NAHC President Bill Dombi: Hospices in for a ‘Bumpy Ride to New Era’

The Medicare Hospice Benefit is ripe for change nearly four decades after its establishment, but moving the needle will include a heavy lift around evolving regulations.

This is according to Bill Dombi, president of the National Association for Home Care & Hospice (NAHC). The hospice industry is undergoing tremendous changes amid rising demand and increased regulatory oversight, Dombi said at NAHC’s Financial Management Conference in Las Vegas.

“Hospice has been on a long-standing honeymoon,” Dombi told Hospice News at the conference. “But hospice has moved into a new era. It’s a very mature benefit at this point and all signs are that people in Congress and at [the U.S. Centers for Medicare & Medicaid Services (CMS)] think it’s overdue for some reform. Hospice is facing potential massive reform.”

Among the signs of major reform on the horizon is an intensified survey and auditing climate in recent years, Dombi stated.

More than half (52.9%) of hospice providers reported undergoing more than one audit simultaneously within a six month period in a survey from LeadingAge, the National Partnership for Healthcare and Hospice Innovation (NPHI), NAHC and the National Hospice and Palliative Care Organization (NHPCO).

NAHC and NHPCO have since recently affiliated, with a new organization name yet to be announced.

Hospices will need a sharp compliance focus with ongoing internal assessments around their admission processes and care delivery approaches to navigate forthcoming changes, according to Dombi. Issues of fraud in the hospice industry echo events that previously affected the home health space, and providers can learn from that prior experience, he said.

Much of the regulatory activity was spurred by a rash of new providers that emerged predominantly in four states: California, Arizona, Texas and Nevada. A large contingent of these companies were established with the purpose of selling the license at a profit, with little concern for patient care.

“I think hospices are going to find value in the oversight, but it’s going to be a bumpy ride for them,” Dombi told Hospice News at the conference. “Whenever audit volume goes up, claim denials [also] go up, appeals go up, bankruptcies go up. Sharpen your game before someone knocks on the door. You’ve got to admit that there is risk out there, and you can be part of the solution to that risk.”

A swelling aging population is another factor fueling change, he indicated. Hospice care delivery costs have been on the rise as more seniors with terminal illnesses reach the end of life. Hospice claims represent roughly $24 billion in Medicare spending, according to Dombi.

Increasing demand and rising costs pose a large problem when it comes to sustainable payment in today’s reimbursement climate, he stated. But the path toward improvement will be a long journey, Dombi added.

Though hospice reimbursement structures have seen incremental rises, these have been insufficient to combat the financial, economic and workforce pressures that providers are facing. Providers will need far more than the 2.6% increase in hospice per diems that CMS included in its 2025 proposed rule, Dombi said.

The drafted Hospice Care Accountability, Reform and Enforcement (Hospice CARE) Act from U.S. Rep. Earl Blumenaur (D-Oregon) could be a beacon of change that aims to address the program integrity and payment issues in end-of-life care.

Blumenauer announced the bill in June at the Hospice News Elevate conference in Washington D.C. Though the bill language is still in development, it will likely contain proposed updates to payment mechanisms for high-acuity palliative services, changes to the per-diem payment process and actions to improve quality and combat fraud.

The Hospice CARE Act could bring stronger reimbursement structures and tighter regulatory guidelines, but solidifying these will take careful consideration, according to Dombi.

“[With] the proposed rule, we expect it to be a plain vanilla kind of thing, but this is what we really pay attention to in hospice,” Dombi said. “It is not necessarily going to happen in the near term. There is not part of the hospice benefit that is untouched in this [Hospice CARE Act] reform measure. It may take a few years to get there, but this is absolutely something that’s going to happen in the future of hospice. More detail is necessary to get there, [but] we can win every one of these battles if we have all of you to be that army.”