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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Heath care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

IN FOCUS Part 2: The Proposed FY2016 Hospice Payment Rule -- The Data Behind Proposed Hospice Payment Reforms and Oversight Activities

May 29, 2015 09:46 AM

The National Association for Home Care & Hospice (NAHC) published an initial overview of the proposed FY2016 Hospice Payment Rule in NAHC Report on May 1, 2015.  To provide more in-depth coverage of specific elements of the proposed rule, NAHC is developing a series of “IN FOCUS” articles that will be published over the coming weeks.  Part 2 of the “IN FOCUS” series focuses on the data behind proposed hospice payment reforms and oversight activities.

Late April 30, 2015, the Centers for Medicare & Medicaid Services (CMS) placed on display at the Office of the Federal Register a proposed rule (Medicare Program; FY2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements [CMS-1629-P]).  CMS also posted additional data slides (on its Hospice Center web page at:​15-.pdf)that include more in-depth information from findings by Abt in support of payment reform. 

The rule contains numerous changes to hospice policy, the most noteworthy of which are its proposed reforms of the hospice payment system for care delivered at the routine home care (RHC) level.  CMS has had hospice payment changes under review since 2010; previous indications were that the agency was giving serious consideration to implementation of a tiered payment system for RHC (a tiered payment system is a modified version of the “U” shaped payment model for hospice care that was initially proposed by the Medicare Payment Advisory Commission [MedPAC] to Congress in 2009). 

However, the preamble to the FY2016 proposed rule explains that a tiered payment system presented “operational concerns and programmatic complexity” that led CMS in a direction that would allow for payment reform “that could be implemented with minimal systems changes that limit reprocessing of hospice claims due to sequential billing requirements.”  CMS also indicates its belief that use of the service intensity add-on (SIA) for RN and social work visits provided during the last seven days of life serves as one of the “first steps in addressing the observed misalignment between resource use and associated Medicare payments and in improving patient care through the promotion of skilled visits at end of life…” 

In recent years CMS has analyzed and published a significant amount of data that has been gathered as part of its hospice payment reform efforts.  This year’s proposed rule contains additional data that highlights areas of hospice practice that raise continuing concerns for CMS and others.  NAHC has developed this summary of informational data that CMS has included in the preamble to the proposed FY2016 hospice payment regulation to inform hospice providers and other stakeholders of important and ongoing data analysis in this area.  While CMS has communicated that it does not plan to issue a technical report containing its latest data findings in conjunction with the proposed rule, we expect CMS to post slides on its Hospice Center Web Page that provide additional findings, and NAHC will alert its members to posting of that data when it occurs.  It is anticipated that CMS will continue to monitor data and practice trends in hospice; CMS has stated that as more robust data becomes available through the additional data on claims and the revised and expanded hospice cost report, the agency will weigh modifications to the proposed payment changes.


Woven throughout the proposed rule are data findings that CMS has drawn from its payment reform analyses and other sources.  These findings provide insights into CMS’ rationale for the payment changes it is proposing and ongoing oversight and enforcement activities it may pursue. 





Beneficiaries served


1.3+ M


$2.8 B.

$15.3 B.

Average lifetime LoS

54 days

98.5 days

Projected growth:  8% annually (CMS Office of the Actuary projection)


CMS provides comparisons of changes through the years in hospice principal diagnoses and shifts among top diagnoses.  In recent years CMS has placed increased focus on adherence to ICD-9-CM coding guidelines that prohibit use of certain diagnoses as a principal diagnoses in most cases.  These “unspecified” diagnoses include debility, adult failure to thrive, and certain dementia diagnoses.  Effective Oct. 1, 2014, CMS implemented a claims edit that returns to provider (RTPs) hospice claims using manifestation or other codes determined by the coding guidelines to be inappropriate principal diagnoses.  Data comparing FY2013 and FY2014 claims (below) indicate that -- even prior to implementation of the edit -- hospices began to respond to CMS’ direction.


