Hospice CEOs: Action Needed on Staffing, Value-Based Care, Oversight

Hospice leaders would like to see some changes in the space this year, particularly around staffing, payer relationships and regulation.

Hospice executives in December 2022 shared their predictions for what would happen in the space during 2023. To follow up, a range of CEOs discussed with Hospice News what they would like to see happen this year and where they see a need for change.

The labor shortage is unsurprisingly a top concern.


“We really need a look at how we create and cultivate more clinician availability. More access to care is critical,” Alex Mauricio, CEO of Bristol Hospice, told Hospice News at the Home Care 100 conference. “I think providers need to come together and figure out how we continue to attract more talent to the health care space, how we partner with schools, how we partner with each other.”

Workforce pressures and associated costs are overwhelmingly the industry’s most damaging headwind, including the associated wage hikes, enhanced benefits and bonus programs. The shortages also have reduced clinical capacity, which has contributed to drops in patient census and length of stay for many providers.

Turnover rates for registered hospice nurses reached 25.15% in 2022, according to the 2022-2023 Hospice Salary & Benefits Report, published by Hospital & Healthcare Compensation Service (HCS) in cooperation with the National Association for Home Care & Hospice (NAHC). Nurses also accounted for 16.97% of vacancies.


Hospice aides and CNAs also represented a large percentage of job vacancies and saw high turnover rates, 19.05% and 29.84%, respectively. Only LPNs and LVNs had higher rates, reaching 31.52% turnover and 25.12% for vacancies.

Providers have reported shortages among social workers and nonclinical staff as well.

Hospices should be assessing the number of clinicians they need in each market to meet demand, according to Enhabit (NYSE: EHAB) CEO Barbara Jacobsmeyer.

“Everybody keeps talking about labor, right. But I would say for us this year there’s a little bit of a different focus on that, and that is really getting a feel for what is the true clinician headcount we need to have,” Jacobsmeyer told Hospice News. “The reason is because, historically, we very much focused on most of our staff, who were all full-time. What we’re seeing is this shift of employees wanting more part time and [pro re nata (PRN)]. So we have to change the local mindset, making sure that everyone in each of our local areas knows the headcount they need.”

Another focus for providers this year should be adapting towards risk-based payment models or the potential for hospice coverage through Medicare Advantage (MA), some executives say.

The hospice component of the value-based insurance design (VBID) demonstration entered its third year on Jan. 1, 2023. Often called the MA hospice carve-in, the four-year voluntary demonstration is designed to assess payer and provider performance within Medicare Advantage.

While the ultimate outcome of the demo remains to be seen, many in the space expect that in time MA will become more involved in hospice.

“This entire Medicare Advantage carve-in, it makes sense. This is the sole benefit that’s carved out of a private insurance relationship,” St. Croix Hospice CEO Heath Bartness told Hospice News at Home Care 100. “We need to be able to show others outside of the bureaucratic government agencies that we are a great value, and I think that we could work probably better with the payers, to show not just the financial impact, but ultimately, the quality of care impact.”

Other changes need to occur in the regulatory arena at the state and federal levels, according to some leaders.

Some changes to tighten oversight are already in the works. The U.S. Centers for Medicare & Medicaid Services (CMS) will be implementing a revised compliance survey process and has convened a Technical Expert Panel to develop a hospice Special Focus Program.

Providers have also reported spikes in Targeted Probe and Educate (TPE) audits by Medicare Administrative Contractors (MACs), as well as those by Unified Program Integrity Contractors (UPICs), with some seeing penalties like reimbursement suspension or repayments.

Meanwhile, the U.S. Department of Health & Human Services Office of Inspector General (OIG) will conduct a national audit for patient eligibility. Questions as to whether enrolled patients are legitimately appropriate for hospice are a common factor in Medicare claims denials and has also driven a rise in False Claims Act cases.

While many operators furrow their brows over potentially expensive, often out-of-blue audits, efforts to improve program integrity in the Medicare Hospice Benefit is a positive development, according to Jet Health CEO Stacie Bratcher.

“We’ve seen a lot of regulatory oversight, and I don’t think that’s a bad thing. We’ve seen a lot of new hospices kind of pop up in [non-certificate-of-need] states, and we think more oversight of that is good,” Bratcher told Hospice News. “With patients, you always want to have high compliance. It’s important from a regulatory standpoint how you deal with the narcotics in the home.”

The proliferation of new for-profit hospices emerging in states like California, Texas, Nevada and Arizona has become a concern of rising importance as reports of fraud and abuse continue to mount.

The issue first rose to the forefront in 2021 in California. ​​Lax oversight has contributed to high concentrations of hospice fraud in California, the state’s Department of Justice indicated. Lawmakers have passed a number of laws to combat the problem, including a moratorium on new licenses.

In November, hospice industry organizations called on CMS to examine the issue nationally. Signatories on the joint letter included LeadingAge, NAHC, the National Hospice and Palliative Care Organization (NHPCO), and the National Partnership for Healthcare and Hospice Innovation (NPHI).

These issues represent an area in which the industry needs to “clean up,” Traditions Health CEO David Klementz told Hospice News.

“If we self-reflect as an industry, there are some things that need to be cleaned up. Frankly, I think what California is doing with its latest regulatory changes is not a bad thing,” Klementz said. “If you look at the growth in hospice in Texas, California and Arizona, it’s like 35% of growth comes from those states. We need to make sure people are getting into the space that want to professionalize high-quality care, not just to grow and flip a business.”

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