Part Two | Hospice Leaders Break Down Hospice Reform, Medicare & Quality Care

What does the future of hospice care really look like—and who’s shaping it?

In Part Two of this compelling conversation, healthcare leaders Tom Koutsoumpas and Carole Fisher join Chris Comeaux and Cordt Kassner to discuss the future of hospice reform, Medicare modernization, quality care standards, and the challenges facing nonprofit hospice providers across America.

From fraud prevention and workforce shortages to Medicare Advantage and innovative disease-specific care models, this episode delivers an inside look at the policy, leadership, and operational decisions shaping the future of end-of-life care.

Whether you’re a healthcare executive, hospice professional, nonprofit leader, policymaker, or business leader, this discussion provides valuable insight into how hospice organizations can remain relevant, sustainable, and mission-driven in a rapidly evolving healthcare environment.

⸻

Episode Highlights

✔️ Why hospice quality reporting and transparency matter more than ever
✔️ The growing impact of Medicare Advantage on hospice care
✔️ Challenges facing nonprofit hospice organizations
✔️ Innovation in palliative care and disease-specific support models
✔️ How NPHI is advocating for hospice reform and accountability
✔️ The workforce and financial pressures affecting hospice providers
✔️ The truth about the hospice carve-in debate and what the data shows
✔️ Why leadership and mission remain critical in end-of-life care

⸻

Key Quote From The Episode

“The future of hospice and palliative care is making sure we are staying relevant, necessary, and sustainable.” — Carole Fisher

⸻

About This Episode

This episode explores the intersection of healthcare leadership, hospice advocacy, Medicare reform, patient-centered care, and operational sustainability. The conversation emphasizes the importance of preserving the mission of hospice while adapting to changing healthcare systems and patient expectations.  

Featured Guests

🔹 Tom Koutsoumpas — National Partnership for Healthcare and Hospice Innovation (NPHI)
🔹 Carole Fisher — President, NPHI

🎙️ Hosted by Chris Comeaux, President / CEO of TELEIOS
     Co-Hosted by Cordt Kassner,  PhD, Publisher of Hospice & Palliative Care
     Today & CEO and Founder of Hospice Analytics 

⸻

Subscribe & Connect

👉 Subscribe for more conversations on leadership, healthcare innovation, hospice care, and nonprofit strategy.
👉 Share this episode with healthcare professionals, executives, clinicians, and industry leaders.
👉 Learn more about TCNtalks /Anatomy of Leadership, and NPHI in the links below.

TCNtalks
https://www.teleioscn.org/tcntalkspodcast
NPHI
https://www.nphihealth.org/
People Over Profits
https://www.nphihealth.org/peopleoverprofits/
Inside View Podcast
https://www.nphihealth.org/podcast/

The Anatomy of Leadership podcast explores the art and science of leadership through candid, insightful conversations with thought leaders, innovators, and change-makers from a variety of industries. Hosted by Chris Comeaux, each episode dives into the mindsets, habits, and strategies that empower leaders to thrive in complex, fast-changing environments. With topics ranging from organizational culture and emotional intelligence to navigating disruption and inspiring teams, the show blends real-world stories with practical takeaways. The goal is simple yet ambitious: to equip leaders at every level with the tools, perspectives, and inspiration they need to lead with vision, empathy, and impact.

https://www.teleioscn.org/anatomy-of-leadership

Transcript

Jeff Haffner 0:00

Welcome to TCN Talks, and Anatomy of Leadership. We continue our conversation with Tom Koutsoumpas and Carole Fisher in part two of Hospice Leaders Break Down Hospice Reform, Medicare, and Quality Care. And now here's Chris Comeaux and Cordt Kassner.

Modernizing Medicare And Measuring Quality

Chris Comeaux 0:22

As we go to this next segment, Carole and Tom, you know, think about what you were just saying, Carole, about just the trying to differentiate based upon quality. I do think the baby boomers, um, number one, they're going to demand better. And, you know, we're all conditioned. How many of us order something from Amazon and we go and we look at those star ratings? But yet it's not as easy today to be able to do that in healthcare. Um, although there's some good data starting to show that people are looking at some of those like Google ratings, et cetera, to make healthcare decisions, which might be a whole new frontier as far as where we go, as far as all that hard work and maybe how it shows up in Google ratings. So, Carole and Tom, what policy advocacy efforts that your organization is pursuing? Does the Medicare benefit need modernizing? Are there other regulatory challenges? You know, I feel like Cordt was kind of poking on earlier. What is it? Maybe only is it 30% of hospices in America report cap scores? It may be a little bit higher than that, but it's abysmal that people can actually not do patient satisfaction. And so love for you guys to talk about what you're doing to play offense in a lot of those areas.

