How the Hospice Care Index Can Help Shape an Operator’s Future

Strong performance on the Hospice Care Index is becoming increasingly essential to securing payer and referral contracts and will be a key consideration in the federal government’s forthcoming Special Focus Program (SFP).

The U.S. Centers for Medicare & Medicaid Services (CMS) designed the Hospice Care Index (HCI) to paint a picture of care processes that occur between a patient’s admission and discharge, but as currently designed it may not be an effective measure of quality.

Payers and referral partners are paying closer attention to hospices’ performance on publicly reported quality measures, which as of Fiscal Year 2022 includes the HCI. Each provider receives a single numerical score ranging from zero to 10, based on a set of quality indicators.


Health care consumers are also becoming more aware of these data, Angela Huff, managing consultant for FORVIS, said at the National Hospice and Palliative Care Organization’s Annual Leadership Conference.

“The Hospice Care Index can be a referral driver. As individuals are making selections about care for their patients, more and more they may be talking about different hospices that they were considering,” Huff said. “A lot of times I hear people on their own saying that they looked them up on [Care] Compare.”

To calculate HCI scores, CMS uses claims data to determine whether a hospice has reached certain performance thresholds for each of the 10 indicators. The agency then gives the provider one point for each threshold it meets and adds them to determine the final score. If the hospice achieves five of the 10 thresholds, for instance, it would receive a score of five.


As of June 2022, about a third of hospice agencies have an HCI score of 10, and of those about 82.2% of national provider identifiers (NPIs) fall between eight and 10, according to Trella Health research.

In addition to early live discharges, the indicators include: Continuous Home Care (CHC) or General Inpatient (GIP) Provided, Gaps in Skilled Nursing Visits, Late Live Discharges, Per-beneficiary Medicare Spending, Skilled Nursing Care Minutes per Routine Home Care Day, Skilled Nursing Minutes on Weekends and Visits Near Death.

The HCI also uses two indicators for burdensome transitions. The first is Live Discharges from Hospice Followed by Hospitalization and Subsequent Hospice Readmission. The second indicator is Live Discharges from Hospice Followed by Hospitalization with the Patient Dying in the Hospital.

“[HCI] is one measure, but it’s broken down into 10 different indicators. That being the case, [CMS] has a good chance of getting true data. Collectively, these indicators are going to comprehensively characterize the hospice, rather than looking at one care dimension,” Nanette Minton, senior clinical director of coding services for MAC Legacy, said at the NHPCO conference. “Each indicator affects the single score, and then the hospice receives one point for meeting each criteria for each of the 10 claim-based measures. So they can be from zero to a perfect 10. You definitely do not want to be at that bottom 10%.”

HCI data will be a key component of the algorithm that CMS will use to determine which hospices qualify for the SFP, coming in 2024. CMS plans to target hospices who fall within the lowest 10% of performers on a range of quality metrics and survey data.

CMS finalized the Jan. 1 implementation date in its 2024 home health payment rule, which contained several hospice provisions.

The SFP program will have the authority to impose enforcement remedies against hospices with poor performance based on its algorithm. Hospices flagged by the SFP also will be surveyed every six months rather than the current three-year cycle and could face monetary penalties or expulsion from the Medicare program.

Though the hospice community generally has voiced support for the program, many contend that the agency’s methodology for identifying hospices for the SFP is deeply flawed. Stakeholders, including hospice providers and members of Congress, have called on CMS to postpone the program and revise that algorithm.

But for now, the algorithm will remain as is.

Even beyond the regulatory implications, performance on the HCI can have a profound impact on a provider’s business.

As hospices move towards value-based care, they will need to leverage strong performance on these data in their negotiations with payers. ​​Medicare Advantage plans, for example, look closely at star ratings, quality data and Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores when determining which providers to include in their networks.

“[Hospices] all are competing, actually competing with all the other agencies in the country. And they are looking at that data,” Huff said. “Other payers, as they potentially come into the hospice sector, they too, would use that [data]. Managing your Hospice Care Index can affect your future for potential contracts.”

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