Facility-Bound Hospice Patients Less Likely to Get SIA Visits

Hospice providers in facility-based settings may be underutilizing Medicare’s service intensity add-on (SIA).

Compared to routine home care, patients receiving the general inpatient level of care (GIP) were 22.8% less likely to have a SIA-applicable visit, according to an analysis by Abt Associates. SIA visits for patients in GIP on average had 67.6 fewer minutes.

These data demonstrate that location matters when it comes to SIA utilization, according to Abt Associates researchers Michael Plotzke, principal associate in health and environment, and T.J. Christian, senior associate.


“Based on these results, we find that institutionalized beneficiaries were less likely to receive SIA services, and even among those that did, received shorter visits,” Christian and Plotzke indicated at the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA) Annual Assembly.

Researchers analyzed 2020 claims data to identify associations between SIA utilization and hospice Medicare beneficiaries’ characteristics such as site of service, level of care and length of stay, among others.

In another example, patients in an inpatient hospital setting are 8.5% less likely to receive a SIA-applicable visit during the last two days of life compared to those in routine home care, the Abt analysis found. Both settings were associated with fewer SIA minutes than occur in the home.


A primary reason for the variances is facility-based patients may be less likely to receive a routine home care visit and may not qualify for SIA visits on the last day of life, Plotzke indicated.

The variances in utilization may also stem from limitations around the SIA’s parameters, according to Plotzke and Christian.

“This [variation] largely occurs because hospices cannot provide SIA when the level of care is not [routine home care],” they said during the assembly.

The U.S. Centers for Medicare & Medicaid Services (CMS) introduced SIA in 2016. It allows hospices to bill on an hourly basis for registered nurse and social worker visits during the last seven days of a patient’s life, in addition to the standard per diem reimbursement. 

Staff can bill for these services for as many as four hours each day in the last week of life.

SIA utilization has risen incrementally since its inception. More than $200 million SIA payments were distributed in 2021, compared to less than $100 million in 2017, according to the Abt research. In terms of patients, that’s more than a million beneficiaries receiving SIA services in 2021, versus under 850,000 beneficiaries in 2017, the data found.

Stakeholders such as LeadingAge have previously called on Congress to eliminate or modify the service intensity add-on, citing “the difficulty of predicting an exact date of death.”

The number of registered nurse and social worker visits during a patient’s final week is one of the seven quality measures that CMS uses to evaluate providers. SIA provides a financial incentive for hospices to improve performance on the measure.

Monitoring SIA utilization allows payers and providers the ability to “better understand whether any patient groups appear to be underserved at the end of life,” Christian and Plotzke stated.

Companies featured in this article:

, , ,