Health Reform WK-EDGE More hospice oversight needed through data, enforcement tools
Thursday, December 5, 2019

More hospice oversight needed through data, enforcement tools

By Cathleen Calhoun, J.D.

Why is CMS limited in its enforcement tools for hospice providers?

CMS should conduct more detailed oversight of hospice providers, and have more enforcement options when it finds problems, according to a Government Accountability Office (GAO) report. A GAO review of quality scores of for-profit and non-profit hospices determined that CMS should incorporate the use of additional information that could be used to identify quality of care issues into its survey process for hospice oversight (GAO Report, GAO-20-10, October 1, 2019).

Hospice. The number of Medicare hospice beneficiaries has almost tripled since 2000, with 1.5 million beneficiaries in 2017. Although hospice care is designed for beneficiaries with a life expectancy of 6 months or less, beneficiaries can receive hospice care beyond 6 months if they continue to meet hospice eligibility requirements.

In response to requirements in the Patient Protection and Affordable Care Act (P.L. 111-148), CMS established the Hospice Quality Reporting Program. That program uses two data sets to evaluate the quality of a hospice provider’s care:

  1. Provider-reported quality measure data. This includes seven measures that reflect the percentage of all hospice patients’ stays where the provider completed various key care processes, such as screening patients for pain and shortness of breath.
  2. Caregivers’ experience survey data. This is a national survey that captures, from the caregiver’s (family member or friend) perspective, the patient’s experience with hospice care.

Review of providers. CMS oversees the quality of Medicare hospice care mainly through inspections, or surveys, that are conducted by state survey agencies contracted by CMS or CMS-approved national private accrediting organizations. The report found CMS does not instruct surveyors to review, prior to surveying hospice providers, providers’ performance on CMS quality measures or other indicators of quality that could identify potential areas of concern. In addition, surveyors prepare for hospice surveys by reviewing documents of record including licensure records, previous survey findings and complaints, media reports, and other publicly available information about the provider. CMS does not instruct surveyors to review other information such as providers’ performance on CMS quality measures or other indicators of quality, such as knowing whether the hospice provided no visits during the last days of life, that surveyors could use to identify potential problem areas.

Limited enforcement remedies. The only enforcement remedy that CMS has is termination of the Medicare provider agreement—the strongest action CMS can take for provider non-compliance. The report found that termination happens rarely, with only 19 hospices involuntarily terminated from 2014 through 2017 (less than one-half of one-percent of the total number of hospices during that time). Congress has provided additional penalties for home health agencies and nursing homes, include civil money penalties, denial of payment for all new Medicare and Medicaid admissions, and imposition of training requirements for situations where it is determined that education will likely lead to provider compliance. However, these are not available for hospices.

Recommendations. The report recommends that Congress consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. In addition, the report states that CMS should incorporate the use of additional information, such as quality measures or other information that could identify potential quality of care issues, into its survey process for overseeing hospice providers.

ReportsLetters: GAOReports AgencyNews HospiceNews QualityNews NewsFeed

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