited due to the structure of the home health benefit.

Important to note is that CMS isn’t really doing anything new here. These billing codes for palliative care already exist and home health agencies can already use them. The language in the proposed rule was little more than a reminder of that.

What will really determine how significant this might be is subregulatory guidance forthcoming from CMS that will provide further details on how providers should use the codes and in turn offer palliative care.

One issue is that patients will have to meet the eligibility requirements for home health care before they can receive palliative services from those agencies. This means that the patients will have to be homebound. The many patients who are not homebound but could benefit from receiving palliative care are excluded (though they may receive those services in another setting or from a different type of provider, like a hospice).

Second, hospices, which provide about 50% of palliative care in the United States according to the Center to Advance Palliative Care, can’t use these billing codes unless they have a Medicare-certified home health business. The hospice sector is particularly rich with palliative care expertise, and they can’t get involved through this home health benefit.

Third, home health agencies really aren’t incentivized to provide comfort care that is essentially non-curative. The quality measures for which they are accountable are largely improvement measures that indicate whether “grandma” is making progress. A palliative care patient might not show those signs of improvement, which could impact home health agencies’ quality scores.

The question also remains as to whether home health agencies have the capacity and expertise to effectively provide palliative care, given current workforce constraints and the limited availability of training to provide those services. Can they provide the full scope of interdisciplinary palliative care? Will the reimbursement support that?

An additional unanswered query is: What do we mean by palliative care?

A common adage says, “If you’ve seen one palliative care program, you’ve seen one palliative care program.” CMS to date has not prescribed a care model that indicates what “palliative care” should look like through this benefit. What actually will these patients be getting?

I hope that some of these questions can be addressed through the forthcoming subregulatory guidance, but of course that remains to be seen.

More details will come in a Hospice News piece slated for tomorrow, but I wanted to share my opinion on this CMS action here. What is your opinion on this?

I hope everybody enjoyed the July 4 holiday. We are a troubled nation these days but can still find reasons to celebrate. I had friends come to visit from Minneapolis, people I consider to be chosen family, and it was great to spend time with them and our mutual Chicago-based chums.

The government is an active 250-year-old, giving the hospice industry quite a bit of notable news to chew over right before the holiday weekend.

The U.S. Centers for Medicare & Medicaid Services (CMS) in its proposed home health rule for 2027 introduced new measures intended to combat fraud, waste and abuse. While they appeared in a home health proposal, these measures would also apply to hospice providers as well as other health care settings. The proposals, if finalized, are projected by CMS to generate approximately $82 million in annual savings.

CMS Administrator Dr. Mehmet Oz said the proposals would provide the agency with additional tools to protect Medicare beneficiaries and taxpayer funds by ensuring that only qualified providers and suppliers participate in the program.

Among the proposed changes, CMS would expand its authority to recover Medicare payments from providers and suppliers whose enrollment is revoked. Under current policy, the agency can recoup payments retroactively only for certain types of enrollment revocations. The proposal would extend that authority to all revocation categories, allowing CMS to seek repayment regardless of the reason for the revocation.

CMS is also proposing to broaden the circumstances under which it can deny or revoke Medicare enrollment. The proposed changes include allowing the agency to:

• Revoke a provider’s or supplier’s Medicare enrollment if it determines the enrollment poses a high risk of fraud, waste or abuse because the provider or supplier is located in a geographic area with an unusually high concentration of Medicare providers and suppliers.

• Deny or revoke Medicare enrollment for providers or suppliers convicted within the past 10 years of certain misdemeanor offenses related to sexual assault or financial misconduct.

On the surface, these aren’t bad ideas. Strengthening barriers to entry could help curb the proliferation of fraudulent providers entering certain markets. Though I am a little concerned about the agency’s language on revoking a providers’ enrollment simply because of where they are located. It makes a certain amount of sense to apply additional scrutiny to new providers in those regions, as well as a close examination of existing companies.

However, CMS has been somewhat undiscerning in its payment suspension and revocation practices to date, with legitimate providers swept up in enforcement dragnets. I think some safeguards to protect those legitimate hospices should also be in place. Fraud needs to be confirmed before enrollment is revoked or payments suspended, which could cause a hospice to shut down.

Another major provision in the proposed rule was to allow payments for community-based palliative care through the home health benefit. You will see more from me on this issue here as well as further coverage on Hospice News after we gather some more information.

In the meantime, what do you think about these new proposed program integrity provisions from CMS? Drop a comment.

Conversations with loved ones about our end-of-life wishes, goals and values are essential, and we must take them seriously. And as hospice providers know all too well, avoiding such conversations can complicate people’s process of transitioning to hospice care.

Therefore, it’s in the interest of providers to promote these conversations. One hospice and palliative care social worker, Lisa Pahl, developed a game with this objective.

In fact, a number of games, usually with cards, have emerged in recent years that are designed to foster those discussions in a thoughtful but entertaining way. I have seen at least three, and I think these games could serve as an interesting tool for families as they think about these issues.

Pahl’s game, The Death Deck, uses multiple-choice cards and open-ended discussion questions to examine players’ feelings about death and dying, the legacy they wish to leave and their understanding of end-of-life care options like hospice, as well as their beliefs in things like ghosts or an afterlife, among many other topics.

I had the idea of convening a group of hospice and palliative care leaders to play this game with me. I wanted to see the kinds of conversations The Death Deck could stimulate. Also, quite frankly, I have owned this game for years, and no one has ever been willing to play it with me – a testament to how uncomfortable the subject matter is to many people.

The group that came together to do this was fantastic. They were open and forthcoming. They brought the full measure of not only their expertise in the field but also the full measure of their humanity, lived experience and hopes for the future.

Some aspects of the game were deeply personal, so I am not going to quote the participants by name when I reference those portions, out of respect for their privacy. However, I definitely want to extend my sincere thanks to hospice and palliative care physician Dr. Michael Fratkin, Hospice News Senior Reporter Holly Vossel, Mettle Health Co-Founder Sonya Dolan and Altonia Garret, COO of the hospice provider Blue Ridge Care. I also answered the questions.

We played for one hour and kind of wanted to keep going, but our duties called. We followed that with a brief Q&A about the experience.

Dealing with death growing up

The first question we encountered was multiple choice — Growing up, my family dealt with death:

a) By talking openly, sharing feelings, stories, and dark humor

b) In a no-nonsense sort of way, sh*t happens, you move on

c) Keeping it all bottled up and avoiding any discussion.

Not all of us fit neatly into one of these three categories, but the question did foster a good discussion. Here are some excerpts from the responses:

“I have had a lot of deaths over my life. As a child, there wasn’t a lot of discussion. It’s very rooted in faith, and ‘on to the other side,’ and transition in the celebration of life, all of that. So it’s kind of like when it happened, it was joyous. It was sad, sure, but we recognize that folks are going to join the ancestors, and it’s a celebration of this life that was lived … but there wasn’t a lot of talk about it, though, and not a lot of talk leading up to the death.”

“It’s definitely, ‘C: keeping it all bottled up and avoiding any discussion.’ I know after my brother died, I was afraid to mention his name to my parents, because it would upset them so much. And I actually had a cousin, John, who died the same way. He was shot at age five, and after the funeral, family members went through his parents’ house and took down all the photos of him off the wall, thinking they were being kind to remove a painful reminder, but it was almost like erasing him a little bit, and I find that kind of disturbing. So, definitely keeping it all bottled up was our approach.”

Imagining your mortality

One of the more open-ended questions we came across was, “Would you say that you imagine your death or the death of your loved ones more often?”

“I tend to be a person that worries about others more, especially with my parents. Full disclosure, I’ve been a full-time caregiver to both parents in different roles. They both have their own chronic conditions, and I started that too early, I think … I always worry about – for instance, my father, who doesn’t live anywhere near me – what could happen to him. It has happened, I have had to drop my life and abandon [my colleague] for a week, and go down to Florida to care for him. I worry what would happen if he could die without me present.”

“I deal with a lot of worry that I’ll get the illnesses that my patients get. So lately, I’ve been feeling anxious about ALS, because I’m working with a couple of guys with ALS, and what if that happens to me. I always think if there’s something at the sort of boundary of empathy that I sometimes absorb anxiety for it. So I thought about it a lot long before I had a family, and now that I have a family, I think about my children and my wife. When she gets a pain in her tummy or something like that, I am kind of more anxious than I might look on the surface.”