Tom Koutsoumpas 1:32

Yeah, I think that um certainly one of the most important things sort of moving into the future is really making sure that we can keep up with the changes that are overall affecting the system in general, not just us, but others as well, and how the system is changing. If Medicare Advantage is growing at a tremendously high rate, uh, how do we make sure that we can continue to work with Medicare Advantage plans? We've got to make sure we have quality scores. We've got to show them data as to why we're why we do what we do is better, why they should want to work with us, or have their patients and families engage with us. So all of those things, I think, are things that we keep looking at really on a regular basis to make sure that we aren't an afterthought in the future, in the system of the future, that we are actually engaging in leading the dialogue around that and not being at the end of it but at the beginning of it.

Carole Fisher 2:30

I think one of the things that you'll appreciate too, Cordt and Chris, is that um we've brought to the attention with Dr. Oz and with Kim Brandt and team that hospices, the smaller ones under 50, don't have to report their quality scores. And that's really a problem because there's so many small hospices, and I'm not referring to our members who diligently report their quality scores, but these these hospices that are very small, that are eager to earn profit, not reporting quality scores is not acceptable. Not providing all four levels of care, not acceptable. So really we're bringing that um attention and having those really challenging conversations and looking at strategies on how do we fix that? How you know, how do we get everyone to report outcomes? And I think we're making a lot of progress.

Tom Koutsoumpas 3:21

Oh, I think we really are. So when when um when Dr. Oz uh was getting confirmed, uh we actually had a conversation and he asked us to provide him with a list of immediate things that could be done uh that would be uh addressing many of these issues, um, obviously recognizing that there are a lot of long-term things that take much more time, but you know, what could we do to address some of the really fraudulent and bad things that are happening? And, you know, one of the answers was, you know, the levels of care. Uh the regulations are clear. And why are people getting away with not providing uh the levels of care? Um the cap, you know, we put the cap in originally to make sure that we would avoid fraud and abuse issues. Uh it was very well thought out when we did it. And uh in our view, if you lowered the cap, uh that would immediately eliminate the ability for many players to uh for to get excessive profits and would it would help address that. Uh you know, more regular surveys could absolutely help all programs on a regular basis. Uh we we also talked about positive things like safe harbors for the not-for-profit community programs that meet certain quality standards, which all of ours do, to eliminate the need for the OIG audits that are burdening our programs uh unequally, in my opinion. Uh the large guys can simply hire a lot of lawyers and pay for them to handle it. But our programs aren't doing that and can't do that. So those are things that we've been working on as well that we think are really important.

Chris Comeaux 5:09

Oh, that's a really good one, Tom. That last one. I think it was an MPHI meeting many years ago. We're having a dinner with Howard, and it was one of our MPHI CEOs that said something I had never heard of before. I think he called it the game of tens or provider numbers and how the for-profits, you know, they may have one big banner, but they're using it's basically a bunch of little 25 ADC hospices. So when the auditor looks at that, why would they go pick on a large nonprofit provider? Is because, well, it looks like there's a lot more patients. Yes, because they're doing a better job, but yet they won't go look at those little ADCs that might be under one big brand, but they're multiple provider numbers. It's a it's a game that they play to fly under the radars for a scrutiny.

Tom Koutsoumpas 5:53

Right. It it is absolutely a strategy. Also, you know, another example of that is they're auditing so many of our members who have inpatient units. Uh and you know, I keep saying, and we keep saying, this is clearly one of the most frustrating things from my perspective. In Washington, D.C., there's one inpatient unit. The one inpatient unit is a not-for-profit community-based program, happens to be Capital Caring Health. And that's the only inpatient unit in the city of Washington. And, you know, yet uh why aren't they auditing the programs that aren't providing inpatient care? Because that's really illegal. That's that's not part of uh that that's abusing the regulation as opposed to the program that's actually doing the right thing. So those are, you know, those are struggles that we keep working on. And we're getting people to recognize it and really getting uh people to understand it. The I mean the the behemoth of HHS and uh you know the system, the bureaucracy here uh is extraordinary. And uh obviously you all know that. I mean, it it it is not easy when you talk to one side of the of of the of the organization that the other side has no idea. And you've got to make sure you address all of those things. So these are not easy and simple things, but in our view, they are easy and simple things that need to be addressed.

