Removing ulcer-coded claims still leaves about $4.11 more Medicare spending per hospice day

The best available CMSCMSThe Centers for Medicare & Medicaid Services is the federal agency that administers Medicare and issued the hospice rule analyzed here. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf)-centered estimate is approximately $4.11 more per hospice dayhospice dayA hospice day is one day for which a beneficiary is recorded as receiving Medicare hospice care. [CMS 2026 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2026.pdf). After removing pressure-ulcer-coded carrier claims, MedicareMedicareMedicare is federal health insurance mainly for people aged 65 or older and certain younger people with disabilities or qualifying conditions. [Medicare](https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare)-paid services outside hospicehospiceHospice is comfort-focused end-of-life care for a person certified as having a life expectancy of six months or less if the illness follows its normal course. [Medicare](https://www.medicare.gov/coverage/hospice-care) rose from about $10.51 per day in FY2020 to $14.63 in FY2024. That is the answer the public data support, but it is not exact because CMS publishes the relevant day totals only as 126.0 million and 148.0 million. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf) [CMS 2024 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2024.pdf) [CMS 2026 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2026.pdf)

Think of the denominatordenominatorA denominator is the quantity used to scale a total, here the number of hospice days over which spending is spread. [CMS 2024 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2024.pdf) as miles traveled. A larger fuel bill can reflect a higher price per gallon, more miles, or both. Hospice days increased over this period, so comparing total spending alone would overstate the change in spending for each day of exposure. CMS's day counts let us make a close approximation, but the agency has not published an unrounded FY2020 count from the same May 2025 data extraction used for the final rule. [CMS 2024 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2024.pdf) [CMS 2026 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2026.pdf)

CMS Table 5 reports Medicare payments for outside-hospice Part A and Part B services by claimclaimA claim is a provider's request for payment for a medical service, drug, supply or item. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf) type. Adding its six rows gives $789,928,982 in FY2020 and $2,065,535,136 in FY2024. Table 6 reports Medicare-paid Part D amounts of $552,953,466 and $813,107,802 for those years. Combined spending therefore rose from $1,342,882,448 to $2,878,642,938, an increase of $1,535,760,490. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf)

These are Medicare payments to providers or drug plans outside the hospice payment while a beneficiary was enrolled in hospice. CMS apportioned longer Part A and B claims across their service days and counted only the portions overlapping a hospice electionhospice electionA hospice election is the beneficiary's formal choice to receive Medicare's hospice benefit for a terminal illness and related conditions. [Medicare](https://www.medicare.gov/coverage/hospice-care), excluding admission and live-discharge days; Part D spending was assigned by the drug-event service date with the same boundary-day exclusions. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf)

CMS says carrier claims coded for pressure ulcers increased from approximately $18 million in FY2020 to $714 million in FY2024 and were largely associated with skin substitutes. The approximately $696 million difference equals 45.3% of the combined $1.536 billion increase. Subtracting it leaves approximately $839.8 million. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf)

The wider skin-substitute market gives CMS a reason to scrutinize the category, but not grounds to label every claim improper. The HHS inspector general reported that Medicare Part BMedicare Part BPart B helps cover clinicians, outpatient care, home health, medical equipment and preventive services. [Medicare](https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare) skin-substitute spending exceeded $10 billion annually by the end of 2024 and identified utilization, prices and billing vulnerabilities as concerns. That national finding supplies context, not proof about any individual hospice claim. [HHS OIG](https://oig.hhs.gov/reports/all/2025/medicare-part-b-payment-trends-for-skin-substitutes-raise-major-concerns-about-fraud-waste-and-abuse/)

CMS's 2024 Hospice Monitoring Report supplies a boundary-day-excluded count of 126.0 million hospice days for FY2020. Its newer 2026 report, using the May 9, 2025 extraction also used for the final-rule spending totals, reports 148.0 million such days for FY2024. Dividing the two residual totals by those rounded day counts produces approximately $10.51 and $14.63 per day. [CMS 2024 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2024.pdf) [CMS 2026 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2026.pdf)

The denominator problem is narrower than the original article suggested. CMS does publish methodologically relevant daily counts, so a per-day estimate is possible. What it does not publish is an unrounded FY2020 count from the same extraction as the final rule, which prevents an exact result. The older report warns that late-FY2024 results could be incomplete, while the newer report revises FY2024 using later claims data. [CMS 2024 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2024.pdf) [CMS 2026 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2026.pdf)

