The 2024 final hospice payment rule included a modest payment increase for general inpatient care (GIP) at a time when regulators are zeroing in on increased utilization and longer stays.
The U.S. Centers for Medicare & Medicaid Services (CMS) included in the rule a 1.031% increase to hospice GIP services. Daily rates for general inpatient services were set at $1,145.31, up from FY2023’s rate of $1,110.76.
Alongside the bump in GIP reimbursement, CMS included requests for information (RFIs) around access barriers to these services, pointing towards claims data that reflected underutilization.
The high costs and regulatory risks associated with general inpatient services are two main barriers to increased utilization, according to Mollie Gurian, vice president of home-based and home- and community-based care based policy at LeadingAge.
Regulatory scrutiny has become an increasingly difficult challenge for providers when navaging GIP services amid rising demand, she said.
“CMS in the rule put out all this data that it’s underutilized, but it’s also being cracked down on it very intensely from a program integrity perspective with more auditing activity,” Gurian told Hospice News. “For hospices that provide a substantial amount of inpatient care, it’s part of understanding the business that you expect audits. “
GIP utilization’s regulatory, reimbursement seesaw
GIP is a more medically intense level of hospice intended for patients with symptoms that cannot be managed in the home. The intensity of GIP care often includes higher-cost services such as increased medication management, 24/7 clinical staffing assistance and other operational expenses.
CMS recognized in the rule language that cost was among the barriers to GIP, continuous home care (CHC) and inpatient respite (IRC) noted in public comments the agency received when the rule was proposed.
“We appreciate the comments and suggestions received regarding hospice utilization,” CMS indicated in the final rule. “We acknowledge commenters’ statements and concerns related to the increase in non-hospice spending, barriers associated with the provision of GIP, IRC, CHC and complex palliative procedures under the hospice election, as well as the financial risks associated with providing these services.”
General inpatient care is the second-highest level of care in terms of daily reimbursement rates, according to the U.S. Department of Health & Human Services (HHS) Office of the Inspector General (OIG).
OIG also cited a high incidence of improper billing associated with general inpatient hospice services (GIP).
Roughly one-third of Medicare GIP claims are submitted in error, the OIG reported. Inaccurate billing was among the driving forces behind the OIG’s recently announced nationwide audit of general inpatient hospice services (GIP), the regulatory watchdog stated.
Longer general inpatient hospice stays and the associated costs are reasons for the audit, dubbed the “Audit of Selected, High-Risk Medicare Hospice General Inpatient Services,” the OIG indicated.
The increased regulatory oversight around GIP — alongside the CMS inquiries around addressing barriers to utilization — has left hospice providers with less than a clear path forward on how to balance compliance with patient needs, according to Gurian.
“It’s almost as if two pieces aren’t talking to each other on inpatient care,” Gurian said. “You take on more risk for oversight for providing it, but you don’t get the same force of consequences for not doing this level of patient care. It would be great if there was a little bit more consistency between payment policy encouraging it, paying more for it, and oversight. Because the difference there is really having a chilling effect.”
Length of stay challenges in the hospice benefit structure
Length of stay represents another area of concern in the hospice payment and regulatory realm.
On one hand, longer hospice stays can improve quality outcomes. On the other hand, regulators consider these to be red flags that can lead to audits by Medicare contractors.
This is another point of contention for hospices seeking to reach patients earlier in their health trajectories and improve access while balancing payment and compliance concerns around length of stay, according to Davis Baird, director for government affairs for hospice at the National Association for Home Care & Hospice (NAHC).
“Hospices are frustrated with a hyperfocus from the audit and regulatory side. It’s making it really hard for a lot of folks to operate, which is counterintuitive to the hospice benefit,” Baird said during a recent Congressional briefing. “They are now serving more patients who have unpredictable trajectories, and that’s a real win for the benefit to be serving that diverse community. They might be the ones who have those longer lengths of stay, but they’re still driving quality of life and fiscal benefit to the program, to the community.”
Some providers and organizations are calling for an overhaul to the hospice benefit structure that would include stretching out the six-month prognosis eligibility period. Some voiced similar concerns in responses to CMS’ RFIs in its proposal for the 2024 rule.
Patients and families benefit from longer hospice stays in terms of quality experiences and supportive end-of-life care, while Medicare could reap the benefits of lowered health care costs, according to Gurian.
“Ultimately, savings is accrued from people being on hospice longer, it saves Medicare money in the long run with less hospitalizations and urgent care use,” Gurian told Hospice News. “We would ultimately see those savings accrue by having people on hospice longer with more care coordination.”
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