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June 20, 2016

Andrew Slavitt, Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
Attention: CMS–1652–P
P.O. Box 8010
Baltimore, MD 21244-8010

Re: CMS–1652–P

Dear Mr. Slavitt:

The Center for Medicare Advocacy (Center) is pleased to provide the Centers for Medicare & Medicaid Services (CMS) comments on its proposal “Medicare Program; FY 2017 Hospice

Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements” (81 Fed. Reg. 25498) published on April 28, 2016. The Center, founded in 1986, is a national, non-partisan education and advocacy organization that works to ensure fair access to Medicare and to quality health care. At the Center, we educate older people and people with disabilities to help secure fair access to necessary health care services. We draw upon our experience of working with thousands of individuals to educate policy makers about how their decisions affect access to services.  Additionally, we provide legal representation to ensure that people receive the health care benefits to which they are legally entitled, and the quality health care they need.

We address the following in our comments:

  • proposed quality measures; and
  • Hospice Compare website.

Introduction to Comments

Hospice care is holistic care for the dying as well as emotional and educational support for their caregivers. Hospice became a Medicare benefit in 1983 and is available to those who have been diagnosed with a limited life expectancy of six months or less. Once a patient elects hospice, the hospice provider creates a plan of care that “includes all services necessary for the palliation and management of the terminal illness and related conditions.”[1]

Proposed Quality Measures

The Center supports the two proposed quality measures described in the proposed rule that would begin in FY 2017. Both are composite measures.

The first composite measure looks at the number of visits when death is imminent: 1) the number of patients who receive at least two visits from clergy, social workers, spiritual counselors, licensed practical nurses, or hospice aides during their last seven days of life and 2) the number of  patients who receive at least one visit from a physician during their last three days of life.[2] The Center believes this composite score can improve the quality of comfort care and caregiver support to patients during their final days. Skilled care may be necessary during the patient’s final days because, in part, skilled nurses can teach caregivers not only how to administer pain and anxiety drugs, but also how to care for the unique needs of the patient as his or her body begins to shut down. As noted by MedPAC in its May 31, 2016 comments on the hospice proposed quality measures, “a very important function of hospice is to provide appropriate clinical and psychosocial support throughout a patient’s hospice stay. Therefore, we believe quality measures that gauge the extent to which hospices are providing visits to patients in their last days of life are valuable.”[3]

According to a spring 2014 Abt Associates report commissioned by CMS that relied on all hospice data submitted in 2012, over 53,000 hospice patients (around nine percent out of a total of 585,648 beneficiaries) who received routine home care did not receive a visit from skilled hospice staff during their last three days of life.[4] Additionally, a total of 189,000 patients who received routine home care (28.9 percent out of a total of 656,355 patients) in 2012 did not receive a skilled visit on their last day of life.[5] Further, patients who died on a weekend were more likely than patients who died on a weekday to have gone without a skilled visit during their final days.[6] The Abt Associates report surmises that the large percentage of beneficiary deaths can be “partially explained by beneficiaries dying suddenly or unexpectedly where a hospice would not be able to send out a staff person in time to perform a visit.”[7] Routine home care patients can receive up to eight hours of hospice care a day. Given that 97.7 percent of hospice billing in 2014 was coded as routine home care, it is critical that routine home care patients have access to Medicare’s hospice services during their final days of life.[8] While we support this measure, we encourage CMS to recognize that the patient or the family may wish to decline a visit from a physician, clergy member, social worker, etc. in the last days of the patient’s life. In short, a patient’s wish to decline visits from providers of services during these last days should  not count against the hospice agency. Additionally, CMS should be sensitive to creating incentives that drive visits for the sake of visits rather than quality of care.

The Center also supports the proposed composite measure that aggregates a hospice’s performance across all seven Hospice Item Set (HIS) quality measures at admission. These seven process measures are the following: addressing the patient’s beliefs and spiritual values (if desired), pain assessment, pain screening, dyspnea screening, dyspnea treatment, documentation of treatment preferences, and provision of bowel regimen for patients receiving an opioid.[9] [10] This composite assessment would provide a holistic score upon which prospective patients could evaluate hospices on Hospice Compare. Currently, hospice providers already make an assessment at admission using the seven existing HIS quality measures, but a composite score provides a new score with which to holistically measure the hospice. CMS states that a composite measure better guarantees that all of these assessments are conducted at admission.[11] The proposed rule states: “Collecting information about the total number of care processes conducted for each patient will incentivize hospices to conduct all desirable care processes for each patient and provide services that will address their care needs and improve quality during the time he/she is receiving hospice care.”[12]  The Center hopes, however, that this assessment does not delay the delivery of necessary services for patients and their families.

The Center agrees with the suggestions of MedPAC that CMS should in the near future develop hospice outcome measures in order to further guarantee that quality care and assessments are being delivered to patients.[13] One of the major challenges to implementing hospice outcome measures is the short duration of many hospice stays. A January 2016 JAMA article’s authors interviewed close family and friends of deceased hospice and non-hospice patients and found that survivors were more likely to report excellent end-of-life care when patients received hospice care for more than three days (58.8 percent of those surveyed) than those who received fewer hospice days or did not elect hospice at all.[14] The study shows that assessing the outcomes of bereavement and palliative services among patients and loved ones in hospice throughout a hospice stay could provide hospices with valuable data concerning the benefits of providing certain services.

