Eli's Hospice Insider

Hospices are enjoying a well deserved break from dramatic payment or policy changes in the 2019 final rule. But the regulation does include a number of Hospice Compare revisions that could shake up providers’ quality programs.

Check out these changes coming to the site used by potential patients and referral sources:

1. Two new measures. Back in its 2017 hospice rule, the Centers for Medicare & Medicaid Services finalized the decision to display the quality measures “Hospice and Palliative Care Composite Process Measure — Comprehensive Assessment at Admission” and “Hospice Visits when Death is Imminent” on Hospice Compare. In the 2019 final rule issued Aug. 1, CMS confirms that it will begin displaying the composite measure in fall 2019 and the visits measure some time in the fiscal year.

The composite measure addition will come with a streamlining of the seven Hospice Item Set based measures that comprise it: Treatment Preferences (NQF #1641); Beliefs/Values (NQF #1647); Pain Screening (NQF #1634); Pain Assessment (NQF #1637); Dyspnea Screening (NQF #1639); Dyspnea Treatment (NQF #1638); and Bowel Regimen (NQF #1617). Instead of displaying each of these seven items individually, the site will offer them “in an expandable/collapsible format under the composite measure itself, thus allowing users the opportunity to view the component measure scores that were used to calculate the main composite measure score,” the rule explains.

CMS offers the composite measure as an example of burden reduction in its fact sheet about the rule. It “enables more efficient use of Hospice Compare data,” the fact sheet contends.

The measure also “is more illustrative than the component, high performing measures and, on average, a much lower percentage of patient stays received all 7 desirable care processes at admission,” CMS says in the rule. Thus the measure “sets a higher standard of care for hospices and reveals a larger performance gap.” While six of the seven measures making up the composite measure score in the mid- to high-90s, the mean score for the composite measure is only 71 percent, the rule reveals.

Action item: If you are lagging on the composite measure score, you may want to take a look at the one component with a lower mean score — Pain Assessment (NQF #1637) at 72.5 percent.

Multiple commenters did take issue with the new Visits when Death is Imminent measure. One said “stakeholders have not had enough feedback data on their own individual measure performance to become comfortable … and take steps to improve their measure performance prior to public reporting.”

CMS responded that the Visits measure will be on “the CASPER QM reports before public reporting of the measures so that providers can become familiar with them,” according to the rule. It “will also appear on providers’ Preview Reports to ensure the scores to be displayed are accurate. Preview Reports will be released approximately 2 months prior to the Hospice Compare refresh in which measures are released.”

Other commenters noted problems like factors outside of their control influencing the measure, such as patient or family refusal of services.

CMS pledges that it will “carefully craft explanatory language” on Hospice Compare “to ensure that consumers understand the measure’s intent, relationship to quality, and any necessary measure specific nuance.”

2. Two divisions. In response to comments on the proposed rule, CMS acknowledges in the final rule “that it is important for consumers to be able to distinguish between process, outcome, and consumer feedback measures. Therefore, we have decided to separate the data into two sections on the Hospice Compare website: ‘Family experience of care’ and ‘Quality of patient care.’” That change has already taken place.

Both sections have accompanying text explaining their data source, CMS says “The website explains that the ‘Family experience of care’ data comes from a national survey that asks a family member or friend of a hospice patient about their hospice care experience. The ‘Quality of patient care’ section explains that this data is reported by hospices using the Hospice Item Set (HIS).”

Plus: “We have included text explaining why these measures should be important to consumers,” CMS adds.

3. Public Use File. Data on utilization, payment, submitted charges, primary diagnoses, sites of service, and hospice beneficiary demographics organized by CMS Certification Number (6-digit provider identification number) have been available to providers via Public Use Files since 2016, CMS notes in the final rule. In the proposed rule, CMS suggested posting some PUF-derived information on Hospice Compare. Examples it offered were percent of Routine Home Care days provided, percent of diagnoses, and sites of service (nursing home, hospital, etc.).

Some commenters warned that posting PUF data could lead to “consumer confusion and unintended consequences,” according to the final rule. For example, “posting data about primary diagnoses served could lead consumers to falsely assume a hospice does not serve a particular diagnosis group,” which “would disproportionately affect small hospices,” they told CMS.

