Hospices Call on Congress to Support Rural Hospices, Patients

Hospice providers, industry groups and other stakeholders recently penned a letter urging Congress to improve payment infrastructures that would increase access to end-of-life care among rural populations.

The letter highlighted the unique challenges that rural and frontier hospice and palliative care providers face, and how strengthened financial support could lead to sustainable access and better care transitions for serious and terminally ill rural-based patients.

Among the signatories were 63 hospice and palliative care providers across the country, 14 state hospice and palliative associations, the National Hospice and Palliative Care Organization (NHPCO) and the health care technology company Axxess.


Today’s reimbursement rates are insufficient to sustain hospice care delivery in rural regions, according to Sandy Kuhlman, executive director at Hospice Services of Northwest Kansas. Financial pressures are deterring growth among a dwindling supply of rural-based hospices, leaving patients with limited end-of-life care resources, Kuhlman said.

“For some rural areas, they’re not seen as financially feasible or sustainable to larger programs,” Kuhlman told Hospice News. “So, for access to rural care, we’re going to have to depend on smaller rural programs. That’s why this makes it a big issue. At some point the realization hits for companies looking to reach out to rural areas that it is not financially sustainable as it is. You’re going to have to support these services with other funds, community or charitable dollars or something else. There are just not enough patients to make it financially feasible with so many challenging things in rural areas.”

Barriers impeding rural hospice access

Engaging lawmakers raises the collective voice of rural hospice communities and allows for greater recognition around the issues that impact quality and utilization, according to Logan Hoover, vice president of policy and government relations at NHPCO.


“Payment and workforce are two issues really driving challenges in rural communities,” Hoover told Hospice News. “Even with a good payment update, we’re still behind the actual need of what rural providers are facing. A hope is that providers are heard. This letter represents issues that need to be fixed and addressed [and] hopefully it spurs a little extra movement and attention from lawmakers that are connected to these communities.”

The letter to Congress detailed the unique challenges that rural hospice providers face, including:

  • Lower effective payment rates due to the structure of the Medicare wage index system
  • Unprecedented staffing shortages exacerbated by the pandemic and lagging reimbursement
  • Challenges with telehealth and broadband access that impact care management
  • Increased closures among referring rural health care providers and facilities
  • Challenges accessing patients in certain critical access hospitals
  • Difficulty ensuring staff safety amid travel to patients in remote, rural and frontier areas

“If we don’t protect the rural provider from going out of business in these communities across the country, then it does become an access issue,” Greg Wood, executive director at Arkansas-based Hospice of the Ozarks, told Hospice News. “People that live there will have a harder time having someone come to them with hospice and palliative care if we don’t keep the rural provider alive and vibrant.”

Among the persisting obstacles in rural communities is an insufficient supply of hospice and palliative clinicians.

About 18% of hospices nationwide operated in rural areas in 2021, according to a report from the Medicare Payment Advisory Commission (MedPAC). Hospices in urban and suburban areas made up the remaining 82%, the report found.

The volume of rural-based hospice providers in the United States has been declining in recent years. About 845 hospices provided care in rural-based regions in 2021, a drop from 878 organizations in 2017, the MedPAC report found.

“Things that are unique for rural and frontier providers are trying to find qualified staff, registered nurses, physicians, social workers or spiritual care providers,” Wood said. “These individuals are not always in the rural communities. We’re having a harder time finding certain disciplines in our locations just because we’re not offering enough money.”

Staffing shortages plaguing the hospice industry have hit rural-based providers harder as more clinicians leave for higher paying positions at larger organizations in urban and suburban areas, according to Wood. This puts rural and frontier hospices at a disadvantage when it comes to growing their workforce and clinical capacity, he stated.

Additionally, hospice clinicians often travel far distances to reach patients in rural areas, resulting in lower census volumes and safety risks in more remote areas, according to Kuhlman. The result is that not enough patients are seen and not reimbursement is received, she stated.

Because patient volumes are generally larger in more populated regions, providers in those areas often generate more revenue, Kuhlman indicated.

States with high rural populations had more than 10% of residents living further than 60 minutes in driving time from a hospice in 2008, a study from the Journal of Nursing Care Quality found.

Telehealth flexibilities instilled during the COVID public health emergency (PHE) have been a crucial part of improved access to hospice among rural regions, according to Kuhlman. Telehealth has enabled rural hospice providers to stay in contact with far-flung or isolated patients with greater frequency, reducing the need for clinicians to travel long distances unnecessarily, she said.

Some telehealth flexibilities that were temporarily implemented during the PHE) are scheduled to sunset at the end of 2024. The end of these telehealth waivers will have a detrimental effect on timely access to hospice in rural areas, Kuhlman stated.

The ability to afford technology that helps connect providers and patients and streamlines operational efficiencies is a large part of sustainable rural health care, according to Deborah Hoyt, senior vice president of public policy at Axxess.

Expanding financial support for rural regions “makes sense” from a cost perspective, especially for hospices in need of additional technology resources that improve efficiency and clinical capacity, Hoyt said.

“Rural care delivery is more costly. As a nation, we can’t allow or afford rural providers to close their doors,” Hoyt said. “When providers have adequate reimbursement, they can care for more people and the technology can help make that happen in real time. Telehealth, broadband and Wi-Fi access are often limited, making care planning with long-distance family members challenging. Bottom line, these rural providers require increased Medicare payment rates to serve these unique communities. From a technology perspective, it’s trying to make things easier for staff, more cost effective than traveling and more compliant with documentation redundancies so they risk less reimbursement issues.”

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