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.

I read a disturbing article today in The Atlantic about a health care exigency that puts patients at serious risk nationwide — emergency department boarding. It’s an issue with implications for end-of-life care, and one that I think could be addressed through more timely access to at-home care, including for hospice.

I’ll share more thoughts on this piece below, but first, if you haven’t seen my post from last Thursday about the ways that hospice fraud is being politicized, check it out here.

And, if you’ll be at the NPHI Conference in Chicago this week, look for me or shoot me a note. I’ll be there and would love to connect with folks.

The Atlantic piece by Elisabeth Rosenthal, a former ED physician turned author and journalist, focused largely on her personal narrative about her late husband’s health care experience in hospitals near the end of his life, along with other valuable context. In at least once instance, he languished in an ED for days awaiting an inpatient bed, even though he had been admitted to the hospital (and was being charged an inpatient rate).

This is emblematic of a severe national problem that puts patients at risk.

“Emergency department (ED) boarding is a public health crisis in the United States, with harmful impacts on patients, hospital staff, and public safety,” the U.S. Agency for Healthcare Research & Quality (AHRQ) stated in a 2024 report. “Patients who are sick enough to require inpatient care can wait in the ED for hours, days or even weeks after a physician has decided to admit them while waiting for an inpatient bed to become available.”

Among 46.2 million hospitalized patients between 2017 and 2024, more than 40% were boarded in the ED for longer than four hours, and 6.3% were boarded for more than 24 hours, a 2025 study published in Health Affairs found. Now, 6.3% doesn’t sound like a huge number, but out of a population of that size it amounts to nearly 3 million people.

Other research bears this out. For patients whose acuity levels require immediate care (less than one minute), the average wait time is 28 minutes, according to data from the Government Accountability Office. The percentage of those visits in which the wait time exceeded recommendations was close to 74%.

For patients with “emergent” acuity, the recommended response time is one to 14 minutes, GAO indicated. But their average wait time is 37 minutes. More than 50% of cases exceeded the recommended time frame.

The causes of this are multi-faceted. Widespread staffing shortages throughout the health care system is a main driver, among a range of other factors. Also, as AHRQ lays out, hospitals have financial incentives to reduce bed counts and prioritize patients receiving more lucrative elective treatments.

“A longstanding focus on shifting the U.S. health care system toward outpatient care has reduced the number of available inpatient beds, while the number of ED visits requiring admission has increased,” AHRQ reported. “To ensure their financial well-being, hospitals prioritize higher revenue patients, such as those needing elective surgery, over lower-revenue patients, such as those admitted through the ED. Delays in discharging inpatients, including those resulting from prior authorization and other administrative requirements, prevent hospitals from making inpatient beds available efficiently for ED patients.”

Efforts to address this issue have trickled through the system. For example, the U.S. Centers for Medicare & Medicaid Services (CMS) has developed a voluntary reporting system for ED boarding times that will begin in 2027 and become mandatory in 2028.

But ultimately — despite a lot of talk — the system and government stakeholders are not doing enough.

“Despite more than 25 years of incontrovertible scientific evidence that the practice is associated with significant harm, little progress has been made in confronting its structural and economic drivers at a national scale,” AHRQ indicated.

The care-at-home solution

One potential mitigator for this crisis is rarely discussed: Care for more patients at home.

Earlier and easier transitions to hospice or home health have repeatedly been proven to reduce emergency department visits and hospitalizations, generating billions in cost savings and improving patient outcomes. Further investment in home-based services, including emerging models like hospital-at-home, could help relieve the burden on hospitals and prevent patients from suffering on stretchers in overcrowded ED hallways or overflow areas.

Of course, not every patient is eligible for hospices or home health, but I feel fairly certain that more could receive that care than actually do.

Hospice and home health providers can’t solve the problem of emergency department boarding, but they could definitely help. But first we have to help them.

Easing some of the restrictions for accessing those services, such as the woefully outdated six-month terminal prognosis requirement for hospice, could also foster greater utilization and help keep patients where they belong and where they prefer to be.

Home-based care providers should also be getting more robust reimbursement increases that actually meet or exceed inflation rates so they can increase capacity and improve access for more patients. This would only benefit patients, families, providers and the system at large.

