Home Health & Hospice Week

From CAHPS data to surveyor inconsistencies to fraud confusion, Medicare’s proposed Special Focus Program for applying more scrutiny to poor-performing hospices will do more harm than good if adopted as proposed. So say many of the 900 commenters on the 2024 home health proposed payment rule, which contains the SFP proposal.

Plus: Only about half of hospices report CAHPS data, note Douglas Irvin and Sara Dado with the Illinois Hospice and Palliative Care Organization in the trade group’s comment letter. Since CMS proposes not penalizing hospices’ that don’t report it in the SFP, IL-HPCO worries it will “allow poor performing hospices that do not publicly report quality data to avoid scrutiny. We suspect that under the proposed algorithm, hospices that report CAHPS survey data are systematically more likely to fall into the group of 10 percent highest scoring (lowest performing) hospices as compared to nonreporting hospices,” they say.

And the surveys themselves are just rife with problems, many commenters noted. They “are long and require someone to complete a paper form and send it back,” rather than easier electronic responses, Irvin and Dado point out. Plus, “some negative surveys are inevitable and represent outliers based on a family’s feelings surrounding the death rather than a poor performance by the hospice,” they add.

• Bottom line: “We do not believe [it] was the intention of the TEP nor CMS to incentivize lack of quality reporting, but unfortunately this is the natural consequence of using an ill-conceived and flawed math equation that was rushed to rulemaking,” Westfall charges. The methodology “appears to thoughtlessly select hospices for this new SFP who participate in [the Hospice Quality Reporting Program] and provide information to the marketplace about their care,” he maintains.
• State survey agency shortfalls. The problem with basing so much of the SFP selection and completion criteria on state survey data, is that many states have big flaws in their systems.

Some states like Texas are significantly behind on their survey schedules, notes Jennifer Elder with the Texas Association for Home Care & Hospice in the trade group’s comment letter. Delays are up to a year, Elder reports.

QCOR data shows that Washington state has 11 hospices with overdue recertification surveys, for 28.2 percent of hospice providers, Hansen notes. “How can it be a level playing field for the calculation of the SFP algorithm if there is no current data for as many as one-fourth of hospices?” she asks.

Nationally, QCOR data shows about a third of hospices are overdue for their surveys, notes Ben Marcantonio with the National Hospice and Palliative Care Organization in the trade group’s comment letter.

Other states have a significantly higher or lower rate of condition-level citations and/or complaint surveys. Washington state has “very few complaint surveys completed” — only one in 2022 — “while other states show they have had many of these types of surveys done,” Hansen adds. “How will CMS account for the disparity in the completion of these types of surveys between different states?”

• Surveyor inconsistency. CMS is only a short way down the road of improving its surveyors, and the staffing shortages plaguing healthcare providers affect survey agencies too, which exacerbates the problem.

“CMS released the update to the State Operations Manual, Appendix M – Hospice earlier in 2023,” Hansen points out. “Have all State Agency and Accreditation Organization surveyors completed the standardized training? Can hospices now be assured of surveyor interrater reliability?” she asks CMS.

“In Texas, the state agency has had a high turnover of surveyors and many of the surveyors are new; there has also been an uptick in complaints about surveyor unprofes­sionalism and lack of knowledge and experience,” Elder relates. “Many of them do not have the experience necessary to properly survey an agency based on their interpretation of regulations. This means that the hospice agency could be subject to enforcement action, while participating in the Special Focus Program, without justification,” she tells CMS.

• Vague final selection. The rule is pretty clear about how hospices will end up on the list of bottom 10 percent performers. But it’s much less forthcoming on how CMS will then choose hospices from that pool to enter the SFP, saying only that “we propose to identify a subset of 10 percent of hospice programs based on the highest aggregate scores determined by the algorithm” and “the hospices selected for the SFP from the 10 percent would be determined by CMS,” according to the rule.

“CMS should provide transparency on how CMS chooses hospice providers to enter the SFP from the list of the bottom 10 percent of hospice providers,” Meghan Woltman and Denise Keefe with Charlotte, N.C.-based Advocate Health say in the health system’s comment letter.

• Access risks. “We are worried that hospices will not have the resources to handle multiple audits and surveys at the same time [as SFP], particularly small and rural hospices, and that such demands could significantly reduce access in already underserved areas,” AAHPM’s Yang says. “The hospice SFP should provide opportunity, resources, and assistance for hospices to improve performance, not overwhelm hospices and put them out of business.”
• Confusing quality with fraud. The SFP “is not intended to — nor able to — sufficiently address egregious actors that fraudulently take advantage of the Medicare hospice benefit and Medicare beneficiaries,” Yang stresses. “We strongly recommend that CMS clarify through preamble language this distinction in order to provide more clarity and certainty to the hospice stakeholder community,” she says.

“We recognize there are hospices engaging in fraudulent behavior,” says Kathy Messerli with the Minnesota Home Care Association in the trade group’s comment letter. “However, we respectfully suggest CMS focus energy on identifying fraudulent activities and those agencies, while providing more education and support to the hospice industry in general to promote safe, quality end-of-life care,” Messerli says.

Note: The hospice SFP provisions of the rule are on pp. 104-112 of the PDF file at www.govinfo.gov/content/pkg/ FR-2023-07-10/pdf/2023-14044.pdf.