Changing regulations and workforce shortages have created a churning undercurrent of risk within both the home health and hospice industries, according to Dr. Steven Landers, CEO of the National Alliance for Care at Home. 

Hospice and home-based care providers need a deep understanding around the wide scope of changes happening at policy, legislative and regulatory levels, Landers recently told Hospice News.

This year has come with a new presidential administration as well as a change of guard in leadership for the U.S. Department of Health and Human Services (HHS), the U.S. Centers for Medicare & Medicaid Services (CMS) and in Congress. Hospice and home health providers need a firm grip of insight into the new priorities that are taking shape, and the potential impacts on care delivery and workforce sustainability, according to Landers.

Hospice News sat down with Landers to discuss the top policy issues facing the industry.

What are some of the “under the radar” in hospice and home-based care delivery? What is important for providers to understand about these trends?

We live in a world where news travels pretty fast, and there are things that aren’t entirely known. Probably one of the biggest areas of question marks for everyone is exactly how, from a public policy standpoint, our new administration with new HHS and CMS leadership and a new Congress will handle issues related to care at home.

Areas that are a bit unknown are the balance between really sound program oversight and burdensome regulation and processes that harm access. We know that Dr. [Mehmet] Oz who’s recently been confirmed as CMS administrator is poised to focus on waste, fraud and abuse early in his tenure. At the same time, we know that the Trump administration is very concerned about deregulation over regulation. How that needle gets threaded between both needing to address very real concerns around fraud and abuse, and then at the same time do it in a way that is business-friendly, provider-friendly and reasonable. That is something to really watch.

There’s [also] a lot of broad brushstroke conversation in the ether about different topics … There’s a lot of unknowns. Some of the things to pay attention that may not be on the tip of everyone’s tongue are what role will Medicare Advantage play in the future. Medicare Advantage is a massive strategic issue for the whole care at home community. Will we see continued growth, or even accelerated growth, because of the policies that are accommodating, or will we see some of the scrutiny and critiques that have been part of recent conversations around Medicare Advantage? Will we see those slow the pace or just sort of maintain the status quo there?

The broader topic of value-based models, whether it’s through MA growth or other reforms within Medicare and Medicaid, that story continues. For providers to be successful, they’re going to have to continue to evolve their care models and their technology.

From a policy standpoint, we have to stand united as a hospice movement to prevent bad ideas around the role of managed care in hospice from taking hold again. There are still people searching for an angle to reinvigorate that [Medicare Advantage] topic, it’s not an entirely dead topic.

Do you foresee any overlap or parallels of challenges among hospice and home health care providers in coming years?

For all of us who care for people with serious chronic illness and care for an aging population, we’re all concerned about who will provide the care. This is a dominant issue. The areas of highest concern are the nursing and personal care workforce.

Where will our providers get the purchasing power to make sure that home care and hospice have what it takes to compete in this war for talent? When we look at what’s happened with payment updates and inadequate inflationary adjustments, basically the purchasing power of home health, hospice, home care providers to compete in this talent war has eroded. It’s eroded in addition to needing to find ways to get a new workforce, creative policy and creative programming at the provider and local community levels. [It’s] finding ways to pull more people into caring fields, to build these earn-while-you-learn pathways for our workforce so that we’re moving people up, and also so people don’t see their jobs as dead ends but as real growth.

Of course, the topic of reimbursement is an issue that cuts across all these areas. What reimbursement means in our world is the ability to recruit and retain talent. By and large, it’s a question of what resources are there to bring people into care delivery and the leadership you need in this sector is critical.

The other area that cuts across all providers in this serious, chronic illness and aging care space is where does government oversight go? How is that oversight done in a way that truly gets rid of sham and criminal operations, which have no business in health care at all. At the same time, you have well-run and well-managed providers in the country wasting their resources on things that ultimately get adjudicated in their favor, but after much hassle, expense and distraction from actually taking care of people.

What’s on the Alliance’s hospice legislative and regulatory wishlist for 2025? What are some of the key hospice issues the Alliance is rallying around this year?

In hospice, the face-to-face [telehealth] certification flexibilities are an important issue. We want to make sure that after this continuing resolution expires, that face-to-face telehealth flexibilities get extended. That will be on our radar, and advocating for that is an important topic as well.

Moving forward, we want to see adequate inflationary updates in the hospice payment system.

We also want to make sure that the implementation of the [Hospice Outcomes and Patient Evaluation (HOPE)] tool is on a reasonable timeline with adequate resources for education and preparation.

And, when CMS comes around to readdressing the Special Focus Program, we want to be at the table to make sure that the same mistakes are made again in terms of flawed methodologies.

What are your thoughts on a potential reintroduction of some type of legislation that could mirror or build upon the Hospice Care Accountability, Reform, and Enforcement (Hospice CARE) Act? What is the possibility of the proverbial torch that could be carried in moving some form of hospice legislation forward?

The Hospice CARE Act, introduced by Rep. Earl Blumenauer in September of last year, represents an important attempt to modernize and strengthen the hospice benefit. The Alliance has been actively engaged with this legislation since its inception, working directly with former Representative Blumenauer’s office to provide member feedback and advocate for effective reforms that would benefit patients, families and providers.

Following Blumenauer’s retirement, we continue to engage around this legislation. We’ve had positive conversations with offices who have asked for our thoughts and feedback on the bill’s many provisions and we would not be surprised if a member of Congress picks up the legislation this session.

The Alliance supports the legislation’s general intent to modernize the Medicare Hospice Benefit. We appreciate provisions that would increase flexibility for providers around respite care, including the addition of in-home respite options that would better serve patients and families. However, other aspects of the proposed legislation remain concerning. Radical changes to hospice payment structure or poorly targeted, overly burdensome program integrity measures could ultimately threaten patient access to care.

We continue to advocate vigorously for legislation that reforms the benefit by enhancing care for patients and families and push back on proposals that fail to improve access, quality or that take the hospice movement backwards.

What are the root issues in the hospice space that you’re working to address at advocacy and policy levels?

First and foremost, in any discussion about hospice policy, providers and policymakers must make the patient — who has made an informed decision to forego curative care in exchange for comfort and dignity with their loved ones — the central focus. Any policy that inhibits this care undermines the core purpose of hospice — full stop.

The Medicare Hospice Benefit stands as one of the most successful programs in American health care. Its interdisciplinary approach improves patient and family satisfaction and enhances end-of-life quality, all while generating significant cost savings for our health care system.

Despite [more than] 40 years of success and increasing utilization, only about half of eligible beneficiaries access hospice care. We are concerned that reimbursement has not kept pace with inflation, and how that trend hurts staffing levels and access to care.

As we look to future benefit reforms, our advocacy focuses on meaningful innovation opportunities, like a concurrent care option that would enable comprehensive care for people with life-limiting illness who wish to continue active treatment.

We also remain committed to effective oversight mechanisms that identify bad actors and prevent fraud, protecting patients and families as well as the reputation of the vast majority of hospice providers who deliver exceptional, high-quality care every day.