End the Hospice Benefit

THE PALLIATIVE LENS

By Andrew Esch, MD

Let’s stop pretending hospice just needs “reform.”

It doesn’t.

The modern hospice benefit has drifted so far from its original purpose that honest people should stop talking about tweaking it around the edges.

It should be ended.

Not because hospice as an idea is wrong.

Hospice, at its best, is one of the most humane concepts in modern medicine.

But the benefit we built around that idea has become something else entirely:

• bloated,

• distorted,

• administratively top-heavy, and

• increasingly disconnected from the bedside.

At some point you have to stop saying, “This could work if we just fix a few things,” and admit:

This model has failed.

The Number That Tells the Whole Story

For decades we have tried to improve hospice.

And after all of it:

• all the conferences,

• all the task forces,

• all the strategic plans,

• all the white papers,

• all the legislation......

the median hospice length of stay remains about 17 days.

That is not improvement.

That is not progress.

That is an indictment.

We have spent twenty-five years “working on the problem,” and the average American still gets hospice for barely more than two weeks before death.

If your flagship outcome has not meaningfully improved in a quarter century, you do not have a struggling system.

You have a broken one.

Meanwhile, the Industry Expanded Beautifully

Just not around patients.

Walk into enough hospice offices and you start noticing something.

• The clinical teams are stretched thin.

• The nurses are drowning.

• Social workers carry impossible caseloads.

• Chaplains are split across territories that make no sense.

• Case managers are charting until midnight.

But somehow the administrative wing keeps growing.

There is always money for:

• another vice president

• another regional director

• another quality officer

• another compliance officer

• another operations executive

• another “strategic initiatives” position

• and ( insert puke emoji ) "value based care" or "population health" leaders - whatever the hell that is- 25 years in medicine and my conclusion is that it's rebranding of capitation

Hospice organizations now resemble mid-sized corporations.

• Everyone has a title.

• Everyone has a meeting.

• Everyone has a dashboard.

Everything, apparently, except enough bedside staff.

I Remember One Moment Clearly

Years ago I asked a hospice CEO for a social worker for our team.

Not a luxury ask.

Not a vanity project.

We needed one because the team didn't have a dedicated one and was drowning and families were suffering.

He refused.

Said the budget would not support it.

He told me this while sitting in a massive glass-walled office in an administrative wing of other leaders, behind a locked door, elevated above the clinical floor like some kind of throne room.

I remember staring at him while he admin-splained fiscal restraint.

He was wearing a golf shirt.

Loafers. No socks.

Sitting in an office that probably cost more than my house, it certainly was bigger than my house at the time.

And he was telling me we could not afford another social worker.

That, in one image, is modern hospice.

We somehow found money for:

• The architecture.

• For the executive suite.

• For the branding consultants.

• For the management infrastructure.

  
  

But not for the person helping the dying family hold themselves together.

The Physician Role Has Become a Farce

Even the physician role has changed.

In many hospice organizations, hospice physicians spend much of their time completing recertification paperwork rather than delivering meaningful clinical care.

Their direct patient involvement is often limited to:

• mandatory face-to-face recertification visits

• phone coverage for patients they may not know personally

And when they decline to recertify a patient, those decisions are not always final.

In some organizations, leadership or administrative oversight reviews those determinations and reverses them.

That should alarm everyone.

The physician says no.

Administration says yes.

When physician judgment becomes subordinate to organizational pressure, the model is no longer centered on clinical integrity.

You are participating in theater.

Hospice Now Revolves Around the Wrong Things

Hospice was supposed to be about:

• time

• presence

• interdisciplinary support

• human connection

Instead it has become about:

• recertification cycles

• audit defensibility

• prognosis documentation

• census maintenance

• revenue preservation

We built a benefit intended to care for dying people.

And turned it into an administrative machine built to sustain itself.

