NURS 501 Week 6 Health Policy Issue Paper on an Existing Policy in Need of Revision Example

The Choice No One Should Have to Make: Revising the Medicare Hospice Election Requirement to Allow Concurrent Care

Abstract

The Medicare hospice benefit requires a beneficiary who elects hospice to forgo Medicare coverage of other care related to the terminal illness, including treatment intended to prolong life. The rule forces seriously ill patients to choose between hope and comfort, and the evidence suggests many delay that choice until the final days of life. In 2024, more than 1.8 million beneficiaries used hospice, yet the median length of stay among decedents was 19 days and a quarter stayed 5 days or fewer. This paper analyzes the election requirement, its stakeholders and the evidence on concurrent care. A federal evaluation of the Medicare Care Choices Model, which allowed hospice-style support alongside ongoing treatment, found lower Medicare spending, fewer hospital admissions and more hospice use, and pediatric concurrent care under the Affordable Care Act shows that the approach can operate within public insurance. Four options are compared: maintaining current policy, reviving the model as a voluntary demonstration, creating a statutory transitional concurrent care benefit, and raising hospice payment for high-cost patients. The paper recommends legislation establishing a time-limited concurrent care benefit with quality and spending safeguards and describes how advanced practice nurses can support its passage and implementation.

Keywords: hospice, Medicare, concurrent care, end-of-life policy, advanced practice nursing

Introduction

A composite patient helps frame the problem. A 71-year-old retired teacher with metastatic pancreatic cancer is still receiving chemotherapy when pain, weight loss and exhaustion begin to dominate each week. The oncologist suggests hospice. The patient wants the nurses, the medications for pain and the help for the family that hospice offers, but is not ready to stop the chemotherapy that might buy a few more months. Under Medicare's rules, the patient cannot have both. The patient continues chemotherapy, is admitted twice in the next six weeks, and enrolls in hospice four days before death.

That story is ordinary, not exceptional. The Medicare hospice benefit is one of the program's success stories, serving more than half of all beneficiaries who die, but its design demands a stark trade from patients in the very weeks when fatigue, pain and fear leave them least equipped to weigh it. This paper examines the hospice election requirement as an existing federal policy in need of revision. It describes the policy, defines the problem it creates, identifies the stakeholders, reviews the evidence on concurrent care, compares four policy options and recommends a statutory change, with attention to cost, equity, political feasibility and the role of the advanced practice nurse.

Background of the Policy

The Medicare hospice benefit covers palliative and supportive services for beneficiaries who are terminally ill, meaning that two clinicians expect death within six months should the disease follow its usual path (Medicare Payment Advisory Commission [MedPAC], 2026). Services include nursing visits, aide care, social work, chaplaincy, medications and equipment related to the terminal illness, short-term inpatient care for symptoms and respite for family caregivers, paid as a daily rate to the hospice.

To receive these services, a beneficiary must file an election statement. Under the federal regulation, the statement must include the beneficiary's acknowledgment that they understand the palliative rather than curative nature of hospice care and that certain Medicare services are waived by the election (Election of Hospice Care, 2025). MedPAC (2026) summarizes the effect plainly: when beneficiaries elect hospice, they agree to receive palliative care for the terminal illness and related conditions under the hospice benefit and forgo care related to the terminal illness outside of hospice, while Medicare continues to pay for unrelated care. The beneficiary may revoke the election and resume standard coverage, but cannot receive both forms of care for the terminal condition at once.

In 2024, more than 1.8 million Medicare beneficiaries received hospice services from about 6,700 providers, and Medicare spending on hospice totaled $28.3 billion (MedPAC, 2026). The share of decedents using hospice reached a record 52.9%. The benefit has grown steadily, and most observers regard it as a high-value service. The question this paper addresses is not whether hospice works, but whether the price of entry keeps it from working for patients who need it sooner.

