CMS announces Hospice Compare website

CMS released the Hospice Compare website on August 17, 2107. The website allows consumers to make informed decisions about hospice providers based upon the quality of care they provide. Consumers can use the website to find providers in their area and compare them using quality of care metrics.

Reporting

 Hospices are required to report to CMS on several quality measures under Section 1814(i)(5) of the Social Security Act (SSA). The Hospice Quality Reporting Program (HQRP) requires hospice providers to submit data from the Hospice Item Set (HIS) and Hospice Consumer Assessment of Healthcare Providers and Systems (Hospice CAHPS®). The Hospice Compare website compiles data so that consumers can evaluate things like the percentage of patients that were screened for pain or difficulty breathing and whether patients’ preferences were satisfied. The website compiles data from 3,786 hospice providers.

Measures

The Hospice measure set displayed on the website currently includes the following National Quality Forum (NQF) measures from the HIS:

  • Hospice and Palliative Care- Treatment Preferences – NQF #1641
  • Hospice and Palliative Care- Beliefs/Values Addressed- NQF #1647
  • Hospice and Palliative Care- Pain Screening- NQF #1634
  • Hospice and Palliative Care- Pain Assessment- NQF #1637
  • Hospice and Palliative Care- Dyspnea Screening- NQF #1639
  • Hospice and Palliative Care- Dyspnea Treatment- NQF #1638
  • Hospice and Palliative Care- Patients treated with opioids who are given a bowel regimen- NQF #1617

The website will be updated to include the CAHPS data in winter 2018.

Hospices see modest payment increase, new clinical doc reporting for FY 2018

Hospices serving Medicare beneficiaries would hospices would generally see a $180 million or 1 percent increase in their payments for fiscal year (FY) 2018 under a Proposed rule updating the hospice wage index, payment rates, and cap amounts. In an advance release of the Proposed rule, CMS also detailed new quality measure concepts under consideration for future years, solicited feedback on an enhanced data collection instrument, and described plans to publicly display quality measure data via the Hospice Compare website in 2017. CMS also seeks comments regarding the sources of clinical information for certifying terminal illness and would change the Hospice Quality Reporting Program (Hospice QRP), including adding new quality measures utilizing data collected in the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey. The Proposed rule is set to publish May 3, 2017.

Annual rates

Section 411(d) of the Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10) (MACRA) amends section 1814(i) of the Social Security Act setting the market basket percentage for hospices in FY 2018 to 1 percent. This translates to about $180 million for hospices in the next fiscal year. In addition to the basket percentage increase, the cap amount for accounting years that end after September 30, 2016, and before October 1, 2025, must be updated by the hospice payment update percentage, rather than the Consumer Price Index (CPI). Therefore, the cap amount for FY 2018 will be $28,689.04 compared to the 2017 cap amount of $28,404.99.

Hospice CAHPS Survey

The Hospice CAHPS® Survey is a component of the Hospice Quality Reporting Program and is important for the hospice community because the results of the survey will allow for comparisons on a national basis. CMS noted that the data would help beneficiaries to select a hospice program, as well as encourage hospices to improve quality of care. Under the Proposed rule, two global CAHPS measures would be adopted. CMS expects to begin public reporting via a Hospice Compare Site in CY 2017 to help customers make informed choices.

Terminal illnesses

CMS’ expectation is that a referring physician/acute/post-acute care facility’s clinical documentation serves as the basis of the certification of terminal illness. As such, the agency is seeking comments on a clarifying proposal that would identify the source of clinical information, whether a referring physician or acute care facility, when certifying that life expectancy in a hospice situation is six months or less. CMS also wants to explore whether the use of clinical documentation from an in-person visit from the hospice medical director or the hospice physician member of the interdisciplinary group could support the certification of terminal illness and whether such documentation is needed to augment the clinical information from the referring physician/facility’s medical records.

Measures under consideration

CMS offered no new proposed measures, but did seek additional feedback on two claims-based measures under future consideration: (1) avoiding hospice care transitions and (2) accessing levels of hospice care. The agency noted it would be detailing the measures in future rulemaking.

8 years of illegal kickbacks costs Hospice Plus $12M

A group of hospices owned by Curo Health Services and operating under the Hospice Plus brand agreed to pay over $12 million to resolve allegations that they paid kickbacks in exchange for patient referrals in violation of the False Claims Act (31 U.S.C. §3729). The scheme came to light after several whistleblowers filed qui tam lawsuits on behalf of the United States, consolidated as U.S. ex rel. Capshaw v. White. The United States had previously partially intervened in the lawsuit against the corporate defendants for purpose of settlement; the suit remains pending against two former Curo executives, and the United States requested permission to intervene in the remainder.

