Am I a party pooper? A Debbie Downer? You can decide, but I don't think the hospice provisions in the Impact Act of 2014 are going to do much to increase transparency, sort out the "good" hospices from the "bad," or, sadly, improve the quality of care provided by hospices. Let me explain...
My focus is on two hospice provisions in H.R. 4994, the Improving Medicare Post Acute Care Transformation (IMPACT) Act of 2014:
- For the next ten years, hospices will be surveyed no less frequently than every three years;
- There will be medical reviews of hospices that have a yet-to-be determined percentage of patients with a length of stay longer than 180 days.
These provisions, interestingly, represent the two types of hospice scrutiny:
- Medicare certification and complaint surveys for compliance with the Medicare Conditions of Participation (CoPs) in Subparts C and D of the hospice regulations. The focus of these surveys is on patient health and safety and quality of care; and
- Payment-related scrutiny dealing primarily with Subpart B of the hospice regulations. The focus of these audits is initial and continued eligibility for hospice care and higher levels of care, related/not related issues, potential fraud and abuse, etc.
Let's consider each of these types of scrutiny separately and look at how the IMPACT Act will and will not affect them.
Survey & Certification Scrutiny (CoPs Compliance)
This first type of scrutiny has been sorely lacking in the hospice industry due to budgetary cuts as well as a lack of a statutory mandate for hospice survey frequency (as has existed for home health agencies and skilled nursing facilities). This has resulted in hospices being the lowest priority for survey and certification surveys for many years. Hospices can go more than 10 years without ever being surveyed. The Office of Inspector General (OIG) expressed its concern about this in a 2007 report regarding the inadequacies of CMS oversight of hospices. NHPCO and NAHC have both advocated for years for more frequent surveys.
But let's step back. It has not been that terrible. Complaint surveys have continued so there has been a mechanism in place to deal with quality of care when issues surface to the level of complaints. Though clearly less than ideal, surveys have occurred. In addition, CMS has required that those 5% of providers at most risk for performing badly be surveyed each year. Again, not ideal, but another mechanism in place to try to deal with the need for oversight within significant budgetary constraints. And there have been enough surveys to generate CMS' annual list of top ten survey deficiencies, which is virtually the same every year.
But here is the heart of my argument. There are three national accrediting organizations that have deeming authority for hospices: the Joint Commission, CHAP, and ACHC. To be awarded deeming authority, each of these organizations has gone through an arduous and ongoing process to demonstrate to CMS that their standards meet and/or exceed the Medicare Conditions of Participation for hospices. It is believed that hospices that undergo voluntary accreditation are demonstrating their commitment to quality care and high standards. Hospices that are accredited by these organizations may be deemed in compliance with Medicare regulations and must be surveyed every 3 years in order to maintain their accreditation. It is difficult to find exact numbers but some estimate as many as 1 in 4 hospice locations are accredited by one of the three accrediting organizations. Or, to perhaps illustrate my point more poignantly, many of the hospices mentioned by Peter Whoriskey in his Washington Post articles skewering hospices are accredited. For example, in his excruciating article entitled Terminal Neglect? How some hospices treat dying patients he cites the following hospices:
LifePath Hospice - accused of not providing continuous care when it was warranted. LifePath is accredited by the Joint Commission.
Access Hospice Care - accused of not providing documented nursing visits for patients in pain/near death and failing to provide any continuous care in 2011 or 2012. Access Hospice Care is accredited by the Joint Commission.
Mar Vista Hospice - accused of failing to provide a visit or pain management when a patient needed it. Mar Vista Hospice is accredited by the Joint Commission.
Heartland Hospice/HCR ManorCare - a branch in Santa Rosa did not provide any GIP or continuous care. Heartland/HCR ManorCare (all branches) is accredited by CHAP.
Clarity Hospice - accused of not providing any continuous care or GIP during 2012. Clarity Hospice is accredited by CHAP.
In other articles, Whoriskey criticizes Aseracare Hospice (accredited by CHAP) and VITAS (accredited by the Joint Commission). In addition, Optum, formerly known as Evercare has been in the hospice fraud news lately and Optum is accredited by CHAP.
So what are we to make of this? By virtue of their accreditation, all of the hospices mentioned above that have been in the "hospice bad news" recently have, in fact, been surveyed every three years. If none of them were accredited I might be more inclined to believe that the problems cited were due to infrequent surveys or could be solved by increased oversight. The fact that most of these hospices ARE accredited confirms my contention that the IMPACT Act's provision to increase the frequency of hospice surveys to at least every three years is not likely to make that much of a difference. An increase in the frequency of surveys for all hospices, accredited or not, is most likely a good thing. However, it is not the solution to the many problems and issues raised in the Washington Post articles.
Let's move on to payment-related scrutiny.
The second hospice provision of the Impact Act, requiring medical review of hospices with a soon-to-be-determined percentage of long length of stay patients, strikes me as more or less what hospices are already dealing with - in spades. For at least the past 5 years, hospices have faced an unprecedented level of payment scrutiny from the alphabet soup of Medicare contractors - particularly MACs and ZPICs.
Payment-related scrutiny has to do with Subpart B of the hospice regulations (as opposed to the CoPs in Subparts C & D) with the focus on eligibility, election, levels of care, discharge etc. The primary focus of payment scrutiny and the primary risk area for hospices is patient eligibility for admission to hospice care, eligibility for recertification and eligibility for higher levels of care. Medicare contractor auditing is a pay and chase system that is extremely arduous, expensive and tedious for everyone involved. It is hard to imagine that adding yet another type of Medicare contractor audit is going to make any difference other than increase the burdens of hospices already trying to survive the intense financial and operational havoc caused by current levels of hospice payment scrutiny. It remains to be seen who the audits will be assigned to - which Medicare contractor (oh, so many choices!).
There is nothing really new about this "new" medical review in the IMPACT Act. It will still be about the quality of documentation regarding patient eligibility. Yes, it may be more targeted with a focus on hospices that meet or exceed the determined threshold of patients with long lengths of stay. Perhaps hospices will have a greater incentive to keep their numbers of long length of stay patients below that threshold. Will that contribute to improved quality of care? Not likely.
So there you have it. Is the Impact Act a good thing? Sure. It certainly can't hurt. But it is not a silver bullet, a panacea. To think that these provisions are just what hospices need to turn the recent tide of negative public opinion and attention around and solve the quality of care problems our industry faces is naive and simplistic. My wish, which hopefully is not naive and simplistic too, is that we will see the IMPACT Act as only one tiny baby step in the direction of engaging in a thoughtful, non-defensive, conversation about what is happening to hospice care in the United States and what we need to do to rebuild public trust in the quality of care provided by hospices.
Posted by Heather P. Wilson, PhD CEO, Weatherbee Resources, Inc.
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