The U.S. Centers for Medicare & Medicaid Services (CMS) designed the Hospice Care Index (HCI) to paint a picture of care processes that occur between a patient’s admission and discharge, but as currently designed it may not be an effective measure of quality.
Payers and referral partners are paying closer attention to hospices’ performance on publicly reported quality measures, which as of Fiscal Year 2022 includes the HCI. Each provider receives a single numerical score ranging from zero to 10, based on a set of quality indicators.
But some stakeholders have called those thresholds into question, arguing that the differentiation among hospices are insufficient for a well-founded comparison, according to Carter Bakkum, senior data analyst for health care insights at Trella Health.
“I think that the core concept [of the HCI] is a really good idea, and it’s something that should definitely be explored,” Bakkum told Hospice News. “But when almost 40% of the hospice agencies have a value of 10, that doesn’t give a lot of nuance. It doesn’t differentiate the best of the best from just somebody who’s mediocre.”
To calculate HCI scores, CMS uses claims data to determine whether a hospice has reached certain performance thresholds for each of the 10 indicators. The agency then gives the provider one point for each threshold it meets and adds them to determine the final score. If the hospice achieves five of the 10 thresholds, for instance, it would receive a score of five.
Currently, about a third of hospice agencies have an HCI score of 10, and of those about 82.2% of national provider identifiers (NPIs) fall between eight and 10, according to Trella Health research.
This lack of differentiation can be particularly tricky for hospices that operate in smaller markets, Bakkum indicated. In Wyoming, for example, 20 out of the 21 hospices in the state have a score of seven or above.
Simply put, the CMS thresholds can make it too easy for providers to gain points.
For the early live discharges, for example, hospices need to be below the 90th percentile to earn a point. They would have to perform better than only the lowest 10% of providers.
This means that a hospice that beat 99% of its competitors would receive the same number of points as a provider that performed better than only 11%.
This makes it difficult to gauge which hospice achieved the desired results more consistently.
“It’s a binary value, and it doesn’t necessarily give a good indication that they were functioning well,” Bakkum said. “If they’re in the 89th percentile, then they get a point even though they were worse than 89% of other hospice agencies.”
The HCI could be more effective if CMS were to use a median or an average to calculate the score, according to Bakkum.
In addition to early live discharges, the indicators include: Continuous Home Care (CHC) or General Inpatient (GIP) Provided, Gaps in Skilled Nursing Visits, Late Live Discharges, Per-beneficiary Medicare Spending, Skilled Nursing Care Minutes per Routine Home Care Day, Skilled Nursing Minutes on Weekends and Visits Near Death.
The HCI also uses two indicators for burdensome transitions. The first is Live Discharges from Hospice Followed by Hospitalization and Subsequent Hospice Readmission. The second indicator is Live Discharges from Hospice Followed by Hospitalization with the Patient Dying in the Hospital.
Providers’ HCI scores will soon be made public on the CMS Care Compare website, along with a number of other quality metrics. This can have a profound impact on a provider’s business.
As hospices move towards value-based care, they will need to leverage strong performance on these data in their negotiations with payers. Medicare Advantage plans, for example, look closely at star ratings, quality data and Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores when determining which providers to include in their networks.
These data are also becoming a key consideration in mergers and acquisitions, with strategic buyers and investors paying close attention to quality metrics when identifying companies to purchase.
Moreover, a rising number of patients and families are using Care Compare when choosing a hospice to care for them.
“Star ratings are not just consumer-facing measures — although that’s how a lot of Medicare Advantage plans use them — they also dictate your revenue,” SCAN Health Plan CEO Dr. Sachin Jain previously told Hospice News. “If you have a large Medicare Advantage book like we do, the change between a four-and-a-half star rating and a four-star rating actually quantifies in the tens of millions of dollars.”
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