“When I was little, I would actually do very deep dives into what would happen if my parents died. I [would] really, really think about it, and to the point of sobbing. But I think it was a really good exercise of just what is it to experience loss or think about loss … My mom did die in my 20s, and she was like fully my person, and that’s why I’m even here in this space doing this work. It is because of that, but I think her death really opened for me that this is around all the corners, if she – someone who is healthy, someone who didn’t have any crazy, dangerous habits – has died.”

Sharing your feelings

Another multiple choice question we considered was this – “How often do you let the ones you love know how you feel?”

The options were:

1. Very rarely, I’m not one to share my feelings

2. Fairly often, in the right moments and on the right occasions

3. Constantly, and they’ve asked me to stop.

Here are a couple of the answers:

“I’d say for me it would be ‘c’ – it’s constant, but they haven’t asked me to stop. When I talk to my daughters or my grandson, it’s the first thing that I say. ‘Hi, I love you.’ That’s how I lead, and I’m saying, saying those words to friends and people all the time. I feel like death is always in the room, whether we like to think about it or not. Anything we do or say could be the last thing we do or say. So, I think a lot about what I want those words to be, what I want those actions to be. Do I want it to be something selfish, unkind or angry? Hopefully not. So, yeah, I do kind of constantly tell them how I feel.”

“I am squarely in ‘c.’ I do it a lot. I make a point to do it. I do a lot of texting of people just out of the blue to tell them I’m thinking about them and what I appreciate about them, or what I love in my relationship with them. This is the thing that I have to give, my love and care and attention. Why would I not do that on a daily basis, and let people know how I’m feeling?”

Coda

These are just a handful of examples of the topics we covered, but I think they make a solid representative sample. At the end, everyone seemed to agree that playing the game had been a positive experience that generated some food for thought about how we feel, what we want and what we need to do (like, for some of us, documenting our health care wishes). This was a thought-provoking and fun exercise, and I got to know some great people just a little bit better.

“Death is always in the room.” “This is around all the corners.” We need to talk about this thing that we all must confront and stop treating it as a dirty little secret.

I also think that awareness of our mortality and its potential imminence can bring out our softer edges, something that may be sorely needed in today’s world.

What do you think? Would you play a game like this? Do you talk about these issues and concerns with your loved ones?

Today, I am grateful for air-conditioning, ice and chocolate. Chicago is scorching hot this week with temperatures expected to rise beyond 100 degrees. Not everyone has the privilege of taking shelter and relief from the heat, and I am thankful for the opportunities that I have.

The chocolate thing is largely irrelevant to the temperature; I just happen to be eating some at the moment even though it’s the early morning.

While I’m starting a new day here with a sweet treat, I’m also reflecting on New Day Healthcare. I recently enjoyed a conversation with Kathy Poland, the newly appointed CEO of the home health and hospice provider. She succeeded prior CEO G. Scott Herman who sadly passed away about four months ago. Since then, Kathy has served as the company’s interim leader.

I published the interview on Hospice News last Friday. However, due to the length of the piece, some material didn’t make it into that version. To my chagrin and that of my fellow journalists, most readers only peruse about 20% to 28% of words on the page when it comes to web-based content, according to research by the Nielson Norman Group. So we tend to try to keep things on the shorter side when possible.

I wanted to share the rest of the interview here, including Kathy’s thoughts about New Day’s home health business, the growing role of AI and what would make her feel like a success one year into her tenure as New Day’s top executive.

Here are the excerpts:

What are your growth plans for home-based care service lines in the next two years?

On home health, we’re in three states, and we’re caring for over 4,000 in those three states on our home health side. Medicare Advantage is obviously a big part of that, a large part of our population is Medicare Advantage. We have lots of contracts with Medicare Advantage payers. When I say lots, it’s an excess of 30 plus, where we are partnered with these managed care payers.

So you’ve got to be able to go in and talk to these referral sources, these hospital systems in acute settings, and say that we’re ready to not only take all of your managed care payers or Medicare Advantage payers, but we’re definitely here to take care of the ones that are your traditionals.

You have to have enough people to take care of the patients. It’s one thing to get the referral; it’s another thing to actually have caregivers, to have nurses, to have therapists to actually care for the patients.

So, the other part of the puzzle is you’ve got to have a culture and a recruiting system in place where you can attract people and retain people, and we excel. We retain most of our clinicians. We have a very low turnover rate.

Are there any AI use cases that you think are overhyped currently from your perspective?

There’s actually everything that we’re looking at right now, not overhyped. I think the word AI might be thrown around a little bit too much, and sometimes people will say, well, “I use AI.”

Well, then you have to ask for more clarifying questions: What does that mean? Does that mean using ChatGPT, or does that mean you’re using some technology that’s really impacting the patient care and the ability to go see more patients, or the ability to see improved outcomes?

What does it really mean? Because AI, the term is used a lot until you ask the clarifying question. Otherwise, you really can’t understand exactly what it means for your business.

Now looking into the future, if we were to have this conversation say a year from now, what accomplishments would make you feel like you’ve had success?

Well, step one is that the team remains intact. We have an amazing team that we’ve built, and we need that team to remain intact, and everyone to understand that we’re marching in the same direction.

Scott was a big personality. Scott was a big part of our culture. Scott, if you knew him, he could light up a room, he can make everyone laugh in some crazy ways, and he learned how to make people feel really comfortable bringing out the tough stuff, because humor was something he excelled at.

When you lose someone like Scott, [when] we all work together for decades and you lose someone, there’s an uneasiness at first. What does this mean? What does it mean for our company? What does it mean for our team? What did we all work together for all these years? What about everything we built?

So, keeping us intact is super important. We’re in a good spot, and then now is just building on that momentum [from everything that we have done together], keeping Scott top of mind, keeping the legacy top of mind, celebrating the wins. Then, overall, it’s about taking good care of patients. Are outcomes exceptional? They remain exceptional. Are we taking care of more that need our help? Are caregivers staying here with us? Are people staying here with us? And are we performing as expected? All those things are constant.

Those are the plates, and they’re always spinning. If all those things happen over the next 12 months, then it’s been a good year.

That’s it for today. I hope you’re all staying cool and comfortable. Try having some chocolate, but don’t let it melt.

My grandson Caleb turns 4 in a few weeks, and I am very excited about the whole thing. I am trying to decide what I should give him. He likes Spider-Man, monster trucks and, somehow, Michael Myers from the Halloween movies. He has never seen those movies.

But I must turn to a somewhat dryer subject, although one that might scare some hospice providers even more than another Halloween film: a recent Government Accountability Office (GAO) report recommended that the U.S. Centers for Medicare and Medicaid Services (CMS) transition hospice reimbursement to a per-visit system rather than a per diem. This would apply to routine home care.

Medicare spent about $27.5 billion on hospice care in 2024, according to the report. GAO estimated that for a large subset of routine home care services, Medicare would have spent roughly $7.6 billion less if payments were based on individual visits rather than a fixed daily rate.

We covered this on Hospice News here.

Proponents of these changes would say that per-visit payment would better align reimbursement with the actual services delivered and could reduce overpayments to providers that furnish relatively few visits. Medicare also could save billions of dollars and improve program efficiency.

However, I think this would be a bad move. Hospice and home health function very differently in terms of reimbursement, and they are not interchangeable.

Some have called hospice “the original value-based care.” The hospice benefit is a bundled, capitated payment system in which the provider assumes essentially the total cost of care. Home health doesn’t work that way. For one, hospice per diems include things that home health visits do not, such as durable medical equipment and medications.

Hospice care involves more than face-to-face visits, including care coordination, on-call availability, family support and interdisciplinary team management, among other things. Not to mention travel costs.

A per-visit model also could create incentives to increase visit counts rather than focus on patient needs, and major payment changes could affect access to hospice services, especially in rural or underserved areas.

GAO’s recommendation doesn’t really take the full picture into account.

Anyway, it would require an act of Congress to change the payment system so dramatically, and that seems unlikely to me.

Do you think that the hospice payment system needs reform? What kind? Drop a comment!

Also, here is a picture of Caleb to cheer us up:

Ahoy!

We at WTWH Healthcare, Hospice News’ parent company, had a large in-person meeting this week. We have all worked remotely since the pandemic, so it was great to see and reconnect with some of my favorite colleagues – and it was gratifying to be able to share how much growth and engagement we’ve had on Inside Hospice since launching just a few months ago. So, thank you all for reading, commenting and supporting this endeavor!