I would love to hear your thoughts on issues in the larger health care system that hospices can help address. Please drop a comment or send me a message.

The government is turning up the heat on hospice fraudsters. However, policymakers and legislators are getting lost in partisan politics that only complicate and hinder real solutions.

Fraud causes significant harm to patients, families and the taxpayers who fund Medicare, as well as legitimate providers. This needs to stop now, and that will require a robust government response.

Both Democrats and Republicans have decried fraud in the hospice and home health space. And I understand that a certain amount of political grandstanding is a standard part of Congressional hearings and other governmental actions. Nevertheless, members of those parties are growing increasingly focused on pointing fingers at each other, which distracts from the real issues.

Consider these remarks from Rep. Jason Smith (R-Mo.), chairman of the House Ways & Means Committee:

“Democrat governors and states have let these and other fraud schemes fester and even encouraged them for years. When the truth about the systematic, systemic fraud came out, they questioned why it was their states that were under investigation. The real question is why Democrat governors like Gavin Newsom and Tim Walz allowed Medicare beneficiaries to become easy targets for fraudsters for so long. The Trump administration, on the other hand, has made fighting fraud a top priority.”

Smith in comments at a hearing on Tuesday also criticized the Biden Administration’s actions to root out fraud.

Smith is correct that Democrat-led California is a hotbed state for fraud, particularly in Los Angeles County, which has become a “poster child” for malfeasance. But he ignores the reality that fraud is also rampant in Republican-led states such as Texas and Nevada. Ohio and Georgia, both also controlled by Republicans, have also been identified as areas of concern for hospice fraud.

In March, the House Committee on Oversight and Government Reform announced that it would investigate hospice fraud occurring in California (but not Texas, Nevada, Arizona, Georgia or Ohio.) While Congress taking an interest is a positive step, the Oversight Committee’s announcement largely amounted to an attack on California Gov. Gavin Newsom, who is expected to run for president in 2028.

“In California, your administration’s Departments of Public Health, Social Services and Health Care Services all have a role in overseeing federally funded hospice programs. The Committee is concerned your administration does not have sufficient internal controls to prevent and detect fraud and is not conducting proper oversight of these hospice programs,” committee members wrote in a letter to Newsom. “As a result, Americans across the country are paying for California’s rampant hospice fraud and vulnerable patients are being exploited. California has a well-documented history of fraud in its hospice programs. Your administration has been aware of credible reports of hospice fraud for at least four years. Despite these red flags, it appears California has enabled hospice providers to defraud the American taxpayer and exploit vulnerable patients.”

But so far, California is the only state in this group to take meaningful action. It has imposed a moratorium on issuing new hospice licenses and introduced additional enforcement measures. Over the past two years, more than 280 licenses granted to new hospice operators have been revoked, according to the governor’s office.

The state has also established a hospice fraud task force, bringing together the California Department of Public Health, the California Health & Human Services Agency, the Department of Health Care Services, the California Department of Social Services, and the state Department of Justice’s Division of Medi-Cal Fraud and Elder Abuse.

Since 2019, investigations by the fraud and elder abuse division have led to hundreds of prosecutions. Meanwhile, public health officials have flagged about 300 hospices for suspected wrongdoing, and those cases are now under review for possible license revocation.

Meanwhile, Democrats are largely playing the same game. In the Tuesday Ways and Means Committee Hearing, Rep. Lloyd Dogget (D-Texas), took swings at U.S. Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz and Health and Human Services Secretary Robert Kennedy Jr, as well as the larger Trump Administration.

“The Trump administration has pardoned these health care criminals, fired the taxpayer watchdogs at each of the relevant agencies who detect and prevent fraud, dismissed a number of employees at CMS responsible for policing fraud, and cut essential programs that millions of Americans rely upon,” Dogget said at the hearing. “Outrageously, when anti-fraud provisions and proposals run up against some special interests that have a generous lobbyist, the anti-fraud provisions are ignored, and consumers and taxpayers pay as a result of it.”