Statement of the Problem

Late Enrollment and Very Short Stays

The clearest sign of the problem is how short many hospice stays are. MedPAC (2026) reported that the median lifetime length of stay among hospice decedents in 2024 was 19 days, and that a quarter of decedents had stays of 5 days or fewer and a tenth of 2 days or fewer. The average stay of 99.6 days is pulled upward by a smaller group of very long stays, often among patients with dementia. For half of the patients Medicare pays hospice to care for, the benefit arrives in the last three weeks of life, too late for most of what hospice teams are designed to do. Pain and symptom control can begin within hours, but preparing a family, managing medications at home, preventing crisis admissions and providing spiritual care take time.

The Forced Choice

Many factors delay hospice enrollment, including late referral, prognostic uncertainty and cultural preferences, but the election rule adds a specific barrier. Treatments that patients and oncologists regard as reasonable, such as palliative chemotherapy, immunotherapy, transfusions or dialysis, may be classified as related to the terminal illness and therefore excluded once hospice is elected. Patients who are not ready to stop such treatments postpone hospice, often until a hospital admission forces the decision.

Enrollment Barriers Within Hospices

The per diem payment compounds the problem. Because hospices receive a fixed daily rate, a patient who needs expensive palliative treatments can cost more than the rate covers. In the first national survey of hospice enrollment policies, Aldridge Carlson et al. (2012) found that 78% of 591 hospices had at least one enrollment policy that may restrict access for patients with potentially high-cost needs, such as chemotherapy or total parenteral nutrition, with smaller and for-profit hospices reporting more restrictive policies. The authors identified hospice enrollment decisions as a likely contributor to underuse of the benefit.

Equity Concerns

These barriers do not fall evenly. Beneficiaries from racial and ethnic minority groups, those dually eligible for Medicare and Medicaid and those in rural areas have historically used hospice less often. Niedzwiecki et al. (2024) found that these groups were underrepresented among enrollees in the Medicare Care Choices Model, even though the model's benefits extended to every subgroup analyzed. A policy that makes hospice easier to accept without giving up treatment could narrow those gaps, but only if access is designed for the people least likely to enroll.

Stakeholders

The beneficiaries and their families are the primary stakeholders; they bear the burden of the forced choice and the crisis admissions that follow delay. Hospice providers have mixed interests: a concurrent care benefit would bring patients to them earlier, but would also raise costs and require new coordination with oncologists and hospitals. Oncologists, cardiologists, nephrologists and other specialists want to keep treating patients who still benefit and to add support at home. Hospitals have an interest in fewer avoidable end-of-life admissions, particularly under value-based contracts. The Centers for Medicare & Medicaid Services and Congress are concerned with spending, program integrity and fairness; MedPAC advises both. Medicare Advantage plans, which managed hospice in a recent demonstration that tested transitional concurrent care, have an operational stake in any design. Nurses, finally, deliver most hospice care and see the consequences of late enrollment more directly than any other profession (Mason et al., 2016).

Review of the Evidence

Early Palliative Care

The rationale for concurrent care rests partly on evidence that palliative care delivered alongside disease treatment improves outcomes. In a landmark randomized trial of 151 patients with newly diagnosed metastatic non-small-cell lung cancer, Temel et al. (2010) found that patients who received early palliative care integrated with standard oncologic care had better quality of life at 12 weeks and fewer depressive symptoms, and, although fewer of them received aggressive end-of-life care, they lived longer than patients receiving oncologic care alone. Palliative care consultation is not the same as hospice, but the trial showed that adding comfort-focused care need not mean subtracting treatment.

The Medicare Care Choices Model

From 2016 to 2021, the Center for Medicare and Medicaid Innovation tested this idea directly. The Medicare Care Choices Model allowed eligible beneficiaries with cancer, heart failure, chronic obstructive pulmonary disease or HIV/AIDS to receive supportive and palliative services from participating hospices while continuing treatment for their terminal condition. The independent evaluation compared deceased enrollees with matched beneficiaries receiving usual care. Kranker et al. (2023) reported that enrollees were 15 percentage points less likely to receive an aggressive life-prolonging treatment at the end of life, spent more than five additional days at home, had 26% fewer inpatient admissions and 12% fewer outpatient emergency visits, and were 18 percentage points more likely to use hospice. The model also reduced net Medicare expenditures by 13%. The authors noted that the Centers for Medicare & Medicaid Services did not expand the model because of concerns about whether the results would generalize beyond the participating hospices and enrollees.

