Between 2012 and 2016, 20% of U.S. hospices experienced a condition-level finding from regulators that posed serious risks to patient life and safety, according to a new report from the U.S. Department of Health & Human Services Office of the Inspector General (OIG), but that proverbial coin has another side: 80% of hospices did not.
OIG examined U.S Centers for Medicare & Medicaid Services (CMS) state agency survey results as well as findings from accreditation organizations such as The Joint Commission and Community Health Accreditation Partners (CHAP), focusing on a sample of 50 types of serious deficiencies.
Nearly all Medicare-certified hospices underwent a survey during the studied time period. The inspector general’s report revealed several examples of egregious patient safety events, including pressure ulcers that were allowed to become gangrenous and patients not receiving necessary home visits.
The morning after the reports were released, hospice industry organizations — and providers themselves —began to speak out to affirm the value of hospice care, saying that while the report illustrated serious incidents that draw legitimate concern, the data do not represent the industry at large.
“Extreme patient stories highlighted by the media that are not representative of the care most Americans receive can do more to frighten the public than inform them about the benefits of hospice care. NHPCO continues to stress that outliers in the field do not adequately reflect the vast majority of hospice care provision in the [United States],” Edo Banach, president of the National Hospice and Palliative Care Organization (NHPCO), said in a statement.
Though data on quality performance in hospice care are limited, those available show that hospices generally perform well on quality measures and family satisfaction surveys, according to the Medicare Payment Advisory Commission (MEDPAC).
CMS since 2014 has required hospices to report data on specified quality measures. MEDPAC in March reported to Congress that in aggregate hospices’ performance on seven quality measures related to processes of care at hospice admission is “very high for almost all measures.”
For six of the seven measures in 2017, hospices performed processes effectively between 96% and 99% of the time. The score was somewhat lower, 88%, for the measure indicating the proportion of patients who received a comprehensive pain assessment within one day of screening positive for pain. MEDPAC also noted that hospice performance on quality measures improved between 2016 and 2017.
MEDPAC also reported that scores on family satisfaction surveys were generally high, though the commission noted that hospices had more room for improvement on the survey measures than the seven quality measures. CMS requires hospices to provide the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to families following a hospice patient’s death.
Hospice CAHPS scores were highest on measures related to providing emotional support and treating patients with respect. Approximately 90% of families selected the most positive response for those practices, MEDPAC indicated. The lowest scores were in the areas of providing help for pain and symptoms, providing timely care, and caregiver training, with an average of 75% to 78% of families giving the most positive response.
In overall assessments of the hospice, nearly 81% of CAHPS respondents rated the hospices a 9 or 10 on a 10-point scale.
In response to the OIG report, a number of hospices organizations said that enforcement efforts should focus on providers that experience serious safety events, and that regulators should avoid targeting the industry at large.
“The finding of the Office of the Inspector General sends a clear message that more action is required to safeguard vulnerable hospice patients. The egregious examples of harm discovered by the OIG require an immediate focus on the small number of providers with incidents of jeopardizing patient safety,” the National Association for Home Care and Hospice (NAHC) said in a statement. “CMS should employ a variety of methods to address these agencies’ failings, including subjecting them to the closest of scrutiny until they are able to demonstrate the ability to meet quality standards and the conditions of participation on an ongoing basis.”
Some proposed that regulators should focus attention on providers whose state survey results show a history of serious deficiencies that could endanger patients.
“When there is clearly this level of deficiencies going on in the industry we would hope to work with CMS and the Congress to target these bad actors rather than using these more generalized net that they are currently using,” said Mollie Gurian, chief strategy officer for the National Partnership for Hospice Innovation told Hospice News. “The report said that many of the providers with these types of deficiencies had a number of these problems over time and looking at those patterns in state surveys would be a good place to start.”
Hospice leaders were also concerned that widespread media reporting of the OIG’s findings could dissuade patients and families from electing hospice at a time when the medical community and payers are increasingly recognizing the clinical and financial benefits of hospice and advocating for increased utilization.
“I feel like policymakers are looking in all the wrong places to try to do right. This is a black eye even for hospices that are doing well,” Christy Whitney, CEO of Colorado hospice provider HopeWest, told Hospice News. “And now that [the OIG report] is a topic in all the newswires, I think it’s even more damaging to the public.”