Today, I want to talk a little bit more about the recent rash of hospice Medicare payment suspensions.

Some stakeholders in the hospice space posit that recent payment suspensions on hospice providers by the U.S. Centers for Medicare and Medicaid Services could drive up health care costs by moving more patients out of hospice and into the hospital system.

I’ve reported extensively on the payment suspensions and the way that legitimate providers are being swept up in this crackdown, both on this site and on Hospice News, and more stories on this are on the way. Check out the linked stories for more context.

One of the major concerns associated with this is continuity of care. When a hospice isn’t getting paid or can’t sustain operations, what happens to their patients?

According to the conversations I have had with about 13 affected providers, these are some of the common outcomes:

• The patient is transferred to another hospice

• The patient stays on the original hospice’s census, but the provider stops accepting new patients

• The patient is discharged alive and does not receive further hospice care before they expire

CMS is trying to cut down the economic cost of fraud in the space, though some may question whether these suspensions – and the methodology behind them – is the right approach. However, some contend that the agency’s “sledgehammer” approach to fighting fraud could ultimately cost Medicare more money. The prospect that at least some of these patients wind up in the hospital or in an emergency department visit seems very probable.

We know that hospice reduces higher acuity care and saves the system a substantial amount of funds. I cited some of the data in another Inside Hospice post just the other day, so I don’t think I need to repeat it all here. In the absence of hospice, or if patient care is delayed due to a transfer, patients have few other places to turn than hospitals, according to one hospice CEO who spoke to me on background.

“After you discharge them, they may have to be readmitted multiple times. What’s the purpose of having Medicare pay $5,000 a day for multiple readmissions in the hospital?” the CEO said. “Why not let me pay $220 to a hospice and let them take care of them at home? That’s a huge cost savings.”

I think this is food for thought. It would be helpful to see some research into this to get some data on what happens to patients after these suspensions, but for now unanswered questions persist.

Also, I would like to point out one of Substack’s other features – Notes. There are short, separate posts that I have been using to pose questions to you, my readers. I get no responses. I think because the site doesn’t notify readers when one is posted.

This is my most recent note, with a question about the HOPE tool. I would love to hear your feedback on this. To find past posts of this kind, please click on the “Notes” tab at the top of the home page. Thanks for taking a look!

I read a fascinating article in Forbes a few days ago that I wanted to share here. For the piece, author Wes Kilgore interviewed Dana Corrigan, a former acting inspector general for the U.S. Department of Health and Human Services. Corrigan is also a former director for the Center for Program Integrity at the U.S. Centers for Medicare and Medicaid Services (CMS). In those roles, she was heavily steeped in the fight against hospice fraud.

In August 2025, the article reported, Corrigan and her sister had to place both their parents in hospice care within a matter of days. I was struck by Corrigan’s statement that hospice care as a lived experience was very different from what she saw in documents and spreadsheets in her regulatory office.

“It was surreal being on the other side,” Corrigan told Kilgore. “I spent a significant amount of time during my career analyzing fraud and abuse, taking actions against bad hospice providers, and trying new approaches. But seeing it through the eyes of a daughter caring for her own parents changed that.”

As much as I enjoyed the article, I wish it had elaborated a little more on this point and what differences Corrigan saw. But instead it moves on to talk about hospice fraud, which is appropriate given the trend’s prominence in the news lately and Corrigan’s background in that area.

Corrigan goes on to discuss the role of data breaches in hospice fraud, including the use of the dark web and other tools by bad actors to steal Medicare Beneficiaries Identifiers (MBIs). They then proceed to bill Medicare for patients who are not eligible for those services, often without the patients’ knowledge.

In Forbes, Corrigan recommends that state and federal regulators tackle bigger questions than a “Whack-a-Mole” approach to slamming individual fraudulent operations. This can include “harder policy questions,” such as certificates of need, changes in payment incentives and more robust surveys, among others.

One other interesting idea from Corrigan is to place limits on the numbers of hospices a physician can support, though that may run into questions about whether enough doctors are available to support current and future demand.

But, Corrigan maintains, the specter of fraud “overshadows a fundamental policy failure,” which is an outdated Medicare Hospice Benefit. I believe this view has merit.

As the Forbes article points out, and as I and many of our sources have said previously on Hospice News, the more than 40-year-old benefit was designed with cancer patients in mind. Cancer has a much more predictable trajectory than many of the diagnoses hospices encounter more frequently today, such as dementia-related illnesses and other neurodegenerative conditions.

Patients with these conditions often live longer than the designated six-month benefit period for hospice. The six-month terminal prognosis requirement can be a disservice to these patients who need longer periods of care, even though they can go through recertifications.

The requirement also butts hospices up against compliance concerns, such as the Medicare payment cap, long lengths of stay and live discharges. A wave of payment suspensions recently sent to hundreds of hospice providers in certain markets were based on live discharges.

Palliative care expansion, hospice benefit reform

In Hospice News editorials, I have posed the questions: How nice would it be if we could just give people the care they need when they need it?

This could be easier said than done within the confines of the Medicare Hospice Benefit, especially in its current form. But other options exist as well, such as the establishment of a community-based palliative care benefit that would offer comfort care to the non-terminally ill. Corrigan called for this in the Forbers article, and over the years I have called for this on Hospice News.

The National Hospice and Palliative Care Organization, which is now the National Alliance for Care at Home, advocated for such a benefit for several years. Now, the National Partnership for Healthcare & Hospice Innovation is working to design a model.

Expansion of palliative care, and the existence of a payment model that supports the full range of interdisciplinary care, could have a range of benefits. It would benefit patients in need earlier in their disease trajectory and aid in smoother transitions to hospice when the time is right. It could relieve some regulatory restrictions on accessing comfort care, and it could slash health care costs due to reduced hospitalizations and emergency department visits.

Corrigan also recommended extending the hospice benefit period from six months to one year to reflect the growing trend of longer stays based on patient needs.

“Six months or less feels different from a year,” Corrigan said in Forbes. “This is subjective, of course. But there is a really good study by Jonathan Gruber and Jetson Leder-Luis about how an over-focus on fraud prosecutions in hospice can be a mistake if it drives up overall health care costs.”

I believe that to be this study published last year from the American Economic Review. Early hospice enrollment for people with Alzheimer’s disease and related dementias was associated with nearly $29,000 in savings per patient over five years compared with traditional hospital care, the study found.

The researchers also found that when families avoid hospice because of fear or confusion about legal and medical decisions, patients often cycle back through emergency rooms, specialist visits and additional procedures, increasing costs to the Medicare system.

When families avoid hospice because of fear or legal confusion, patients return to emergency rooms, see specialists, undergo procedures and drive up Medicare costs, the study indicated.

Other research bears this out. 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.

Corrigan raises some really thought-provoking points on these issues in the Forbes article that I think warrant greater attention in the policymaking space.

Things the hospice community should think about include:

• Does the Medicare Hospice Benefit need reform?

• How can the benefit be restructured to better serve the needs of today’s patients?

• Should the six-month terminal prognosis requirement be re-evaluated?

• Do we need a community-based palliative care benefit, and what would be the implications of that for patients and for the nation?

I would love to hear your take. Please drop a comment.

In 2017, I went to Burning Man, a festival of the arts (not music) that takes place in the Nevada desert.

I had gone through a series of major changes in my life around that time, including my youngest daughter going away to college. Very little in my life at that time was the same as it was before. I did keep my beard though.

So I thought attending Burning Man, a ritual of “creative destruction” and reflection on the temporary nature of existence, would make for a good punctuation mark on my past and a springboard for the future.

It was not a mid-life crisis! Even from afar, the event had an influence on my life. Around 2008 I had gotten involved in the Chicago “burner” community, which fostered investment in the arts, community involvement and charitable work – as well as a good deal of fun. I built many lasting, close friendships through that community. It jumpstarted my creativity and exposed me to many new ideas. So I thought I should actually go there at least once, and this seemed like the right time.

The hallmark of the event is the burning of a massive wooden structure shaped like a man, which was kind of an awesome display as well as a boisterous celebration. However, Burning Man doesn’t end there. It culminates the following night with what is called the temple burn.

The temple, which has no religious affiliation whatsoever, is a place to grieve, reflect on loss and major life changes. Visitors are permitted to write messages on the walls and leave objects, often of great significance, to go up in flames as a ritual of letting go. In the temple I saw things like wedding dresses and military uniforms left to burn, as well as thousands of messages of both hope and renewal and expressions of deep pain.