How the model produced these effects matters for policy design. Rowan et al. (2024) analyzed 217,156 encounters with 7,263 enrollees and interviews with staff of high-performing hospices. They identified five services that kept patients out of acute care: early and frequent needs assessments, direct observation in the home, immediate response to medical complaints, round-the-clock telephone access to nurses, and coordination with primary care physicians and specialists. Most of these are nursing functions. Niedzwiecki et al. (2024) added that the model increased hospice use, increased days at home and reduced aggressive treatment for every underserved subgroup examined, and reduced some disparities, although those groups were underrepresented among enrollees.

Concurrent Care for Children

A version of concurrent care already exists in federal law. Section 2302 of the Affordable Care Act requires Medicaid and the Children's Health Insurance Program to cover hospice for children without requiring them to forgo curative treatment (Patient Protection and Affordable Care Act, 2010). Cost studies of the provision are mixed. Using a national Medicaid database of 18,152 children in hospice, Svynarenko et al. (2024) found that concurrent care was associated with fewer live discharges from hospice but higher Medicaid costs, and that it was most cost-effective for the youngest children. Pediatric findings cannot be transferred directly to older adults, but they show that concurrent care can operate in a public program and that its costs depend heavily on who enrolls.

Limits of the Evidence

The strongest adult evidence comes from a voluntary model in which hospices and patients chose to participate, so selection may explain part of its success. The model also limited eligibility to four diagnoses and to beneficiaries with recent hospital use. These limits argue for a carefully designed benefit with continued evaluation, not against change.

Policy Options

Four options were compared against the same criteria: effect on timely access, cost to Medicare, equity and political feasibility.

Maintaining the status quo avoids new spending but preserves the late enrollment and crisis admissions described above. A revived voluntary model could be launched by the Center for Medicare and Medicaid Innovation without new legislation and would generate more evidence, but its reach would again be limited to participating hospices, and the earlier model attracted fewer enrollees than planned. A statutory benefit allowing a defined period of concurrent care, for example up to 90 days, would reach every eligible beneficiary and could be scored by the Congressional Budget Office using the model's results. Raising the per diem for patients with high-cost needs addresses the enrollment restrictions identified by Aldridge Carlson et al. (2012) but does nothing for patients who decline hospice because they would have to stop treatment.

Recommendation

This paper recommends option three: legislation creating a transitional concurrent care benefit within Medicare hospice. Under the proposal, a beneficiary certified as terminally ill could elect hospice while continuing treatment for the terminal condition for up to 90 days, after which the standard election would apply unless the treating clinician and hospice documented that continued treatment remained consistent with the patient's goals. Hospices would be paid the routine daily rate, with treatment billed separately as it is today, and would be required to provide the services Rowan et al. (2024) identified, including 24-hour nurse telephone access and coordination with the treating specialist.

Three safeguards would address cost and program integrity concerns. First, the benefit would be evaluated with a matched comparison design like the Care Choices Model evaluation, with results reported to Congress. Second, hospices would report the share of enrollees from underserved groups, with outreach requirements where enrollment lags. Third, payment would be reviewed after three years, allowing Congress to adjust the 90-day period if spending exceeded projections. The recommendation is supported by the evidence that the earlier model reduced net spending by 13% while improving end-of-life care (Kranker et al., 2023); a benefit open to all eligible beneficiaries may not match that result, which is why the safeguards are included.

