Comparing Hospices: the US and Canada

By Phelim Boyle

In the mid 1970s, both Canada and the United States opened their first palliative care units. In each case, the inspiration came from the work of Dame Cicely Saunders, the remarkable founder of St. Christopher’s Hospice in London. The mission of these New World hospices was to provide compassionate care for individuals at the end of life and support for their families. The hospice sector has since evolved along different paths in Canada and the United States. Comparing their histories is instructive. For Canada, there are valuable lessons to be learned and significant pitfalls to be avoided. The comparison also points toward a set of concrete recommendations for strengthening hospice care in Canada.

In the United States, the key development occurred in 1982 when Congress created the Medicare Hospice Benefit. Under this program, hospice providers are paid fixed daily amounts for the care of enrolled patients. This funding infusion spurred dramatic growth in the sector, and there are now approximately 5,900 Medicare-certified hospices across the country. In Canada, where health care is a provincial responsibility, hospice growth has been more sporadic. Canadian hospices are mainly funded through local community support and provincial governments, with some limited and indirect federal funding.

The US hospice sector has flourished as a result of the predictable, stable funding provided by Medicare. That same funding has made hospices prime targets for privatization. Currently, around three-quarters of US hospices are for-profit. There is an inherent tension between profit and the provision of good patient care. Research by the RAND Corporation and others shows that, on average, care quality tends to be higher in non-profit hospices than in for-profit ones. The Medicare benefit structure also enables an unscrupulous provider to game the system — for example, by favouring long-stay patients who generate the most revenue.

Canada’s hospice and palliative care sector has developed at a more fragmented pace in terms of scale and access. It remains essentially non-profit and community-driven. The extensive use of volunteers creates strong bonds with local communities. These features make Canadian hospice care distinctive. However, the sector would benefit greatly from permanent, dedicated federal funding that preserves this character and avoids the pitfalls of the US system. Both the CHPCA and the CSPCP have noted that fewer than 30% of Canadians currently have access to high-quality hospice palliative care, despite the fact that more than 90% of all deaths in Canada would benefit from it. In November 2025, the Palliative Care Coalition of Canada — which includes CHPCA — took this message directly to Parliament. It called on the federal government to invest an additional $29.8 million to strengthen national standards, build data infrastructure, and expand services for underserved communities. Any such funding should be accompanied by national standards, quality reporting, and accountability mechanisms. Currently none of these exist at the national level.

The funding model has a direct bearing on quality measurement. In the US, the Medicare Hospice Benefit gave the government the financial leverage to mandate reporting on hospice care quality. Every Medicare-certified hospice must comply with federal Conditions of Participation, submit to inspection, and report on standardized quality measures including the CAHPS Hospice Survey. Canada’s multi-source funding model comes at a cost: there’s no single federal lever to nudge the sector. Hence there is no equivalent mandatory reporting in Canada.

Designing meaningful measures of hospice care quality is genuinely difficult. The patient — the most important person in any assessment — is usually too frail to complete a questionnaire. It would be unfeeling to bother them with such tasks. Family members are called upon to act as their proxies. This is a reasonable approach, but it adds complexity. Bereaved relatives see hospice through the lens of their own grief and anxiety, and their experience may differ from the patient’s. Quality care has many dimensions — clinical skill, emotional support, dignity, communication, and spiritual sensitivity — and fitting all of them into a standard form is no easy task. The timing of any survey matters too.

In the United States, for example, the CAHPS Hospice Survey is sent to bereaved family members two to five months after the patient’s death. By then, the raw edges of grief have eased a little while the memories are still fresh. Voluntary surveys tend to attract respondents who feel strongly one way or another, which can skew results. None of these limitations are reasons to abandon the measurement of care. They are reasons to design surveys carefully, interpret results with caution, and build in safeguards from the start. Well-constructed surveys remain among the best tools we have for measuring and improving hospice care.

There are strong arguments for national performance assessments. Without standard measures, we cannot know whether care is getting better or worse. That matters to funders, policymakers, and the public. Making survey questions public also allows independent scrutiny of whether the approach is statistically sound. The CSPCP, responding to the Canadian Institute for Health Information’s 2023 national report on palliative care, was blunt: it could not say whether access to quality care in Canada was improving. “We just don’t know,” it concluded. The Society went further, calling for clear national standards and quality indicators explicitly tied to funding through Accreditation Canada.

Public reporting creates accountability in several ways. Families can make informed choices among providers. Funders can see how well their money is being spent. Researchers and policymakers can spot patterns and act on them. And the incentive effect is powerful. Organizations that know their results will be public have a stronger motivation to improve than those that report only to themselves.

However, there are legitimate reasons why Canadian hospices may have reservations about such surveys. In a small hospice, results can be skewed by random variation. To counter this, setting minimum sample size thresholds helps. A small rural hospice may also struggle to match the performance of a large, well-resourced urban one. Many hospice teams are small, overstretched, and operating under real pressure. Standardized data collection and reporting involve significant costs in time and staff capacity. However, the most fundamental objection may be philosophical. In Canada, hospice culture rests on values of trust, relationships, community, and respect for each person’s individuality. Some hospice staff will be uneasy with the idea of reducing a person’s dying experience to numerical scores and rankings. These are real concerns, and any well-designed system must take them seriously. But they are reasons to design measurement carefully — not reasons to abandon it.

Our discussion of Canada’s hospice history and the US comparisons lead to three recommendations. First, Canada needs permanent, dedicated federal funding to close the gap between the 30% of Canadians who currently receive quality end-of-life care and the 90% who would benefit from it. Second, that funding should come with a national framework of publicly reported quality standards, so families, funders, and policymakers can monitor the quality of patient care. Third, any quality measurement system must be designed with the particular character of Canadian hospice care in mind. Over the past fifty years Canada has made significant progress in providing palliative care, but there is still quite a distance to travel.

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