2024 Final Rule May Signal Changes in CMS’ Approach to Hospice Quality

Both innovative opportunities and cost challenges underly quality and health equity components of the U.S. Centers for Medicare & Medicaid Services’ (CMS) recently finalized hospice payment rule.

The final rule included some key updates — and raised important questions — in the agency’s planned changes to quality measures and data collection, including those related to health equity.

The focus on gathering data to both measure and understand gaps in access and quality signal an increased drive toward reducing disparities in end-of-life care — a goal regulators and hospice providers can agree upon, according to Ben Marcantonio, COO and interim CEO of the National Hospice and Palliative Care Organization (NHPCO).


The concern, however, is that hospices lack the financial support and incentives needed to bridge barriers, with reimbursement a main point of contention, he said. The 3.1% base rate increase included in the final rule is insufficient to support the necessary investments in staffing and programs to reach underserved communities, Marcantonio said.

“These updates underscore the importance of hospice program integrity and access to care,” Marcantonio told Hospice News. “Providers should be submitting all the quality data that helps inform and improve quality of care for patients and families. Providing more equitable access to underserved communities is becoming an area of focus for quality measures. But the ability to do that without the right amount of resources is the concern. A 3.1% increase is not going to be enough to help hospices meet that need and do that well.”

Rural patients are at particular risk when hospice reimbursement rates lag behind the rising clinical costs, according to Frontpoint Health CEO Brent Korte.


In some cases, reimbursement pressures have led to a halt of end-of-life, community-based services in certain regional pockets of the country, he said at the NAHC Financial Management Conference in New Orleans.

“We’re going to continue to be under mounting pressure to address those access issues,” Korte said. “Thinking about home health [and hospice] deserts, it’s a tragic thing to imagine that people wouldn’t have access. It is possible that there’s an opportunity that at some point payers are going to realize that there’s a huge impact to us not being able to provide care.”

Penalties go up for HQRP noncompliance

One significant change was the agency’s decision to increase penalties for hospices that do not report data to the Hospice Quality Reporting Program (HQRP). Going forward, those providers will face a 4% payment reduction, up from 2%, CMS stipulated in the rule.

To be in compliance, hospices must submit their data within a specified timeframe. CMS requires providers to submit at least 90% of their records and data for the Hospice Item Set within 30 days of the patient’s admission or discharge, or other applicable deadlines.

CMS estimates that, based on historical performance trends, around 18.4% of hospices will incur these reductions, the agency indicated in the final rule language.

“Setting an expectation for quality data to be submitted is not necessarily something we’re opposed to, being a 4% penalty for those that don’t,” Marcantonio said. “What we would like to see is maybe some incentive alongside that for those providers that do it and do it effectively as well. It is [also] really important that quality data is collected so that patients and families can make informed choices about their care.”

The intent of the HQRP, and the penalties for noncompliance, is to allow for increased transparency around the quality of end-of-life care that patients receive, according to CMS.

Imposing higher penalties could put further strain on some hospices struggling to remain afloat during tough financial times, according to Theresa Forster, vice president for hospice policy, National Association for Home Care & Hospice (NAHC)

Care delivery costs have risen alongside inflation, wage hikes and increased clinician travel expenses, among others. Concerns are mounting among hospices that the 3.1% pay raise won’t be enough to support care amid these financial pressures, she said.

Some hospices have indicated that they’ve experienced “substantial administrative challenges” related to the quality reporting requirements, according to Forster.

“Specifically, [hospices] have concerns about recording claims alongside audit notices, delayed payments and other oversight requirements,” Forster said during the NAHC conference. “From a quality aspect, to the extent to which [hospices] are incentivized to have good quality scores that connect to delivery of services – that invokes an open-ended question of ‘how’ right now. I think that’s what is going to really matter, ultimately.”

Measuring health equity remains a challenge

For several years, CMS has linked health equity to quality, though specific measures or data collection requirements are still in development.

In 2022, CMS convened a technical expert panel (TEP) on health equity to provide additional input that will be used to inform the development of health equity quality measures. The panel released its report in May.

The proposed version of the 2024 rule contained several requests for information from providers, which included questions on potential health equity measures. The agency sought data around factors that hospice providers included when identifying underserved populations, such as data around geographic location, sociodemographics, social determinants of health, race, ethnicity and primary language spoken.

CMS received 20 comments in response, many of which described barriers and challenges associated with collecting data on health equity and social determinants. These included patient resistance, difficulties in recording social determinants in electronic medical records (EMR), limited resources to support these activities and a lack of specificity in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) questionnaires.

Some recommended that CMS develop educational tools about cultural norms to facilitate discussions about hospice care and implement a required, standardized assessment tool that included data on social determinants, including information on health literacy, race, ethnicity and language, sexual orientation and gender identity, among others.

Some of the commenters questioned whether the forthcoming Hospice Outcomes & Patient Evaluation (HOPE) tool will address health equity.

“Some commenters expressed interest in the role HOPE will play in advancing health equity, including voicing support for the collection of social risk data, including social determinants of health (SDOH) data,” the rule language indicated. “One commenter recommended that CMS review [loca coverage determination] guidelines in the context of health equity.”

Integrating more consistent social work engagement among underserved populations is one way hospices can support their health equity efforts and increase access, according to Nicole McCann-Davis, vice president of communications and chief health equity officer at Empassion Health.

“We need to move from awareness to action when it comes to health equity,” McCann-Davis told Hospice News. “This is really going to need to be done in order for us to improve care coordination and address the needs of the whole patient. We know the different experiences [underserved populations] have had to overcome. Integrating consistent social work engagement and knowing that health is about much more than physical needs is something that also could be used to make progress to minimize those disparities.”

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