Calls Grow Louder for Greater Federal Support of Rural Hospices

Calls are growing louder for Congress to build stronger reimbursement and workforce incentives aimed at improving the availability and sustainability of rural-based end-of-life care.

Rural-based hospice providers face a range of challenges to improve access among their underserved patient populations. Current reimbursement structures within the federally established Medicare Hospice Benefit do not sufficiently support the level of care needed in rural-based communities, according to the National Hospice and Palliative Care Organization (NHPCO).

The costs of providing hospice to rural-based regions outweighs the reimbursement received for it, an issue gaining traction among terminally ill patients and families in need, according to Logan Hoover, vice president of health policy and government relations at NHPCO.


“We hear from countless community providers and state association leaders that rural hospices are in financial trouble,” Hoover wrote in a recent letter to the U.S. House of Representatives’ Ways and MeansCommittee. “With Medicare accounting for the overwhelming majority of hospice payments, hospice care is at the mercy of the federal government to continue providing high quality care. There is a strong financial incentive and the benefits of allowing beneficiaries to access care in their community to invest in and support rural providers.”

The letter described experiences of rural-based hospice and palliative care providers, highlighting examples of common challenges they experience. For instance, providers in rural regions can face greater difficulty reaching patients during adverse weather that impacts travel conditions. It can also be more difficult to address social determinants of health needs and provide assistance with activities of daily living (ADLs) with caregiver support lagging among rural populations, providers noted.

NHPCO penned the letter in response to a recent Congressional Hearing on Enhancing Access to Care at Home in Rural and Underserved Communities. The hearing focused on the common access issues among rural populations.


Rural communities “struggle with access, which results in worse health outcomes, compared to wealthy urban areas,” House Ways and Means Committee Chairman Jason Smith (R-Mo.), said during the hearing.

Addressing access issues in rural regions can come with higher costs around care delivery, workforce transportation and wages, as well as technology, NHPCO indicated.

NHPCO urged Congress to improve rural-based hospice support in the following areas:

  • Provide reimbursement more reflective of the care provided
  • Incentivize and support hospitals and nursing homes to utilize care in the home experts
  • Support the hospice and palliative care workforce
  • Expand the use of telehealth to levels used throughout the COVID-19 public health emergency
  • Support palliative care in the community

Factors such as the wage index put rural providers at a disadvantage compared to those in urban and metropolitan regions, according to NHPCO. Rural providers often struggle to recruit and retain a sustainable workforce as a result, the organization indicated.

“Medicare has acknowledged the struggles of rural providers through the Home Health Rural Add-On, and this should be extended to hospice providers,” Hoover stated in the NHPCO letter.

A lack of trained hospice and palliative care professionals in rural regions also presents a barrier to access. The letter included a push to pass the Palliative Care and Hospice Education and Training Act (PCHETA), which if passed would provide incentives to expand training programs for physicians, nurses, pharmacists, social workers and chaplains. The legislation has taken a circuitous route through Congress in recent years, repeatedly reintroduced without passing since 2017.

“Nurse practitioners and physician assistants are essential in covering the gap in providers in rural communities,” Hoover said. “They must be able to work at the top of their license by allowing them to complete the certification of terminal illness and the administrative face-to-face.”

An additional access issue is trickling down from the increasing financial pressures faced by referral sources such as rural-based clinics, skilled nursing facilities and critical access hospitals (CAHs). As more of these facility-based resources close, the availability for hospice general inpatient (GIP) care has become more pressurized, according to NHPCO.

Providing greater financial support and more flexible payment structures around GIP care in hospital and skilled nursing settings could be a move toward improved access and outcomes, the organization noted.

“Patients are losing access to important services due to the closure of rural providers and facilities across the health care system,” Hoover said. “Hospice providers need to have nursing facilities and hospitals available to partner with … Congress needs to investigate the causes and impacts of these closures as well as find incentives for all providers to enter and stay in rural and frontier communities.”

The letter also called on Congress to make permanent some of the telehealth flexibilities enacted during the COVID-19 public health emergency, set to expire at the end of 2024. Allowing the use of telehealth for face-to-face visits prior to hospice recertification has allowed for increased provider efficiency by reducing travel time and burnout among rural-based clinicians, according to NHPCO.

Case in point, recent research has found that telehealth utilization helped improve support for caregivers of rural hospitalized patients. Telehealth services can be more cost-effective to provide in these regions, the research found.

Improving reimbursement for community-based palliative care could also impact rural-based hospice access, NHPCO indicated. Developing a federally established Medicare palliative care benefit could help hospice improve reach to seriously ill patients further upstream in their illness trajectories, according to the organization.

“Currently there is no Medicare benefit for palliative care but innovative models such as community-based palliative care and the Medicare Care Choices Model can enhance the care patients receive in the home by allowing patients with serious illness and a prognosis longer than six months to receive comprehensive services,” Hoover said.

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