Today’s hospice executives are entering the field with change in mind for improved quality. But concerns have mounted around sustainable growth strategies that will keep pace with rising demand amid myriad challenges in end-of-life care delivery.

Hospice News spoke with c-suite executives who have recently stepped into their roles to learn more about what led them to the space and their top priorities. Regulatory challenges are among hospice leaders’ most significant concerns. They also envision opportunities to reform the Medicare Hospice Benefit and diversify their scope of services.

A common thread is a desire to make a difference in the quality of patients’ lives, according to Compassus CEO Michael Asselta, who took the helm of that company in May. A fragmented health care environment can make this a complicated, but not impossible, goal to achieve, Asselta added.

“There’s tremendous opportunity in this corner of health care to do some really phenomenal things,” Asselta told Hospice News. “We have these tremendous levers to pull with palliative care, hospice, home health and home infusion, just massive levers to pull. The CEO gets a front row seat to potentially change the industry for the better and be a part of that change. It’s buying into the mission, vision and values.”

Hurdles on the horizon

Hospice executives are facing a plethora of challenges, said Karen Brubaker Miller, who last July was tapped as the CEO of Maryland-based Montgomery Hospice & Prince George’s Hospice. Brubaker Miller entered the field as a social worker in 1993 and has held leadership positions at hospice organizations for the last 14 years.

C-suite leaders need a holistic mindset around their organization’s care delivery approaches that focuses on patient dignity, autonomy and compassionate support, Brubaker Miller said. Keeping the meaningful purpose of hospice care at the forefront equips business leaders with a strategic focus that centers on quality, she stated.

“Leading a hospice organization is certainly not for the faint of heart,” Brubaker Miller told Hospice News in an email. “There are so many challenges facing hospice providers — staff shortages in a tight labor market, reimbursement that doesn’t keep pace with inflation, intense government audit scrutiny, cybersecurity threats, M&A and fierce competition — plenty to keep us up at night. When we remember how meaningful hospice is to our patients and families, this touchstone safeguards against discouragement from the daunting challenges we face and spurs us onward to keep making a difference in the lives of families and communities we serve.”

Regulators are increasingly cracking down on hospices in an effort to curb fraud, waste and abuse and improve quality in the space. The regulatory environment has grown all the more complex, according to Nancy Littlefield, president and CEO at Hospice of the Piedmont.

Littlefield ascended to the role at the Virginia-based hospice and palliative care organization in October 2023. She has roughly three decades of experience in health care, including serving as a nurse, a chief nursing officer and as an executive vice president, among others.

Poor and negligent operators in the hospice space have hindered legitimate providers’ ability to compete and break down common misconceptions about their services, Littlefield indicated. C-suite executives need an adaptable approach to their compliance strategies and public outreach efforts to stay ahead of the curve, she stated.

“It’s unfortunate that one bad apple makes the whole barrel a little bit more challenging,” Littlefield said. “But anything where the outcome is changed by following that goal improves the betterment of the patient is worth it. It might cause a very big shift in what we already have to do, but if it ultimately helps pain and suffering, then it is absolutely the right thing to do.”

Indeed, regulatory concerns are top of mind for providers nationwide. Program integrity issues have regulators taking a broad brush across the industry and made for a challenging hospice auditing climate, according to Dr. Marny Fetzer, chief medical officer at Maryland-based Hospice of the Chesapeake. Fetzer stepped into her current role last year in July with a background in emergency medicine, and entered the hospice field after receiving exposure to these services in a hospital and health system setting. 

Hospices are often undergoing multiple audits simultaneously, with auditors examining different types of information. The variances have created a difficult path for hospices to prepare for and respond to the auditing activity, Fetzer stated. Additionally, the auditing processes can be lengthy, time- and resource-intensive, as well as costly, she added.

“The regulatory and audit environment are a challenge, but we do need these just like any other part of health care,” Fetzer said. “I worry that the environment casts a very wide net. Auditors are looking at different types of things and sometimes they are looking at the same things. We’re seeing a fair bit of variability in how different agencies approach documentation audits. There needs to be a little consistency in how auditors are approaching things. Once that consistency is achieved, it will better inform their roles. Until then, there’s kind of this moving target of getting a different approach to how auditors view the guidelines and different responses from whoever is judging the audit.”

Future changes to reimbursement are also on executives’ minds. Though virtually all of their services are reimbursed through the Medicare Hospice Benefit, value-based payment streams may be widening.

Hospice leaders need to be aware of payment changes occurring across the Medicare landscape that could have rippling effects on their organizations, Littlefield stated.

“There’s a lot of unknown changes in Medicare. What do those changes look like for the hospice industry?” Littlefield told Hospice News. “Different Medicare programs can impact hospice, and we just have to be educated of what they are and what we need to do to adapt to that. We have to learn to be nimble and keep our patient and caregiver in front of us always, then figure out operationally where we need to go from there.”

Outlook for change

The Medicare Hospice Benefit has largely remained stagnant since its inception roughly four decades ago, with calls for change growing louder among industry stakeholders. Case in point, the recently introduced Hospice Care Accountability, Reform, and Enforcement (Hospice CARE) proposes several changes to the benefit, including payment and regulatory reforms, among others. The legislation has the potential to dramatically reshape end-of-life care delivery.

Changes to the hospice benefit are long overdue, Brubaker Miller said. Care preferences and illness trajectories have vastly changed in the scope of end-of-life care.

“My hope is that the Medicare Hospice Benefit can adapt to meet the needs of dying patients in America,” Brubaker Miller said. “For example, hospice regulations originally written in 1983 established eligibility criteria as six months or less if the illness runs its normal course. In the early years of the hospice benefit, most patients had cancer diagnoses and more predictable diagnoses, so they easily met this requirement. Since that time, nearly half of Medicare [decedents] now receive hospice care, and many of them have life expectancies that aren’t as simple to predict.”

Changes to the hospice benefit could introduce significant opportunities to improve access and utilization. If hospices had stronger reimbursement for upstream services such as palliative care, for instance, this could help reach patients earlier in their trajectories, reduce high-cost emergency department and inpatient utilization and lead to higher quality experiences, said Littlefield.

While hospice eligibility requirements focus on patients with a prognosis of six months or less of life, more providers have diversified their service lines to support patients before they reach this point.

“My hope is that we look for every opportunity to serve those who are facing life-limiting illness with an open access theory or frame of mind,” Littlefield told Hospice News. “As far as upstream, we can bring palliative care services in to help bridge the gap of managing symptoms and help the hand off to hospice. We can help teach families how to communicate well at the end of life and be transparent about what’s happening to a patient.”