Larry Beresford
While the majority of hospice agencies work hard to provide good care, stories about those that fail to live up to their ethical or legal obligations have appeared in prominent journalistic settings in recent years. Most recently, on February 3 of this year, hospice owner Petros Fichidzhyan of Granada Hills, CA, pled guilty to a $17 million Medicare fraud scheme for operating sham hospice companies.1
But if we dig deeper into quality, we see lots of questions about what quality hospice care really means. How can we define it, measure it, and make comparisons between providers that will be useful to consumers? And what can Academy members, individually and collectively, do about those hospices that diverge significantly from what we would consider minimum quality of patient care? What kinds of messages should hospices be delivering to their various publics about quality and about choosing the provider that will meet their particular needs?
For Judi Lund Person, a Virginia-based hospice consultant who spent many years as a regulatory expert for the National Hospice and Palliative Care Organization (NHPCO, now called the National Alliance for Care at Home), the important question is whether a hospice is mission driven—or mission driven enough. Mission meaning patient- and family-focused, consistently caring, compassionate, and responsive management of the care needs of terminally ill patients and their families.
“If we are constantly thinking about things like: What are the goals of our care? What does this patient need? What does the family need? What are they telling us? Are we listening well enough?—all of those things help lay the foundation for making sure that we are taking care of quality,” said Lund, who is now a senior advisor to the National Partnership for Healthcare and Hospice Innovation. “But then the question is, how can you quantify that kind of quality?”
The Centers for Medicare and Medicaid Services (CMS) has been working to answer that question, Lund Person explained, while the Academy, the National Alliance for Care at Home (formerly NHPCO), and other provider groups have been trying to advise the government on how to improve its measurement of hospice quality. (See Measuring Quality below for an outline of the federal government’s formal hospice quality initiatives.)
The art and science of quantifying quality are full of dilemmas, she said. Other observers suggest that reforming the Medicare Hospice Benefit is both overdue and essential to the quality question. But what do political upheavals in Congress and at the Department of Health and Human Services portend for hopes of progress on that front?
“Also, maybe at the end of the day, we need to be thinking about how many hospices there should be,” Lund Person said. “Some of these hospices that we see, they barely understand what hospice care is.”
Quality vs Fraud
There’s another current dilemma for the hospice field. Lund Person recalled sitting at a table at a recent conference discussing these issues with a number of Southern California AAHPM member physicians, who also shared their perspectives in a conference call with this publication about blatant hospice fraud.
According to data from the California Department of Public Health, as of January 2022, the state had 2,836 state-licensed, Medicare-certified hospice programs, with 1,841 of them in Los Angeles County. How many of those 1,841 LA hospices could possibly have physician leaders with hospice and palliative expertise, or qualified bereavement and spiritual care professionals on staff, or contracts for the required general inpatient level of care, or access to an on-call service for after-hours crisis calls—even a working phone number?
The Southern California physicians Lund Person spoke to want to ensure that when they refer a patient to a given hospice, they are going to get care and actual visits from the hospice, which will answer the phone when it is called. Yet they say many “hospices” are not only failing to offer the full complement of hospice services, but they’re not even trying, while others likely are committing outright fraud.
The proliferation of hospices in California led to a moratorium on licensing new hospices in the state, which is in effect until 2027. But authorities have not been able to crack down on the blatantly fraudulent existing hospices—despite a 2022 state audit finding that weak oversight had opened the door to large-scale fraud and abuse.2
“It is important to differentiate hospice quality issues from organizations that are clearly bad actors.”
Holly Yang, MD, a hospice and palliative medicine specialist in San Diego, said it is important to differentiate hospice quality issues from organizations that are clearly bad actors. For those that are providing care but not to the level we might wish, “can they be helped to elevate their quality?” she asked.
“But then there is the problem of just plain flagrantly abusive activity, stealing people’s Medicare numbers, signing them up for hospice when they’re not even aware they’re being signed up, just flat out doing things that are not legal,” she said. “I think, in the national media, these two things get lumped together.”
Rebecca Yamarik, MD, a physician at the Long Beach Veterans Affairs Medical Center, said she personally feels a moral crisis over this issue. “If I talk to patients about hospice care and everything it can do for them, I don’t know whether they will actually get that kind of care. Can I even recommend hospice in the way it’s currently working in Southern California?” she said.
“I know of patients who have shown up in the emergency room, never having interacted with a hospice agency, and when they give their Medicare number, they are told, ‘Oh, you’re on hospice.’” Dozens of these fake hospices might be located in the same building, and they pass the patients around to each other, Dr. Yamarik said.
Dr. Yang said the Academy has been clear about its support for the delivery of high-quality hospice care and its condemnation of abusive practices that impact hospice integrity, working on both concerns with federal legislators, getting policies passed at the American Medical Association, and partnering with other coalitions to address these concerns.
She also acknowledged that the physicians she knows want to see more action on these issues. “It gives everyone a bad name, and unfortunately, it increases things like government audits, which only hurts the hospices that are trying to deliver good care. It doesn’t hurt those that are just taking advantage of people and actually causing great harm to the system.”
