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Insurance rules diminish the gift of hospice care

Updated: May 18, 2023

Thank you, Investor’s Business Daily for this article of tribute to Dr. Cicely Saunders, which focuses on her many leadership traits. My interest is in the article's insightful observations about dying and the benefits of hospice.


Recently, hospice has received unfair press related to the design of hospice insurance not with the hospice care model of palliative care.


Saunders's vision for hospice was about caring for patients and accepting that at the end of life, curing the uncurable may not be what is best for the patient. She worked to keep things simple, pragmatic and evidence-based. Unfortunately, hospice insurance has abandoned these core principles. Let me review three flaws in hospice insurance design that discourage the use of hospice and make its care delivery unnecessarily complex:

  1. The insurance requirement that two doctors certify a patient will die in six months. No physician wants to tell a patient they will die in six months, so they don't offer this care and wait until a patient is a few weeks from dying to raise the option. Saunders' criteria was much simpler and evidence-based - if the patient has a terminal diagnosis they qualify for hospice. This approach keeps the time factor of death off the table, making it easier for everyone to discuss hospice.

  2. The insurance requirement that patients give up their regular Medicare insurance benefits in order to qualify for hospice benefits. Based on evidence from a Medicare Innovation project, patients with both regular Medicare and the hospice benefit at the same time are more willing to embrace hospice, better cared for, more satisfied and the cost of their care is one-third less. Once they experience the hospice benefit, they move from the curative treatment model that isn’t helping them.

  3. The insurance rule that hospice is paid via ICD-10 coding, a process that is ridiculously time-consuming and invites fraud. The more complex we make the payment process, the more room there is to manipulate the coding to maximize payments. Venture capital is chasing after hospice because they can make a 15-20% margin by manipulating coding.

These insurance requirements are unnecessary, complicated, time-consuming and distracting, taking caregivers away from caring for patients facing numerous and important end-of-life issues.


Saunders was a great leader because she knew that if you follow the evidence and keep things simple, good things happen. Her vision and approach to end of life care gave everyone a better model of care for dying patients. Unfortunately, unnecessarily complex insurance rules are diminishing the legacy of Dr. Cicely Saunders and her gift of hospice. My book The Journeys End offers a new path forward to improve EOL care that honors the Saunders legacy.


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