Fraud Is Not the Exception—It Is a Predictable Byproduct

People like to talk about hospice fraud as if it is just a few bad actors and that not for profits are above it.

It is not. They are not

Fraud and abuse are what happen when you create a per diem system that rewards:

• longer stays

• vague prognostic diagnoses

• recertification elasticity

• documentation gymnastics

  
  

Then we act surprised when organizations optimize for those incentives?

Of course they do.

That is what systems do.

They respond to incentives.

And ours rewards enrollment, duration, and defensible paperwork, not necessarily better care.

Stop Pretending Policy Will Save It

Every few years someone proposes:

• better workforce support

• stronger oversight

• improved referrals

• more education

• tighter regulation

Fine.

But we have tried all of that.

And here we are.

• Still talking about the same median stay.

• Still seeing the same late referrals.

• Still watching the same bloat.

• Still discussing the same fraud.

Because the issue is not implementation.

The issue is the design itself.

What Defenders of the Hospice Benefit Will Say

They’ll say:

• The hospice benefit isn’t broken, it's underused.

• That patients are referred too late.

• That physicians struggle with prognostication.

• That families resist “giving up.”

• That cultural barriers, misinformation, and fear delay enrollment.

• They’ll point to data showing hospice improves symptom control, reduces hospitalizations, and increases family satisfaction.

They’ll argue the problem isn’t the structure, it’s access and timing.

• Fix the referrals.

• Educate clinicians.

• Start earlier conversations.

And the system will work the way it was intended.

They’ll also warn that dismantling the benefit risks destabilizing one of the few parts of American healthcare that reliably delivers interdisciplinary, home-based care at scale.

In other words:

Don’t tear it down.

Use it better.

Why That Argument Falls Apart

All of that sounds reasonable. It just doesn’t hold up.

Because we’ve been saying those exact things for decades.

If the core problem were late referrals, you would expect gradual improvement over time.

• More education.

• More awareness.

• More integration into oncology and primary care.

And yet the median length of stay barely moves.

Not meaningfully.Not consistently.Not enough to suggest the system is correcting itself.

At some point, you have to ask a harder question:

What if late referral isn’t a failure of clinicians?

What if it’s a predictable response to the way the benefit is designed?

The hospice model forces a binary decision:

• Curative or hospice.

• Treatment or support.

  
  

Even when we soften that language, the structure is still there.

So clinicians delay. Patients hesitate. Families resist.

Not because they don’t understand hospice, but because the system asks them to cross an artificial line that doesn’t reflect how serious illness actually unfolds.

And while we blame “education,” the system quietly adapts in other ways:

• Organizations expand enrollment criteria.

• Recertification becomes more elastic.

• Diagnoses get stretched.

• Clinician decisions get overturned by administration

  
  

Not out of malice, but because survival depends on it.

So we end up with two parallel failures:

• Patients who enroll too late to benefit meaningfully.

• And patients who remain enrolled longer than intended under increasingly flexible interpretations of eligibility.

  
  

That’s not a utilization problem.

That’s a design flaw.

And the idea that we can “educate our way out of it” ignores something more fundamental:

Incentives always win.

We can keep training clinicians to refer earlier. But as long as the model is built on prognostic thresholds, per diem payments, and enrollment boundaries that don’t match clinical reality, we will keep getting exactly what we are getting.

End It

Not hospice as philosophy.

Not comfort care.

Not interdisciplinary support.

Not serious illness care.

End the benefit structure.

Burn down the payment model and rebuild it into something honest.

Create a system that:

• starts earlier

• is based on need, not prognosis games

• pays for care, not days enrolled

• rewards staffing the bedside, not staffing the boardroom

Because what we have now is not sacred.

It is not beyond criticism.

And it is not working.

We can keep pretending hospice has just “lost its way.”

Or we can admit what many of us quietly know:

The hospice benefit did not merely drift.

It evolved exactly as its incentives allowed it to.

And what it evolved into no longer deserves defending.