To that end, AAHPM’s Hospice Policy Ad Hoc Workgroup, made up of Academy members with expertise in hospice, is conducting ongoing meetings to develop policies and positions that would address fraud and improve quality in hospices while also maintaining access to needed care and services. AAHPM will also post updates of the work that is happening behind the scenes and the structures that it has put in place, using its Connect member platform. Members are encouraged to participate on Connect and to remain abreast of what’s happening on the quality front more generally.
For Alan Kaplan, MD, CMO of Alleviate Care, a hospice serving four counties in Southern California, these quality problems pose real issues for patient choice. “Most patients and families come to hospice care in a crisis, almost by definition,” he said. “They’re just looking for help. It’s an information mismatch.”
The Academy also has a patient-facing website, PalliativeDoctors.org, which includes questions consumers can ask when they’re looking for a hospice team. “I just think most people just trust what hospital staff tell them. They go with whatever service they are offered,” Dr. Yang said. “Even savvy people don’t know to ask, for example, if the hospice medical director is hospice and palliative medicine (HPM) board certified or has a hospice medical director certification (HMDC) credential.”
She added that resources like Care Compare, which compiles quality data on Medicare providers including hospices, while not a perfect measure of hospice quality, can help with information. “Does the hospice see very many patients? Is it reporting quality data? Because if it has no reported data on Care Compare, I’d say don’t pick that hospice.” Hospices with smaller censuses are not mandated to report this quality data.
What Can Academy Members Do?
Palliative care and other physicians who refer their patients for hospice care might explore which agencies should get their referrals and what they can do to help make sure that their patients are served by hospices that are truly committed to quality care. Dr. Yang said that where she works, she is able to make recommendations of hospice providers while letting patients know federal regulations allow them to choose any hospice they want, just as a physician would recommend a particular surgeon for a patient.
Other hospitals may have preferred providers, but if the physicians feel they don’t have a choice because their institution has chosen a contracted provider, there may be other avenues within the organization to push for better hospice options.
“In my experience, some self-respecting palliative care systems and services in hospitals go through an arduous vetting process, deciding which hospices they prefer to work with,” said Martina Meier, executive medical director of Providence Hospice LA County and SoCal Palliative Care, based in Torrance. “And yet there are so many mechanisms in place in the hospital that allow patients to get referred outside of those preferred hospices. If even 50% of the patients were referred to the preferred hospice, I would rate that a big success.”
Physicians who complete a 1-year fellowship in hospice and palliative medicine have an opportunity to learn more about hospice quality and the hospice medical director’s role for influencing it. But in many fellowship programs, the time and attention devoted to hospice quality are less than what’s spent on the clinical aspects of caring for a dying patient, said Martha Twaddle, MD, medical director for Palliative Medicine and Supportive Care at Northwestern Medicine.
Dr. Twaddle, who works with the HPM fellowship program at Northwestern, said it’s up to a fellowship’s preceptor what to emphasize. There are minimum learning requirements defined for the fellowships, she said, but variability in how these are met. “Here at Northwestern, I teach the didactic portion of the hospice medical director’s role—and I’m available to students for further coaching.” But the reality is that most HPM fellows will move into palliative care positions within health systems, often based in hospitals, with fewer taking full-time positions as hospice medical directors.
Studying for the HMDC credential, for clinicians who choose to pursue this additional credential, will answer many of these needs, Dr. Twaddle said. She has also been developing an initiative in collaboration with AAHPM and the Hospice Medical Director Certification Board: a post-fellowship, self-paced learning curriculum and organized training program for physicians to learn more about Medicare’s Conditions of Participation for hospices, the hospice physician’s role in regulatory compliance, how to write a clear narrative in the chart, and the like.
“We also encourage new graduates working in hospice to find a mentor—especially if they work for a smaller program. If we can build on existing educational products, such as [through] the Academy’s Learn center, we could start to roll out models so they better understand their role in quality and how to take leadership in the hospice’s quality,” Dr. Twaddle said.
What Is Mission Driven?
Joseph Shega, MD, executive vice president and CMO of VITAS Healthcare, a multistate, for-profit hospice company, said he is proud of the work VITAS teams do every day to individualize care plans for their patients and families. Dr. Shega agreed that families need to have some means of identifying high-quality, mission-driven hospices. “And it’s really imperative that hospices and hospice groups—the mission-based hospices—work with CMS to come up with better common-sense, informative, reliable, and accurate data that would help patients and families make those informed decisions.”
Different hospices have different philosophies about what’s important regarding quality, he said. “For example, at VITAS we believe it’s important to have access to all four levels of hospice care,” which helps patients and families receive their care in the location of their choice. But currently that’s not part of hospice quality assessment by CMS.
“My experience is that referring physicians sometimes don’t think about this enough, even though it has a profound impact on the end-of-life journey for their patients and families. If you’re the palliative care clinician at a health system or group practice, you may not be in a position to choose which hospice is in the preferred network. But you can advocate for patients and families to ensure that the hospice has the capabilities to support their end-of-life goals.”