As for me, I wrote the names of my lost loved ones on one corner of the wall and placed a wedding ring I no longer needed on the ground inside the temple.

The burning of the temple was a profoundly moving experience. While the burning of the man was a big, loud party, at the temple burn, literally tens of thousands of people gathered in silence. I heard no one speak, no cheers, no sound except the roaring of the flames. Around me people were holding hands and holding each other, and many were crying quiet tears.

I attended the burn alone, and I was struck by a deep catharsis. I wept, overcome with grief and anger, fell to my knees and I punched the sandy desert ground. Even though I was some distance away from the fire itself, I could feel the heat on my face. After all, this was a building-sized structure on fire.

The temple burn didn’t solve my problems or erase my grief, but it did acknowledge and honor it through a kind of ritual. Afterwards, I felt lighter, as though I had expunged something dark for at least a while.

I ended up walking over to one of the French camps and drinking a couple glasses of good red wine and had great conversations with a man from Ireland, a woman from Singapore, a couple from Denmark and two older adults I happened upon who lived 20 minutes away from me back home. Small world.

The temple got me thinking about the ways we process grief, which I really had never done. I held on to it like a cruel treasure. Would it dishonor my loved ones if I felt better, if I just accepted this? Shouldn’t someone feel bad – and in some cases angry – that they were gone? I had decided that person should be me. I had to carry this for their sake.

Perhaps I could have benefited from bereavement care from a hospice. Hospices hold families’ hands through their first year after a loss, as an extension of their mission and compliance with a regulatory requirement.

The problem that we have to acknowledge is that not all hospices do this well. While many offer direct, in-person or telehealth counseling, support groups, grief camps for children, workshops and other programs, others simply send out a monthly mailer or the occasional phone call. It can be pretty uneven from provider to provider.

Bereavement care, along with chaplain services, is among the least regulated and loosely defined aspects of hospice care. No guidelines or requirements specify what grief services should look like. Hospices have to define and design their programs on their own, and some do it better than others. Hospices really don’t get paid for it either, so they do this with no business incentive or support.

A 2013 study found that 78% of hospices provide bereavement care to patients’ families and 76% offer these services to the larger community regardless of whether the deceased had utilized their services. I can’t even guess at what’s going on with the 22% that apparently don’t provide this care.

However, only 23% of hospices provide “labor-intensive” grief services, and 27% offer “comprehensive care,” according to this research. Larger hospices appear more likely to offer labor-intensive or comprehensive care, the study found, and no significant differences were identified by ownership type. Although, nonprofits were more likely to offer care to the larger community rather than strictly to the families of their patients.

“Our results demonstrate substantial diversity in the scope and intensity of services provided to families of patients with terminal illnesses, suggesting a need for clearer guidance on what hospices should provide to exemplify best practices,” the study authors concluded. “Consensus within the field on more precise guidelines in this area is essential.”

More recent research from 2025 indicated that a family’s experience with grief greatly influences their perceptions of the end-of-life care their loved ones received. Also, high-quality care itself helped family members cope with their losses.

Also, thanks to reader Jerry Soucy who got me thinking about this with a comment on another post.

“Bereavement support is as wildly variable among hospices as everything else, there are too many crappy and mediocre hospices providing crappy and mediocre psychosocial support,” he said. Good point.

I urge hospices to take a sharp look at their bereavement programs to ensure they are robust and able to meet families needs. Could you be doing better? Could you be doing more? And what kind of determination and resources would you need in order to improve?

Also, as policymakers mull various payment reforms, such as altering the per diem structure or introducing payments for high-acuity palliative services, perhaps they should also consider some type of reimbursement and quality measures for bereavement care, beyond the Consumer Assessment of Health Care Providers and Services surveys.

Hospices of course can’t take away a person’s grief – even if they want to – but they can help, and families and loved ones need that help.

I read an interesting post on LinkedIn this morning that related public perceptions of hospice care to Walter White, the protagonist of the AMC crime drama Breaking Bad. For those who don’t remember, Breaking Bad was a television show about a high school science teacher who starts a meth lab in order to make quick money to leave for his family after he is diagnosed with terminal cancer. As end-of-life care choices go, this isn’t a good one – but it did make for decent TV.

The piece I read was by David Howlett, director of marketing for the home health and hospice provider VNS Health. In it, Howlett makes the point that a character like Walter White wouldn’t choose hospice because of a “warrior mentality” that’s pervasive in our culture.

“For decades, health care systems have leaned on the ‘warrior’ narrative,” Howlett wrote. “It’s an empowering tool during curative treatment, but it becomes a massive hurdle during the transition to comfort care. If for years, someone has been encouraged to ‘never give up,’ hospice doesn’t feel like a service. It feels like a brand failure.”

I think that’s a valid point. You can hear it in the language we use. We often speak about “battles” against cancer or other diseases … Other bellicose language is also used commonly to convey that serious illness is a fight, a war to win or lose. And that is not entirely untrue. Very sick people are locked in combat against a host of debilitating symptoms and, ultimately in many cases, an eventual decline.

This mentality lies deeper than a lack of education about the nature of hospice, according to Howlett. It ties into something more primal.

“If we want to improve the patient experience, we have to stop treating hospice resistance as an educational gap,” he wrote. “It is a loss aversion problem. In behavioral economics, the pain of losing something (in this case, the identity of a ‘fighter’) is twice as powerful as the joy of gaining something (comfort and peace).”

Of course, patients on hospice tend to live longer than others, according to a substantial body of research. Here’s one study on this from the Journal of Symptom Management. But most people don’t know that, so this is generally not included in the public discourse about the end of life. People don’t think about hospice this way: That when you are getting good care, you can stabilize and persist.

But what concerns me, and Howlett, is framing terminal illness as “losing.” Of course, hospice patients and their families are facing a loss. But, as the warrior mentality may imply, they are not “losers,” and accepting hospice care isn’t a defeat. Hospice election is not a defeat, but a choice to strive for a better quality of life rather than a longer life.

As Jimi Hendrix said: “I’m the one that’s got to die when it’s time for me to die, so let me live my life the way I want to.” This extends even into our final days and moments.

Howlett’s piece is thought-provoking, and I hope you check it out. I’d love to hear what you think about the idea of a “warrior mentality” and how it affects end-of-life choices.

Another good read was my colleague Holly Vossel’s article on Hospice News a few days ago on the ways that fraud is heating up in Texas – one of the four “hotbed” states for malfeasance, along with Arizona, California and Nevada. Georgia and Ohio should also be on your radar.

Right now, the eyes of the hospice community and the U.S. Centers for Medicare and Medicaid Services (CMS) are fixed on California in our fight against fraud. This is important, but we also have to remember that this problem extends beyond that state’s borders.

Today, I want to talk about mental health — because mine is shot! OK, that’s a joke. I’m fine, though I do see a psychologist weekly for PTSD treatments, and it has vastly improved my quality of life.

Behavioral health care services are essential to many people in the United States and demand is going strong. In the midst of this, several hospices are stepping up to provide an expanded suite of mental health services that go beyond traditional bereavement care. I don’t think this is common enough to be considered a trend, but it would be great if it became one. For now, a few hospices here and there are moving in that direction.

I covered one of these yesterday on Hospice News: Community Hospice and Health Services in California. I won’t recap the entire article, but here are some of the essentials:

In addition to its bereavement care program, the nonprofit launched Hope Counseling Mental Health Services to provide talk therapy for community members needing additional support. The center is staffed by licensed clinical social workers and a marriage and family therapist, according to Monica Ojcius, director of strategic development at Community Hospice.

Ojcius said the initiative reflects the organization’s broader goal of delivering whole-person care. Clients at the center seek treatment for anxiety, depression, relationship challenges, substance use disorders, post-traumatic stress disorder and other concerns. The center currently serves 107 clients and has treated more than 500 people over the past five years, Ojcius said. Those served include children, adolescents and adults.

Community Hospice is not alone in this. The first time I saw a hospice do something like this was Maine-based Androscoggin Home Health Care + Hospice, which in 2022 acquired behavioral health care company Care & Comfort for an undisclosed sum. Androscoggin has since rebranded as Andwell Health Partners.

According to CEO Ken Albert, the decision to purchase the company was based on four key factors: Care & Comfort’s strong community reputation, its financial performance, low employee turnover, and staff members’ positive view of the organization.

