Small Hospices at a Disadvantage in Medicare Star Ratings

The U.S Centers for Medicare & Medicaid Services’ (CMS) star ratings system for hospice quality may have unintended consequences for small providers.

CMS began posting star ratings for hospices on its Care Compare website last month. With new quality measurement methodologies still in the works or in the early days of implementation, Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results are currently the key indicator informing those ratings.

Other methodologies are in development or in the eary stages of implementation, including the Hospice Care Index and the forthcoming Hospice Outcomes & Patient Evaluation (HOPE)


For now, however, the reliance on CAHPS data puts some hospices at a disadvantage, according to Katy Barnett, director of home care and hospice operations and policy at LeadingAge.

“One of the issues that we find within our provider membership with the CAHPS survey is that you can get an exemption for having fewer than 50 participants in your program. It’s a relatively low number,” Barnett told Hospice News. “So when folks go to the CMS website that’s supposed to help you figure out what hospice is right for your loved one, that can give them this perception that maybe their quality is not as high when the reality is they just have a small population.”

CAHPS survey ratings are among the most important sources of hospice quality data. CMS requires that hospices send the survey to families following a patient’s death to gauge their satisfaction with the services they’ve received, which the agency uses to determine a provider’s star rating.


CMS plans to update publicly reported CAHPS scores quarterly, and the star ratings themselves, every other quarter. These metrics will be a key consideration, not only for patients, but for payers also and referral partners as they select hospices to work with. Performance data will also be a priority for investors in the space as they evaluate potential partnerships or acquisitions.

When a hospice has a small patient census, mathematically, one “bad review” can significantly affect the results that get reported.

Pennsylvania-based Clarion Forest VNA cares for patients in remote rural areas in two counties in their home state. The organization’s average daily census ranges from 25 to 30 patients most of the time, and clinicians often travel as much as 80 miles in a day for home visits.

Currently, the organization has a rating of 4-out-of-5 stars on Care Compare.

“With a lower census, a single survey response can skew my data really bad. It’s not fair, to be honest with you,” Clarion Forest VNA CEO Lisa Steiner told Hospice News. “In our quality assessment and performance improvement meetings, I will pull up our data analytics from our [CAHPS] vendor. We will drill down to what patients said about us. We’re constantly looking at quality, because if there is one bad survey, we have to fix that problem or our data will be skewed.”

As Barnett said, providers with a patient census lower than 50 can request an exemption from the CAHPS survey requirement. While they are not officially penalized for this by CMS, the end result is that they have no star rating. 

Unless they are among the few members of the general public who understand the nuts and bolts of quality measurement, this could lead stakeholders to assume that zero stars means that hospice provides substandard care.

CMS adds a footnote to those agencies’ Care Compare pages to explain why they have no star rating.

“But that’s open to interpretation, again, by the consumer. That’s one of the barriers that we see in small hospices really using the survey to showcase their quality of care,” Barnett said. “If you’re a consumer looking at what hospice you should choose, you might see that five-star rating and assume that that’s the highest quality and go to that one, not knowing the difference between being rated or unrated.”

Another problem in the hospice space that can impact CAHPS scores is that of patients coming to hospice too late to truly reap all the benefits of the service.

Nearly 54% Medicare decedents received hospice care for 30 days or less in 2018, according to the National Hospice and Palliative Care Organization (NHPCO). About 28% percent of those beneficiaries were in hospice for seven days or less.

The short duration of care in those instances limits families’ opportunities to interact with hospice teams, making it difficult to evaluate their experiences with the provider.

“The biggest challenge is that we’re getting these hospice referrals late, and you’re trying to cram a lot of teaching in to a short amount of time,” Steiner told Hospice News. “That’s the big concern I have with CAHPS and the star ratings. Look at the percentage of how long you have a patient — that is huge for this CAHPS rating.”

Companies featured in this article: