If enacted, the Hospice Care Accountability, Reform and Enforcement (Hospice CARE) Act could open up reimbursement pathways for high-acuity palliative services during a time when demand and costs are rising.

Developed by U.S. Rep. Earl Blumenaur (D-Oregon) and announced in June at the Hospice News Elevate conference, the bill proposed massive reimbursement and regulatory changes to the Medicare Hospice Benefit. Currently in a discussion draft phase, the bill includes ways for hospice providers to have clearer definitions and improved payment for more intensive forms of palliation, such as radiation therapy, blood transfusions or dialysis, among others.

Having stronger community-based palliative care reimbursement could help hospice providers improve access, utilization and outcomes, according to Susan Ponder-Stansel, president and CEO of Florida-based Alivia Care.

“The challenge with a bill like this is going to be in how to write the regulations on things like palliative and transitional care – that’s a huge opportunity,” Ponder-Stansel told Hospice News at the National Association for Home Care & Hospice’s (NAHC) Financial Management Conference in Las Vegas.

The high-acuity conundrum

Seriously ill aging populations lack sufficient options in the nation’s fragmented health care system, with many limited to facility-based care if they do not have caregiver support. This leads to high costs, strained workforces and care that does not always align with patients’ goals to age in place, Ponder-Stansel said at the NAHC conference.

NAHC recently completed its affiliation with the National Hospice and Palliative Care Organization to form the NAHC-NHPCO Alliance.

Hospices often provide complex palliative services without sufficient financial resources — an issue the Hospice CARE Act could help address, Ponder-Stansel added.

“Right now, there are not enough meaningful options for families to choose from,” she said at the conference. “But things that we didn’t understand were palliative actually are services many hospices are providing to communities. It’s just very hard to sustain when you’re losing money on 80% of your patients.”

The drafted Hospice CARE Act included potential avenues to improve payment for high-acuity palliative treatments. If enacted, the bill proposes to reimburse for those services at 200% of the routine home care rate for Fiscal Year 2026. This would be effective Oct. 1, 2026 through Sep. 30, 2031. Services eligible for these payments would include:

• Palliative chemotherapy, radiation or radiation therapy provided under the supervision of an oncologist
• Palliative transfusions provided to blood cancer patients with the supervision of an oncologist
• Palliative dialysis provided under the supervision of a nephrologist, with certain restrictions

The issue of payment for these types of services is also on the radar of the U.S. Centers for Medicare & Medicaid Services’ (CMS). The agency in its 2025 proposed hospice payment rule included a Request for Information (RFI) to gauge provider sentiment on potential solutions, including the development of a separate payment mechanism. These palliative services represent rising care delivery costs for hospice providers, CMS stated in the final version of the rule.

Stakeholders submitted comments on the RFI that called for new payment pathways that more adequately support access to those types of care, according to CMS.

“Commenters stated providing complex palliative treatments and higher intensity levels of hospice care may pose financial risks to hospices when enrolling such patients,” the agency reported in the final rule. “Commenters stated that the current bundled per diem payment is not reflective of the increased expenses associated with higher-cost and certain patient subgroups.”

Hospices that provide high-acuity services to patients need stronger reimbursement incentives that alleviate cost pressures on patients and their families when electing the benefit, according to the the NAHC-NHPCO Alliance. While the organization voiced support for a reimbursement structure that would account for the costs of high-acuity care, the group indicated that the proposed 200% may not be enough.

“Given the very high and variable costs of some forms of the four specified palliative interventions, 200% of the prevailing [routine home care] rate would likely be far too little in order for this provision to have its intended effect of meaningfully improving access to hospice care for patients that could benefit from provision of these complex palliative services,” the alliance indicated in a comment letter on the bill. “Additionally, a single uniform rate for all of these kinds of services does not account for the large discrepancies in their unique costs.”

The NAHC-NHPCO Alliance also contended that more high-acuity services beyond those currently listed in the bill may be necessary and require similar reimbursement.

Though many welcome the proposed reforms, the drafted Hospice CARE Act also has raised some concern in the industry around potential unintended impacts, including how the bill addresses high-acuity care. Though many providers argue that stronger reimbursement is needed within the hospice benefit, this will require careful consideration when designing the regulations and quality measures.

Addressing seriously ill patients’ needs includes the ability to cover a wider swath of high-acuity services than current hospice payment systems support, according to Jon Broyles, CEO of the Coalition to Transform Advanced Care (C-TAC).

“We support changes that would enhance payments for transitional concurrent care including palliative chemotherapy, radiation, blood transfusions and dialysis,” Broyles said in a recent statement regarding the bill. “We would add intravenous inotropes for heart failure to this list. We support plans to provide additional payments for unusual variations in the type of routine care provided if sufficient evidence supports it.”

A large aim of the legislation is to improve cost structures and goal-concordant care for patients with increasingly complex physical, emotional, spiritual and psychosocial needs, according to Blumenauer.

Revamping the hospice benefit with expanded palliative care coverage is needed to drive down costs and improve outcomes, he stated at the Elevate conference in Washington D.C.

“This aging population is changing the manner in which we’re providing services. If we’re not able to tailor [the hospice program] to the needs of families and individuals, we’re going to be chasing our tails,” Blumenauer told Hospice News at the conference. “This is an opportunity to do something in Congress [with] this concrete, specific way that will save money and improve quality of care for some of our most vulnerable people.”

Hospice News / Merz Photography