West Virginia's Certificate of Need law is once again under attack. Critics argue that eliminating CON would improve access and competition in hospice care.
That argument may fit neatly into economic theory. It does not fit the reality of hospice care in West Virginia.
Unlike many healthcare services, hospices are not purchased by consumers shopping for the best price. Hospice is almost always covered by Medicare, Medicaid or private insurance, leaving little or no out-of-pocket cost for families.
Patients typically enter hospice following a physician's referral during one of the most difficult moments of their lives, not after comparing providers online. Success should not be measured by how many hospice agencies exist. It should be measured by whether patients receive exceptional care when they need it most.
By that standard, West Virginia is already succeeding.
A situation that does not require fixing
Our state consistently ranks among the nation's leaders in hospice quality as measured by the Centers for Medicare and Medicaid Services. Family satisfaction scores from the national hospice survey routinely place West Virginia among the top-performing states, demonstrating that families believe their loved ones receive compassionate, high-quality end-of-life care. Independent research reviewed by the Medicare Payment Advisory Commission has also found that nonprofit hospices consistently outperform for-profit hospices on multiple family satisfaction measures. These are standardized federal quality measures, not marketing claims, and they reflect decades of investment in patient care.
That investment has largely come from community-based nonprofit hospices, which care for the vast majority of hospice patients in West Virginia. Rather than distributing profits to shareholders, these organizations reinvest every dollar into services that strengthen communities through bereavement counseling, pediatric hospice, charity care, volunteer programs, community education and specialized clinical services.
Perhaps nowhere is that commitment more evident than in inpatient hospice care.
Inpatient and outpatient care
While most patients appropriately receive hospice services at home, some develop symptoms that simply cannot be managed there. Others live alone or require intensive pain and symptom management during their final days. For these patients, inpatient hospice units provide an essential level of care.
West Virginia has built one of the nation's strongest inpatient hospice systems. Maintaining these facilities requires substantial investment in buildings, specialized staff and around-the-clock care. They rarely generate significant financial returns, but they are indispensable to patients and families during life's most difficult moments.
Certificate of Need makes these investments possible. By preventing unnecessary duplication of services in markets that are already adequately served, CON provides the stability nonprofit hospices need to maintain expensive community resources. Without that stability, new providers can enter profitable markets offering only routine home hospice while existing nonprofits remain responsible for inpatient units, charity care, bereavement services, and other mission-driven programs. That is not healthy competition, it is cost shifting.
West Virginia's geography makes this even more important. Delivering hospice care across rural, mountainous communities requires nurses to travel long distances while maintaining 24-hour availability. Financial stability is essential to sustaining that level of service.
Where Certificate of Need comes in
Supporters of repealing CON often argue that more hospice providers automatically increase access. If that premise were true, the states with the most hospice providers would also have the highest hospice utilization and the best quality scores. They don't. In fact, the Medicare Payment Advisory Commission, the independent agency that advises Congress on Medicare policy, has found that hospice utilization across states is unrelated to the number of hospice providers per 10,000 Medicare beneficiaries. Hospice utilization is driven primarily by physician referrals, patient needs, demographics and public awareness, not simply by the number of licensed providers. Licensing more hospices does not mean more patients receive hospice care.
When markets become oversaturated, providers often compete for the same eligible patients rather than expanding care into underserved communities. California illustrates the risk. A dramatic increase in hospice providers, particularly among newly established for-profit agencies, was accompanied by widespread allegations of fraud and abuse, prompting state and federal enforcement actions and Medicare enrollment moratoriums in affected counties. More providers did not translate into better access or better care.
Public policy should be guided by evidence, not ideology. West Virginia has built a hospice system that delivers nationally recognized quality, maintains critical inpatient hospice capacity, and remains deeply rooted in nonprofit community service. Certificate of Need has helped create an environment where providers can invest in services that communities need, not just those that are most profitable.
Healthcare policy should be judged by results, not rhetoric. By every meaningful measure, West Virginia's hospice system is delivering for patients and families. Before dismantling a model that has served our communities so well, we should ask one simple question:
If our hospice patients are already receiving some of the highest-rated care in America, why would we risk breaking what is already working?
