Interim Healthcare CEO Jennifer Sheets: CMS, OIG Should Want Longer Hospice Stays

When Interim HealthCare and Caring Brands International CEO Jennifer Sheets speaks about hospice length of stay, it “strikes a nerve.”

A disconnect exists between the ways providers perceive hospice lengths of stay and the views of regulators. Generally, providers point out the research showing that stays of six months or longer correlate with improved patient outcomes, as well as a recent study showing an annual $3.5 billion in cost savings.

But government agencies and their contractors tend to see longer stays as potential indicators of fraud or abuse, including the U.S. Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services Office of the Inspector General (OIG).

“That is a big miss on the part of CMS and the government,” Sheets told Hospice News. “We should want to see an increase in lengths of stay on the benefit.”

Interim Healthcare is a subsidiary of Caring Brands International (CBI). The franchise company offers a continuum of care in the home, including home health, senior care, hospice, palliative care, pediatric care and health care staffing services. The company’s footprint includes more than 330 locations in the United States and internationally.

The private equity firm Wellspring Capital Management acquired CBI in 2021 for an undisclosed amount.

Hospice News spoke with Sheets about the issues around lengths of stay, the 2024 proposed hospice rule and how to define a “good” hospice.

I’m sure that you saw the hospice proposed rule for 2024. What were your big takeaways?

With any proposed rule, we have to make sure that we’re looking at the whole picture, not a couple of states where there may be some concerning trends popping up.

We really have to advocate against any reduction in annual payment now or going forward. But we also have to think about really pushing for expanding that length of stay, which is something else that’s on the table. Because in reality, if you look at the current stats and the data, it very much shows that even with long lengths of stay patients have better outcomes with reduced costs to the overall health care system.

I agree completely with the idea of standardized compliance and quality measures. My hope is that CMS will work with providers to see what “good” should look like.

We’re doing a lot of work, and [the National Hospice and Palliative Organization (NHPCO)] and the [National Association for Home Care & Hospice (NAHC)] are as well, on helping define exactly what those should be.

I think the idea of expanding telehealth for certification is going to be wonderful. But I also think we need to stop expanding it a year at a time. It’s really hard to plan when you have no idea what the future is going to look like beyond a short period of time. I think that should just become permanent. It’s already used in almost every other care setting.

Can you say a little more about the work that Interim is doing to define “good care”?

When you think about the quality of care, there are a few things that we should be looking at. Obviously, it’s around symptom management; it’s around comfort; it’s around support. That’s always been a big part of the philosophy and the measurement of hospice  — but it goes beyond that.

It goes to measuring the length of stay. So many people do not receive hospice nearly long enough. So how can we start measuring it in a way that’s similar to what we do on home health with timely initiation of care?

Transitioning patients to hospice at the right time makes all the difference in the world, and we have to figure out how we do that.

I think we also have to think about some kind of an [Alternative Dispute Resolution (ADR)]. So if there is a deficiency noted, just like in every other setting, there’s an ability to speak with the regulator to say, “Hey, here’s something you missed. This is why this patient needed hospice services.”

Hospice really hasn’t had any major changes to some of the regulations or quality standards since the 80s. So we’re long overdue. I think we have to think about, again, how we look at lengths of stay, transitioning patients on time, allowing them to get the full benefit and ensuring that hospices are providing that support for families, for example.

That’s a big differentiator for that benefit that the family has  — that extra 13 months of service, and not all hospices are doing that. So we need to make sure they’re actually providing that service.

I think we need to monitor hospices’ ability to fluctuate between routine home care and a more inpatient level of service so that we are managing those symptoms, and of course, readmissions, trips to the ER, all of those kinds of things.

That’s a lot of the work that we’re doing, focused on what “good” looks like. It’s more about the experience and the care that’s provided, whether the care needs to be personalized, needs to be innovative or needs to be delivering better outcomes.

We need to be able to show that we’re doing those things and then be able to educate the referral sources of future patients and seniors on what that means.

It’s interesting that length of stay comes up when you talk about how we define good care, considering that those long stays are considered red flags for regulators. How do you bridge that kind of disconnect between quality as it’s defined by the provider in terms of patient outcomes versus it’s perceived by these other stakeholders?

Here’s the reality: The value of hospice is really undisputed, or it for darn sure should be. Hospice improves the quality of care and quality of life for patients, especially as you think about people that are entering that last phase of life.

All the research out there shows that hospice admissions in the last six months of life not only kind of correlate with increases in patient satisfaction, better symptom control, fewer hospital days, fewer deaths in the hospital, all of those great things. That’s why I want to focus on the outcomes rather than on that six-month magic number because you say this is when the benefit stops

If you look at the last year of life just for Medicare, the total cost of Medicare beneficiaries was somewhere around $3.5 billion less if they used hospice compared to those that did not. If they stayed on a year or longer, it’s still more than a 3% reduction in cost. That should be a positive thing,

The hospice benefit, in my opinion, is one of the rare phenomena in our health care delivery system. Because you get a benefit that is bundled, that supports the patient and family, which no other benefit really does. There’s a lot of support for families in the hospice benefit.

But it also produces significant savings by avoiding unwanted and burdensome treatments during the last phase of a person’s life. So when you think about things like the length of stay, and the penalties around that, for me, that’s a really big sticking point.

Even if a patient is on service for longer than 190 days, the spending is still lower. They have a better quality of life. They’re surrounded by their families.

The other metric we really need to focus on is the opposite side of that. When you look at the need for eligible patients to enroll earlier in hospice, it’s huge. More than a quarter of the folks that are enrolled receive care for only one week. It’s not near long enough to take advantage of all that hospice offers.

Regarding the proposed 2.8% rate increase for next year, Is there an extra layer of complexity for a company like Interim that uses that franchise model, in light of the geographic adjustments?

In general, when you think about the right adjustments for large companies, even the increase is nowhere near what’s needed.

When you think about things like the fact that on average folks in our sector are seeing about an 8% increase in the cost of labor, to keep their current labor and to recruit. That’s huge.

Recruiting costs are through the roof, as are things like mileage rates. Especially in hospice, mileage rates that are going from 55 cents to 63 cents, for example, that’s millions of dollars for large organizations. It can be crippling.

We appreciate rate increases. But until they start really taking into account the cost of care, it’s still disproportionate.

We’re talking about hospice here, but when you think about the home health side of the world, they’re looking at the largest cut in the history of the benefit right now. And so when you think about companies that provide both home health and hospice services, which is often the case, you’re getting punched in the face on one side and a little bit of an increase on the other.

How is the relationship shaping up between Interim, CBI and Wellspring since the acquisition? How’s that integration going?

The thing I most appreciate about Wellspring as our current PE partner is that they have experience in the health care space.

There’s a lot of private equity coming into our space because it is expanding in such a way, so it’s beneficial when your PE partner comes with experience in regulated environments and complex environments.

Every business has complexities, but a business like ours — where it’s not about a widget or it’s not about how good your food is, for example — it’s truly about impacting a person’s life. Having somebody coming in with that knowledge is just as tremendously beneficial.