As the nation’s health care costs soar, providers, payers and policymakers are beginning to recognize the hospice and palliative care value proposition, and their potential to reduce the need for high-acuity services. While a boon to many patients, the growing prevalence for home-based care has drawn the eyes of regulators seeking to ensure quality and compliance in an expanding marketplace.
Demand for hospice and palliative care has grown rapidly in the last two decades as the senior population swells. The U.S. Census Bureau projected in 2018 that adults 65 and older would outnumber children by 2034, reporting that seniors would total 77 million, or 23.4% of the population, while those 18 and younger would reach 76.5 million (19.8%).
Providers are feeling both the brunt and benefit of rising demand for hospice. Many are reaching more patients, but fear that in the coming years the available workforce will be insufficient to meet the growing need. While working to attract and retain staff, hospice leaders also seek to innovate to ensure sustainable operations.
“One of the most significant opportunities in hospice is the ability to serve more patients and their families,” Cheryl Medawattage, executive director of hospice of Washington-based EvergreenHealth, told Hospice News. “The demand for home hospice services is higher than ever, particularly as the health system capacity challenges continue to ebb and flow. Leaders have become more nimble than ever.”
Seniors represent a high majority of the hospice patient population. Hospice utilization among Medicare decedents rose to exceed 50% for the first time during 2018, according to the U.S. Centers for Medicare & Medicaid Services (CMS). Though hospice generates cost savings by reducing hospitalizations, rising utilization means that Medicare is paying more for hospice care, to the tune of an additional $1 billion annually.
Consequently, the agency and other regulators have kept a closer eye on the industry. The increased regulatory scrutiny has many hospices seeking a seat at the table in discussions of public policy and government-led payment systems.
Providers will need to give a voice to the values of hospice care, according to Susan Ponder-Stansel, president & CEO of Florida-based Alivia Care, speaking at the recent National Association for Home Care & Hospice’s Financial Management Conference in Chicago.
“If we really believe the work that we do in hospice really changes lives because it impacts the way people leave this world, then we want to get out there to the extent we can in the current regulatory environment and really be as open as possible,” said Ponder-Stansel. “All of us really need to skate where the puck is going, because it’s toward high-need and high-cost care. I encourage us all to ask how we are being a guide in a health system that is very fragmented, because we know how to do that kind of care.”
Hospice organizations are under increasing legal and regulatory scrutiny related to medical necessity complaints under the False Claims Act and the closely related anti-kickback statute. Documentation errors and omissions, live discharges and lengths of stay beyond six months are the main red flags that could bring regulators to a hospice’s doorstep.
In its Fiscal Year 2022 proposed rule for payments to home health agencies, CMS signaled its intentions to revamp the hospice survey enforcement process. While the rule in its current form is a proposal rather than final, CMS has limited flexibility on the scope of changes they can make. Congress mandated many of these provisions in the Consolidated Appropriations Act of 2021. Legislators added the hospice language in response to July 2019 reports on hospice quality from the Office of the Inspector General (OIG) at the Department of Health and Human Services (HHS).
These actions come on top of changes to the CMS Conditions of Participation for hospices; some of which the industry welcomed, such as making permanent a waiver related to aide competency evaluation standards.
Engaging with national and state legislators will be key for hospices to have a voice and influence policy changes in an evolving regulatory health care landscape, according to Brent Korte, Evergreen’s chief home care officer.
“We all have the ability to influence policy. Meeting the very basic needs of patients is the bread and butter that we have to focus on in the future,” said Korte during the conference. “Our staff at Evergreen has knocked on the doors of constituents, and it is a super powerful tool that has actually helped provide us the ability to reach out and be a link.”
On the legislative front, hospices are watching a number of bills that the Congress. In the Senate, a bipartisan group of lawmakers have proposed legislation that would establish a community-based palliative care benefit. This has been a long-term goal for the hospice community.
Federal lawmakers are also wrestling with questions of whether to resume Medicare sequestration, which reduces health care provider payments by 2% across the board. CMS temporarily suspended the practice during the COVID-19 public emergency. Legislative efforts to bolster the direct care workforce are also underway, in addition to exploration of which of the temporary telehealth flexibilities instituted during the pandemic could be made permanent.
Hospices can help shape some of these initiatives through stronger ties to their congressional delegations, according to Beth Slepian, president & CEO of Granite VNA, an organization that formed earlier this year through the merger of two New Hampshire providers. The organization offers hospice, home health care, palliative care, home-based pediatrics and personal care services.
“We have a great relationship with our delegation,” said Slepian. “There are misunderstandings that we providers don’t make a difference, but you can’t underestimate what those relationships can do as we move forward with initiatives and implementation [in health care].”
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