NAHC Comments to Washington Post on Hospice “Consumer Guide”
November 13, 2014 11:56 AM
On October 27, 2014, the Washington Post published its fifth in its series “The Business of Dying,” on issues related to hospice care in the United States. In conjunction with the article, “Quality of U.S. Hospices Varies, Patients Left in Dark,” the Post included a Consumer Guide to Hospicethat contains a partial list of Medicare-certified agencies with a limited set of informational items about the hospices including tax status, location and contact information, years in business, accreditation status, most recent survey, number of patients served, spending per patient day, and additional items. The authors included the Consumer Guide with the intent that they would assist consumers in selecting a provider for end-of-life care.
The National Association for Home Care & Hospice (NAHC) fielded numerous questions from hospice providers on the Guide and solicited comment from its membership to assist in commenting on the Guide. NAHC has also encouraged hospice providers to submit specific comments related to the information for their hospice program to the Post through the “Contact Us” interface on the front page of the Guide.
NAHC submitted the following comments to the Post relative to the Guide:
We read with interest your recent article on hospice care titled, “Quality of U.S. hospices varies, patients left in dark” and its accompanying Consumer Guide. We appreciate your desire to provide consumers with useful guidance from which to make informed decisions about end-of-life care. We also know that securing pertinent, timely, and accurate data and presenting it in a succinct and user-friendly format is challenging, at best.
Absent the availability of validated quality data for all hospice providers (which will be available in the future from CMS), it is difficult to compare hospice programs using a limited set of factors with any absolute certainty. In addition, there are real risks associated with use of unaudited hospice cost report data -- and hospice cost report data generally -- as it has numerous flaws and could lead to faulty calculations. Finally, the data used for the Guide has not been risk adjusted for specific patient characteristics and therefore may not be as useful for comparison of hospice programs as might otherwise be the case.
Different types of patients at different points in their disease trajectory have very different care needs. For these reasons, it is often the reports of actual users of hospice services that may provide the most valuable information to individuals who are seeking recommendations on a hospice program. It may also be useful for patients or their families, when talking with hospice programs, to inquire as to what quality indicators the hospice is currently tracking as part of their Quality Assessment and Performance Improvement (QAPI) programs (required under the Conditions of Participation) and whether they are willing to provide information about the scores they receive (particularly if they track patient or family satisfaction).
With the caveats listed above in mind, we have several comments we hope will assist in your future efforts to refine the Consumer Guide.
COMPREHENSIVENESS/ACCURACY OF HOSPICE IDENTIFYING INFORMATION
We have heard from a number of sources that the listing of hospices for their specific states excludes a significant number of operating hospice programs. Further, we have also heard from hospice programs for which the identifying information is incorrect or significantly out of date. Both of these factors are related to the accuracy and comprehensiveness of the data sources used for the Guide, but we believe that any effort to ensure greater accuracy and completeness of the listings will be of benefit to consumers.
GENERAL IDENTIFYING INFORMATION
TAX STATUS: We understand that you are seeking input on whether patients or family members should be directed to consider a hospice provider’s tax status as a sole or key criterion in choice of a hospice. While we have no objection to inclusion of tax status as part of the guide, we believe that tax status alone provides no indication of the quality of care provided by a hospice, nor an indication of the hospice’s track record of compliance with federal or state requirements.
SURVEY FREQUENCY DATA: The article accompanying the Guide provides explanation as to why some hospices have not been the subject of a state survey in a significant amount of time. We believe it may be useful to explain as part of the Guide, at a minimum, that infrequency of surveys is due to limited federal funding; otherwise an unknowing consumer might misinterpret the infrequency of survey to be the hospice provider’s choice.
ACCREDITATION STATUS: The Guide indicates whether the hospice is accredited by a private accrediting organization. The guide should clarify that hospices that are accredited have been subject to surveys by the accrediting organization every three years as this may not otherwise be apparent. If some information from an accrediting body is not available, that lack of information should be noted, as well.
AVERAGE DAILY SPENDING PER PATIENT: The inputs for this statistic have not been provided so we must deduce that this figure represents the amount of money spent on patient care divided by care days. While the Guide provides state averages for comparison, if payment rates for levels of care are used as part of this statistic, the rates include a wage index that could vary substantially from one area of a state to another. Additionally, if this statistic includes costs for different levels of care, comparisons of average daily spending may be misrepresentative. We would suggest that a focus on spending per patient at the Routine Home Care level, with adjustment for wage index values, may provide a more comparable figure for comparison between hospice programs on average daily spending per patient. We would also note that the number of patients served could significantly impact the average daily spending per patient -- generally speaking smaller programs have higher overall average daily spending per patient if indirect costs are included.
BREAKDOWN OF DAILY SPENDING FOR PATIENT CARE
DOCTOR CARE: Based on comment from some hospice providers, we are not certain what this data represents. One hospice indicated that he invests a considerable amount of money on employment of physicians to staff the hospice but his hospice’s data reflect NO spending on doctor services. Is this data comprised only of care that is separately charged by the hospice as physician services?
OTHER CARE INDICATORS
CRISIS CARE: Our understanding is that the CRISIS CARE designation indicates that the hospice provided either Continuous Home Care and/or Inpatient Care (we are not absolutely certain whether Inpatient Respite is included in this statistic) during the time period from which the data is drawn. We are not certain how this percentage has been calculated and whether the statistic represents the percent of patients for which the care was provided or the number of days of crisis care that the hospice billed during the time period. Data related to the number of patients that received some type of CRISIS CARE may be the most instructive to a consumer. We understand that approximately 25% of hospice beneficiaries receive some type of short-term crisis care -- be that General Inpatient, Inpatient Respite or Continuous Home Care (if Respite is excluded the percentage drops by about 3.5%).
This may assist patients and/or family members in having a better understanding of the nature of these levels of care, the number of hospice patients that the hospice provides this care to, and that Medicare intends that they be made available in extreme circumstances and for relatively short periods of time, rather than on a routine basis. Consumers should also be aware that patients with longer lengths of stay may be less likely to need some type of crisis care as their conditions are, in relative terms, more stable than those patients that are on service for shorter periods of time [earlier entry to hospice care can result in greater stability of a patient’s status over the length of care]. Therefore, a hospice with a long average length of stay may provide crisis care to a smaller percentage of patients.
LIVE DISCHARGE RATE: We are interested in securing information about how the live discharge rate has been calculated for all hospices included in the Guide. Some hospice providers indicate that the live discharge rate reported in the guide significantly exceeds their own internal calculation of their live discharge rate.
HOSPICE DIRECT PROVISION OF INPATIENT CARE: You may want to consider inclusion of an indicator that some hospices provide inpatient care directly in their own facilities.
NAHC will continue to review information included in the guide and will submit additional comments and concerns as they arise. If hospice programs have suggestions about data elements that they believe would assist patients or their families in choice of a hospice, please submit those suggestions to Theresa Forster of the NAHC staff at firstname.lastname@example.org.