By Dietrich Knauth
The HHS Office of Inspector General (OIG) urged CMS to strengthen oversight of federally-funded hospice care, saying in a portfolio report that CMS should seek additional statutory authority if needed to combat fraud and poor care quality. CMS disagreed with several of OIG's recommendations (OIG Report, OEI-02-16-00570, July 31, 2018).
Hospice care. End-of-life pain management is an increasing piece of Medicare spending, rising from $9.2 billion in 2006 to $16.7 billion for 1.4 million beneficiaries in 2016. But the program has many vulnerabilities, according to OIG, which found that hospices do not always provide needed services and sometimes provide poor quality care. Beneficiaries and their families and caregivers do not always receive crucial information—including the fact that entering hospice care may cut off other avenues for treatment—and the payment structure of Medicare hospice skews available treatment by encouraging hospice providers to seek long-term patients with uncomplicated needs, which could reduce the care available for needier patients. Hundreds of hospices only provide routine home care, leaving patients without options if their needs change, and most hospice beneficiaries do not receive care on weekends and never see a hospice physician to consult on their care, according to the report. Fraud schemes that inappropriately enroll beneficiaries into Medicare hospice often negatively affects beneficiaries, since Medicare hospice does not pay for curative treatment for a beneficiary’s terminal illness.
Recommendations. OIG made several recommendations, but CMS did not concur with all of them. OIG recommended that CMS strengthen its compliance survey process, seek statutory authority to establish remedies for hospices with poor performance, improve the information available to beneficiaries and their families, promote physician involvement and accountability in hospice decisions, and analyze claims data to reduce inappropriate payment. In addition, the OIG stated that CMS should also seek statutory authority to reform the way it pays for hospice care to ensure that services rendered adequately serve beneficiaries’ needs.
CMS may need additional statutory authority to change the way it pays for hospice care and the way it addresses poor care. CMS’s only current remedy for addressing serious deficiencies is to terminate the hospice from the Medicare program, an extreme remedy that limits CMS’ flexibility to address performance problems. CMS should seek power to take intermediate measures including directed plans of correction, directed in-service training, denials of payment for new admissions or for all patients, civil monetary penalties, and imposition of temporary management, according to OIG. CMS may also need to seek statutory authority to change its hospice payment system, such as reducing the amount paid for hospice care for patients already in nursing facilities, and studying the extent to which the current system incentivizes hospices to provide appropriate care for beneficiaries with greater needs, and adjust payments based on that analysis. Notably, section 3132 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) requires Medicare hospice reform.
CMS’ response. CMS pushed back on several of OIG’s recommendations disagreeing about the need to strengthen the survey process and the recommendation to publicly release deficiency data and complaints it uncovers during its surveys. It also did not concur with the two recommendations to promote physician involvement and accountability, saying that physicians are adequately involved through the hospice interdisciplinary groups that are required approve general inpatient care and document that approval. CMS also did not agree with a recommendation to work more closely with hospices to ensure that they are providing drugs covered under the hospice benefit as necessary.
CMS also disagreed with OIG’s recommendations on changing hospice payments. CMS said that it had already reformed the hospice payment system to more appropriately pay hospices for the cost of providing care to beneficiaries and better align payment with beneficiary care needs during the course of a hospice stay, and that it is required to pay hospice providers based on their incurred costs for care. And reducing hospice care payments for patients living in nursing facilities would run counter to hospice claims data that shows that such patients receive more visits and more care than patients residing at home, CMS said.
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