CMS’ Proposed Technique of Deciding on SFP Hospices Might Be Flawed

Whereas the hospice group has usually embraced the idea of a Particular Focus Program (SFP) to handle high quality considerations, some are troubled by the federal government’ methodology for figuring out suppliers.

The U.S. Facilities for Medicare & Medicaid Companies (CMS) plans to launch this system in 2024, based on language included within the company’s proposed residence well being rule for 2024. A chief concern is the algorithm that the company has determined to make use of to pick out suppliers for this system.

The algorithm relies on quite a few high quality indicators, together with the Hospice Care Index (HCI) rating, complaints to CMS a few supplier, survey outcomes and Client Evaluation of Healthcare Suppliers and Methods (CAHPS) scores. Based mostly on these metrics, CMS will choose these within the lowest 10% for the SFP.


Algorithm knowledge doubtless incomplete

Gaps in these knowledge might imply that some suppliers might slip by way of the cracks, based on Larry Atkins, chief coverage officer for the Nationwide Partnership for Healthcare and Hospice Innovation (NPHI).

“The basic downside is that a big portion of hospices don’t report CAHPS knowledge, and solely a 3rd of them report star rankings from the CAHPS knowledge. A few quarter of them don’t report HCI knowledge,” Atkins instructed Hospice Information. “Plenty of hospices aren’t going to have the standard knowledge. And for these hospices, [CMS] simply usually assumes that they’re working at in regards to the common stage, which suggests they gained’t be chosen.”

Additional, this technique might skew this system in favor of enormous hospices who report a bigger breadth of knowledge, based on Ethan McChesney, coverage director at NPHI.


It might additionally imply that some suppliers who’re doing a “respectable” job could land within the SFP, ending up in that backside 10% as a result of poorer performers weren’t included within the knowledge, McChesney stated.

Quite a lot of hospice business organizations have raised considerations in regards to the algorithm, whereas voicing assist for the SFP itself.

“LeadingAge is broadly supportive of the concept of [an SFP]. Concentrating on low-performing hospices for elevated oversight through a particular program is sensible and is aligned with our total ideas on desirous to assist high-quality hospice …,” LeadingAge indicated in public feedback on the proposed residence well being rule. “Our members are involved that the algorithm, as proposed, wouldn’t obtain the objective of focusing on the poorest-performing applications.”

This was a standard theme amongst advocacy teams’ feedback on the proposed rule, together with LeadingAge, NPHI, the Nationwide Affiliation for Well being & Hospice and the Nationwide Hospice and Palliative Care Group (NHPCO).

These 4 organizations in August penned a joint letter to CMS, calling on the company to delay this system and supply time to work out a unique type of algorithm. NHPI, LeadingAge, NAHC and NHPCO have been collaborating extra carefully this 12 months to handle high quality points and fight fraud within the area.

“We assist a Particular Focus Program that’s successfully tailor-made to establish and assist poor performing hospices, however actually there’s a hazard of instantly implementing a program with a flawed methodology,” Patrick Harrison, senior director of regulatory and compliance for NHPCO, instructed Hospice Information. “That variable could create crimson herrings and fail to actually establish those that aren’t offering care at a stage they need to be.”

Potential repercussions for hospices

CMS indicated within the proposed rule that 5,943 hospices could be eligible to take part within the SFP and that the company would choose suppliers from the bottom 10% of performers based mostly on high quality knowledge, survey outcomes and different components.

This system was among the many necessities established by the Consolidated Appropriations Act of 2021.

Congress included the hospice language in response to July 2019 experiences on hospice high quality from the Workplace of the Inspector Common (OIG) within the U.S. Division of Well being and Human Companies (HHS). CMS expects that implementing these proposals would value an estimated $5.5 million yearly.

If designed equally to these utilized in different settings, the SFP would have the ability to impose enforcement cures in opposition to hospices with poor efficiency on regulatory or accreditation surveys. Hospices flagged by the SFP could be surveyed each six months slightly than the present three-year cycle.

This system would have the authority to impose fines, droop reimbursement, appoint non permanent administration to deliver the hospice into compliance or revoke a supplier’s Medicare certification altogether.

“The implications of being chosen for the SFP are extreme, which is why the choice standards have to be designed to establish the subset of hospices which can be really the poorest performers and most in want of remediation to handle high quality considerations,” NAHC indicated in its feedback on the rule. “An interim efficiency interval (or preview interval) would assist suppliers perceive the algorithm, find out how their efficiency compares to others nationally, and establish the place they should goal enhancements to make sure high-quality care.”

CMS initially pitched the concept for 2022 however as an alternative convened a Technical Knowledgeable Panel (TEP) to additional information the event course of. The TEP accomplished its work late final 12 months, and now, per the 2024 proposed residence well being rule, the company desires to maneuver forward with it subsequent 12 months.

No changes for affected person census

One other key concern in regards to the SFP is that, as proposed, condition-level deficiencies and substantiated complaints wouldn’t be scaled to account for the variety of beneficiaries {that a} hospice serves.

This conflicts with suggestions from the TEP, which might have scaled these deficiencies and complaints per 100 Medicare beneficiaries.

“There are some important deviations [from the TEP recommendations]. For instance, after we discuss survey knowledge and deficiencies, there was an understanding that after we take a look at how these knowledge could be calculated, or how deficiencies would rely in opposition to the hospice, this might be scaled in based on the scale of the hospice,” Harrison stated. “The priority here’s a senior CMS deviated from that individual strategy and this rule, which means {that a} hospice company with a affected person census of 500 with a condition-level deficiency would primarily get the identical rating as a hospice with a census of fifty.”

Along with calling for a delay, the 4 business organizations additionally really helpful that CMS conduct a nationwide pilot to check the SFP methodology.

Through the pilot interval, SFP outcomes wouldn’t be posted publicly and suppliers would obtain interim experiences on their efficiency underneath this system’s designated metrics.

“We’re not asking for a delay simply to delay,” Logan Hoover, vp of coverage and authorities relations at NHPCO, instructed Hospice Information. “We’re actually asking CMS to take the time wanted to craft a superb functioning method, to work with the TPE and produce a fruitful algorithm.”

Backlog of uncompleted surveys

One other main concern is that CMS has an in depth backlog of hospices which can be lengthy overdue for a recertification or accreditation survey, based on the company’s High quality and Certification Oversight Studies (QCOR). Surveys would supply key parts of the info for use within the proposed algorithm.

At present, QCOR experiences present that 35.1% of the nation’s 7,152 lively Medicare-certified hospices are overdue for a recertification survey. The CMS web site reveals that “hospice supplier and survey info will solely be correct and full by way of September 29. 2022,” NHPCO indicated in its public feedback on the rule.

“If we’re going to be utilizing surveys as a characteristic of the algorithm as an enter, however we’re solely wanting on the final 36 months, it doesn’t fairly work if a 3rd of your inhabitants doesn’t have an up-to-date survey,” Hoover stated. “That’s completely one thing that CMS can enhance upon.”