The senior care advocacy group LeadingAge has praised the U.S. Centers for Medicare & Medicaid Services (CMS) inquiries into high-acuity palliative care, but expressed concern over reimbursement and staffing issues.

The agency’s 2025 proposed hospice rule featured a series of requests for information (RFI) on issues like health equity, social determinants of health and future quality measures.

The RFIs contain further questions about the utilization of higher-cost palliative treatments under the Medicare Hospice Benefit. The agency posed similar queries in its proposed rule for 2024. The new proposal seeks greater clarity on the financial risks and costs that providers say represent barriers to providing those services, such as palliative chemotherapy, radiation blood transfusions or dialysis, among others.

Though such treatments are often considered to be “curative,” they can also provide palliation without changing the patient’s prognosis. They would remain hospice-eligible.

This RFI could indicate that CMS is thinking about potential changes to how it covers those advanced palliative services, according to Mollie Gurian, vice president of Home-Based and HCBS Policy at LeadingAge.

“[The treatments] are too expensive for hospices to pay for under their current payment structure in a coordinated, equitable way,” Gurian told Hospice News. “Right now, there are certain hospices that will pay for some of that care, but it really varies by hospice provider. So a more concrete payment mechanism would allow for a more level playing field.”

For now, one can only speculate as to what such a payment mechanism would look like. Under CMS’s current authority, the addition would have to be budget neutral, Gurian said.

In its comments on the proposed rule, LeadingAge recommended that CMS establish a Technical Expert Panel to examine the issue and identify potential solutions.

“There would have to be some mechanism to account for the variations in the costs of these various kinds of therapies and treatments,” Gurian said. “Ultimately, a lot of work would need to be done around that from a clinical perspective to inform payment policy, but in a shorter term, some sort of supplemental payment could be a way to get the ball rolling.”

In addition to the RFIs, the proposed rule also included a 2.6% hospice base rate increase for 2025, a number which some stakeholders, including LeadingAge, have called insufficient in light of continued inflation, interest rates, staffing shortages and wage hikes.

One of the major associated challenges is the ongoing staffing shortage. With reimbursement lagging, hospices are hard pressed to compete with larger, more capitalized health care employers like health systems that can offer higher compensation.

This could be exacerbated with the implementation of CMS’ new staffing mandate for skilled nursing facilities. Those organizations will by necessity be doing a lot of hiring, particularly for nurses. This could make the labor market even more competitive, putting providers like hospices and home health agencies at a disadvantage, according to Katy Barnett, director of home care and hospice operations for LeadingAge, told Hospice News.

“We’re really nervous about what the skilled nursing staffing mandate is going to mean for home health and hospice providers,” Barnett told Hospice News. “These are services that are predominantly nurse focused. When you have a mandate that is going to create competition within post-acute care providers, we’re really concerned that we’re not going to be competitive. I think the other side of that coin is we’re pitting post-acute care providers against each other.”