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GAO wants more quality considerations injected into survey process.

Hospice surveys are under fire again, this time from the Government Accountability Office.

Like with a pair of HHS Office of Inspector General reports released this summer, a new GAO report calls into question Medicare鈥檚 oversight of hospices via surveys. Unlike the earlier OIG reports, the GAO document does not include survey horror stories such as patients with maggot-infested wounds or gangrenous limb amputations after wound care neglect, which grab national headlines (see Eli鈥檚 HCW, Vol. XVIII, No. 24).

鈥淭hankfully, the most recent report doesn鈥檛 include another 鈥榩arade of horribles,鈥欌�� says Washing- ton, D.C.-based healthcare attorney Elizabeth Hogue.

The GAO report looks at current Hospice Quality Reporting Program quality measures, noting that for- and nonprofits had comparable scores on the seven measures. The data shows that hospices in general performed well on the QMs, points out attorney Robert Markette Jr. with Hall Render in Indianapolis.

GAO staff found bigger differences be- tween profit types on 鈥減otential indicators of quality鈥� it generated from interviewing a 鈥渟ample of researchers鈥� and reviewing 鈥渞elevant research studies,鈥� according to the report released Nov. 14. Those indicators were:

• live discharge rate, and
• visits in the last three days of life.

A high live discharge rate 鈥渃ould indicate dissatisfaction with care leading to the beneficiary鈥檚 decision to leave the hospice provider,鈥� the GAO argues. Providing visits in the last three days of life, 鈥渁 critical time in providing quality care,鈥� can represent a hospice鈥檚 鈥渕edical and emotional support鈥� in that time.

鈥淔or-profits had higher rates of live discharges than nonprofits, with 22.1 percent of beneficiaries served by for-profits being discharged alive compared to 12.0 percent of beneficiaries served by non-profits in 2017,鈥� GAO researchers found. 鈥淭his disparity remained true after accounting for whether benefi颅ciaries had a cancer or non-cancer diagnosis.鈥�

For visits in the last seven days of life, 鈥渇or-profits and non-profits both averaged about 6 provider visits鈥� in 2017, the GAO notes. But for the last three days, for-profits fell behind their non-profit peers for skilled visits 鈥� 77 percent versus 85 percent. Non-skilled visits were the opposite, however 鈥� 68 percent versus 57 percent.

Conclusion: 鈥淲hile [the Centers for Medi- care & Medicaid Services] instructs surveyors to review previous survey findings and complaints, CMS does not instruct surveyors to use information on providers鈥� performance on quality measures or other potential indicators of quality as part of the survey process,鈥� the GAO says. 鈥淭his information could be used to enhance the survey process.鈥�

The GAO also laments that CMS has only termination as an enforcement option 鈥� a criticism shared by earlier OIG reports. And CMS uses termination only 鈥渞arely,鈥� the GAO adds.

Recommendation: CMS should incorporate QMs and other quality indicators into its survey process, the GAO urges. Congress also should grant CMS the authority to use alternative sanctions, such as those used for home health agencies and nursing homes.

鈥淢eaningful quality measures can also serve as key indicators of provider quality,鈥� the Department of Health and Human Services agrees in its comments on the report. 鈥淲e will look into ways to incorporate the use of this meaningful quality measure data into the hospice survey process,鈥� HHS says, referring to Hospice Compare data.

GAO May Want Minimum Visit Target

Yet more focus on hospice surveys means they are likely to get even tougher, predicts attorney Meg S.L. Pekarske with Reinhart Boerner Van Deuren in Madison, Wisconsin. 鈥淲e have seen a rise in survey intensity since before the OIG report and expect it will continue,鈥� Pekarske tells Eli.

Keep in mind: 鈥淐MS had the OIG reports for internal review prior to release,鈥� points out Theresa Forster with the National Association for Home Care & Hospice.

Like home health before it, the hospice industry has been on an enforcement ramp-up as government agencies churn out reports focusing on suspected fraud and abuse in the sector, Markette contends. And hospices can expect to see the enforcement efforts continue to intensify (see related story, p. 339).

This GAO report has some problems, however, experts counter. For one, QMs are not Conditions of Participation, Hogue says, and surveyors aren鈥檛 trained on them. 鈥淧atients may pass away suddenly and unexpectedly so that the lack of visits during the 3 days prior to death may not be indicative of a lack of quality care,鈥� Hogue offers. Or 鈥渟uppose the family doesn鈥檛 want or need visits within the 3 days prior to death?鈥� Patients and their loved ones may not want visits from any hospice staff members during the final days, 鈥渆specially if symptoms and pain are well-controlled,鈥� she adds.

Effectively mandating a 鈥渕inimum visit frequency鈥� for unnecessary or unwanted visits is short-sighted and could be costly, Hogue indicates.

Live discharges also don鈥檛 necessarily mean poor quality care, Markette says. Sometimes, if palliative care improves a patient鈥檚 health so that she now exceeds the six-month prognosis, a live discharge could actually indicate good quality care, he points out.

CMS notes that 鈥渕eaningful鈥� quality data is useful. But the 鈥減otential indicators鈥� the GAO uses could mean any number of things, experts charge.

Plus: 鈥淎ttempts to use quality data by surveyors will almost inevitably result in subjective conclusions that may be very unfair to providers,鈥� Hogue warns.

And another thing: Even focusing on survey data to indicate quality has its pitfalls, Markette argues. Surveys are inherently subjective, which is evidenced by the citation statistics that vary greatly from state to state.

Add to that, hospices don鈥檛 have an avenue to appeal or even really address citations they don鈥檛 agree with unless they are put on the termination track, Markette says. Survey findings are often seen as the result of a fact-finding process, but they are much more subjective and really should be considered more like allegations, he contends.

Given surveys鈥� gray areas, 鈥渋t鈥檚 unfair to base policies on survey findings,鈥� Markette believes.

Note: The 41-page report is at .