Hospices Wrangle With ‘Complicated’ Quality Metrics on CMS’ Radar

Regulators are sharpening their focus on several aspects of hospice quality data to help weed out fraud, waste and abuse.

Hospice Quality Reporting Program (HQRP) requirements have seen an overhaul in recent years as the U.S. Centers for Medicare & Medicaid Services (CMS) works to curb malfeasance in the industry. Program integrity concerns have been ignited in part by poor and negligent hospices that bill for services that were never provided or, and in some cases, enroll patients who were not eligible or terminally ill.

Understanding how regulators shape and evaluate data algorithms will play a significant role in hospice compliance. Some of the changes in CMS’ methodologies around quality data collection and analysis can be complex for hospices to navigate, according to Chris Attaya, vice president of product strategy at Strategic Healthcare Programs. The California-based company offers data analytics and performance improvement software.

“Quality programs for hospices really evolved over the last 10 years,” Attaya said at the National Association of Home Care & Hospice (NAHC) Financial Management Conference in Las Vegas. “Quality has been in question, and that’s what triggered some of the things [that] CMS [is] looking at in terms of improving, identifying poor performers. CMS uses different tools to identify where hospices are not performing well … This will continue to evolve. CMS is going to find a way to peel off those poor performing hospices.”

One relatively new data issue is the CMS algorithm for selecting hospices for its Special Focus Program (SFP), according to Attaya.

Designed to identify red flags in a hospice’s quality data, the SFP algorithm examines a wide scope of data, including survey reports with Condition-Level Deficiencies (CLDs), complaints with substantiated allegations, CMS Medicare data sources from the HQRP program, Medicare claims and Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores.

The SFP methodology also incorporates data from the Hospice Care Index (HCI) data, with CMS targeting hospices who fall within the lowest 10% of performers on a range of quality metrics and survey data.

Providers and industry stakeholders alike have called on CMS to reconsider some of the SFP’s methodologies, with some seeing it as deeply flawed.

Understanding the SFP eligibility criteria is challenging enough, let alone digging into the potential pitfalls, Attaya said. Hospices need greater clarity around the overlapping pieces of quality data that CMS uses to determine the lowest quality performers to place on an SFP program, he stated.

“The [SFP] algorithm … it’s pretty complicated,” Attaya said. “There’s a lot of gyrations that [CMS] is going to go through to actually do the calculations to determine a score that would then be matched up to every other hospice to determine who are the lowest performers. There’s a potential problem with the algorithm. That’s a concern. How do we address that? How is CMS going to address it? They really haven’t described yet with the algorithm how hospices will be chosen within the 10%.”

Hospices will need to have a firm understanding of their quality data when determining their potential compliance risks, according to Angela Huff, senior managing consultant at Forvis Mazars, a global accounting and consulting services company.

Four key quality scoring areas on regulators’ radar are pain and symptom management, timely access to care, overall hospice experience and a willingness to recommend the provider, Huff said. Hospices need to consistently examine where they measure up in quality outcomes to gain a leg up on compliance, she indicated.

Data around live discharge and revocation rates, for example, plays a large role in signaling potential risk of malfeasance, according to Huff.

“Live discharges are a big thing,” Huff said. “I would definitely recommend that you look at your live discharge rates and [have] strategies around some of those key areas, such as educating on eligibility. CMS is also asking a lot of questions about those different levels of care [and] any increased frequencies of death. All of those are things you need to be looking at in how they relate to those four areas. It does give us a roadmap to know where to focus first.”