For John Mulder, MD, chief medical consultant for hospice and palliative care at Holland Home in Grand Rapids, MI, it’s important to point out that receiving hospice care from a mission-driven organization is not always a guarantee of high-quality care. Patients may not be aware of the quality they are receiving from a hospice because they have nothing to compare it to, he said.
Others might get their medications delivered on time and receive needed professional services and prompt responses from the team. “But the families are not satisfied because they didn’t want their parent to have cancer, or because they died before they had a chance to reconcile with each other,” he said.
“I am a firm believer that the best quality care is delivered through relational medicine, not transactional medicine.”
“The healthcare system continues to be more and more transactional as time goes on,” Dr. Mulder said. “But I am a firm believer that the best quality care is delivered through relational medicine, not transactional medicine. If I know my patients and they understand me and I understand what their values and their care preferences are, there’s a greater likelihood that I’m going to be offering them quality care.”
Not Just Parking Violations
Edward Martin, MD MPH, chief medical officer of HopeHealth in Rhode Island, agrees that these questions about hospice quality need to be addressed. He compared the current environment to watching a bank being robbed while the police are outside looking for overtime parking violations.
“It’s just so frustrating that real fraud has been ignored by the government,” he said. Meanwhile, Medicare Administrative Contractors survey hospices for whether there’s a missing date on a physician’s signature. “We could provide wonderful hospice care for six months, but if they find a missing date on a physician signature, they don’t have to pay for those six months of high-quality care.”
Dr. Martin believes the government’s regulatory efforts have failed to address real fraud. “Unfortunately, I don’t think hospice, per se, can turn this around alone. It’s up to CMS and the regulatory bodies that have the power to do this. We need to support their efforts to combat actual hospice fraud.”
“Quality is like a puzzle where all these pieces [need to] fit together. It starts with what kind of hospice provider you want to be in your community.”
For Jennifer Kennedy, EdD BSN RN, vice president of quality standards and compliance with Community Health Accreditation Partner, which accredits hospices, quality in hospice care remains a puzzle. “You have compliance and hospices submitting data to CMS, which puts the data on public reporting sites. But there are all those other pieces—such as community engagement. Are your staffing levels what they should be? Do you have good relationships with vendors? Quality is like a puzzle where all these pieces [need to] fit together. It starts with what kind of hospice provider you want to be in your community,” she said.
Hospices that have chosen to be in this business because their philosophical North Star is providing good, quality hospice care should report when they see other hospices in their community crossing the line—to get them out of the marketplace, Dr. Kennedy said. She recommended contacting CMS, the Office of Inspector General, and/or state attorneys general.
She related that her mother died under hospice care in 1998. “It was a phenomenal experience,” she said, with exquisite care and support provided by the hospice team. “My mom died in my dad’s arms, in the house I grew up in, which is where she wanted to be. Because of that experience, I started working in hospice and never looked back. That’s what I want for every patient. It’s that ability for the hospice team to go in there and truly take care of that family’s and patient’s needs.”
Measuring Quality
The federal government’s Hospice Quality Reporting Program includes a number of different facets for gathering quality data in different ways.
- Hospice Item Set (HIS) measures, gathered and submitted at the time of hospice admission and discharge, incorporating seven component quality measures used to calculate one overall composite measure—the Hospice and Palliative Care Composite Process Measure—which quantifies the proportion of the hospice’s patients who received all seven care processes on admission
- The Consumer Assessment of Health Care Providers and Systems Hospice Survey, which calculates eight patient experience measures
- A publicly accessible star rating of hospices at Care Compare, derived from surveys submitted by family caregivers after the patient’s death
- Claims-based Hospice Care Index measures calculated from 10 indicators on Medicare hospice claims, aiming to capture care processes at a given point in the hospice stay
- Hospice Visits in the Last [3] Days of Life, also derived from submitted claims data
- The new Hospice Outcomes and Patient Evaluation (HOPE) assessment tool, designed to be implemented starting October 1, 2025, submitted while hospice care is being provided and replacing HIS. HOPE aims to provide a more comprehensive understanding of each patient’s care needs and will be important for the hospice and for CMS to have more robust data on the patients served in hospice.
References
- Man pleads guilty in connection with $17M Medicare hospice fraud and home health care fraud schemes. Press release. US Department of Justice Office of Public Affairs. Published February 3, 2025. Accessed March 21, 2025. https://www.justice.gov/opa/pr/man-pleads-guilty-connection-17m-medicare-hospice-fraud-and-home-health-care-fraud-schemes.
- California State Auditor. California Hospice Licensure and Oversight: The State’s Weak Oversight of Hospice Agencies Has Created Opportunities for Large-Scale Fraud and Abuse [2021-123]. Published March 29, 2022. Accessed March 21, 2025. https://information.auditor.ca.gov/pdfs/reports/2021-123.pdf.
Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.