Abt Associates submitted the Hospice Care Index Technical Report to the Centers for Medicare & Medicaid Services. The report provides context and descriptive analyses for the Hospice Care Index (HCI). The HCI is a new quality measure for the Hospice Quality Reporting Program (HQRP) that will be publicly reported on Care Compare in August 2022. The measure was added to the HQRP in 2022 and is a single measure comprising ten indicators calculated from Medicare claims.

The ten claims-based indicators comprising the HCI are shown below.

Hospices have had concerns about the indicators seemingly focusing more on program integrity issues than quality of care.  CMS repeats in this report what it has said in the past – that the HCI provides a broad overview of hospice care quality. CMS further explains that each indicator in the index represents a particular care practice of concern, as identified by CMS’ information gathering activities and that the HCI was developed to fill several identified information gaps:

• Provision of Higher Levels of Hospice Services:

CMS requires hospices be able to provide both continuous home care (CHC) and general inpatient care (GIP) to manage more intense symptom crises. However, around a quarter of all programs do not provide GIP services each year, and it is unclear if patients in crisis received appropriate care (a similar concern exists regarding the CHC level of care.)

• Visits by Professional Hospice Staff:

Medicare Conditions of Participation (CoPs) require the hospice interdisciplinary team to ensure on-going patient and caregiver assessment, plan of care implementation, and 24/7 availability of hospice services. Additionally, the end of life is typically the period in the terminal illness trajectory with the highest symptom burden, necessitating close care and attention from hospice staff.

• Patterns of Hospice Live Discharges and Transitions:

Providers are expected to have some live discharges, but rates that are substantially higher than other hospices could signal a potential problem such as poor care quality, poor program integrity, failing to meet patients’ or families’ needs, or admitting patients who do not meet  eligibility criteria. Atypical transition patterns suggest problems in hospices’ care processes, advance care planning to prevent hospitalizations, or discharge processes. Revocations may also be related to business practices or quality of care.

• Medicare Spending:

CMS currently reports per-beneficiary spending estimates for other care settings. Half of hospice expenditures are for patients that have had at least 180 or more days on hospice, raising concerns that some programs do not appropriately discharge ineligible patients, enroll patients with longer predicted lengths of stay in hospice, or inappropriately bill for highlevel, higher-rate services such as GIP.

Per CMS, the indicators represent a hospice’s ability to address patients’ needs, best practices hospices should observe, and/or care outcomes that matter to consumers. Each HCI indicator has its own numerator, denominator, and resulting indicator score. A hospice earns a point each time it meets the threshold for an indicator. Hospices’ HCI scores are calculated as the total number of earned points across the ten indicators and can range from a perfect 10 to a 0.  Index Earned Point Criteria were set based on CMS’ statistical analysis of national hospice performance to ensure meaningful distinction between hospices. It is only the Index score that will be publicly reported in August, but hospices can see their performance compared to norms in the Provider Preview Reports available in their CASPER folders.

For this recently released technical report, 100 percent of Medicare Fee-For-Service (FFS) claims data from eight quarters across calendar years 2019 through 2021 were used by CMS to calculate scores for the ten indicators and the overall index to assess the HCI against National Quality Forum (NQF) performance standards for validity and variability. Nationally, the average HCI score is 8.8, with 37.9 percent of hospices receiving a score of 10. No hospice scored a two or below. The report states that the  range of scores indicates sufficient potential to differentiate hospice performance which is one of CMS’ goals for quality measures.

In general, HCI scores were higher on average among larger hospices, older hospices, non-profit hospices, and facility-based hospices. Scores were also higher on average among hospices in northern states. There was not a strong difference in average HCI scores between hospices in urban and rural areas. CMS found a correlation between a higher HCI score and a higher percentage of caregivers reporting that they would recommend the hospice (through the CAHPS® Hospice Survey).  The report provides details of the correlation between indicators, the likelihood of HCI indicators for which hospices failed to achieve points and the HCI indicators’ relationships to CAHPS® Hospice outcome scores.  The report also provides details about the design and structure of the HCI including the rationale for the indicators and a scoring explanation.