Disruptive reimbursement and regulatory challenges are top of mind for today’s hospice c-suite executives, who recently sat down with Hospice News to discuss what they see as the largest hurdles to sustainable end-of-life care delivery.

Reimbursement pressures and changes among the most significant concerns for today’s hospices, according to Kristen Yntema, president and CEO of AuthoraCare Collective. The North Carolina-based nonprofit provides hospice and palliative care, among other services.

The Medicare Hospice Benefit remains the primary avenue for hospice reimbursement, but pathways are growing in the value-based arena, Yntema said at the National Association for Home Care & Hospice’s (NAHC) Financial Management Conference in Las Vegas. Quality will be hospices’ biggest value proposition in a value-based environment, she stated.

“Payment reform is top of the list of biggest concerns,” she told Hospice News. “Tying quality care to payment is evolving. Most other parts of the continuum are tied to value-based care and the outcomes paid for under that. It’s something that hospices are going to have to figure out how to do, because that’s going to be part of our world.”

Payment pain points

The ability to quickly adapt billing and care delivery approaches will also be key to thriving in the future, said Yntema. Hospice reimbursement is long-overdue for an overhaul, she added.

Legislators are currently drafting a bill that could revamp the Medicare Hospice Benefit. Currently in discussion and draft phase, the Hospice Care Accountability, Reform and Enforcement (Hospice CARE) Act proposes to change the way hospices provide inpatient respite care. The legislation, if enacted, would also reduce hospice daily rates and add per-visit payment for clinical services to ensure that hospices are delivering appropriate care to patients.

Additionally, the U.S. Centers for Medicare & Medicaid Services (CMS) has signaled a move toward value-based care. Part of the CMS’ refreshed strategic goals announced in 2021 including a drive towards more equitable and high-quality person-centered care. The agency outlined a plan aimed at driving up value-based care during the next decade.

A growing number of hospice patients are enrolled in value-based programs, according to a study published last February in JAMA Health Forum. Of the nearly 3.2 million hospice decedents researchers examined, those enrolled in Medicare Advantage outnumbered those in traditional Medicare, the study found.

Value-based payment trends suggest that hospices could be navigating a sea of unknowns on the horizon, Yntema stated. Sustainability will in part hinge on a nimble and agile approach to billing practices, staffing training, care models and payment strategies.

Hospice is in a period of disruption … Payment reform is top of the list of biggest concerns. Tying quality care to payment is evolving.

— Kristen Yntema, president and CEO, AuthoraCare Collective

“Hospice is in a period of disruption,” Yntema said. “We’re going to be paid differently. It’s billing differently, or how you’re providing care may be different under a certain model. We’re going to have to figure out how to be ready to adapt, to be successful in any payment model and be able to be in multiple payment models — whether it’s an [Accountable Care Organization (ACO)] , Medicare Advantage or a different structure.”

Regulatory, compliance impacts

Regulatory changes represent another significant concern challenging hospice sustainability, said Tarrah Lowry, COO and interim president at the nonprofit senior care provider Empath Health.

Increased auditing activity and changes to quality requirements and reporting have come alongside program integrity concerns of fraud, waste and abuse in the hospice industry.

Regulatory concerns have hospices facing increased compliance pressures that have impacted operations and the way they run their businesses, Lowry indicated at the NAHC conference. Greater consideration is needed to drive further change in quality measures and reporting requirements, she stated.

“The audit activity is something that I think is hard for all hospice providers,” Lowry said. “Every audit known to man has come to our organization. Trying to navigate all of that and staffing for that is a big part of our business right now. We do believe that there’s things that need to be changed. We’re not opposed to changes, but we want to make sure that they’ve got the whole picture when they’re talking about those changes.”

Program integrity issues have surfaced, particularly concentrated in four states: Arizona, California, Nevada and Texas. Regulators have been closely eying these states amid hundreds of newly licensed hospice operators in recent years. Multiple reports of unethical or illegal practices have cropped up, particularly among new companies receiving federal funding, despite a ban on new licenses.

In some instances, multiple hospices have been operating out of the same address without a corresponding increase in the population of eligible patients. Some individuals also hold management positions at several of these hospices simultaneously.

Hospices in these hotbed states have increasingly felt the weight of program integrity issues when it comes to communicating the quality of care they provide, according to Joseph Furtado, administrator of MD Home Health and MD Home Assist. The Phoenix, Arizona-based provider offers medical and nonmedical home health and hospice.

“In Arizona what we’ve been dealing with in real-time with the licensure of new hospices is all this fraud happening. There’s a reason that people are going after hospice for fraud,” Furtado told Hospice News’ sister publication Home Health Care News at the conference. “Because if you do things wrong, you can really make a lot of money. But most of us don’t do things wrong.”

Program integrity issues have intensified regulatory oversight in the hospice space, a trend mounting concern among providers around compliance, operational and financial impacts.

Hospices providing quality care have increasingly feared facing greater compliance risks of being caught up in the mix of poor and negligent operations, Furtado stated.

Sustainable hospice care delivery will be impacted by how regulators approach reform, he indicated. For one, careful consideration is required to ensure that changes to quality reporting and compliance measures do not have unintended consequences. Some hospices worry that with regulatory changes will come limitations around their ability to provide a diverse range of interdisciplinary services and compete in a crowded market, Furtado added.

“It’s scaring us, this fraud stuff,” he said. “We’re afraid … because if [regulators] come down too hard, they’re going to gut the hospice benefit. It’s already hard enough to compete. If they start gutting the hospice benefit, we won’t be able to do the amazing things that we do in hospice.”

We’re afraid … because if [regulators] come down too hard, they’re going to gut the hospice benefit. It’s already hard enough to compete. If they start gutting the hospice benefit, we won’t be able to do the amazing things that we do in hospice.

— Joseph Furtado, administrator, MD Home Health, MD Home Assist