Kickbacks were allegedly paid to (1) American Physician Housecalls, a physician house call company in the form of sham loans, free equity interest in another entity, stock dividends, and free rental space; and (2) to medical providers, including doctors and nurses, in the form of cash, gift cards, and other valuable items. According to the consolidated whistleblower complaints, the house call company allegedly received kickbacks from 2007 through 2012, while providers allegedly received payments from 2007 through 2014.

The involved hospices primarily operate in and around Dallas, Texas, and were first known as Hospice Plus, Goodwin Hospice, and Phoenix Hospice. The three companies were purchased by Curo Health Services in 2010 and consolidated under the Hospice Plus brand.

Hospices beware, OIG is taking a closer look at patient care

Hospice has become one of the areas targeted for investigations by the Office of Inspector (OIG) and the Department of Justice (DOJ) in their common goal to reduce the vulnerabilities of the Medicare and Medicaid programs, including reducing improper payments and holding wrongdoers accountable, HHS Inspector General Daniel Levinson told attendees of the Health Care Compliance Association (HCCA) 20th Annual Compliance Institute. In light of the government’s focus on hospice services, a HCCA breakout session addressed the top five hospice risk areas and provided details of what compliance officers need to know and what they need to do.

The risk areas presenters Laura E. Ellis, Senior Counsel, HHS-OIG, Office of Counsel to the Inspector General (OCIG); Jason E. Christ, Member, and Serra I. Schlanger, Senior Associate, of Epstein Becker Green; and Lynn Strange, Chief Compliance Officer, Nathan Adelson Hospice identified, include: (1) eligibility and appropriateness, (2) financial arrangements with referral sources and medical directors, (3) the level of care, (4) documentation, and (5) governance and effective oversight. Other risks noted were problems with admitting a patient at the wrong time, families not being aware that the beneficiary is in hospice care, ensuring that marketing incentives do not include patients exceeding six months on an average length of stay, and risks specific to profit or nonprofit organizations.

Why focus on hospice? Risks and recommendations

The presenters noted that in 2013, Medicare expenditures for hospice services totaled about $15.1 billion which was more than a 40 percent increase in spending since 2000. Of that amount, nearly $9 billion was spent on patients with lengths of stay exceeding 180 days. From 2000 through 2012, the length of stay at the 90th percentile increased from 141 days to 246 days.

Eligibility and appropriateness of hospice benefits. Among the specific areas that the presenters identified that the government will be looking at in terms of eligibility, include whether the patient’s diagnosis and prognosis meet the eligibility requirements for admission, re-admission, and long lengths of stay; whether the hospice failed to discharge clinically ineligible patients; and the hospice’s live discharge rates. Presenters stressed that eligibility for admission or readmission must be supported in medical records, including the patient’s condition and prognosis. The presenters recommended that hospice providers audit and monitor high risk areas, evaluate data to identify trends and outliers, and review PEPPER reports and hospice CAP overpayment trends. The presenters also suggested that compliance officer look at reports on a monthly basis.

Financial arrangements and marketing practices. Financial arrangements include kickbacks to referral sources, swapping arrangements, arrangements with medical directors, and incentives tied to admissions and census goals. To mitigate risks in financial arrangements, the presenters suggested focusing training for marketing staff on interactions with referral sources and beneficiaries, contracting review for financial arrangements with referral sources, and evaluating internal compensation and incentives. Specifically, the presenters told listeners to look at relationships with other facilities, the qualifications of medical directors, and whether the hospice pays bonuses to the right people at the right time. Further, compliance officers should develop a good relationship with and provide for training for sales and marketing staff.

Levels and location of care. Presenters identified appropriateness of hospice general inpatient (GIP) care, use of continuous crisis care services, and services provided to beneficiaries in assisted living facilities (ALFs) and skilled nursing facilities (SNFs) as risk areas for hospices to keep on their radar. Auditing and monitoring higher levels of care, evaluating data to identify trends, investigating outliers, and increasing oversight of ALF and SNF patients will mitigate these risks, presenters said. They also recommended involving physicians in decisions regarding care.

Documentation. CMS will be looking at the adequacy of physician attestations, clinical documentation, financial records and any other documents that support claims for payment, the presenters noted. To ensure compliance, systems should be implemented to ensure timely certifications and face to face evaluation. In addition, hospice providers should operationalize documentation practices and provide documentation training for its staff member.

Governance and effective oversight. Risk areas at the Board level include failures to: (1) set compliance direction at the top, (2) take action early due to a  lack of knowledge, and (3) allocate sufficient resources. To mitigate risks to the hospice, presenters stressed that compliance officers meet with the Board regularly in executive session; develop a compliance dashboard for the Board; encourage questions and discussions, including feeding questions to the Board if none are asked to start the ball rolling; and involve executive leadership in risk identification and remediation. Lynn Strange, added that conducting an “external audit brings credibility to the Board.”