In an evolving payment and regulatory environment, hospices would benefit from stepping up their engagement with federal, state and local agencies and legislators.

This may be particularly urgent now, with the public comment period still open on the 2023 proposed payment rule, and as policymakers debate whether COVID-related waivers and assistance should end.

Federal agencies in particular are mulling critical decisions that would impact hospice — Medicare payment sequestration, continued access to expanded telehealth, and robust palliative care reimbursement, among others.

Providers need to advocate for themselves to ensure they understand what is at stake for providers and their patients, according to Jon Rawlson, founder and president of Armory Hill Advocates, LLC.

“I think hospice providers always need to be on the front lines of having conversations with members of Congress on how any type of change in reimbursement methodology impacts them,” Rawlson told Hospice News. “This should encourage them to have conversations at home in the district with members of Congress and congressional staff on a regular basis. And I think the smaller the provider, the more important that conversation.”

Those smaller providers often operate on razor-thin margins, meaning that even apparently slight changes in reimbursement could cause significant pain.

One example is Medicare sequestration, which reduces payments to hospices and other health care providers by 2% across the board.

Congress temporarily suspended this practice through much of the COVID-19 public health emergency, but the U.S. Centers for Medicare & Medicaid Services (CMS) began phasing sequestration back in as of April 1.

The agency will sequester 1% of payments until June, when the amount will return to the typical 2%. Some providers have said that the effects of this reinstatement could be “devastating.”

Advocates in the hospice space have repeatedly called on Congress to extend the moratorium or end sequestration altogether.

“Congress found an additional $200 billion dollars to spend above last year’s appropriations, but they ignore the plight of hospices struggling to keep their doors open with skyrocketing inflation and a health worker shortage,” said Edo Banach, president and CEO of the National Hospice and Palliative Care Organization (NHPCO) and president of the Hospice Action Network (HAN), in a statement. “Once again, our seniors and those with life-limiting illnesses get the short end of the stick.”

Though many believe the pandemic is winding down, the economic effects for providers will not disappear overnight.

​​Hospices continue to face surging costs for personal protective equipment (PPE) and COVID-19 testing kits, paid leave for staff and investments in telehealth. They have also seen declines in institutional referrals and hospice length of stay.

Providers are also contending with rising wages in an intensely competitive labor market, as well as the price inflation affecting the nation at large.

As of January, the consumer price index was up 7.9% from a year earlier, according to the U.S Department of Labor, reaching a 40-year high.

Industry groups such as NHPCO routinely engage with policymakers, as do the National Association for Home Health & Hospice, the National Partnership for Hospice Innovation, and the National Coalition for Hospice and Palliative Care, among others.

But more can happen at the grassroots level, even for organizations that do not have room for campaign donations in their budget.

This includes giving input on proposed payment rates.

“My opinion is that there’s a really good argument for for hospice agencies to lobby the government to raise reimbursement rates,” Carter Bakkum, senior data analyst for health care insights at Trella Health, told Hospice News. “There’s a massive argument that increasing the reimbursement rate for hospice could reduce costs associated with inpatient claims, skilled nursing claims.”

A reimbursement increase could also partially ameliorate the industry’s most significant headwind, the workforce shortage, particularly in light of rising wages and intense competition for new hires, according to Bakkum.

Some fear that if labor pressures are unaddressed, hospices eventually may lack the capacity to meet the rising demand for care.

“In order to do the highly emotional, highly scientific and technical work they do, health care workers need to be paid very well,” Bakkum said. “For hospice businesses, one way to offset that in the short term is by getting some funding either from private equity firms or from government institutions.”

To date, federal legislation designed to bolster the hospice and palliative care workforce has repeatedly stalled.

For instance, the Provider Training in Palliative Care Act would allow members of the National Health Service Corps to defer their service for as long as one year to pursue additional palliative care education.

A second bill, the Palliative Care and Hospice Education and Training Act (PCHETA) would provide funds for physician and nurse training, among other interdisciplinary professions such as pharmacy, social work and chaplaincy.

Both have been introduced and reintroduced, but not passed.

While agencies such as CMS routinely work with hospices; the same may not be true for many legislators or state officials.

To tell their story, providers will likely have to educate some government stakeholders about the benefits of hospice and the challenges they face, just as they do other clinicians and the public.

In addition to letters and calls to legislative offices, hospices can comment on regulatory changes published in the Federal Register. For the 2023 proposed rule, the comment period ends May 31.

Another beneficial strategy is for a hospice to invite policymakers to tour their facilities or to accompany staff on patient visits, according to Rawlson.

“It’s one of the best ways to educate and inform a member of Congress, let them see it hands on,” Rawlson said. “Members of Congress are aging. Their parents are aging. They may have family who have gone through hospice. You find all of a sudden that you’ve struck a chord with member of Congress who now understands hospice to a greater degree”