As a sensitivity test, broader MedPACMedPACThe Medicare Payment Advisory Commission is an independent congressional agency that analyzes Medicare and advises Congress. [MedPAC 2026](https://www.medpac.gov/wp-content/uploads/2026/03/Mar26_Ch10_MedPAC_Report_To_Congress_SEC.pdf) totals of 127.8 million days in 2020 and 148.2 million in 2024 produce a slightly larger nominal increase of $4.24 per day, from $10.37 to $14.61. Those totals are rounded and do not reproduce CMS's boundary-day exclusions or data-extraction sequence, so $4.24 is a robustness check rather than the preferred estimate. [MedPAC 2022](https://www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_Ch11_SEC.pdf) [MedPAC 2026](https://www.medpac.gov/wp-content/uploads/2026/03/Mar26_Ch10_MedPAC_Report_To_Congress_SEC.pdf)

The $4.11 estimate is nominal, meaning each year's dollars retain that year's purchasing power. AHRQ's PCE-Health index increased from 105.442 in 2020 to 116.048 in 2024. Restating the FY2020 residual in 2024 health-care prices raises its baseline from $10.51 to about $11.57 per day, leaving an approximate constant-dollar increase of $3.05. [AHRQ price-index guidance](https://meps.ahrq.gov/about_meps/Price_Index.shtml)

AHRQ recommends the broader GDP price indexGDP price indexThe GDP price index is a broad measure of price changes across goods and services produced in the United States. [AHRQ](https://meps.ahrq.gov/about_meps/Price_Index.shtml) for comparisons of total expenditures from a societal perspective. That index increased from 105.398 to 125.430, which restates the FY2020 baseline at about $12.51 per day and reduces the estimated increase to $2.11. The choice answers different questions: PCE-Health asks how spending changed relative to health-care prices, while the GDP index compares it with prices across the domestic economy. [AHRQ price-index guidance](https://meps.ahrq.gov/about_meps/Price_Index.shtml)

The residual is not a mystery category. Approximately $492.5 million comes from other carrier claims and $260.2 million from Part D drugs. Outpatient and inpatient services add approximately $58.3 million and $41.0 million, while smaller increases in durable medical equipment and home health are partly offset by a roughly $21.0 million decline in skilled-nursing-facility spending. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf)

CMS's policy concern is that the hospice per diemper diemPer diem means that Medicare pays a hospice for each day a qualified beneficiary is under its care. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf) is supposed to cover care related to the terminal illness and related conditions, while Original MedicareOriginal MedicareOriginal Medicare is the federal program consisting of Part A and Part B, with optional separate Part D drug coverage. [Medicare](https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare) may continue paying for genuinely unrelated care. Claims data can show that another part of Medicare paid a bill during a hospice election, but the national totals cannot by themselves decide whether each service was related, clinically appropriate or incorrectly billed. [Medicare hospice coverage](https://www.medicare.gov/coverage/hospice-care) [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf)

Beneficiaries also face cost sharingcost sharingCost sharing is the portion of a covered medical cost assigned to the beneficiary or another payer through a deductible, coinsurance or copayment. [Medicare](https://www.medicare.gov/basics/costs/medicare-costs) outside the hospice bundlehospice bundleThe hospice bundle is the group of related services, drugs, supplies and equipment intended to be covered by Medicare's daily hospice payment. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf). CMS reported $510 million in Part A and B deductibles and coinsurancecoinsuranceCoinsurance is a percentage of an approved medical charge assigned to the beneficiary after any applicable deductible. [Medicare](https://www.medicare.gov/basics/costs/medicare-costs) for FY2024. Its Part D table records $71,000,446 in patient payments and $2,354,151 in other true out-of-pocket amounts, totaling $73,354,597. These claim fields measure assigned or recorded cost sharing, not a household survey of who ultimately supplied the cash. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf) [Medicare costs](https://www.medicare.gov/basics/costs/medicare-costs)

An exact calculation would require an unrounded FY2020 hospice-day denominator built with the same exclusions and claims extraction as the final-rule numerator, plus unrounded pressure-ulcer-coded carrier totals for both endpoint years. CMS already publishes the underlying methodology and later-year day totals, so adding that small reconciliation table would close the remaining gap. [CMS final rule](https://public-inspection.federalregister.gov/2026-15686.pdf) [CMS 2026 monitoring report](https://www.cms.gov/files/document/hospice-monitoring-report-2026.pdf) [CMS SSVISSVIThe Service and Spending Variation Index is a CMS score combining eight hospice-utilization measures with one outside-spending measure to identify potentially concerning provider patterns. [CMS SSVI overview](https://www.cms.gov/files/document/ssvi-overview.pdf) overview](https://www.cms.gov/files/document/ssvi-overview.pdf)

The defensible conclusion is not that the residual cannot be measured per day. It is that the public data place it near $4.11 per day, while withholding the matched precision needed to put extra decimal places on the answer.