The nation has an ample supply of hospice programs and, through Medicare, Medicaid, or employee-sponsored health insurance, most people have nearly full coverage for hospice care. Yet, less than one third of dying persons use hospice care. Little is known about what prevents physicians from referring to hospice care and how effective hospices are in reaching out to physicians to generate referrals. In 1999, we conducted in-depth telephone interviews with 30 experts in hospice care across the country and made site visits to four different hospice programs. The interviewees identified numerous barriers to accessing hospice care that are complex and often overlapping. Some barriers relate to physicians and other health care professionals, such as their difficulty accepting death and their lack of education in end-of-life care. Other barriers are the result of patient/family misinformation and aspects of the hospice system that limit the number and types of patients deemed appropriate for hospice care. Factors that facilitate hospice referrals (which we call enablers) are also numerous and include active efforts by hospices to educate and reach out to physicians and consumers, as well as physicians' practice styles. The research provided powerful validation of trends that hospice and palliative care providers in the trenches have been describing anecdotally for several years. Ultimately, this information could be used to develop a toolkit for hospices and palliative care organizations to assist them with marketing and physician outreach.