Jim’s Notebook: Hospices’ Biggest 2026 Headwinds

Photo credit: GEORGE DESIPRIS

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