Early Hospice Payment Reform Analysis Presented by CMS, Abt Associates
April 2, 2013 05:12 PM
Hospice stakeholders attending the National Association for Home Care & Hospice’s (NAHC) March on Washington heard the initial findings of an analysis performed by Abt Associates for the Centers for Medicare & Medicaid Services (CMS). Abt is CMS’ contractor for development of a new hospice payment model.
While work on the payment model is not complete and payment changes have not yet been decided on, the findings indicate that CMS and Abt are looking broadly at hospice cost report, claims, and beneficiary data to gain a better idea of hospice care delivery patterns. Additionally, Abt is analyzing care patterns related to the hospice face-to-face to determine whether the new requirement is having an impact on hospice use.
Presenting on behalf of Abt was Michael Plotzke Alyssa Pozniak and Brant Morefield also on hand from Abt to answer attendees’ questions. Plotzke discussed three areas under exploration as part of Abt’s work for CMS:
Trends in Hospice Cost Reports
Trends in General Inpatient Utilization (GIP)
Impact of the Face-to-Face Requirement on Hospice Benefit Periods
TRENDS IN HOSPICE COST REPORTS
Abt examined cost reports for freestanding hospice providers from 2004 through 2011, eliminated problem cost report data, conducted analysis and drew several conclusions:
The average cost of drugs, biologicals, and infusion costs, per patient have decreased over the period
Medical supply costs, per patient, have remained steady over time
Roughly one-third of providers report zero inpatient costs, causing skewed average costs. Providers frequently report zero inpatient costs with non-zero inpatient days
Up to 25 percent of providers report no costs in their non-reimbursable cost centers, despite the requirement to provide bereavement services
Total costs per patient have not significantly increased from 2004-2011
Analysis: The findings clearly indicate that a significant number of hospice cost reports are inaccurate - reporting of no inpatient costs despite reporting of inpatient days; failure to report nonreimbursable costs despite requirements to provide non-reimbursed services. As a result, decisions related to payment reform may not be based fully on the actual cost experience of hospice providers.
The findings support the need for refinements to the hospice cost report, and CMS’ plans for changes to the hospice cost report are expected to be made public in the near future. The findings also clearly indicate that CMS is studying a wide range of hospice payment and care-related issues (including GIP) and CMS will be in a much better position to explore reform of payment for levels of care other than routine home care in the future.
Takeaway: All hospices must make a concerted effort to ensure that cost reports are filed correctly; additionally, hospices should prepare for the expansion of cost report requirements. NAHC’s Home Health and Hospice Financial Managers Association (HHFMA) has developed a Uniform Chart of Accounts for Hospice that represents the organization’s “best guess” of the additional items CMS will be requesting on the cost report. For more information, please see: NAHC Report Feb. 20, 2013.
TRENDS IN GIP UTILIZATION
Abt examined trends in hospice use of GIP to better understand the characteristics of hospice providers who do and do not provide GIP services and found the following:
25 percent of all hospice beneficiaries had at least one GIP day in 2010-2011; the average number of GIP stays per beneficiary was 1.11 days
79 percent of all hospice providers provided at least one GIP day in 2010-2011; there was variation in use of GIP among hospice providers depending on age, size, share of GIP days, geographic location
A higher proportion of older hospice providers used GIP compared to newer hospice programs
Only half of small providers provide GIP versus nearly all large providers use GIP
The South has the greatest number of hospice providers, but the lowest percentage of hospices that use GIP
Most GIP stays are short (5.7 days) but length of stay varies by site of service
Analysis: The variation in use of GIP raises questions about what factors contribute to use or non-use of GIP by hospice providers, such as whether GIP is being used appropriately - too frequently or too infrequently, for example - by some hospice providers, do some hospices have difficulties securing a site for GIP. Are hospices, for whatever reason, substituting a different level of care for GIP?
Takeaway: This is an opportune time for hospice providers to analyze their own operations and ensure that they are complying with GIP usage rules.
IMPACT OF FACE-TO-FACE REQUIREMENT
CMS asked Abt to study the impact that imposition of the face-to-face requirement might be having on hospice usage. Abt examined the number of consecutive benefit periods for beneficiaries with a first benefit period start date between October 2009 and January 2010, and the number of consecutive benefit periods for beneficiaries with a first benefit period start date between Oct. 2010 and Jan. 2011.
Abt found the following:
The percentage of beneficiaries who did not make it past their second benefit period is nearly identical for the period impacted by face-to-face as compared with the period not impacted
There were some minor differences in discharge status across the two groups; slightly more benefit periods ended in live discharge or were still in hospice, but fewer periods ended in death for the periods affected by the face-to-face compared to the period not affected
Analysis: While it was expected that the face-to-face requirement might result in more live discharges (based on patient’s failure to meet eligibility criteria) that was not the case. Abt intends to conduct additional analysis for later periods of time to see if the findings change.
Information related to Abt’s research on behalf of CMS in the area of hospice care was also presented at a poster session at the Academy of Hospice and Palliative Medicine’s annual meeting in New Orleans. Links to the posters follow:
Hospice Cost Reports: Benchmarks and Trends, 2004-2011
Analysis of Trends in General Inpatient Care (GIP) Utilization
Analysis of Face-to-Face Visit Requirement
During the presentation, representative of CMS urged members of the hospice community to submit recommendations and thoughts relative to payment reform as well as their insights on Abt’s research findings. As additional information becomes available from Abt’s research into hospice payment, further coverage will be available in NAHC Report and Hospice Notes.