CMS has publicly stated it is looking closely at the hospice industry due to increasing concerns regarding fraud, waste, and abuse. The Hospice Special Focus Program (SFP) is a new CMS program that identifies poor-performing hospices, takes action to inform the public, and engages those hospices to either improve their performance or terminate the hospice from the Medicare program. The Home Health Proposed Rule, released in June 2023, included two significant hospice topics: the Hospice Informal Dispute Resolution (IDR) and the SFP. Hospice providers may not be aware that this information was published and subsequently finalized in the Calendar Year (CY) 2024 Home Health (HH) Prospective Payment System Rate Update due to the publication of this information outside of the normal cycle for hospice rulemaking. Hospice providers should review and understand this information.
CMS has created a new algorithm for the SFP, which uses hospice survey data and Hospice Quality Reporting Program (HQRP) data. Hospices will receive a single score based on the algorithm, and will be ranked against other hospices to identify those with poorer care quality. The algorithm uses the following data:
- Quality-of-Care Condition Level Deficiencies (CLDs) – Hospices are surveyed for compliance at least every 36 months to assess compliance with the 23 Conditions of Participation (CoPs), of which 11 are identified as directly related to quality of care. The algorithm considers CLD citations of noncompliance with the 11 quality-of-care CoPs occurring in the last three years of in-person hospice surveys.
- Substantiated Complaints – The algorithm considers the total number of substantiated complaints for each hospice based on the last three years of complaint and follow-up survey data.
- Hospice Care Index (HCI) – The HCI is a composite score derived from 10 indicators captured from hospice claims data. The HCI is an existing publicly reported HQRP measure that captures multiple aspects of care delivery.
- Consumer Assessment of Healthcare Providers & Systems (CAHPS) Hospice Survey – The CAHPS data utilized in the algorithm comes from four of the eight measures from the CAHPS Hospice Survey that reflect caregiver-reported experiences in key areas of hospice quality not reflected in claims or inspection surveys. CMS has developed a CAHPS Hospice Survey Index specifically for use in the SFP methodology based on the scores from the following measures:
- Help for pain and symptoms
- Getting timely help
- Willingness to recommend the hospice
- Overall rating of the hospice
Publicly reported CAHPS Hospice Survey data availability for SFP-eligible hospices has been reported to be less than half of the providers. As a result, CMS has generated two different approaches to the algorithm to account for those providers with and without CAHPS Hospice Survey data.
Hospices are eligible and might be selected for the SFP if the following criteria apply:
- The hospice has data from at least one algorithm indicator, including CLDs, substantiated complaints, HCI, or CAHPS Hospice Survey.
- The hospice is listed as an active provider, which is defined as billing at least one claim to Medicare fee-for-service in the last 12 months.
- The hospice operates in the U.S., including U.S. territories and the District of Columbia.
- The hospice is not currently under CMS enforcement action.
- The hospice’s score ranks among the poorest 10% of providers.
The data used in the algorithm is standardized and weighted and then combined into a single score, which is utilized to rank hospices in order of quality-of-care performance. CMS outlines in more detail its approach to preparing the data for use in the SFP algorithm in the CY 2024 HH Prospective Payment System Rate Update.
Below is a table from the SFP User’s Guide for agencies to reference to understand date ranges and exclusion criteria for each data indicator.
| Data Indicator | Source | Date Ranges for Q1 CY2024 | Exclusion Criteria |
|---|---|---|---|
Hospice Care Index (HCI) | Hospice Provider Data Catalog File: Hospice – Provider Data Updated: Annually (November) | November 2023 Refresh Dates Included: January 1, 2021- December 31, 2022 | Less than 8 quarters of data Less than 20 claims over 8 quarters of data |
1/1/2023 | 500 | 1100 | Activity |
2/1/2023 | 1000 | 1100 | Activity |
3/1/2023 | 200 | 1100 | Activity |
Hospice providers selected for the SFP will be a subset of the bottom 10% that will be announced toward the end of CY 2024 and publicly identified in the SFP selection list that CMS will publish. Those selected providers will be subject to surveys every six months for 18-months. The status of providers in the program will be publicly reported in the SFP Status List, which will be published annually and periodically updated with one of these four categories for each provider, which are as follows: 1) still in the program, 2) completed the program, 3) on a termination track, or 4) terminated from the program. Completing the program successfully or terminating from the program are the only two outcomes for hospices available for those in the program.
Hospices should note that if they are in the bottom 10% and not selected for the SFP, they will still be publicly reported in the SFP 10 Percent List published by CMS.
Hospices should take note of the SFP even if they don’t believe they will be in the bottom 10% in order to make sure they are performing strongly in all of these indicators utilized in the selection algorithm. If agencies are concerned that they may fall into the bottom 10%, we recommend that providers prepare for that possibility and start focusing on improvement now to position your organization to successfully complete the program. If you have more questions or would like to engage a professional to learn more about this program or other CMS quality or regulatory initiatives, contact our Home Health and Hospice team at FORVIS.