FY2013 (% OF CLAIMS) 

FY2014  (%  OF CLAIMS)

1.    Debility Unspecified (9%)

Alzheimer’s (9%)

2.    CHF (7%)

CHF Unspecified (8%)

3.    Lung Cancer (6%)

Lung Cancer (6%)

4.    COPD (6%)

COPD (6%)

5.    Alzheimer’s (6%)

Senile dementia, Uncomp. (3%)

6.    Adult Failure to Thrive (5%)

Heart Disease, Unspecified (3%)

7.    Senile Dementia, Uncomp. (4%)

CVA/Stroke (2%)

8.    Heart Disease, Unspecified (3%)

Dementia, Unspec., w/o Behav. Disturbance

9.    CVA/Stroke (2%)

Parkinson’s (2%)

10.Dementia in other diseases w/o Behav. Disturbance (2%)

Colon Cancer (2%)



One of the driving forces behind enactment of the hospice benefit was the argument that beneficiaries could receive more appropriate care at the end of life, and at reduced cost to the Medicare program.  In an effort to analyze potential cost savings resulting from the use of hospice care, CMS conducted analysis to evaluate pre-hospice spending for beneficiaries who ever used hospice and that died during FY2013.  CMS found that hospice patients with the longest lengths of stay had lower pre-hospice spending relative to hospice patients with shorter lengths of stay on hospice; those patients with longer stays tended to be patients with neurological conditions (such as Alzheimer’s, other dementias, and Parkinson’s disease).  Other research examined by CMS indicated that adjusted mean Medicare expenditures for hospice enrollees with cancer were lower than for those who did not use hospice while expenditures for hospice enrollees without cancer were 11 percent higher than for non-enrollees.

As part of additional data provided on the CMS website, Abt compares median daily Medicare spending prior to hospice admission for several major diagnosis groups to demonstrate variation in the degree to which pre-hospice spending compares with the hospice routine home care payment rate.  CMS also provides data comparing pre-hospice spending for diagnosis groups with average total lifetime hospice days.


As part of the FY2015 proposed hospice payment rule, CMS provided a great deal of information from its research related to non-hospice spending for hospice beneficiaries during an election; MedPAC has conducted research on this subject, as well.  The FY2016 proposed payment rule includes updates on the status of CMS’ study in this area. 

For FY2013, CMS found that combined Medicare spending (Parts A, B, and D) outside of hospice was about $1 billion, which is comparable to the estimate for FY2012.  In addition, beneficiaries were subject to spending for these items and services in the form of copays and other cost sharing.  The average daily rate of expenditures outside of the hospice benefit was $7.65, but CMS found significant geographic differences -- the highest rates per day occurred for hospice beneficiaries in West Virginia ($13.74), Delaware ($12.76), Mississippi ($12.31), South Florida ($12.24) and Texas ($12.10).  Approximately 56% of beneficiaries receiving care outside of hospice resided at home. 

To further evaluate instances where drugs, supplies, durable medical equipment (DME), and Part B services may be related to the principal diagnosis on the hospice claim but are being billed outside of hospice, Acumen LLC conducted spending analysis and developed case studies on items/services billed outside of hospice for four of the most commonly reported principal hospice diagnoses on claims, and CMS examined clinical manifestations related to the core diagnosis as well as clinical practice guidelines indicating such items/services are appropriate to treatment of the hospice diagnoses.  Summaries of spending for DMEPOS outside of hospice across terminal conditions, as well the findings and four case studies, are provided below.

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies across Terminal Conditions:  Acumen identified $27 million in spending for hospital beds, wheelchairs, oxygen and supplies, orthotics and prosthetics, medical/surgical supplies and other DME for which orders were initiated during a hospice stay (DME rental products that beneficiaries began using prior to a hospice stay were not included) for patients within the top 20 hospice diagnoses, and which CMS believes were likely related to the hospice terminal illness.

Malignant Neoplasm of the Trachea, Bronchus, and Lung:  CMS found Part D expenditures related to 89,925 hospice stays for patients with a principal diagnosis in this category -- totaling more than $2 million dollars.  The drugs included common palliative drugs, and anti-neoplastics (chemotherapy).  Oxygen equipment and supplies, hospital beds, and wheelchairs were also billed outside of the hospice benefit for patients in this category, as well as diagnostic imaging and radiation services. 