Carole Fisher 7:19

Well said. And I'm smiling because I I really do feel like we're making progress. Yeah, me too. Yeah. I uh people are listening. You know, go ahead and uh audit the folks that are not providing GIP level of care. And you take your resources and shift that. And we're we're seeing the light bulbs go off, and the conversation's very receptive with administration. So we really appreciate that.

Cordt Kassner 7:40

Yeah. Tell me a little bit more about the the innovative practices that your members are engaging in. What's what what are some of the cutting-edge activities that NPHI is involved in? Well, you it Cordt, this is a question.

Tom Koutsoumpas 7:53

I don't know, do we have a couple of hours? Because we we've got a lot to say. We are really proud. We have a whole division of the organization focused on innovation. Dr. Cameron Meer oversees that, and there's a great team. And we have been working on so many different innovative initiatives, you know, encouraging our members to participate in PACE programs, in home-based primary care programs, in other kinds of in palliative care, obviously. But what else can we be looking at? So we've created these different guides that are really extraordinary, disease-specific guides. We have a guide on heart disease, we have a guide on dementia, uh, we have uh pulmonary cancer, and they're very, really robust guides that help the patient, the family, and the caregiver and the clinician to look at best practices, to look at uh new ways of caring for patients in the home that are suffering from whatever uh the disease may be. And those guides have been extraordinarily important. With each one, we've been working with the national organization that represents the disease. So we've been working very intimately with the American Heart Association, first time they've ever done it, working with the American Lung Association, working with the National Cancer, uh American Cancer Society, um, working with the Alzheimer's. These are really innovative ideas because they've never done this before. And it provides this very deep support system for our members. So, so you know, look at new models of care that you can engage in that are part of the continuum, you know, not stray away, so far away from your core that it creates a challenge. But all related to the core, get into those things. And in addition, work with your community leaders in the disease areas to support people, the clinicians as well as the caregivers, right?

Carole Fisher 9:53

Yeah. No, it's fabulous we're doing fabulous work. And we'll just talk about the guides for a minute. So the guides are available for family members, the guides are available for patients, but the guides are also available for referral sources. So you can really go out and talk to potential referral sources and help them understand best practice when it comes to the disease-specific initiatives. We have a mental health guide, we have a guide on elder abuse, which is just horrible to say is an issue, but it is an issue, right? So making sure that we're protecting the elderly is uh very important for our members. We're working on a pediatric guide, we're excited about that. Not excited that we have to care for children, but certainly excited to be a resource because it's the right thing to do to make sure that children are well cared for too.

What Keeps Hospice Leaders Up

Tom Koutsoumpas 10:37

So you really gives our members uh extraordinary recognition in their communities for leadership. And I think, Chris, I know you're so focused and dedicated to leadership. I think leadership is such a critical part for all of our CEOs, for all of our senior leaders in in the programs, because that really is what's important to uh engage with other community leaders to provide that top-level leadership. And this allows them to work with the different disease state leaders in their communities in a very, very robust way. w

Chris Comeaux 11:12

You guys may have answered this already, but I'm still going to ask it. What keeps you up at night? What are your major concerns regarding the future of hospice and palliative care?

Tom Koutsoumpas 11:21

Well, I think keeping up with the ever-changing system and making sure that, as I said earlier, that we are a part of the of the leading uh edge of discussion, not the back end where we're just told what to do and kind of given a piece of it. I think that uh these fraud and abuse issues are clear. But also so many others are getting into sort of areas within end-of-life care that uh aren't providing all of these uh really extraordinary services uh that are not part of the benefit. But that, you know, we we've got to make sure that we don't uh uh just stay in our niche and aren't able to evolve. We've got to make sure that we keep uh and we want to make sure that we protect the core values and not suggesting that we go away from any of that, but how do we make sure that we can keep providing care to this population into the future? How do we work more with Medicare Advantage plans? How are we engaging with Medicaid, which is changing, you know, uh by the day? Uh how do we engage with all of these different arenas? It's not easy. Uh, this is a lot, it's a lot, it's complicated oftentimes. How do we work better with hospital systems uh and partner with hospital systems, right? How do we how do we create better partnerships? Yeah.

