CMS Proceeding on New Hospice Quality Measure Development

The U.S. Centers for Medicare & Medicaid Services (CMS) is developing two new claims-based quality measures for hospices, to track avoidable transitions from hospice care as well as access to levels of hospice care.

CMS does not require hospices to collect or submit data on claims-based measures. The agency itself assembles the data based on claims organizations file for hospice care. The Transitions from Hospice Measure will include data on patients discharged alive from hospice.

“The intent of the Transitions from Hospice Measure is to assess negative outcomes following hospice live discharge, including death or acute care use shortly after discharge, as these outcomes represent potentially burdensome transitions to patients and families,” CMS has indicated.


Live discharges have been a hot-button issue in recent years. The agency sees live discharges as a red flag that could trigger an audit or further investigation.

As hospice utilization climbs, so does associated CMS spending, spurring the agency to step up enforcement in an effort to control costs. Medicare hospice expenditures rise by about $1 billion annually.

Live discharges comprised 17% of all Medicare hospice discharges in 2017, according to the National Hospice and Palliative Care Organization. About 8.6% were patient-initiated, either through the patient revoking their enrollment in the Medicare Hospice Benefit or due to transferring to another organization.


Hospice-initiated live discharges represented 8.4% of hospice discharges and occurred for reasons such as the patient moving out of the provider’s service area, the patient no longer being considered terminally ill or for-cause discharges.

The second measure in development, Access to Higher-Intensity Levels of Hospice Care, is designed to compare the number of patients whose care including general inpatient care and continuous home care against the number of patients the agency would expect to see receiving those levels of care if the patients were treated by a provider with quality scores that are consistent with national averages.

The measure will be designed to determine whether patients who need these levels of care have it available to them. Currently utilization rates for these services are low; only 1.3% of patient care days during 2016 involved general inpatient care during 2016 and 0.2% of patient care days involved continuous home care.

One factor that could contribute to low utilization is that until finalization of the 2020 proposed payment rule for hospice earlier this month, the cost of providing those levels of care substantially exceeded Medicare’s per diem payments. The agency is trying to turn this around by rebasing the payment rates to include a 2.7% increase in the per diems for general inpatient care, continuous home care and inpatient respite care, with a corresponding 2.7% cut in routine home care payments.

“The use of these higher-intensity levels of care has been linked to an increase in likelihood of a hospice patient dying in his or her location of choice, a decrease in health resource utilization, a decrease in hospice disenrollment, and an increase in patient and caregiver satisfaction with care,” the agency indicated in a Measures Inventory Tool.

To implement new measures CMS will have to put them through the rulemaking process, including a proposal and request for public comment and then ultimately a final rule. The agency has not commented on when this might occur.

“The claims-based quality reporting program will take Measures Application Partnership and public comments into consideration as it develops these measures,” CMS Project Officer Cindy Masuda said in an open forum conference call hosted by the agency. “The hospice quality program will continue to consider ideas for other claims based measures to develop.”