Hospice Compare

The proposed rule also offers more descriptive details concerning the Hospice Compare website. The Center supports CMS’ progress towards the creation of a tool prospective hospice patients can use to evaluate hospice providers.

It’s unclear, however, how much correction CMS will allow hospices when it states in the proposal its desire to give providers the opportunity to “review and correct data they submit on all measures that are derived from the HIS.”[15] If the HIS records errors that have not been submitted, CMS claims that the provider’s correction process is not uniform and depends on the type of error. Concerning modification requests to already-submitted HIS data, CMS states that only the following things cannot be modified: admission date, discharge date, and basic demographic information such as the patient’s Social Security number and date of birth.[16] If providers can modify anything other than clerical errors and substantively change the quality scores of the seven HIS measures, the Hospice Compare website might not offer accurate and useful information to consumers.

All seven Hospice Item Set measures consist of self-reported data.[17] In order to augment such self-reported data, we support timely inclusion of CAHPS survey data into Hospice Compare. Such a measure could mitigate against gaming by providers. One high profile investigation in August 2014 by the New York Times shows, for instance, how Medicare-participating nursing homes have in recent years modified their facility-reported assessment (MDS) data in order to alter their star ratings on the Nursing Home Compare website.[18] Given the increased incentives to modify HIS quality measures inherent in the display of these measures on the Hospice Compare site, the Center would hope that CMS would conduct more audits of hospices to ascertain the accuracy of provider reports. While the IMPACT Act requires that an inspector audit a hospice at least every three years, an increased number of audits can better guarantee that Hospice Compare meet the following goal stated by CMS in its  proposed rule : “It is essential that the data made available to the public be meaningful.”[19]


The Center for Medicare Advocacy appreciates the opportunity to provide comments on the proposed rule.  For further information, please contact Center Senior Policy Attorney David Lipschutz at, 202-293-5760.


Matthew Hubbard
David Lipschutz

[1] 42 C.F.R. § 418.56(c).
[2] CMS. “Proposed Hospice Quality Measures and Information Collection Methods.” 28 April 2016.  (site visited June 14, 2016). P. 25522. CMS. “Hospice Quality Reporting Program: Specifications for the Hospice Item Set-Based Quality Measures.” April 2016. (site visited June 16, 2016). P. 43.
[3] Medicare Payment Advisory Commission. “MedPAC Comment on CMS's Proposed FY 2017 Hospice Payment Rate Update and Hospice Quality Report Requirements.” 31 May 2016.'s-proposed-fy-2017-hospice-payment-rate-update-and-hospice-quality-report-requirements.pdf?sfvrsn=0 (site visited June 14, 2016). P. 2.
[4] Abt Associates. “Medicare Hospice Payment Reform: Analyses to Support Payment Reform.” 01 May 2014. (site visited May 17, 2016). P. 62.
[5] Ibid.
[6] Ibid. P. 63.
[7] Ibid. P. 62.
[8] Medicare Payment Advisory Commission. “March 2016 Report to the Congress: Medicare Payment Policy.” March 2016. (site visited May 17, 2016). P. 302.
[9] CMS. “Proposed Hospice Quality Measures and Information Collection Methods.” P. 25524-5.
[10] While CMS states that the Hospital Item Set “is not a patient assessment instrument and will not be administered to the patient and/or family or caregivers” and that an “item set is a standardized mechanism for abstracting data from the medical record,” CMS seems to be using the HIS in this composite measure as an assessment instrument. CMS uses the word “assess” to describe the function of this composite measure. See: CMS. “Fact Sheet: The Hospice Item Set (HIS).” (site visited June 16, 2016). CMS. “Proposed Hospice Quality Measures and Information Collection Methods.” P. 25524.
[11] CMS. “HIS Manual: Guidance Manual for Completion of the Hospice Item Set (HIS).” Effective July 1, 2014. (site visited June 17, 2016).  P. 7.
[12] CMS. “Proposed Hospice Quality Measures and Information Collection Methods.” P. 25524-5.
[13] Medicare Payment Advisory Commission. “MedPAC Comment on CMS's Proposed FY 2017 Hospice Payment Rate Update and Hospice Quality Report Requirements.” P. 3.
[14] Alexi A. Wright, Nancy L. Keating, John Z. Ayanian, Elizabeth A. Chrischilles, et. al. “Family Perspectives on Aggressive Cancer Care Near the End of Life.” JAMA. January 2016. P. 288-90.
[15] CMS. “Proposed Hospice Quality Measures and Information Collection Methods.” P. 25533.
[16] Centers for Medicare and Medicaid Services Hospice Quality Reporting Program. “Guidance Manual for Completion of the Hospice Item Set (HIS).” Effective July 1, 2014. (site visited June 16, 2016). P. 67-8.
[17] CMS. “Hospice Quality Reporting Program: Specifications for the Hospice Item Set-Based Quality Measures.” P. 36-40. 
[18] Katie Thomas. “Medicare Star Ratings Allow Nursing Homes to Game the System.” The New York Times. 24 August 2014. (site visited June 16, 2016).
[19] “Improving Medicare Post-Acute Care Transformation Act of 2014.” Public Law 113-185. 06 October 2014. (site visited June 16, 2016). P. 18. CMS. “Proposed Hospice Quality Measures and Information Collection Methods.” P. 25532.


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