Hospice Routine Home Care Payment: GAO Says Medicare Paid $573 per Visit at Low-Visit Hospices — and $7.6 Billion More Than a Per-Visit Model
Christian Soriaga, CPA5 min read
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Medicare effectively paid low-visit hospices $573 per routine home care visit in GAO's 2024 cohort, compared with $232 at high-visit hospices — because the daily rate is the same whether a nurse shows up twice a week or five times. That finding, from GAO report GAO-26-107585, sits behind a recommendation that Congress direct HHS to redesign routine home care payment. CMS told GAO it lacks the statutory authority to do so on its own. With hospice fraud enforcement at the top of Washington's agenda and the FY 2027 rates taking effect October 1, visit intensity is becoming the number that defines a hospice. Here is what GAO measured, why it matters to your margins, and how to see your own number before someone else calculates it.
Key Takeaways
- Medicare hospice spending nearly doubled from $15.5 billion (FY 2015) to $27.5 billion (FY 2024), while hospice beneficiaries grew 32%, from 1.4 million to 1.8 million.
- Routine home care accounted for about 99% of Medicare hospice days in FY 2024 and is paid per day regardless of visits.
- GAO's low-visit hospices (bottom 20%) delivered 2.5 visits per week per beneficiary; high-visit hospices (top 20%) delivered 5.5.
- Effective payment per visit: $573 at low-visit hospices vs. $232 at high-visit hospices.
- Under home health per-visit rates for the same staff mix, those visits would have been paid $214 and $156.
- For 1,225,049 beneficiaries discharged in 2024, Medicare paid $16.7 billion for routine home care (2022–2024 claims) versus an estimated $9.1 billion at home health per-visit rates — a $7.6 billion difference.
- Low-visit hospices were paid 6% more per week ($1,313 vs. $1,241), and their patients generated 11% more non-hospice spending ($129 vs. $116 per week).
- GAO's recommendation is a Matter for Congressional Consideration — it is open, and no legislation has been enacted.
What GAO Measured
GAO analyzed routine home care claims from 2022 through 2024 for beneficiaries discharged from hospice in 2024, limited to 4,340 hospices that each served more than 30 of them. It sorted hospices into fifths by visits per beneficiary per week and compared the bottom fifth with the top fifth.
The visit gap
| Metric | Low-visit hospices | High-visit hospices | Source |
|---|---|---|---|
| Total visits per week | 2.5 | 5.5 | GAO-26-107585 |
| Nurse visits per week | 1.4 (more than half of visits) | 2.2 (less than half) | GAO-26-107585 |
| Aide visits per week | 0.8 (one-third) | 2.9 (over half) | GAO-26-107585 |
| Effective Medicare payment per visit | $573 | $232 | GAO-26-107585 |
| Home health per-visit equivalent | $214 | $156 | GAO-26-107585 |
The biggest difference is aide visits: high-visit hospices delivered more than three times as many. GAO also notes that case mix matters — cancer patients typically get fewer visits, weighted toward nurses — so a low visit count is not proof of poor care by itself. It is, however, the pattern that draws a second look.
The $7.6 billion figure, stated precisely
The $7.6 billion is not an annual national number. It is the difference, for GAO's 2024-discharge cohort, between the $16.7 billion Medicare actually paid for their routine home care over 2022–2024 and the $9.1 billion GAO estimates it would have paid at adjusted home health per-visit rates. GAO adjusted the home health rates for services hospice covers and home health does not. Quote it that way and it holds up.
Why the Daily Rate Rewards Fewer Visits
A daily rate buys flexibility: a hospice can tailor visits to each plan of care without billing each one. GAO's point is that the same structure pays the same dollar for less care. GAO's own illustration: a hospice paid $1,000 for a week that delivers two visits earns $500 per visit; one that delivers five earns $200.
What CMS already changed — and says it cannot change
| Year | Refinement | Source |
|---|---|---|
| 2016 | Two-tier RHC rate (days 1–60 higher, 61+ lower) and the service intensity add-on for last-7-day RN/social worker visits | GAO-26-107585 |
| 2020 | Rebased higher levels of care; RHC rates reduced 2.7% | GAO-26-107585 |
| 2026 | CMS told GAO the statute requires per-day payment and further restructuring needs congressional action | GAO-26-107585 |
That is why GAO addressed its recommendation to Congress. Nothing moves until Congress acts, but the analysis is now on the record for any committee looking for Medicare savings.
Why This Is a Finance Question, Not Only a Policy Question
Visit intensity touches three numbers every hospice CFO already watches.
Margin
The same daily rate spread over fewer visits means a lower cost per patient day. That flatters margin now and makes the hospice the most exposed if payment ever shifts toward visits. A hospice with a 2.5-visit profile would lose far more under any per-visit or visit-weighted model than one at 5.5.
Program integrity
GAO warns that daily-rate incentives "may attract fraudsters to enroll as hospices." CMS's SSVI already scores hospices on nine claims-based measures and highlights non-hospice spending — and GAO found that spending runs higher at low-visit hospices. CMS also reports payment suspensions to more than 800 hospices and home health agencies in Los Angeles County this year.
The cost report
Your hospice cost report (CMS-1984-14) already contains the ingredients: visit statistics by discipline and cost by level of care. Few hospices put them side by side. If you want your cost per visit and visits per patient week calculated the same way GAO did, that is part of how we prepare a Medicare cost report filing.
How to Measure Your Own Visit Intensity
A simple internal benchmark, run quarterly:
- Visits per patient week — total RN, aide, and social worker visits ÷ (routine home care days ÷ 7).
- Discipline mix — share of visits by RN, aide, and social worker.
- Effective revenue per visit — routine home care revenue ÷ visits.
- Segment by diagnosis and length of stay, so a cancer-heavy census is not misread as under-serving.
- Compare to GAO's bands of 2.5 and 5.5 visits per week.
Illustrative example
A hospice with an average daily census of 60 has about 260 patient weeks a month (60 × 30.4 days ÷ 7). At 3.0 visits per week, that is roughly 780 visits a month; at 4.5, roughly 1,170. At a constant daily rate, revenue per visit falls by a third moving from 3.0 to 4.5 visits. This is illustrative; your staffing cost per visit decides whether the higher-visit model still carries margin. Getting visit counts by discipline out of the EMR and into the general ledger is a job our bookkeeping services handle every month.
The Bottom Line
GAO put a number on something hospice operators have argued about for years: at the same daily rate, some hospices deliver more than twice the visits of others. Payment has not changed, but visit intensity is now a published benchmark that enforcement, Congress, and your own board can all see. Know your visits per patient week, know your cost per visit, and make sure your cost report tells the same story as your claims. To run that analysis on your data, schedule a free consultation.
Sources
- U.S. GAO, Medicare Hospice: Action Needed to Pay More Efficiently for Routine Home Care (GAO-26-107585), June 9, 2026
- U.S. GAO, GAO-26-107585 full report (online)
- U.S. GAO, GAO-26-107585 Highlights (PDF)
- CMS, FY 2027 Hospice Final Rule (CMS-1851-F) fact sheet, July 30, 2026
- CMS, Medicare Enrollment Moratoria Fast Facts
Last updated: September 2026.
Soriaga & Associates, LLC is a CPA firm specializing in hospice, home health, and home care accounting and Medicare cost reports.