Carole Fisher 12:47

You know, it's it's about being relevant, it's about being necessary, and it's about being sustainable. And then you look inside the organization and it's about workforce. And so many of our members are really struggling with the workforce challenges. So, how do we keep up and make sure that people are educated and trained and that are covering um caseloads in an effective and efficient way? So those are some of the things that keep us up at night.

Tom Koutsoumpas 13:12

And and and and then ultimately, certainly for everybody, is how do we make sure we can do it financially?

Carole Fisher 13:17

Yeah.

Tom Koutsoumpas 13:18

Um, you know, so many of our members have maybe a one or two or three percent margin. Uh if that. If that. Yeah.

Chris Comeaux 13:25

I think the average now is a negative 1.6 nonprofits.

Tom Koutsoumpas 13:29

Yeah, no, I mean it's uh it's extraordinarily challenging. Uh so how do we support our programs and how do we support each other to make sure that we can uh we can make it uh financially, which is critical, obviously.

Carole Fisher 13:42

Yeah, we also know that we there are more members to be had, and it's not like we're seeking growth, but we know that there's other not-for-profits throughout the country that really need our support and need to be working with one another. So that keeps us up a little bit at night, too. It does, indeed.

Cordt Kassner 13:58

You know, we've certainly covered a lot of ground this morning, and we really appreciate you taking time to participate in this podcast. I it seems to me a lot of what we've been talking about are two sides of the coin. We we can talk about waste fraud and abuse, we can talk about quality. We could, you know, it what's going, you know, great in hospice and palliative care, and where are the challenges? And trying to look at that that full picture. I Chris and I often ask folks, kind of the two sides of of this coin as well. What keeps you up at night? But maybe the other side of the coin is if you're advocacy, if you're if you're transparent with data sharing, if you're you're focused on quality initiatives to differentiate between provider types, uh if we're if we're implementing some of the things we've been talking about this morning in your wildest dreams, what would hospice and palliative care look like in 10 years? Like we're what's gonna what should we be expecting? What are you looking forward to? Not not what keeps you up at night, but what are you looking forward to in in the next decade?

Tom Koutsoumpas 15:10

Well, I think we certainly will uh look carefully at modernization. Uh, you know, do we uh shift our focus to a disease state uh for admission, uh, you know, looking kind of at at all the elements of the benefit that that will allow us to work better with the modern system going forward or with the uh with the uh Medicare Advantage or with the hospitals or with the Medicaid programs. So keeping up with, but also thinking ahead and thinking about uh with the end result being how do we provide more care for more people? You know, I think the the dream would be anybody and everybody who's terminally ill is cared for by a hospice program, by one of our programs that receives extraordinary end-of-life care. Nobody should die without extraordinarily uh uh high quality end-of-life care. And so how how do we make sure that we keep growing it and making sure that people keep uh being able to receive it, I think would be right?

Carole Fisher 16:15

Yeah, no, I I think look, our members, I know our members are passionate, they have a moral obligation to make sure that everyone dies well. You have one chance to do that. And so I think uh supporting our members and and looking forward on how to continue to make sure that people die well is is where we're all headed and we're all in this together to support one another.

Will The Hospice Carve-In Return

Tom Koutsoumpas 16:38

So I think that's right. I think the the uh continuation of the mission is really critical to to make sure that we never lose sight of of the mission of our work and make sure that uh that that's the forefront of our thinking. Uh the patient, the family, uh, the caregiver, the the mission of our work. If if that is our North Star, which it is, then I think we'll be fine into the future. Uh we'll keep up with all of these changes, we'll do what we need to do to advocate on our members' behalf, but that will be our guiding start.

Chris Comeaux 17:16

So I didn't tell you I was gonna ask you this, but it just occurred to me. I did a podcast with Robin, Robin Heffernan, who you know Tom well from CEO of Empassion, debating her on the Carve-in. And so do you guys think that the Carve-in is gonna come back around? And just what are your thoughts about that?