The decision to add these services to the organization’s portfolio followed a community health needs assessment that the Internal Revenue Service requires hospitals to conduct every two years, Albert said.

Over the last three assessment cycles, behavioral health has consistently ranked among the top 10 most pressing needs in each of Maine’s counties, with demand continuing to grow. The 2021 assessment identified behavioral health as either the No. 1 or No. 2 community health need in all counties, with particularly high need in rural areas.

This reflects national trends, in which demand for behavioral health care is rising. The share of adults reporting they received mental health counseling in the past year rose from 10% in 2019 to 13% in 2022, according to the Kaiser Family Foundation. Over the same period, the proportion of adults who said they took prescription medication for mental health conditions increased from 16% to 19%.

This marks not only a growing need in U.S. communities, but a good business opportunity. A huge proportion of the demand for mental health services goes unfulfilled. So room exists for hospices to expand into this arena. It also opens up opportunities to work with new payers, including commercial plans and Medicaid.

The U.S. Health Resources and Services Administration (HRSA) has called the lack of sufficient behavioral health care resources a “mental health crisis.” As of December 2, 2025, 40% (137 million) of the U.S. population lives in a Mental Health Professional Shortage Area, the agency reported.

In 2024, approximately 62 million U.S. adults (23%) had a mental illness and nearly half of them did not receive treatment (48%), the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) reported.

Another hospice that has invested in this space is MiraSol Health in South Carolina. Just last June, the company launched its own mental health program called Rays of Hope Behavioral Health. The program provides both individual and group therapy sessions, offered in person and through a secure telehealth platform. Through Rays of Hope, MiraSol’s licensed therapists support patients and families coping with anticipatory grief, caregiver stress, loss and other challenges associated with chronic, serious or terminal illness.

The home health and hospice provider VNA Health also developed a behavioral health program internally, citing the widespread gaps in need and hospices’ longstanding mission to provide psychosocial support. Programs like these expand that mission beyond a providers’ hospice patients and their families.

I applaud hospices that are seeking new ways to serve their communities and meet unfulfilled health care needs, especially since they are also taking on new challenges. The staffing shortage that afflicts hospice providers, for example, also plagues the behavioral health space. Hospices also have to develop new skill sets and partnerships to support their mental health programs.

Nevertheless, behavioral health has all the makings of a solid investment and a noble expansion of the hospice mission.

What do you think? Should more hospices be doing this? Let me know in the comments or in the Notes section!

And if you’re interested in staying up to date on the latest news and trends in the behavioral health sector, you can subscribe to Hospice News’ sister publication, Behavioral Health Business.

As I report for Hospice News, I like to keep tabs on what industry leaders see as the major trends in the space. Today, I am thinking about headwinds.

Looking back at some of the conversations I have had recently, several obstacles to hospice growth have risen to the top.

Staffing, as always

First, there’s the perennial problem of staffing. As the population ages and demand continues to accelerate, hospices need to ensure that they have enough people in place to take care of that influx of patients. This is easier said than done. Some have also seen a range of uncertainties creep into the space, particularly around regulation.

Here’s a few comments I’ve heard recently:

“The headwind everywhere in this industry is staffing, and there’s always the unknown. What will Medicare do? What will they change? What proposals are being talked about? Which ones will it be? I worry about that when they happen. I mean, you stay nimble; you stay quick, and you have the right staff. Then you react, because if you start trying to react, you’re reacting to something 20 times before you ever get there, and you just waste a lot of energy.”

– Dale Clift, CEO, Enhabit Inc.

“We have to pay attention to staffing. If we do not want patients or families to feel abandoned or have prolonged suffering, we’ve got to make sure that the staffing ratios and number of patients are reasonable”

– Dr. Kristin Ann Keefe, chief medical officer, Care Synergy

Fraud and regulation

Of course, hospice fraud is a huge concern. We’ve reported on that extensively on Hospice News, with this being the most recent piece on CMS’ apparent lack of response to payment suspension rebuttals.

Program integrity is a huge issue for providers, not only to preserve ethical use of the Medicare Hospice Benefit, but also in terms of how they wrestle with regulatory actions that can affect them directly.

Case in point, CMS has implemented a six-month moratorium on home health and hospice enrollment in Medicare. Providers are also facing an onslaught of audits, and some have had their Medicare payments suspended due to live discharges.

This is what some hospice leaders had to say about the issue:

“One of the most important issues right now is program integrity. There is absolutely no room for fraud, waste or abuse in hospice. I think everybody agrees with that, or should. The vast majority of providers are already delivering high quality care, and the Alliance supports efforts to strengthen program integrity and protect that benefit.”

– Jennifer Sheets, president and CEO, National Alliance for Care at Home

“Regulations are always changing. It seems you get through one new iteration and you have to go through another one. We’re doing quality work if we’re following the standards and regulations, they are set up to provide quality care. The more changes are made, sometimes it’s very stressful and costly and that’s a challenge.”

– Jennifer Sheets, president and CEO, National Alliance for Care at Home

Reimbursement pressures

Hospices are also being asked to do more with less. Although Medicare reimbursement has seen modest increases, these adjustments have not kept pace with inflation or the rising cost of care.

Many providers — particularly nonprofit organizations — are experiencing margin compression, forcing difficult decisions and, in some cases, service reductions. In this environment, organizations must rethink how they operate, identifying opportunities to improve efficiency while maintaining quality.

These are some of the things I’ve been hearing:

“One thing I would say that is certainly top of mind for me when we think about hospice, is obviously inadequate reimbursement. We know that inadequate reimbursement has meant that operating environments continue to be challenging for hospice providers. Years of insufficient payment adjustments have led to difficulties keeping up with cost of labor, inflation and more.

Hospice is proven right to save Medicare millions and millions of dollars when compared to other settings. So we know this investment in hospice reimbursement would actually support our Medicare Trust Fund in the long term.”

– Jennifer Sheets, president and CEO, National Alliance for Care at Home

“The reimbursement rate shifts have also made it so we’re doing more with less while there are workforce shortages. It’s hard to be able to pay more and hold onto staff. It’s also very emotionally draining for staff who are out there every day. Hospice staff are usually paid less than hospital staff because of the reimbursement benchmarks and different state payments.”

– Jennifer Sheets, president and CEO, National Alliance for Care at Home

“Funding is always on the chopping block in this day and age. It’s always shifting and changing. Along with that are regulatory shifts. It’s very challenging to keep your eye on quality. There’s so much talk about fraudulent hospices and the terrible care being provided.”

Chantale Patterson, executive director, Hospice & Palliative Care of Martha’s Vineyards

Late referrals, admissions

Finally, even though demand is rising, many of those patients are coming to hospice too late in the game to receive the full range of benefits. Some patients are on service only for days or even hours.

Consequently, many forward-thinking hospices are diversifying their services into things like palliative care, among others, to reach patients sooner in their disease trajectory.

Here’s one insight I’ve heard on the topic:

“As you talk to hospice leaders, of course, you hear us lament — the late referrals to hospice care, the short length of stay. In my last two or three roles I have really seen this trend accelerating, where people are coming to us later than ever. So we spend a lot of time thinking about how can we in a meaningful way get upstream in the ways that we talk about and actually impactfully intersect with patients who need hospice and palliative care at the right juncture.”

– Karen Brubaker Miller, CEO, Lower Cape Fear LifeCare

But back to business …

I published an interview on Hospice News a couple of days ago with Dale Clift, the newly appointed CEO of Enhabit Inc., and I would like to expound on that here. In particular, I want to talk about the company’s future in terms of M&A.

Since its inception as a spinoff from Encompass Health (NYSE: EHC), Enhabit has relied largely on a de novo strategy with a goal of opening 10 new locations annually. Now, I believe, the company will step into the M&A market in a big way.

Part of the impetus behind this is the company’s recent acquisition by the private equity firm Kinderhook Industries for $1.1 billion.

Clift has a longstanding relationship with Kinderhook. According to his LinkedIn profile, Clift served nearly 10 years as CEO of Trilogy Home Healthcare and almost 11 years as president and CEO of Nurse On Call, both Medicare-certified home health agencies. Nurse On Call and Trilogy were both Kinderhook-backed investments that exited in 2012 and 2023, respectively.

Typically, PE firms try to grow their assets through “roll up” acquisitions designed to build value in their portfolio companies for an eventual sale. This is likely to occur with Enhabit.

