The term “hospice” (from the same linguistic root as “hospitality”) can be traced back to medieval times when it referred to a place of shelter and rest for weary or ill travelers on a long journey.  The name was first applied to specialized care for dying patients in 1967 by physician Dame Cicely Saunders, who founded the first modern hospice—St. Christopher’s Hospice—in a residential suburb of London.

Saunders introduced the idea of specialized care for the dying to the United States during a 1963 visit with Yale University.  Her lecture, given to medical students, nurses, social workers, and chaplains about the concept of holistic hospice care, included photos of terminally ill cancer patients and their families, showing the dramatic differences before and after the symptom control care.  This lecture launched the following chain of events, which resulted in the development of hospice care as we know it today.

1965: Florence Wald, then Dean of the Yale School of Nursing, invites Saunders to become a visiting faculty member of the school for the spring term.

1968: Wald takes a sabbatical from Yale to work at St. Christopher’s and learn all she can about hospice.

1969: A book based on more than 500 interviews with dying patients is published, entitled, On Death and Dying.  Written by Dr. Elisabeth Kubler-Ross, it identifies the five stages through which many terminally ill patients progress.  The book becomes an internationally known best seller.  Within it, Kubler-Ross makes a plea for home care as opposed to treatment in an institutional setting and argues that patients should have a choice and the ability to participate in the decisions that affect their destiny.

1972:  Kubler-Ross testifies at the first national hearings on the subject of death with dignity, which are conducted by the U.S. Senate Special Committee on Aging.  In her testimony, Kubler-Ross states, “We live in a very particular death-denying society.  We isolate both the dying and the old, and it serves a purpose.  They are reminders of our own mortality.  We should not institutionalize people.  We can give families more help with home care and visiting nurses, giving the families and the patients the spiritual, emotional, and financial help in order to facilitate the final care at home.”

1974: The first hospice legislation is introduced by Senators Frank Church and Frank E. Moss to provide federal funds for hospice programs.  The legislation is not enacted.

1978: A U.S. Department of Health, Education, and Welfare task force reports that “the hospice movement as a concept for the care of the terminally ill and their families is a viable concept and one which holds out a means of providing more humane care for Americans dying of terminal illness while possibly reducing costs.  As such, it is the proper subject of federal support.”

1979: The Health Care Financing Administration (HCFA) initiates demonstration programs at 26 hospices across the country to assess the cost effectiveness of hospice care and to help determine what a hospice is and what it should provide.

1980: The W.K. Kellogg Foundation awards a grant to the Joint Commission on Accreditation of Hospitals (JCAHO) to investigate the status of hospice and to develop standards for hospice accreditation.

1982: Congress includes a provision to create a Medicare hospice benefit in the Tax Equity and Fiscal Responsibility Act of 1982, with a 1986 sunset provision.

1984: JCAHO initiates hospice accreditation.

1986: The Medicare Hospice Benefit is made permanent by Congress and hospices are given a 10% increase in reimbursement rates.  States are given the option of including hospice in their Medicaid programs.  Hospice care is now available to terminally ill nursing home residents.

1989: The Government Accounting Office releases a study stating that only about 35% of eligible hospices are Medicare-certified.  There are several reasons listed, one of which is the low payment rates HCFA had established for hospices.

1989: Congress gives hospices their first increase (20%) in reimbursement since 1986 and ties future increases to the annual increase in the hospital market basket through a provision contained in the Omnibus Budget Reconciliation Act of 1989.

1991: The Commission on the Future Structure of Veterans Health Care (Mission Commission) releases a report recommending inclusion of hospice care in the veteran’s benefit package.

1992: Congress passes the Indian Health Care Improvement Act of 1992, calling for a hospice feasibility study.

1993: Hospice is included as a nationally guaranteed benefit under President Clinton’s health care reform proposal. Hospice is now an accepted part of the health care continuum.

1994: HCFA sends a memorandum alerting the regions of problems regarding questionable certifications and recertifications of terminal illnesses.  This results in the first “focused medical review” for hospices and a wake-up call to the industry to improve its documentation and certification procedures or be denied payments.

1995: HCFA releases an expanded version of the Hospice Interpretive Guidelines, which provides much needed clarification of the Conditions of Participation (CoP). The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Hospice Benefit is implemented June 1, 1995. It mirrors the Medicare Hospice Benefit in CoPs and reimbursement.

1995: The Office of Inspector General (OIG) announces the Operation Restore Trust (ORT), a special program to combat waste and abuse in Medicare and Medicaid in five targeted states—California, Florida, Illinois, New York, and Texas—would be expanded to include hospice.

1996: The Ninth U.S. Circuit Court of Appeals in San Francisco overrules a Washington State Law against physician-assisted suicide. The Second US Circuit Court of Appeals strikes down New York’s law against physician-assisted suicide. Both rulings are appealed to the US Supreme Court.

1996: Bills are introduced in the U.S. House of Representatives and the U.S. Senate to make technical changes and improvements to the Medicare Hospice Benefit. The hospice industry provides full support for both bills.

1996: Major grant-makers pour money into funding for research, program initiatives, public forums, and conferences to transform the culture of dying and improve care at the end of life.

1997: ORT is extended and expanded to target all 50 states and additional types of health care providers.

1997: The Balanced Budget Act of 1997 (BBA 97) includes hospice provisions that, among other things, restructure the hospice benefit periods and remove physician services from the core services requirement.  BBA 97 also reinstates a hospice cost report and reduces hospice payment updates by market basket minus one percentage point.

1997: Congress passes legislation barring taxpayer dollars from financing physician-assisted suicide. The US Supreme Court rules that mentally competent terminally ill people do not have a constitutional right to physician-assisted suicide, leaving the issue up to the states. Oregon voters affirm the right to physician-assisted suicide by passing for the second time its “Death with Dignity Act.”

1997: The growing end-of-life movement focuses national attention on quality of life at the end of life as well as the need for increased public awareness and physician education. The hospice philosophy and concept of care are central to models for palliative and end-of-life care.

1998: Hospices nationwide report rapidly declining average and median lengths of stay. The percentage of hospice non-cancer admissions decreases dramatically, reflecting the problems associated with determining a six-month prognosis for these patients.

1998: An ORT report on hospice states, “Overall, the Medicare hospice program seems to be working as intended.” The OIG reveals that hospice will not be included in the 1999 work plan.

1999: The U.S. Postal Service issues the Hospice Care commemorative stamp in February.

1999: The Health Care Financing Administration (HCFA) releases the Hospice Cost Report. Medicare-certified hospice programs must file cost data for each fiscal year on or after April 1, 1999.

1999: The Office of Inspector General (OIG) releases the Draft Compliance Program Guidelines for the Hospice Industry.

2000: Hospice Rate Increase approved by Congress.