Costs, Short Lengths of Stay Create Barriers to Some Services for Hospice Patients

The U.S. Centers for Medicare & Medicaid Services’ (CMS) is seeking answers about hospice patients’ access to certain high-cost services.

CMS included a series of requests for information (RFIs) in its proposed 2024 hospice payment rule. Among them were questions about patients’ utilization of complex care services including blood transfusions, chemotherapy, radiation or dialysis.

The agency is seeking providers’ feedback on any current hospice enrollment policies that may be perceived as “restrictive to those beneficiaries” and that may “require higher cost end-of-life palliative care.”


In comments on the rule, hospices and industry organizations have contended that these services are often cost prohibitive for both providers and patients, and that — given the prevalence of short stays — they simply have no time to initiate them.

However, the fact that CMS is asking the questions may be a good sign, according to Logan Hoover, vice president of policy and government relations for the National Hospice and Palliative Care Organization (NHPCO).

“I think this is a start of that conversation. CMS is getting on board with thinking through this problem,” Hoover told Hospice News. “We just want individuals to be able to make a real choice and not feel like they’re forced down a road that ultimately may not be beneficial to them. Those treatments are expensive, things like dialysis and palliative radiation. We want to set up the right process to make sure that we’re providing the right level of care.”


Hospices are likely unable to deliver those high-cost services without some type of separate payment, NHPCO stated in a May 30 letter to CMS.

CMS published the proposal in March with a proposed 2.8% base rate increase for next year, which some in the hospice community have called inadequate.

Issues in complex end-of-life care treatments

The limited use of these treatments for end-of-life hospice care is also tied to length of stay issues, the NHPCO indicated in its letter to CMS.

“Providers report it is highly unlikely these higher cost treatments would be appropriate for most patients with such a short length of stay in hospice,” NHPCO noted. “And even for hospice patients with longer lengths of stay, the burdens of these interventions often outweigh potential benefits. Some patients delay hospice admission to continue receiving these costly interventions, which further contributes to the short length of stay when they do elect hospice.”

In 2021, the average length of stay for Medicare patients enrolled in hospice was 92.1 days according to the Medicare Payment Advisory Commission. The median length declined slightly to 17 days, down from 18 in 2020, MedPAC reported.

Enrollment policies affect high-cost service utilization

CMS’ hospice enrollment policies may be posing barriers to the utilization of complex palliative treatments in end-of-life care, according to the senior services advocacy group LeadingAge.

Among them is the requirement that patients’ forgo concurrent, curative treatments when they elect the benefit. Federal and state laws generally do not specifically indicate which services are considered “curative” versus “palliative.” This can create some confusion as to what hospices are able to do for them.

This, coupled with insufficient funding, creates barriers between hospice patients and high-cost services, LeadingAge indicated.

“One often mentioned barrier to hospice care is the lack of the availability of concurrent care,” LeadingAge wrote to the agency. “We believe that there needs to be a consistent definition of what concurrent care is. In addition to consistent terminology, CMS needs to be consistent in expectations. Many of our members have policies on coverage of blood transfusions, chemotherapy, radiation, or even dialysis. Despite CMS’ continued insistence that it is policy that these treatments be covered under the hospice benefit, there is huge variation, no enforcement, and insufficient funding for coverage to be universal. Realistically, many hospices cannot afford to cover every palliative therapy that may be consistent with a patient’s plan of care.”

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