Fiscal Analysis

Any change to Medicare must answer the cost question first, and the answer here is less certain than advocates sometimes suggest. On one side, the Care Choices Model reduced net Medicare expenditures by 13% among enrollees, largely by preventing inpatient admissions and emergency visits in the last months of life (Kranker et al., 2023). Inpatient care is the most expensive setting in which to die, and a benefit that moves even part of that care home produces savings quickly. On the other side, a statutory benefit would pay hospice per diems for patients who today receive no hospice care at all until their final days, and some of those patients would have used little acute care anyway. The pediatric experience shows that concurrent care can raise total program costs even as it reduces live discharges (Svynarenko et al., 2024).

Two design choices would keep the benefit closer to the savings seen in the model. The first is limiting the concurrent period, since most of the model's effect came from preventing crises in the months before death rather than from long periods of dual care. The second is targeting: beneficiaries with frequent recent hospitalizations, who made up the model's population, are the group in which avoided admissions are most likely to exceed added per diems. The Congressional Budget Office would score the proposal, and the safeguards described above allow Congress to adjust the benefit if early spending exceeds the score. In a program that spent $28.3 billion on hospice in 2024 (MedPAC, 2026), a modest increase in hospice spending that reduces inpatient spending by a larger amount is a reasonable trade, but the evaluation must confirm it.

Implementation Considerations

A concurrent care benefit would change daily work for hospices and treating clinicians, and implementation details would decide whether the evidence is reproduced. Hospices would need agreements with oncology practices, heart failure clinics and dialysis units so that treatment plans and hospice care plans do not conflict, along with a shared record of goals of care. They would also need the staffing to provide the frequent home assessments and round-the-clock nurse telephone access that Rowan et al. (2024) linked to fewer acute care visits, which is difficult for small and rural hospices already facing workforce shortages. Training would be required as well, since many hospice nurses have spent their careers in a model that assumes treatment has stopped, and many specialists still think of hospice as the end of their involvement.

CMS would need clear rules for which treatments count as concurrent care, how claims from hospices and treating providers are coordinated, and how the transition at the end of the concurrent period is documented. The pediatric benefit offers a working example, but adult care involves more chronic diseases and more Medicare Advantage enrollees. A phased start, beginning with the four diagnoses in the earlier model and expanding after the first evaluation, would let Medicare learn from early experience while still reaching patients nationwide.

Political Feasibility and Strategy

End-of-life policy is politically sensitive, but this proposal has features that can attract bipartisan support: it expands patient choice, it is supported by evidence of savings, and it builds on a model tested under both parties' administrations. The main opposition is likely to come from concerns about cost and fraud in the hospice industry, which MedPAC has examined for years. A strategy for passage would include a Congressional Budget Office score informed by the model's evaluation, endorsement by nursing, oncology and hospice organizations, and testimony from families. The advanced practice nurse can contribute through professional organizations, testimony and letters to Congress, and by sharing patient stories that make the forced choice visible to legislators (Mason et al., 2016).

The Role of the Advanced Practice Nurse

Advanced practice nurses are positioned to carry this policy from paper to practice. In hospice and palliative care they assess patients, manage symptoms, lead goals of care conversations and coordinate with specialists, which are the functions that produced the model's results. In oncology and heart failure clinics they can identify patients who would benefit from earlier hospice support. As leaders, they can design the workflows a concurrent care benefit would require, from shared care plans to 24-hour telephone triage, and they can measure whether underserved patients are reached.

Ethical Analysis

The election requirement also raises questions under the principles that guide nursing ethics. Respect for autonomy asks that patients make informed choices consistent with their values, yet the rule constrains the choice before it is made: a patient who values both comfort and continued treatment cannot act on both values at once. Beneficence asks clinicians to do good for the patient, and the evidence that earlier hospice support reduces crises and increases time at home suggests the current rule withholds a benefit from patients who would accept it if it came without the trade. Nonmaleficence is engaged as well, because the admissions and emergency visits that follow delayed enrollment carry their own harms, from delirium in the hospital to deaths in intensive care that patients did not want.

