Home Health & Hospice Week

SFP quotas are a bad idea, multiple commenters say.

A Special Focus Program targeting “poor performing” hospices is on its way, but the feds have a lot of leeway in how to implement it. In comments on the 2023 proposed hospice rule, providers and their representatives are appealing to Medicare officials’ better nature when it comes to crafting the program.

In the hospice proposed rule for 2023 released on March 31, CMS indicated it had “decided to initiate a hospice Technical Expert Panel (TEP) in CY 2022,” the rule says. “Accordingly, CMS plans to use the TEP findings to further develop a proposal on the methodology for establishing the hospice SFP, and we plan to include a proposal implementing a SFP in the FY 2024 Hospice rulemaking proposed rule.”

CMS will issue the 2024 rule in spring of 2023 — likely about 9 months away.

That speedy timeline is just one of the many issues commenters addressed in their letters about the rule.

“As the TEP develops recommendations for an SFP proposal for future rulemaking, we ask CMS to bear in mind that establishing a properly detailed and well-crafted Special Focus Program should be the goal, not the speed at which it is implemented,” said Brian Vamstad with not-for-profit health system Allina Health in the system’s comment letter.

“Significant civil monetary penalties and potential program termination are enormous consequences for deficient programs,” Vamstad emphasized. “We recognize that CMS wants to encourage hospices to address issues identified in program surveys, but the agency’s desire to fast-track this concept cannot come at the expense of carefully crafted details, efficient and thorough communication, and consistent application of policies and procedures,” he urged.

“The program should not be implemented until the TEP has completed its work ... and has had the opportunity to consider” important SFP components,” exhorted Teri Henning with the Pennsylvania Homecare Association in the trade group’s comment letter.

In fact, CMS should look at providing more time for the requirement. “With the continued challenges born from the COVID-19 public health emergency, we suggest that the implementation date be pushed further into the future to allow additional time to work through the challenges,” urged Nick Westfall, CEO of VITAS Healthcare in the Miami-based chain’s letter.

Other SFP topics addressed in comment letters include:

• TEP composition. “The TEP should represent the hospice community as currently constructed, meaning at least one member should be a representative of a not-for-profit hospice provider,” maintained Tom Koutsoumpas with the National Partnership for Healthcare and Hospice Innovation in the group’s letter. “Not-for-profit hospices serve a critically important function as safety-net providers. The very nature of not-for-profit hospice providers frequently leads them to focus on priorities that are different but no less important than for-profit organizations. Their patient care and administrative practices also tend to differ. Failing to include this important voice on the TEP disadvantages the efforts of CMS to create a valuable and effective SFP that can effectively assist underperforming hospices,” Koutsoumpas said.

“In addition, CMS must ensure that the voices of rural providers are heard throughout the process,” Koutsoumpas added.

“We urge CMS to ensure that the TEP includes represen­tatives from a diverse set of stakeholders, including represen­tatives from rural and urban hospices, non-profit and for-profit hospices, and small and large hospices,” physician Tara Friedman, president of the American Academy of Hospice and Palliative Medicine, said in the group’s comment letter.

“We recommend that opportunities to serve on the TEP be open to the public,” PHA’s Henning told CMS. And the panel should “include multidisciplinary and patient/caregiver perspective,” she said.

“We ask that CMS develop a stakeholder group that is diverse and includes representation from the hospice program industry, including those who directly interact with patients and agency surveyors,” Allina’s Vamstad said. “Individuals closest to the work can offer great perspective on improvement opportunities, and the TEP should include feedback from these care providers. Multiple professionals should have the opportunity to provide input on the SFP and the tools used to improve accountability and quality,” he advised.

• TEP transparency. The process the TEP uses to deliberate shouldn’t be a black box. PHA’s Henning asked “that the proceedings of the TEP be as transparent as possible,” according to the group’s letter.
• Survey standardization. Hospices and other providers have long complained that surveys vary greatly, both from state to state and from surveyor to surveyor. “If the SFP is … intended to be a final opportunity for hospice programs to improve upon identified deficiencies, CMS must guarantee there are no variances to how entities conduct their surveys,” maintained Allina’s Vamstad. And that will take time, he stressed.

“Currently, state surveyors and accreditation surveyors are not receiving the same education that would assist in framing a common starting point,” VITAS’ Westfall pointed out to CMS. “Likewise, there is no standardization of the survey process. These tasks must be completed before providers can be compared one to another and one state to another,” he stressed. “This was a lesson learned in developing such a process for nursing facilities,” he added.

• Quotas. “We believe that CMS should depart from the approach used in its SFP for nursing facilities, which identifies SFP facilities and candidate facilities on a state-by-state basis with a specified number of slots per state (i.e., effectively a quota system),” AAHPM’s Friedman told Medicare officials. “Instead, we believe that decisions about hospices’ addition to the SFP should be determined centrally, based on standardized and objective criteria such that hospices are selected based on their performance and not on where they are located,” Friedman said.

“We are notably concerned with the quota system that CMS has implemented with regard to the number of facilities targeted for participation in the SFF Program that CMS operates for nursing facilities, as well as the number included on a candidate list from which new facilities are selected,” VITAS’ Westfall noted. “According to CMS guidance … the ‘number of nursing homes on the candidate list is based on five candidates for each SFF slot, with a minimum candidate pool of five nursing homes and a maximum of 30 per State.’ We believe this quota system places undue emphasis on counts of facilities, rather than on what truly matters — facility performance,” Westfall emphasized.

“In some cases, this may result in high performing facilities in small states with few facilities being added to the candidate list simply to meet the 5-facility minimum required by CMS guidance,” Westfall warned. “We believe that hospices should be assessed on their own merits, not on pre-established quotas. Therefore, we encourage CMS to forego the use of quotas as it finalizes its methodology for the Hospice SFP,” he said.