Tom Koutsoumpas 17:33

Well, you know, it keeps it always uh sort of resurfaces. It it it sort of uh it's you know keeps popping up. Uh but but I think at the end of the day, and interestingly enough, um, we have Flori McWright coming up in one of our discussions today. Uh today, later today, who did the carve-in pilot. And we're gonna talk a little bit uh a lot actually about that and about her thoughts about uh the fact that it didn't work, uh, which was important, right? Because we have data now to show that it's not a good idea. And I think that you know we always have to be careful and we have to be thoughtful about knowing what's going on with respect to it. It's not first on the list right now, but it could be. And you know, it just depends if there's a payer that decides that, or the payer, one of the payer organizations that still believes that that it's the right thing to do for their for their good, then we could see it come back. So, you know, we're right on top of that.

Chris Comeaux 18:34

So you you push back if you disagree, Tom, but my read on the data, it was an NPHI meeting where they brought some of the data. My perception is that some of that data showed that the payers really aren't in support of it. You know, they're doing a lot of, they're spending millions of dollars for healthy aging to support their business model. And what people start to say is, I don't trust my health insurance company to be the one making that referral. It kind of smacked of death panel is kind of my read. And I thought they really felt like, hey, that's radioactive. We really don't want that carbon because of that, because they're putting so much energy and resources into helping as people age, maybe being more healthy, and it feels a little antithetical to them. Was I overreading that or is that in the ballpark?

Tom Koutsoumpas 19:20

No, no, I don't think that's overreading at all. I think that's I think that's right, Chris. And, you know, I would just say uh thanks to uh Lori and the pilot because we have clear data. Uh, and that's remember, one of the most important things that we uh have for advocacy in today's arena. You can't just say we're against it because we don't think it's going to be working well. We have data that shows uh kind of what happened and how it didn't work. And I think that that gives us a really strong backbone to have discussions about this. I I think the smartest thing we did in the past was go for a demonstration because we probably wouldn't be talking about it the way we are today uh if we hadn't instead of in lieu of legislation that was ready to go into the law, uh instead had a demonstration that we extended for a number of years that allowed us to show that frankly the way it was structured wouldn't work.

Carole Fisher 20:21

And the shout out to our members who participated in that demo. Absolutely. I mean, they really worked hard to work with the payers, to pay attention, to provide quality care while practicing and demonstrating that that demo wasn't working. So we put a lot of resources into that.

Final Thanks And Brain Bookmark

Tom Koutsoumpas 20:38

We did.

Chris Comeaux 20:39

Well, the clock's running out on us, and as you guys have been alluding to, you're recording a bunch of podcasts today. We appreciate you guys taking the time just to meet with Cordt and I wanted to give you guys final thoughts. Tom, Carole, final thoughts that you have.

Carole Fisher 20:52

Oh my gosh. Well, just thank you both. You know, you're you're both doing incredible work. And telly us, I mean, shining star with the work you're doing. So really appreciate your support of NPHI and of both of us personally and professionally.

Tom Koutsoumpas 21:05

Yeah, I was gonna say the same thing. I think Chris, you've played for so long such a great leadership position. And, you know, it it really takes all of us working together uh to keep all of this moving in the right direction. And Cordt, you have as well certainly uh we all really respect your work and are grateful for the work you do for both of you. So thank you for having us on. We love this. We'll come on anytime and uh we'll show off our mugs, right?

Carole Fisher 21:31

Inside View.

Tom Koutsoumpas 21:32

Yeah, Inside View by NPHI.

Chris Comeaux 21:35

Good deal, guys. Well, thank you so much. And to our listeners, we want to thank you. At the end of each episode, we always share a quote, a visual. The idea is to create a brain bookmark, a thought prodder, about our podcast subject to further your learning and growth and thereby your leadership. We're going for brain tattoo. We want it to stick. Be sure you subscribe. We'll also include a link to um the Inside View and Carole and Tom's podcast. Um, we're also going to have a link to their people over profits that they alluded to in Anything else that Tom and Carole want us to include, of course, we'll have a link to NPHI as well. You know, it's easy for us to rail against the world and be frustrated by things. Let's be the change that we wish to see in the world. So thanks for listening to today's podcast. And here's our brain bookmark to close today's show.

Jeff Haffner 22:15

"The future of hospice and palliative care is making sure we are staying relevant, necessary, and sustainable" by Carole Fisher.