Justice may be the strongest argument. The patients most likely to enroll late or not at all are often those with the least access to specialists who discuss prognosis early, the least familiarity with hospice and the greatest distrust of a system that asks them to stop treatment. When Niedzwiecki et al. (2024) found that the concurrent care model improved outcomes for every underserved subgroup examined, they also found those groups underrepresented among enrollees. A fair policy would not only permit concurrent care but would require hospices and CMS to reach the patients least likely to ask for it. Weighing these principles together, the current rule is defensible as a cost control but difficult to defend as an ethical design for care at the end of life.

A Christian Worldview Perspective

A Christian ethic of care supports a policy that keeps people from facing death alone or in crisis. Scripture calls believers to "bear one another's burdens" (English Standard Version Bible, 2001/2016, Galatians 6:2), and the election requirement places a heavy burden on patients at the moment they are most vulnerable. Allowing patients to receive comfort and support without abandoning reasonable hope honors both the value of life and the reality of its end. It also reflects stewardship, since the evidence suggests better care at the end of life can cost less.

Conclusion

The Medicare hospice benefit serves millions of beneficiaries well, but its election requirement asks patients to give up treatment for their terminal illness in order to receive comfort care, and many wait until the final days to do so. Evidence from the Medicare Care Choices Model, the children's concurrent care provision and early palliative care research indicates that concurrent care can improve end-of-life care and may reduce spending. A time-limited statutory concurrent care benefit, with evaluation and equity safeguards, offers a practical revision that nurses can help design, advocate for and deliver.

References

Aldridge Carlson, M. D., Barry, C. L., Cherlin, E. J., McCorkle, R., & Bradley, E. H. (2012). Hospices' enrollment policies may contribute to underuse of hospice care in the United States. Health Affairs, 31(12), 2690-2698. https://doi.org/10.1377/hlthaff.2012.0286

Election of Hospice Care, 42 C.F.R. § 418.24 (2025). https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-418/subpart-B/section-418.24

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Kranker, K., Niedzwiecki, M. J., Pohl, R. V., Saffer, T. L., Chen, A., Gellar, J., Forrow, L. V., & Miescier, L. (2023). Medicare Care Choices Model improved end-of-life care, lowered Medicare expenditures, and increased hospice use. Health Affairs, 42(11), 1488-1497. https://doi.org/10.1377/hlthaff.2023.00465

Mason, D. J., Gardner, D. B., Outlaw, F. H., & O'Grady, E. T. (2016). Policy & politics in nursing and health care (7th ed.). Elsevier.

Medicare Payment Advisory Commission. (2026). Hospice services. In Report to the Congress: Medicare payment policy (pp. 293-324). https://www.medpac.gov/wp-content/uploads/2026/03/Mar26_Ch10_MedPAC_Report_To_Congress_SEC.pdf

Niedzwiecki, M. J., Forrow, L. V., Gellar, J., Pohl, R. V., Chen, A., Miescier, L., & Kranker, K. (2024). The Medicare Care Choices Model was associated with reductions in disparities in the use of hospice care for Medicare beneficiaries with terminal illness. Health Services Research, 59(4), Article e14289. https://doi.org/10.1111/1475-6773.14289

Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 2302, 124 Stat. 119 (2010).

Rowan, P., Whicher, D., Luhr, M., Miescier, L., Kranker, K., & Gilman, B. (2024). Supportive services at end of life can help reduce acute care services: Observations from the Medicare Care Choices Model. American Journal of Hospice and Palliative Medicine, 41(9), 1037-1044. https://doi.org/10.1177/10499091231216887

Svynarenko, R., Cozad, M. J., & Lindley, L. C. (2024). An age group comparison of concurrent hospice care: A cost-effectiveness analysis. Journal of Hospice and Palliative Nursing, 26(4), 219-223. https://doi.org/10.1097/NJH.0000000000001037

Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., Dahlin, C. M., Blinderman, C. D., Jacobsen, J., Pirl, W. F., Billings, J. A., & Lynch, T. J. (2010). Early palliative care for patients with metastatic non-small-cell lung cancer. The New England Journal of Medicine, 363(8), 733-742. https://doi.org/10.1056/NEJMoa1000678