Others said “displaying data from the PUF would be misleading for consumers since consumers may misinterpret this data as quality data.”

“The purpose of adding information from the PUF or other publically available CMS data is to provide additional useful information to consumers as they consider hospice,” the rule notes. CMS plans to “(1) average data over multiple years and (2) include text explaining the purpose of these data points and how consumers can use them. By averaging data over multiple years, changes in case mix from year-to-year will be accounted for.”

Plus: Data for small providers (less than 10 hospice beneficiaries in a calendar year) or data points with less than 10 beneficiaries “are suppressed in the PUF and cannot be displayed on Hospice Compare,” CMS notes.

Bottom line: “We will make clear that information from the PUF is one more resource along with, but separate from, the quality of care data to help consumers make a more informed choice of hospice provider,” CMS pledges.

4. CAHPS quarters. If you’d like to see your CAHPS improvements reflected more strongly on Hospice Compare, you’re out of luck. For the CAHPS patient survey measures, “we report the most recent 8 quarters of data on the basis of a rolling average, with the most recent quarter of data being added and the oldest quarter of data removed from the averages for each data refresh,” CMS explains in the final rule. “A couple of commenters suggested that CMS report more recent data ... by reducing the number of quarters of data being reported.”

The decision boils down to numbers. CMS’ goal is “to maximize the number of hospices that are included on the Compare site,” it says. “Among the 4,643 hospices on the active agency list for the most recent public reporting period (Q4 2015–Q3 2017), 61 percent (2,832) had 30 completes over 8 quarters (Q4 2015– Q3 2017).” That compares to 49 percent (2,262) for four quarters. “For this reason, we plan to continue to report eight quarters of data,” CMS concludes.

5. Website functionality. Commenters gave CMS an earful about the problems with Hospice Compare, particularly its lackluster search function and incorrect demographic data.

CMS pointed the finger at MACs and providers themselves for the demographic inaccuracies. “The demographic data reflects what hospices have provided,” CMS says. Hospices should catch any “inaccurate or outdated demographic data … included on the [Provider] Preview Report or on Hospice Compare” and correct it through processes posted on the Hospice Quality Reporting Program page (see www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/Public-ReportingBackground-and-Announcements.html).

However, “updates to provider’s demographic data (for example, address, telephone number, ownership) may take up to 6-months to appear on the Hospice Compare website,” CMS acknowledges. “The process to update demographic data is independent of updating quality measure data or service areas and is controlled by the Medicare Administrative Contractor (MAC),” CMS insists.

For search issues, CMS says it has solved the problems. “The current search function file, uploaded in May 2018, has addressed the accuracy and specificity of the Compare search function, as it is based on three sources of data: Claims, HIS, and geographic data,” the rule explains. “Since the launch of Compare, the refinements we have made to the data underlying the search function have addressed the accuracy of the search function.”

CMS stresses that the Hospice Compare problems relate only to demographic and search areas, and do not affect the actual quality data displayed.

6. Freeze date. CMS is finalizing a new shorter “freeze date” for Hospice Compare display data. “Hospices currently have 36 months to modify HIS records. However, only data modified before the public reporting ‘freeze date’ are reflected in the corresponding CMS Hospice Compare website refresh,” CMS notes in the final rule.

“We proposed that data from HIS records with target dates within the correlating quarter become a frozen ‘snapshot’ of data for public reporting purposes. Any record-level data correction after the date on which the data are frozen will not be incorporated into measure calculation for the purposes of public reporting on the CMS Hospice Compare website,” the rule notes.

That freeze deadline will be about 4.5 months after the end of each quarter, starting Jan. 1. “Requiring that data be reviewed and corrected for public reporting purposes within a defined period of time will result in more timely and accurate data on Hospice Compare, ensuring that consumers have access to a resource with consistent and accurate representations of hospice performance,” CMS says.

“Corrections should not be the rule, but rather the exception,” the agency also highlights.

Note: For more coverage of hospice final rule provisions, including those addressing Physician Assistants, drug reporting, and HQRP changes, see a future issue of Eli’s Hospice Insider.