The Improving Medicare Post – Acute Care Transformation Act of 2014 (IMPACT Act), which became law in 2014, includes new requirements to measure and improve hospice care. The new law will mandate quality surveys every 36 months, increase medical review for long lengths of stay, and align the increase in the aggregate cap with reimbursement over the next decade. NPHI urges that such program integrity efforts be driven by data; a data-driven approach will allow for new documentation and other requirements to focus on outlier providers rather than on the majority of hospices who are not engaging in bad behaviors.

Focused Medical Review for Outlier Programs: NPHI recommends a focused medical review of hospice programs with:

1. Unusually high shares of patients with stays exceeding 180 days;
2. Unusually high rates of patients discharged alive;
3. Low utilization of skilled visits to patients during the last days of life;
4. Programs with a patient diagnosis mix that disproportionately favors conditions that often warrant long lengths of stay;
5. Disproportionately high number s of patients in facilities;
6. Focus on hospices with high costs outside the benefit; and
7. Who misuse or do not administer all four levels of care.

This type of review would focus on the outlier programs for scrutiny which would save the taxpayers’ money without unnecessarily burdening not-for-profit, high-quality hospice providers for whom any additional administrative burdens place further financial pressure on their abilities to meet the needs in their communities.

Targeted Diagnosis Reporting Documentation Requirements: Similarly to focused medical review, NPHI recommends imposing new documentation requirements only on hospice providers who are outliers on metrics such as unusually long lengths of stay, unusually high rates of patients discharged alive, and low utilization of skilled visits to patients during high service intensity periods (beginning and end of a hospice stay), and others outlined above. Targeting this type of documentation requirement would ease the burden on providers with already slim margins who are already providing high-quality care while allowing those providers who may be shifting care to be targeted for program integrity investigations.

Changes to General Inpatient Care (GIP): Requirements should be clarified for GIP eligibility and CMS should pay no more for GIP nursing home than the skilled nursing facility daily payment. This change would remove incentives for providers to overpay nursing homes for hospice referrals. Hospices who do a high proportion of GIP service in the nursing home should be a target for focused medical review. Additionally, NPHI recommends eliminating the visit collection data requirement for hospices who operate their own inpatient unit with GIP patients. The current policy is discriminatory, since hospitals do not have to substantiate patient contacts to receive DRG payment that is at least 10 times the cost of a day of GIP in a hospice facility, and there is no accurate method to collect the data.

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Surveys: Almost all hospices are required to contract with CAHPS survey vendors to assess patient family experiences with care provided across several areas including team communication and coordination, support for religious and spiritual beliefs, support for family members, and other important metrics. However, the CAHPS surveys must be re-examined to better reflect the experience of patients and family caregivers and to provide more timely feedback. For example, the CAHPS survey is too long and if all of the questions are not answered, the survey does not count. CAHPS data should be able to be used to differentiate and highlight the best providers as well as to target outliers who may not be providing quality care. NPHI supports revisions to the CAHPS surveys to ensure that the highest quality of care is provided to patients and ample support is offered to the caregiver.