Secondly, the current six-month moratorium on Medicare enrollments for hospices and home health agencies could make it more complicated to launch de novos. Clift said as much during our interview.

“[The moratorium] would slow down opening brand new branches for a while. It doesn’t necessarily stop you from buying something if you see some right opportunities,” Clift told me. “So I think you have to just do a reallocation. Before, we had people planning all the new branches we wanted to open up. Now we take those people and help them find some more opportunity to buy some mom-and-pops, or maybe some medium-sized ones.”

Clift said that Enhabit plans to “aggressively” grow its hospice business, with greater emphasis than its home health side. Currently, the company’s home health segment is much larger in terms of revenue than its hospice operations, and they want to reduce that differential.

I think in the coming years we will be reporting on a slew of Enhabit transactions.

Question: Is your organization considering buying or selling a hospice this year? What’s the market looking like to you?

Hospice News is a place for strict objectivity and factual reporting, but here at Inside Hospice I am able to be more expressive of my own opinions and perspectives. So, herein, I am going to do something I have never done before in my 26 years of journalism: I am going to endorse a piece of legislation.

I believe that Rep. Beth Van Duyne’s (R-Texas) recently proposed Protecting Seniors and Stopping Fraudsters Act represents a proactive, common sense approach to tackling hospice fraud. While a single bill or enforcement action is unlikely to eliminate all fraud, this could go a long way at stemming the tide of unethical and criminal behavior in the space.

I covered the bill in detail here on Hospice News. But here is a quick recap of its major provisions:

• Increased survey frequency for newly enrolled hospices and home health agencies, providers with ownership changes, or providers displaying signs of fraudulent behavior

• Enhanced screening requirements for providers deemed at “extreme risk” of fraud, including fingerprinting administrators and medical directors and requiring proof of liability insurance

• Greater accountability for accrediting organizations through standardized survey training requirements

• New beneficiary notification requirements to ensure seniors know when they have been enrolled in hospice and understand how to disenroll if fraud or abuse occurs

• Annual reporting to Congress on U.S. Centers for Medicare & Medicaid Services (CMS) program integrity activities, enforcement actions, fraud trends, and efforts to reduce unnecessary administrative burden on legitimate providers

While more frequent surveys and enhanced screening requirements could become cumbersome for some providers, this may be a necessary sacrifice to save the hospice community from scammers. This could help identify the bad actors, as they are often called, earlier and more effectively. Key to this will be how it will be implemented. CMS, state agencies and accreditors will have to make sure they are looking for the right things on those surveys, including potential indicators of fraud.

Standardized training for accreditation agencies could support this. In the course of previous, award-winning reporting by Hospice News, we were told by multiple sources that many of the fraudulent companies were accredited. The California Hospice and Palliative Care Association (CHAPCA) also sounded the alarm on this in a 2024 letter to CMS.

Previous attempts by CMS or Congress to strengthen accreditation oversight and processes either didn’t go forward or didn’t accomplish much in terms of reducing fraud. Standardized training could improve accreditors’ effectiveness in fraud identification. This could also strengthen and inform the implementation of more frequent surveys, if that portion of the bill is enacted.

Full disclosure, prior to joining Hospice News, I worked in The Joint Commission’s publishing arm for 11 years. For most of that time my work was focused on the hospice accreditation manuals as well as patient safety issues.

Personally, I think notifying patients or issuing an explanation of benefits to patients when they are enrolled in hospice is a great idea. One common tactic used by these scammers is enrolling beneficiaries in the Medicare Hospice Benefit without their knowledge or consent. In some cases, these patients have been denied other forms of health care because, on paper at least, they were on hospice.

Due to payment cap restraints, this has also interfered with some beneficiaries ability to access the benefit when they truly became eligible. A notification could help alert patients to these practices and facilitate a swifter response.

Enhanced screening requirements for new hospice owners at extreme risk of fraud, including fingerprinting, could also help identify fraudsters as well as create new barriers to entry. Some owners and executives at fraudulent agencies have actually used fake identities or proxies to set up their hospices, something that enhanced screening could help mitigate. However, we will need specific, evidence-based criteria to define “extreme risk.”

Finally, greater oversight by Congress of CMS’ efforts to root out fraud would likewise be a good thing and could potentially strengthen the agency’s approach. I like that, under the bill’s current language, it would also take into account the potential burden on legitimate providers.

Rep. Van Duyne is a Republican, and I am not. But I believe that this is a time for solutions, not partisanship. I expounded on this in another recent Inside Hospice post. I have met and interviewed Rep. Van Duyne a couple of times, and she has been a tireless advocate for hospice program integrity.

Congress should pass this bill, and it just might. The legislation recently cleared one hurdle in the legislative process; the House Ways and Means Committee has allowed it to move forward. Without this approval, the bill would have been dead on arrival.

To be honest, after more than two decades of trying to keep my personal opinions out of what I write, penning this endorsement feels kind of weird to me, a little like putting my left shoe on my right foot. Nevertheless, I stand by it.

Well, we finally had a couple of warm days here in Chicago, but now it’s chilly again and the Heilung hoodie is back on. Heiling is a group that plays pre-Viking traditional Nordic music and does spectacular live performances. It’s weird, interesting music.

But that’s not what I am here to write about today. I am, unfortunately, going to say more about hospice fraud and the U.S. Centers for Medicare and Medicaid Services’ (CMS) enforcement actions.

CMS has suspended Medicare payments for close to 800 hospices to date, along with a contingent of home health agencies (I should also note that before these measures, the agency also put a moratorium in place for durable medical equipment suppliers, too).

However, in hospice’s case, some of these providers are legitimate and have not been implicated in criminal fraud. Instead, they are largely being targeted based on a single metric — live discharges. Check out our Hospice News coverage here.

We went to some tried-and-true sources for that story – people we have worked with for years. We also got information from CMS, including comments directly from the agency’s administrator, Dr. Mehmet Oz. Finally, we interviewed one of the hospices that received a payment suspension letter, who spoke on condition of anonymity.

Hospice News also got a number of off-the-record comments that we couldn’t publish, but gave second- or third- source confirmation of the details our on-the-record sources told us.

We have a forthcoming follow-up story in the works with additional details.

I thought it would be instructive for our readers to actually see one of the payment suspension letters that CMS’s Unified Program Integrity Contractors (UPICs) are sending out. See it below. While Hospice News only examined one letter, multiple sources confirmed that it fits a pattern — citing live discharges as the reason for the suspension and identifying five patient records. The letter is redacted to remove information that identifies the organization or their patients.

Admittedly, we don’t know exactly how many of the nearly 800 hospices who received these suspensions are legitimate operators, and we have to acknowledge that some fraudulent providers are being suspended or shut down. But multiple sources have told us that the issue is widespread, and legitimate hospices are getting suspensions.

Some are even going out of business as a result.

What’s your take on this issue? Please drop a comment. I would love to hear your thoughts.

After spending a couple of days pondering the various viewpoints, I have to come out and say that I think it’s a bad idea for the U.S. Centers for Medicare & Medicaid Services (CMS) to implement a moratorium on new hospice and home health provider enrollments.

We can pick our metaphors. CMS has been accused by stakeholders in the space of using a “sledgehammer” or a “chainsaw” to excise fraudulent operators, rather than a “scalpel,” which many consider to be a better metaphorical tool.

Most of the documented fraud in the space has occurred in a handful of states, and I think actions targeted to those regions would have been a better option. A temporary moratorium might provide regulators with critical time to tighten oversight, investigate suspected misconduct and stop organizations already under scrutiny from continuing to grow. Yet a nationwide freeze is a broad response to what remains a relatively concentrated issue.

It’s true that there would be some risks with a geographically targeted moratorium, such as fraudsters simply shifting their operations across state lines. But it’s an open question whether the nationwide six-month moratorium meaningfully limits that ability.

And this raises the questions about whether the six-month moratoria will be extended. Is this intended to buy CMS time to prepare for further actions? The value of the moratorium could be determined by what the agency does next.

But the possibility exists that this was a big, bold move that risks doing little to solve one of the industry’s major problems – rampant fraud in certain areas – while exacerbating another of the sector’s top challenges: lack of care access.

In certain rural and underserved areas, a legitimate need persists for additional high-quality hospice providers. After all, only about half (53%) of the Medicare decedents who could potentially benefit from hospice actually receive it. Though some of that number may have died suddenly, certainly a large number could also have benefited from hospice, and some may live in regions in which capacity has not caught up with demand.

