Hospice nurse talks with elderly couple on a couch

In a letter to the Centers for Medicare & Medicaid Services, hospice leaders outlined concerns with the selection algorithm for the proposed hospice Special Focus Program.

Representatives from the National Hospice and Palliative Care Organization, the National Association for Home Care & Hospice, the National Partnership for Healthcare and Hospice Innovation, and LeadingAge signed the letter sent Aug. 16. The organizations argued that the proposed hospice SFP, which could be implemented next year, per the 2024 home health rule, may be inadequate at identifying and improving poor-performing providers, and that certain hospices might be at a disadvantage under CMS’ selection methods.

“The consequences of being selected for the SFP are severe, which is why the selection criteria must be designed to identify the subset of hospices that are most in need of remediation to address quality concerns,” the letter stated. “The ramifications of a poorly targeted selection process could inadvertently lead to access issues for beneficiaries and their families.”

As part of the severe consequences, CMS will make the names of the lowest-performing hospices available to the public.

“The fact that they’re going to publish that bottom 10% bucket and essentially label 600 or 700 as the poorest-performing hospices in the country … it’s going to do some really big damage and impact patient choice,” said Logan Hoover, vice president of policy and government relations at NHPCO, in an interview with McKnight’s Home Care Daily Pulse

Bias against big providers?

Among providers’ worries with the selection method is that the impact of certain violations will not be scaled to the size of the provider. Condition-level deficiencies and substantiated complaints raise the same level of concern for a provider with an average daily census of 50 as one with an ADC of 500. This could put larger hospices at a disadvantage, according to the letter.

“As currently proposed, the selection algorithm misses truly poor-performing hospices and instead targets hospices with higher levels of quality care,” an NHPCO representative said in an email to McKnight’s Home Care Daily Pulse. “Despite convening a Technical Expert Panel, CMS routinely disregards their advice and recommendations in favor of its own ideas. The algorithm is so flawed that the four associations recommend CMS withdraw this portion of the rule and go back to the drawing board with additional input from stakeholders.”

LeadingAge President and CEO Katie Smith Sloan expressed similar concerns in a statement.

“We urge CMS to go back to the drawing board on several important issues, including data selection and scaling, and the weighting used in the SFP algorithm,” she said. “The choices made now will determine whether it will achieve its intended result: improving poor providers’ performance and the sector overall.”

Outdated survey critique

The letter presented other concerns about the SFP proposal. For example, many of the surveys on which SFP selection will be based are outdated or inconsistently administered, the letter noted. Some providers, it said, have not been not been surveyed every 36 months, consistent with the time frames outlined in the Code of Federal Regulations. Hospice leaders recently complained in another letter about inconsistent auditing that makes it harder for providers to prepare for and respond to audits.

Yet another critique: SFP determinations are made using results from the Hospice Care Index and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, but a large number of providers do not have their data publicly available. Providers with non-public HCI scores — 21.7% of hospices, according to the letter — were found to be less likely to be chosen for the SFP.

Providers that aren’t large enough or are too new may not have access to this data, Hoover said, and this can put them at risk of SFP selection. Also, since CAHPS results are given twice the weight of other factors, providers might be incentivized to not participate in CAHPS hospice surveys, the letter said.

“A mediocre score is actually weighed heavier against the hospice than not submitting at all. The data tells us that those that don’t submit are more likely to have poor surveys or more complaints against them,” Hoover noted.

And the lack of transparency about what will happen to hospices selected for the SFP is also cause for consternation, he said. It’s unclear what remedy will be used on an individual basis, and what additional support each hospice will receive.

“We think it’s really critical not just that the selection criteria is right, but that the program is designed in a way to really lift up hospices,” Hoover said.

Editor’s note: This story has been updated with a quote from LeadingAge President and CEO Katie Smith Sloan.