Again, some of these remarks have some validity. Trump has pardoned a number of individuals who had been convicted of various types of fraud, though none of them were hospice operators. The administration did reduce staff at CMS and gutted inspector general offices at some federal agencies.

That said, I don’t think one can draw clear lines between those actions and the prevalence of hospice fraud. Nor do I think that complaining about these actions by Trump will protect Medicare beneficiaries or dying patients who are being ripped off or denied care.

If lawmakers are going to get involved in the fight against fraud, let’s see some real, actionable solutions to address the issue. Politicizing this process is counterproductive. We can’t stop fraud by only targeting states currently managed by a particular political party, be it Democrat or Republican. This matter requires a national, bipartisan solution that prioritizes patients above politics.

I would love to hear your thoughts on this, please feel free to leave a comment or send me a message.

I am writing to you this week from Arizona’s beautiful Superstition Mountains in the Sonoran Desert, where I am helping my dad out after a surgery. The scenery is lovely, but it’s pretty hot down here compared to my home in Chicago.

If you haven’t checked out my latest Inside Hospice post – titled “I Want to Die Here” – please take a look. I wrote it after seeing heavy metal band Converge perform, but hopefully it will resonate with metalheads and non-metalheads alike.

I want to highlight a great conversation I had with Tami Johnson-White, the new chief compliance officer for St. Croix Hospice in Minnesota, and share some of her thoughts that didn’t make it into my Hospice News article. Tami had some great insights about the importance of organization-wide collaboration to support compliance, transparency and growth.

She also had some very interesting thoughts about the way the federal government’s fraud-busting efforts affect legitimate providers and how they can navigate that. Her comments come against a backdrop of intensifying anti-fraud efforts from the federal government, with a task force recently suspending 447 hospices in California. The organizations are suspected of fraudulent activities totaling more than $600 million.

Here’s that supplemental material from my interview with Tami Johnson-White:

Do you think that the government’s efforts to fight fraud in the space are affecting legitimate providers?

It’s affecting all providers. I think the thing that I’m seeing most that is potentially affecting the good hospice providers is something that’s also affecting the bad hospice providers.

We see variations by auditor — whether it’s a [Medicare Administrative Contractor (MAC)] or a managed care company or anything else — that they do not interpret the regulations in the same way, and so much so that it is not even the same interpretation within an entity. So it is about who you got in the draw and what they believe.

That’s a strong concern for a good hospice provider, and it’s even harder on those who are doing a poor job. I think the other thing that is very hard is that producing packets and going through the process is expensive and time consuming and duplicative. And the reason I say duplicative is that we have some MACs who request the same patient’s records multiple times. So they’ve reviewed it once; they’ve made a decision. Two months later, they request it again — again the same packet, the same patient reviewed over and over and over again.

That duplicative review is very difficult, and it forces every organization to spend more time dedicated to the extra resources to meet the review process, instead of focusing on care delivery.

We have to go through audits, but they should be measured and controlled. They should aggregate the results so that they can say, “Hey, you know what, they’re doing good. Let’s look at them again in a year, instead of being a constant process that’s going on every month without end.”

I will say that with a caveat: they pretty much stop reviewing mid-November through December in many instances, so that they can take their holiday breaks and then resume again in the new year.

How can good hospices navigate some of this?

I believe culture is king. If you truly understand that you are critical to providing quality care, that it is your responsibility to be that beacon during difficult times, then that is the first thing we have to focus on.

Then we step back and learn from the results if we’re having problems in an area, whether it be through audit or through care delivery or anything else. It’s looking at the [Quality Assurance and Performance Improvement (QAPI)] process as something that is alive, not just something you do for the sake of saying you have a QAPI program. Then, make sure that those things you do well are repeatable and done by everyone.

This doesn’t mean people don’t make mistakes, but learning from those mistakes and putting that into practice can help the industry. It certainly can help every one of our organizations to be a strong, good hospice program. We should all be striving to not just be good, but to be great, and to continue that constant improvement and never be a bad actor. I hate that we have to deal with the fact that in the industry there are bad actors, but that means that the rest of us have to step up and just be the best we can be.

As always, thanks for reading, and please share any thoughts or reactions below or in the chat!

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):