Hospices have been advocating for lawmakers and regulators to take action on curbing fraud, supporting veterans and bolstering the health care workforce.

A group of hospice leaders recently participated in Hospice Action Week, a lobbying event held last week by the National Hospice and Palliative Care Organization (NHPCO) and the Hospice Action Network. In their meetings with legislators, providers made known their policy priorities.

A key goal of these discussions was to establish open lines of communication with congressional offices to foster continued advocacy on hospice issues, according to NHPCO COO and interim CEO Ben Marcantonio.

“The biggest priority is that the advocates who are here establish or strengthen the relationships with congressional leaders that they have and that we have as a hospice community across the country, with the congressional leaders,” Marcantonio told Hospice News. “They will be able to, through that connection, identify the one or two issues that are most pertinent to them and really share their perspective, share the stories that are related to that.”

Through the myriad issues affecting the space, a handful of initiatives bubbled to the surface.

Battling fraud

Reports of unethical or illegal practices have surged, particularly among hundreds of newly certified hospices in California, Texas, Nevada and Arizona. Recent evidence indicates that more of these providers are being enrolled in Medicare despite the U.S. Centers for Medicare & Medicaid Services’ (CMS) efforts to date on curbing fraud and abuse.

Some of these providers were establishing their business, providing substandard care to a few patients and then selling off their hospices or the license.

So far, California is the only state to take action on hospice fraud, which is leading some fraudulent providers to set up shop in other states, such as Nevada.

“The biggest thing that is top of mind for me are the fraudulent actors,” Lynne Sexten, CEO of Wisconsin-based Agrace Hospice, told Hospice News. “We’re paying really close attention to see if the bad actors start appearing in my state, working closely with Wisconsin’s Department of Health, making sure that they are on the watch and understanding what’s happening in other states.”

Some lawmakers have been receptive to actions designed to excise fraudulent hospices. Recently Rep. Beth Van Duyne (R-Texas) called for a crackdown on these organizations.

In addition, Rep. Earl Blumenaur (D-Oregon) is in the process of drafting legislation designed to tackle the fraud issue as well as improve the quality of hospice care.

Blumenauer announced the bill, the Hospice Care Accountability, Reform, and Enforcement (Hospice CARE) Act, at the Hospice News Elevate conference in Washington D.C. Though the bill language is still in development, key provisions will likely include a new payment mechanism for high-acuity palliative services, changes to the per-diem payment and patient certification processes, amid other provisions.

To date, efforts to combat hospice fraud have received bipartisan support.

“When you start breaking down health care in general, there’s a lot more bipartisan work. These are not partisan issues,” Van Duyne told Hospice News. “I think if we look at the overall regulations that are burdening our health care service providers, we should be on the same page on that.”

Gerald’s Law

Hospice providers and industry groups are also seeking passage of “Gerald’s Law,” intended to close a regulatory loophole that adversely affects veterans.

When eligible veterans die, many of their families are entitled to a financial benefit from the U.S. Department of Veterans Affairs (VA) to defray some of the costs of funerals and cremation or burial. However, when a veteran transitions from a VA facility to hospice, they lose access to that benefit. This is even the case when hospice care is provided by the VA itself.

Rep. Jack Bergman (R-Michigan) first proposed the bill with co-sponsor Rep. Colin Allred (D-Texas).

“Gerald’s Law is such a great piece of legislation. It’s one of those bills that you look at and say ‘How is this a problem?’ Legislating is complicated and occasionally certain oversights happen, and it certainly wasn’t anything that was done intentionally,” Logan Hoover, vice president of health policy and government relations for NHPCO, told Hospice News. “This is really a great bill to support both because it’s good policy, and it’s good politics. But also, this allows us an opportunity to talk to members of Congress that serve on the Veterans Affairs Committee, who maybe aren’t as familiar with hospice.”

The bill’s language has since been bundled into a larger piece of legislation, the Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits Improvement Act. This omnibus bill, introduced in the House at the end of May, is designed to reform various aspects of VA health care, including access to mental health and more home- and community-based services, among other provisions.

“Having grown up in a military family, Gerald’s Law is near and dear to my heart,” Kim Olson, chief compliance officer for St. Croix Hospice, told Hospice News in an email. “This would allow veterans to access full burial and funeral benefits while receiving VA care outside of a VA facility. This law would allow veterans to choose the location of care they desire based on comfort, not cost.”

Rebuilding the workforce

Hospices also want to see action on the Palliative Care and Hospice Education Training Act (PCHETA).

If enacted, PCHETA would authorize $100 million over the course of five years to support programs designed to bolster clinical education in hospice and palliative care, along with related interdisciplinary professions such as chaplaincy, pharmacy and social work.

The legislation would establish fellowships through new palliative care and hospice education centers to provide short-term, intensive training, as well as incentivized award programs across all the relevant disciplines. Additionally, it would support programs to develop career paths within the field.

PCHETA was first introduced in 2017 and again in 2019. The U.S. House of Representatives approved the bill both times, only to stall in the Senate — despite the support of nearly 300 bipartisan cosponsors on the second attempt.

Sens. Tammy Baldwin (D-Wisc.) and Shelley Moore Capito (R-W.Va.) revived PCHETA in 2022 and again in July 2023, but the bill has yet to pass. Nevertheless, the senators have pledged to continue their efforts to move the bill forward.

“Senator Baldwin and I are committed to getting this bill across the finish line so the next generation of hospice and palliative care providers can be trained,” Moore Capito told Hospice News. “As someone whose loved ones have benefitted from hospice care and palliative care, I know how important this care is to both the patient receiving the care and the patient’s family. Unfortunately, like so many areas of health care, hospices are being impacted by workforce shortages and I fear that this could impact the ability of patients and families to access this vital type of care.”

The bill has received endorsements from upwards of 50 industry organizations. These include the National Association for Home Care & Hospice (NAHC), NHPCO, Hospice Action Network, Hospice and Palliative Nurses Association and the American Academy of Hospice and Palliative Medicine, among others.

“I’m ever hopeful that we’ll be able to cross the finish line. But in this political environment, even easy, common-sense things are hard,” Hoover said. “Even bipartisan things are hard, so there are headwinds going into this fall.”

Revising the Special Focus Program

CMS introduced the hospice Special Focus Program (SFP) in its 2024 home health payment rule, which contained several hospice provisions. The program began implementation on Jan. 1.

Though the hospice community generally has voiced support for the program, many contend that the agency’s methodology for identifying hospices for the SFP is deeply flawed. Stakeholders, including hospice providers and members of Congress, have called on CMS to postpone the program and revise that algorithm.

“We are fully supportive of a rating system to help better inform families about the choice they have in providers,” Olson said. “Due to the manner in which the data is captured (or excluded in particular), we believe that the current proposed system will not present a clear picture of quality.”

Congress mandated the SFP in the Consolidated Appropriations Act of 2021, which contained language from the Helping Our Senior Population in Comfort Environments (HOSPICE) Act. This was in response to July 2019 reports on hospice quality from the Office of the Inspector General (OIG) in the U.S. Department of Health and Human Services (HHS).

The program will have the authority to impose enforcement remedies against hospices with poor performance based on its algorithm. Hospices flagged by the SFP also will be surveyed every six months rather than the current three-year cycle and could face monetary penalties or expulsion from the Medicare program.

“There are significant algorithm flaws in the hospice SFP, not the least of which is that you can be excluded from the calculation simply by not submitting data,” Olson indicated. “Additionally, we believe that with some minor tweaking, governmental auditing resources could be better allocated to capture truly fraudulent and poor performing entities.”