Questions also circulate around providers’ ability to use telehealth during the moratorium period, particularly hospice recertifications. Federal law states that if a moratorium were implemented, telehealth hospice recertifications would no longer be allowed.

CMS, however, has said in a statement that existing telehealth flexibilities will remain in effect during the moratorium. The apparent contradiction between the CMS statement and the statutes puts providers in a gray area, with some uncertainty about what they are able to do. This perpetuates a maddening cycle of ambiguity around telehealth policy that has limited this technology from achieving its full promise, as providers and tech innovators alike are hesitant to make meaningful long-term investments without a solid regulatory framework.

Hospice News has sought clarification from CMS on what the actual policy is related to recertifications during the moratorium, but as of today we haven’t gotten an answer. We’ll keep you posted.

Another problem on our radar is the barrage of payment suspensions that many providers nationwide are facing. CMS has suspended payments for more than 700 hospice and home health agencies, due to suspicions of fraud. However, some legitimate providers are being caught in the dragnet and may not be able to survive, further diminishing access to quality care. Check out our Hospice News coverage on this issue here.

What do you think about the moratorium? I’d love to hear your thoughts in a comment or message. To explore this more deeply, my colleagues at Home Health Care News and HME Business are planning a webinar to discuss the issue on June 23. Save the date!

I have to acknowledge that my perspective on the moratorium is coming in its earliest days, and developments to come could change my mind. I’ll have my eye on a few things to solidify my point of view on it, including clarity around telehealth, further CMS action during the freeze, how the agency communicates its progress and intentions and its longer-term impact on the hospice community.

Big news this week: CMS announced a six-month national moratorium on hospice enrollment in Medicare, in a move aimed at curbing waste, fraud and abuse. I’ll share more thoughts on this move in upcoming posts here, and in the meantime, you can read our Hospice News coverage.

Now, on to our regularly scheduled programming:

I was honored to be asked to present at a board meeting of a nonprofit hospice last week. It was a good time. I talked a lot about trends that were happening now in the hospice space and about the direction I think the hospice community is heading.

I would like to share some of my thoughts about one of the topics I spoke about — the potential for some type of concurrent curative and hospice care.

But first, if you haven’t seen it, check out my last post on the urgent needs of hospice family caregivers.

Concurrent care in hospice settings could expand options for patients and families while easing concerns about losing access to additional treatment.

I believe that fears surrounding hospice enrollment — particularly the worry that patients may be unable to receive other needed services — could diminish if concurrent care were more widely available.

It’s also important to note that while distinctions between curative care and palliation may appear straightforward in policy, the reality is often far more complex. Consider the example of radiation treatments that can be used for both curative and palliative purposes. These treatments are often discontinued when a patient enters hospice, even though the patient may still be able to benefit from them in some ways.

The U.S. Centers for Medicare & Medicaid Services (CMS) has also been thinking about this. In recent years, the agency has issued several requests for information regarding the provision of what it calls high-acuity palliative services, like radiation, chemotherapy, dialysis and blood transfusions.

One of the most closely watched examples of how concurrent care could work is the Medicare Care Choices Model (MCCM), a demonstration project launched by the Center for Medicare & Medicaid Innovation between 2016 and 2021 to evaluate the effects of allowing concurrent hospice care.

According to a 2022 report, the model included roughly 4,500 Medicare fee-for-service beneficiaries who had died by March 2021. Participants had a six-month terminal prognosis and diagnoses including cancer, congestive heart failure, chronic obstructive pulmonary disease or HIV/AIDS. Patients were referred to one of 141 participating hospices nationwide.

The model had limitations, including relatively low participation. At the time, nearly 5,000 hospices operated nationwide, while approximately 1.7 million people elected hospice care annually. By comparison, the MCCM enrolled only 4,500 beneficiaries across 141 hospices.

Researchers noted that while the results were statistically significant, questions remain about how broadly the findings can be applied. As with many demonstration projects, the possibility exists that unobserved differences among participants or providers may have influenced the outcomes.

Despite these lingering questions, we can’t throw the baby out with the bathwater.

The MCCM ultimately found that concurrent palliative and curative services reduced total costs of care by 14% compared with a control group — approximately $7,500 in savings per patient.

The model also demonstrated reductions in emergency room visits and ICU utilization while increasing the number of days patients were able to remain at home, outcomes that contributed to the overall cost savings.

Policymakers, in addition to CMS, are also beginning to ask questions about the potential for concurrent care.

During a visit to Capitol Hill a couple of years ago, I met with some of the lawmakers from both sides of the aisle, and some members of Congress brought up the potential for concurrent care. It honestly kind of surprised me that they knew what it was, but concurrent care was on their radar.

I think that examining concurrent care as a strategy could improve utilization, reduce overall health care spending and support aging in place — outcomes viewed as both patient-centered and cost-effective by most stakeholders.

What do you think about the prospect of concurrent care? I would love to hear more about the individual provider perspective on this. Please drop a comment or send me a message.

Notable quote

I came across this remarkable quote about bereavement from musician and author Nick Cave, who has frequently spoken publicly about grief since the loss of his parents and two of his sons.

“Grievers point the way towards tending a world many of us feel is in urgent need of reparation. These apprentices of loss are the holy ones who, for an excruciating time, live in acute and shocking proximity to the essence of things. They stand at the point of revelation, deep in grief, blindly gesturing towards some unbidden thing, unaware that the unbidden thing is grief’s own outrageous beauty awaiting them. They have shown me the way forward, and I love them for that.”

I thought there was a lot of beauty and truth in Cave’s words, which he wrote on his Red Hand Files website.

I watched my sister struggle for years as a caregiver to her son Joshua who had cerebral palsy and a number of related conditions. This ruled her life until he died in hospice care at age 14.

Also, I have my own experience as a caregiver. I provided a great deal of help to my older brother who had congestive heart failure. He served in Operation Desert Storm in Kuwait and Iraq and acquired an infection that his doctors were never able to identify. This caused the heart failure, which he lived with for more than 10 years until his transplant.

Finally, I helped my dad care for my mother who died in 2023 after a long series of illnesses precipitated by implantation of a pacemaker that was contaminated with MRSA, which caused a year long decline leading to her death. She died without the benefit of hospice, largely because no one would tell us if she was terminally ill, even when asked directly.

Without family members providing care at home, services such as hospice and home health care would be far more difficult — if not impossible — to sustain. In response, hospices and other health care organizations are expanding efforts to better support family caregivers, especially as respite care and other assistance remain in short supply.

Consider a few stats that highlight why family caregivers are so crucial to the way hospice care currently is delivered in the United States:

• An estimated 63 million Americans currently provide ongoing, complex care to children or adults with medical conditions or disabilities, according to a 2025 report from the National Alliance for Caregiving and AARP. Altogether, family caregivers now represent nearly one-quarter of the nation’s adult population, a 45% increase since 2015.
  
  

• As the U.S. population ages, caregiving demands are expected to grow. The U.S. Census Bureau projects that by 2030, about one-quarter of Americans will be over age 65, and the Administration for Community Living estimates that two-thirds of adults will need daily caregiver support at some point. At the same time, rising healthcare costs and a shift toward home-based care are increasing reliance on family members.
  
  

• Caregiving often affects caregivers’ own health, especially among older adults or those managing chronic conditions. The Centers for Disease Control and Prevention reports that nearly 20% of unpaid caregivers fall into these higher-risk categories.
  
  

• The financial burden is also substantial. Of the nation’s 48 million unpaid family caregivers, nearly three-quarters spend more than $7,200 annually on caregiving-related expenses, according to AARP—costs that can represent about 26% of household income. These expenses may include medical care, non-medical support, housing, and lost wages. About 30% help pay for a loved one’s rent or mortgage, and 17% contribute directly to medical expenses.
  
  

• Research published in BMC Palliative Care (2020) links caregiver financial strain to a range of negative outcomes, particularly for families already facing economic disadvantage, and suggests these pressures can contribute to inequities in access to hospice and palliative care services.

Beyond measurable financial costs, caregiving often brings sustained emotional and physical stress. Many caregivers experience prolonged periods of anxiety and exhaustion while balancing work, family responsibilities and medical decision-making.

