The most recent iteration of Hospice Care Accountability, Reform and Enforcement (Hospice CARE) Act, currently in a discussion draft phase, could have some unintended consequences in the future of end-of-life care delivery.

Developed by U.S. Rep. Earl Blumenaur (D-Oregon) and announced in June at the Hospice News Elevate conference, the bill proposed reimbursement and regulatory changes that could bring massive reform to the Medicare Hospice Benefit.

The bill comes at a time when negligent and fraudulent actors in the hospice space are heightening misconceptions about end-of-life care, according to Kristen Yntema, president and CEO, AuthoraCare Collective. The North Carolina-based nonprofit provides hospice and advanced illness care, grief support and caregiver resources.

An important aspect of the draft language is that it focuses on ways to address program integrity issues that have percolated in the hospice industry. This includes developing an infrastructure to weed out bad actors, but this can come with challenges for quality hospice providers, Yntema said at the National Association for Home Care & Hospice (NAHC) Financial Management Conference in Las Vegas.

“The bill goes along with the theme of accountability and quality in hospice,” Yntema told Hospice News at the conference. “The handful of bad actors are a minority when most others should be celebrated for what they’re doing without being penalized as regulators find those bad actors. Hospice has really been a value-based model since the beginning and that comes with managing risks.”

Feedback from providers and industry stakeholders around the drafted Hospice CARE Act was recently submitted to legislators and is currently under review by Rep. Blumenaur’s office and members of the House Ways and Means Committee.

Pouring through the provisions will take careful navigation around payment incentives that take program integrity measures into account without burdening providers, according to Katie Wehri, NAHC’s director of home care and hospice regulatory affairs.

Though to date no formal announcements have been made, the bill may be introduced by the end of 2024, Wehri indicated.

The drafted legislation includes provisions to hospice reimbursement that provide a combination or blended payment option that could encourage more visits from hospice providers, she said at the NAHC conference.

“The message here is that hospices are on notice that there will be significant reform like we have not seen since the benefit was implemented 40 years ago,” Wehri told Hospice News. “There’s a mix of payment reform and also program integrity that’s going to take a while to research those two items and figure out the best options for hospices. Hospices should recognize that there’s a message within that blended payment option that could incentivize more visits – and that’s very important for service intensity add on. This would be a wholesale change for hospice.”

Though widened reimbursement pathways for visits at the end of life could allow hospices to strengthen clinical capacity, wholesale changes to the hospice payment model could complicate both care delivery models and billing, according to Susan Ponder-Stansel, president and CEO of Florida-based Alivia Care.

A more dynamic payment mix for providers that incentivizes more patient visits in the last days of life could come with both cost saving potential and quality impacts, but not necessarily positive outcomes, according to Ponder-Stansel.

“The behavior follows the money, and so incentivizing outcomes and patient visit volume toward the end of life could result in negative quality impacts if patients refuse those visits and don’t want an increased bedside presence at that final stage,” Ponder-Stansel said. “Some of these hospice businesses are not acting with program integrity and just on their bottom line business. The challenge is going to be writing regulations that give people choices.”

The discussion draft foretells what hospices can anticipate as far as a regulatory overhaul, according to NAHC President Bill Dombi. The Hospice CARE Act has introduced some of the biggest changes to hospice regulation and payment since the benefit’s inception, Dombi stated.

This will require a balancing of the potential negative and positive effects on providers and patients alike, he indicated. It’ll take significant time and collaborative efforts to shape the legislation in ways that do not hinder or limit the full scope of interdisciplinary services involved in hospice, Dombi added.

“Within this discussion draft are a number of positive things, but there are a lot of things that raise concern for us,” Dombi said at the conference. “There’s a lot of complexity in there, which is why we don’t expect it to have much movement during this particular remaining days of Congress in 2024. This is one of those kinds of things that gets ahead of steam and may take a few years to get there.”

A shift in Congress could impact the legislation’s launch, according to Dombi. Though Blumenauer has announced that he will not seek reelection next year, the Hospice CARE Act will likely receive continued support as it passes through the legislative channels, he indicated.

The legislation signals that policymakers are increasingly recognizing the biggest pain points for hospice providers when it comes to balancing financial and workforce pressures alongside compliance, Ponder-Stansel said.

Hospices are carefully watching the legislation’s development with some concern mounting on the trickle effects on their operations and care delivery approaches, according to Ponder-Stansel. If enacted, some of the bill’s unintended side effects could begin at the onset of implementation as hospices adjust to a new regulatory and reimbursement framework, she stated.

“A lot of the comments on the bill address what problems might happen, what might be broken and what some of the unintended consequences could be of implementing these changes,” Ponder-Stansel told Hospice News at the conference. “How are you going to operationalize it? What are some of the effects on the business models in terms of profit over patient care? What are some of the poor quality practices going on in the industry that a reform act like this could specifically address?”