Chronic Airway Obstruction:  For more than 130,000 hospice stays of patients with this diagnosis, about $8.6 million in drugs was billed under Part D, including common palliative drugs, antiasthmatics and bronchodilators, corticosteroids, and respiratory agents; Medicare also covered oxygen equipment and supplies, hospital beds, wheelchairs, and diagnostic imaging outside the hospice benefit for these patients.

Cerebral Degeneration:  Based on analysis of hospice patients with a principal diagnosis beginning with 331 (cerebral degeneration), CMS found billing under Part D occurring in 208,346 stays and Part B billings for 318,044 hospice stays.  These billings, based on application of practice guidelines and clinical manifestations that accompany cerebral degeneration, are believed to be the responsibility of the hospice.  Included in the billings during the hospice stays were coverage of common palliative drugs, antipsychotic/antimanic agents, psychotherapeutic and neurological agents, hospital bed, wheelchairs and diagnostic imaging.

Congestive Heart Failure:  CMS’ assessment found Part D billings for what appear to be hospice-related drugs for 158,220 hospice stays, and presumed hospice-related Part B services billed outside of hospice for 256,236 hospice stays; the total identified outside of hospice spending for congestive heart failure during hospice stays in DY2013 was $5.8 million.  Among the items and service billed outside of hospice were common palliative drugs, diuretics, beta blockers, anti-hypertensives, anti-anginal agents, cardiovascular agents (misc.), vasopressors, oxygen equipment and supplies, hospital beds, wheelchairs, diagnostic imaging, EKGs, cardiac devices, and diagnostic clinical labs. 


CMS has continued its study of live discharge rates and found that between 2000 and 2013, live discharge rates rose from 13.2% to 18.3%.  Live discharge rates vary widely.  CMS found there appears to be a relationship between above-cap status and high live discharge rates -- for 2013, 40.3% of hospices above the 90th percentile for live discharges were also above the aggregate cap in that year, while only 3.8% of hospices below the 90th percentile for live discharges were above the aggregate cap. For FY2013, CMS also found that hospices with live discharge rates at or above the 90th percentile also, on average provide fewer visits per week than their below 90th percentile counterparts (3.97 vs. 4.48 visits per week).  For the same time period, CMS also found that hospices with live discharge rates at or above the 90th percentile for live discharge provide on average 1.91 skilled nursing or medical social services visit per week, while their below-90th percentile counterparts provided, on average, 2.35 visits per week.

CMS also explored whether there was a relationship between hospices with high live discharge rates, average lengths of stay, and non-hospice spending per beneficiary day and found that hospices in the highest 10% for non-hospice spending had live discharge rates and average lifetime lengths of stay that averaged 76 percent and 52 percent higher, respectively, than hospices in the lowest decile for average per day spending outside of hospice. 

CMS notes that the analytic findings suggest some hospices may consider the hospice program as a long-term custodial benefit rather than an end of life benefit for beneficiaries with a medical prognosis of six months of less, and raise concerns that hospices may be admitting patients who do not met the hospice eligibility criteria.  CMS continues to monitor these trends and collaborate throughout the agency relative to oversight activities, and plans to conduct further analysis on claims and cost report data to determine whether “additional regulatory proposals to reform and strengthen the Medicare Hospice Benefit are warranted.”

VISITS DURING THE BEGINNING AND END OF A HOSPICE ELECTION:  CMS’ continuing study of hospice claims data demonstrates that resource costs are markedly higher in the first two days of a hospice election and in the six days preceding the date of death and on the date of death itself.  Nearly 89% of patients received a skilled nursing or social work visit of 15 minutes or more on the first day of the hospice election; nearly 96% of hospice patients received a skilled visit during the first two days of the election.  Given the CoP requirement that an initial assessment by an RN be conducted during the first 48 hours of care, it is expected that patients would receive a skilled visit during the first two days of the episode.   CMS data indicates that at the end of life, 46.3% of beneficiaries received no skilled visits, on any given day, in the last seven days of a hospice election.  As part of the FY2015 payment rule, CMS indicated that nearly 5% of hospices provided no skilled visits in the last two days of life to more than 50% of their decedents on RHC; 34 hospices made no skilled visits in the last two days of life to any of their decedents on RHC.




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