Families are also being asked to perform more complex medical tasks. When my mother was dying, for example, she needed home infusions. I thought a clinician was going to come into the home to do this, but instead someone dropped off the supplies like we ordered the pizza. I remember watching YouTube videos trying to figure out how to do this, incredibly anxious that I was going to harm her.

The health care system faces challenges in adequately supporting caregivers of seriously and terminally ill patients. Limited assistance and respite options can create barriers to hospice enrollment and home-based care delivery. Studies have also shown that patients nearing the end of life may be less likely to elect hospice care without dependable support from family or friends.

In response, several organizations and health systems have introduced caregiver-focused initiatives.

Croí Health, based in Massachusetts, recently launched a monthly support group for adult caregivers of oncology patients, offering emotional guidance and practical resources for families navigating cancer care.

Meanwhile, Hospice of the Chesapeake in Maryland has implemented a standardized caregiver training program aimed at strengthening and formalizing existing support efforts.

Arkansas-based Hospice of the Ozarks introduced a non-medical caregiver education initiative called Care Coaching. Offered free of charge, the program provides family caregivers with phone support, in-home visits, and assessments conducted by interdisciplinary hospice staff.

Health systems are also expanding services for caregivers.

At RUSH University Medical Center, the Caring for Caregivers (C4C) program supports individuals caring for adults aged 60 and older at home. The initiative helps caregivers address anxiety, depression, and daily caregiving challenges while connecting them with hospital and community resources. Participants undergo assessments to evaluate caregiver burden and mental health needs.

In New York City, Mount Sinai Health System opened the Steven S. Elbaum Family Center for Caregiving in January 2025. The center includes a dedicated caregiver clinic and expanded psychosocial support services for patients’ family members and close friends. In collaboration with Center to Advance Palliative Care, Mount Sinai is also developing caregiving models and operational frameworks intended for broader adoption across health systems nationwide.

As awareness of caregiver strain grows, health care providers are increasingly recognizing the essential role families play in sustaining home-based and end-of-life care. However, these efforts to date are but a drop in the bucket. We need broader, system-wide solutions.

I recently had the pleasure of attending a reception at Chicago’s fantastic Shedd Aquarium with a group of nonprofit hospice providers. It was a fun night filled with some great conversations with hospice leaders, coupled with some glasses of a nice cabernet.

Before I share a story from that evening, here’s a reminder to check out my last Inside Hospice post, “In Hospice, Quality is King.”

One of the conversations I had at the aquarium was with Bill Finn, CEO of Reserve Care in Ohio, formerly known as the Hospice of the Western Reserve. As the aquatic creatures of the Amazon swirled around us in their tanks, Bill recounted an experience he had the year prior with direct relevance to the rash of hospice fraud happening in this country.

Kindly, Bill gave me consent to share his story with all of you. Here it is in his own words:

“When I was attending the [National Partnership for Healthcare and Hospice Innovation (NPHI)] conference in Las Vegas last year, I had a very interesting and upsetting discussion with an Uber driver.

Upon hearing that I was attending a hospice conference, the driver exclaimed ‘I’m starting my own hospice! My ex-wife started a hospice, and now she is a millionaire. She hired a doctor who doesn’t see patients but signs anything she needs signed. She is rich! I only need $300,000 to start my hospice, and I am ready to get going.’

When I exited the Uber, I shared that part of my role as the CEO of a community-based, legacy not-for-profit hospice is to protect our community from fraudsters and profiteers. I shared that, if what he described was true, that his ex-wife may very well be committing Medicare fraud, and he would be doing the same.

The gentleman listened, not having any idea of the regulatory requirements, or any notion of quality care or patient service, just thoughts of a get-rich scheme. He pondered my comments, then said, ‘Well, my ex-wife does have a restraining order against me, so maybe I will report her to Medicare for fraud.’

This is a true event which I shared with Kim Brandt, COO of [the U.S. Centers for Medicare & Medicaid Services (CMS)] the same day.”

If you knew how hard I am resisting the urge to devolve into a stream of angry profanities right now, you would be so proud of me. It sickens me to see people who see the sacred work of hospice as a quick way to make a buck while showing absolutely no concerns for the patients they are supposed to be serving.

Likewise, I have to praise Bill’s restraint for not punching the guy. Way to go, Bill.

The exchange that Bill had with the Uber driver elucidates a few issues and raises some questions. First, it provides a look at just how easy it is for fraudulent providers to enter the market and rake in vast sums of money that should be going to support the seriously ill and the dying.

Clearly, we need to strengthen barriers to entry that help prevent bad actors from starting hospices while also ensuring that patients have ample access to care. Balancing those two goals is a complex proposition, but regulators must find a way, be it through a Certificate of Need process or by otherwise strengthening scrutiny of new providers seeking Medicare enrollment.

Regulators also need to take a close look not only at the hospices, but at the physicians who are making these referrals. What do they know about the hospices to which they are sending their patients? What do they understand about hospice fraud and how to spot it? How many are deliberately complicit or taking kickbacks?

It also raises the question of to what extent plain stupidity – or, to be more charitable, ignorance – is contributing to hospice fraud. Like the Uber driver, some of these people may not even understand that what they are doing is illegal, though most probably do. That is not and never can be an excuse, but if this is part of the problem, it must be examined. Perhaps CMS or state agencies should require some type of education for new hospice owners about what constitutes fraud and the consequences they may face when they’re caught.

Such education could potentially help honest providers avoid mistakes that could get them in hot water or adversely affect patients — and hopefully scare some the scammers away.

I would love to hear your thoughts on this. Please send me a note or make a comment.

Before I get too deep into my thoughts for today, please check out my last post on how home-based care can relieve overcrowding elsewhere in the health care system.

The theme at NPHI this year is Quality in Action, and that concept guided many of the event’s discussions.

I had the opportunity to sit down with NPHI Founder and CEO Tom Koutsoumpas and President Carole Fisher to talk about a range of issues facing nonprofit hospices and the provider space in general. You can see our Hospice News coverage here.

I wanted to share some words from Koutsoumpas and Fisher that didn’t make it into the Hospice News article.

Fisher emphasized that ensuring patients have the best possible experience at the end of their lives should be the primary quality consideration for hospices. But also, from a business perspective, prioritizing quality can give hospices a competitive advantage in the marketplace.

“We’re at a time when quality is so important for so many different reasons. First and foremost, that people help people die well, and you only have one opportunity to do that — with patients, and then supporting caregivers and the loved ones,” Fisher told me. “Then equally important is taking care of this competition situation in so many of our members’ backyards, if you will. Competition is at an all time high. So how do you fight competition?”

NPHI exclusively represents nonprofit hospices, and when it comes to competition, for-profits are often top of mind. As of 2023, approximately 75% of the nation’s hospices were for-profit companies, a far cry from the industry’s origins. At its start, hospice was almost entirely a nonprofit enterprise.

However, any provider can leverage quality to give their businesses a leg up.

A key question is how we define “quality,” and that’s a more complex question than it may seem. I am reminded of Robert Pirsig’s book Zen and the Art of Motorcycle Maintenance, in which the author spent close to 500 pages trying to answer that question. So I am not going to attempt to give a comprehensive answer, but I will talk about some of the elements of quality.

A crucial component is regulatory compliance and strong performance on publicly reported quality measures such as data from the Hospice Outcomes and Patient Evaluation (HOPE) tool and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. These are vital indicators of a quality program.

But the story doesn’t end there. Quality also includes metrics such as reduced hospitalizations and emergency department visits, as well as more intangible factors like family and caregiver support, effective and compassionate bereavement care. It ties to an essential question at the philosophical center of health care: How does the patient feel? And, for hospices in particular, how does the family feel?

“In addition to all the scores, certainly patient and family satisfaction is a huge part of it, making sure that we continue to put the patient and family in the center. Those are quality elements. So are we really living up to that?” Koutsoumpas said. “Do we create an atmosphere of trust? That’s a quality issue. So those are things that we aren’t able to quantify in numbers in the kind of things that the regulatory world does. But quality, to me, is a lot more than that. It’s about going above and beyond.”

The business case for quality is multi-faceted. Solid performance demonstrates a hospice’s potential value to referral partners, as well as payers – especially as the health care system moves closer to a value-based environment. These entities want to work with hospices that can prove their value proposition, the cost savings they generate and the patient outcomes that they achieve.

Do you agree that “Quality is King” in hospice? I would love to hear your perspectives. Please feel free to comment or send me a message.