Home Health & Hospice Week

Plus: Neuro diagnosis codes are most common, data shows.

As hospice continues its explosive growth trajectory, policy- and lawmakers are looking at how to get a handle on the benefit and ensure its program integrity.

To that end, the 2024 hospice proposed rule “includes data analysis on historical hospice utilization trends,” the Centers for Medicare & Medicaid Services notes in the regulation published in the April 4 Federal Register.

One area of focus is higher-level hospice care, of which usage remains very low in CMS’ estimation. Routine Home Care accounted for 93.7 percent of payments in 2022, compared to 0.6 percent for Continuous Home Care, 0.7 percent for Inpatient Respite Care, and 5.0 percent for General Inpatient Care. Those compare to 90.6 percent, 1.8 percent, 0.3 percent, and 7.3 percent in 2013, respectively.

“Despite rebasing payment rates for the higher levels of care, there still remains a high percentage of hospices that provide little to no CHC, IRC, or GIP,” CMS says. However, the agency does not mention the aggressive medical review higher-level claims have received.

“Hospices that are unable, or unwilling, to provide higher levels of care such as CHC and GIP may not adequately be able to care for patients who are in crisis or have symptoms that cannot be managed in the home, resulting in a worse outcome for the patient,” CMS charges in the rule. “Furthermore, not providing those levels of care, and also not providing IRC, places a greater burden on caregivers which may worsen the quality of care at the end of life.”

Take a look at what else CMS highlights in the rule:

• The number of Medicare beneficiaries receiving hospice services has grown from 715,349 in fiscal year 2003 to over 1.7 million in FY 2022.
• Medicare hospice expenditures have risen from $5 billion in FY 2003 to about $23 billion in FY 2022.
• Aggregate hospice expenditures will continue to increase by about 9.1 percent annually, predicts CMS’ Office of the Actuary.
• The percentage of Medicare decedents who died while on hospice increased from FY 2013 to FY 2019, peaking at 52.0 percent, but then declined to a low of 47.7 percent in 2021. In 2022, that figure inched back up to 48.8 percent.
• In FY 2022, 74 percent (4,204 of 5,689) of hospices were for-profit and 16 percent (897 of 5,689) were nonprofit. In contrast in FY 2016, 65 percent (2,842 of 4,373) were for-profit and 23 percent (991 of 4,373) were non-profit.
• In FY 2022, for-profit hospices provided 64 percent of all hospice days while non-profit hospices provided 27 percent of all hospice days. The rest of the days were provided by government and other ownerships.
• Longer-stay “neurological and organ-based failure conditions remain the top-reported principal diagnoses,” CMS says. For example, G30.9 — Alzheimer disease, unspecified is the top-reported code at 7.4 percent.
• Average length of stay increased from 77 days in FY 2019 to 80 days in FY 2022. Median LOS dropped from 20 days in 2019 to 18 days in 2021, although that rebounded a bit to 19 days in 2022.
• From 2013 through 2022, the average live discharge rate has stayed steady at about 17 percent per year. In FY 2022, 35 percent were because of revocations, 36 percent because the beneficiary was determined to no longer be terminally ill, 14.2 percent because beneficiaries moved out of the service area without transferring hospices, 12.9 percent because beneficiaries transferred to another hospice, and the remaining 1.9 percent were discharged for cause.
• Live discharge rates vary by ownership status, with nonprofit hospices averaging rates of 12 percent per year, for-profit hospices 21-22 percent, and government/other types of hospices 15 percent.
• CMS examines non-hospice spending on a number of metrics, and concludes that it’s higher than the agency would like. “Our expectation continues to be that hospices offer and provide comprehensive, virtually all-inclusive care,” the rule emphasizes. “In order to preserve the Medicare hospice benefit and ensure that Medicare beneficiaries have access to comprehensive, high quality and appropriate end-of-life hospice care, we would continue to examine program vulnerabilities and implement safeguards.”

Source: CMS 2024 hospice proposed rule at www.govinfo.gov/content/pkg/FR-2023-04-04/pdf/2023-06769.pdf.