OIG Report on Medicare Hospice Use of General Inpatient (GIP) Level of Care
May 9, 2013 09:41 AM
The Department of Health and Human Services’ Office of the Inspector General (OIG) recently issued a Memorandum Report to the Center for Medicare & Medicaid Services (CMS) on Medicare Hospice: Use of General Inpatient Care, OEI-02-10-00490. This report is based on general inpatient care (GIP) provided to Medicare hospice beneficiaries in 2011.
Hospice GIP is for pain control or symptom management provided in an inpatient facility that cannot be managed in other settings. The care is intended to be short-term and is the second most expensive level of hospice care available after continuous care. GIP may be provided in one of three settings: a Medicare-certified hospice inpatient unit; a hospital; or a skilled nursing facility (SNF). CMS staff has expressed concerns about possible misuse of GIP, such as care being billed for but not provided, long lengths of stay, and beneficiaries receiving care unnecessarily.
The OIG found that the majority of GIP care was provided in hospice inpatient units as opposed to hospitals or SNFs. Twenty-three percent of Medicare hospice beneficiaries received GIP during the year. One-third of beneficiaries’ GIP stays exceeded five days, with 11 percent lasting 10 days or more. The hospices that used inpatient units provided GIP to more of their beneficiaries and for longer periods of time than hospices that used other settings.
In addition to the concern of inappropriate use of GIP, there is also concern with many hospices providing no GIP care. The OIG’s study found that 27 percent of Medicare hospices - 953 hospices - did not provide any GIP in 2011. Approximately 12 percent of Medicare hospices - 429 hospices - provided only the routine home care level of care to beneficiaries. Eight percent of the total Medicare dollars spent on hospice care in 2011 were spent on GIP care. Of this, 67 percent was spent on GIP care delivered in hospice inpatient units.
This OIG study utilized data from hospice claims with dates of service in 2010 and 2011 with 2010 claims being used to identify the level of care of the hospice patients upon admission to hospice. The claims data was analyzed to identify:
Hospice beneficiaries who received GIP during 2011
The number of days that each beneficiary received GIP care
The setting in which the care was provided
The terminal illness of each beneficiary
For each hospice that served Medicare beneficiaries in 2011, the OIG determined:
The number of Medicare hospice beneficiaries it served
The number of hospice beneficiaries for whom it provided GIP care
The settings in which GIP care was provided
The number of beneficiaries for whom GIP care was provided
Other levels of hospice care
Reimbursements received for GIP care and for all hospice care
For purposes of this study, a hospice was considered to be large if it provided care to more than 320 Medicare beneficiaries in 2011 and small if it provided care to 90 or fewer beneficiaries.
As mentioned previously, 23 percent of Medicare hospice patients received GIP care in 2011 with 71 percent of these patients receiving GIP at the beginning of their hospice care. The most common terminal illnesses of patients receiving GIP care mirrored those of the hospice patient population generally: cancer; circulatory disease; respiratory disease; ill-defined conditions; and mental disorders.
Medicare policy does not specify a limit on the number of days GIP is allowed but the rules do require that the stay be “short term”. The OIG study found that one-third of GIP stays lasted longer than 5 days and 11 percent of all GIP stays were 10 days or more. A minute portion - 2 percent - of GIP stays lasted longer than three weeks.
Because GIP is meant for pain control or symptom management that cannot be managed in other settings, the OIG expected that the percentages of GIP stays beginning on weekend days and those beginning on weekdays to be similar. They found that GIP stays were much less likely to begin on Sunday or Saturday than on a weekday.
Hospices that used inpatient units provided GIP to 35 percent of their beneficiaries. In contrast, hospices that did not use inpatient units and provided GIP care in hospitals or SNFs did so for 12 percent of their beneficiaries. Hospices that used inpatient units were also more dependent on GIP dollars. GIP represented 13 percent of the total Medicare dollars of hospices that used hospice inpatient units.
Conversely, GIP represented 4 percent of the total Medicare dollars of hospices that did not use inpatient units and provided GIP in hospitals or SNFs. On average, GIP stays in inpatient units were 50 percent longer than GIP stays in hospitals and 29 percent longer than GIP stays in SNFs. The average GIP length of stay in an inpatient unit lasted 6.1 days, whereas the average GIP length of stay in a hospital was 4.1 days and the average in a SNF was 4.8 days. Forty percent of all GIP stays in an inpatient unit exceeded five days, compared to 22 percent in hospitals and 27 percent in SNFs. Hospices that provided GIP in inpatient units were more likely to be large than were other hospices that provided GIP.
More than one quarter of hospices did not provide any GIP care in 2011. As with all covered hospice services, hospices are required to provide GIP care if the beneficiary needs it. In general, beneficiaries served by hospices that did not provide GIP care had the same terminal illnesses as beneficiaries served by hospices that provided GIP care. Sixty-eight percent of hospices that did not provide GIP also did not provide continuous care. Sixty-two percent of hospices that did not provide GIP did not provide inpatient respite care. In total, 45 percent of hospices that did not provide GIP also did not provide continuous care or inpatient respite care during the year. The hospices that did not provide GIP care were more likely than other hospices to be for-profit. Additionally, hospices that did not provide GIP care were more likely than other hospices to be small.
The OIG study indicates a need for further review of long lengths of stay - defined as over five days - and the use of GIP in inpatient units to ensure that hospices are using GIP as intended and providing the appropriate level of care. Furthermore, the OIG stated it will conduct a medical record review that will assess the appropriateness of GIP care provided in different settings. The OIG advises CMS to focus on these issues as it considers options for hospice payment reform and for developing hospice quality measures.
The OIG pointed out that CMS should focus on hospices that do not provide GIP care and ensure that these hospices are providing beneficiaries access to needed levels of care at the end of their lives, and provided the suggestion of adopting a quality measure regarding hospices’ ability to provide all hospice services as an option for CMS.
The study makes clear that the OIG is investing a significant amount of resources in hospice. They indicated that the GIP study was part of continuing hospice work. In this report to CMS, the OIG referenced five other hospice studies it has conducted in the past - not all related to GIP - and that it is conducting two more hospice-related studies:
A study involving a medical record review of general inpatient claims from 2012 will follow this memorandum report.
OIG is conducting a study that focuses on discharges from acute care hospitals to hospice care. It will address how a hospital transfer payment policy for early discharges to hospice care would financially affect the Medicare Part A program and hospitals.
The OIG did not make any recommendations in this report regarding the use of GIP but expects to do so in a separate report after the GIP medical record review is complete.