Quality Data Crucial for Hospices in Value-Based Reimbursement

Understanding payer priorities in defining the scope of quality is vital for hospices to thrive not only in traditional Medicare, but also in today’s value-based reimbursement climate.

The nitty gritty details of data tracking and management matter when it comes to ensuring both a healthy bottom line and quality patient care. This includes performance on quality measures required by the U.S. Centers for Medicare & Medicaid Services (CMS), the Hospice Care Index (HCI), the Hospice Item Set, and Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

A hospice’s track record on these measures is likewise important when working with Medicare Advantage plans. CMS requires plans to ensure they are working with providers of high-quality care. This means they will be looking closely at providers’ quality data.

Advertisement

Effective processes to measure and track quality are crucial for hospices when it comes to proving their value proposition to payers, according to Dr. Alena Baquet-Simpson, chief executive medical director of insurance giant Aetna, a CVS Health company (NYSE: CVS).

“It is essential that [hospice] providers and payers actively evaluate key performance indicators (KPIs) against CMS requirements and actual service performance,” Baquet-Simpson told Hospice News in an email. “Prioritizing these measurements is crucial to improving health outcomes and lowering costs for enrollees.”

MA plans in particular zero in on providers’ star ratings, which began appearing on the CMS Care Compare website last month. CMS currently bases these ratings on Consumer Assessment of Healthcare Providers & Systems (CAHPS) scores. These data are key considerations when plans choose providers for their networks.

Advertisement

Poor scores relative to other providers can impact a hospice’s competitive position in value-based payment markets, according to Yancey Bond, director of solutions management at WellSky, a national health care software company.

The ways a hospice gathers insight into its quality performance can create both risks and rewards in gaining a competitive edge in the payer world, she stated during the National Association for Home Care & Hospice (NAHC) Financial Management Conference in Las Vegas.

Providers can find themselves wading through murky waters when figuring out how to track and report quality in a way that is comprehensible and valuable to payers.

Payers are most keenly watching indicators such as the number of patient visits in the last days of life, symptom management across the spectrum of their hospice care and any high-cost services provided, according to Katy Barnett, director of home care and hospice operations policy at the senior advocacy group LeadingAge.

Perhaps the biggest quality measure in the eyes of payers are outcomes and experiences reported by family members and caregivers, said Barnett.

“Patient outcomes are a big, big topic that payers look at,” Barnett told Hospice News. “We’re seeing an expansion in the hospice quality metric space, and that’s definitely of interest in terms of looking at who they are going to pair up with. Keeping someone comfortable at the end of life and how a hospice manages all those symptoms and costs is something private and public health care payers are looking at.”

CMS implemented the HCI in its 2022 final rule for hospice payments with an aim of illustrating the care processes that occur between a hospice patient’s admission and discharge. Each provider receives a single numerical score ranging from zero to 10, based on a set of quality indicators.

While these indicators are designed to paint a picture of the care a patient received, some providers have greeted the HCI with confusion and concern. Some stakeholders have called these thresholds into question, arguing that the differentiation among hospices is insufficient for a well-founded comparison.

To differentiate themselves from the competition, hospices need to cast a wide net when looking across patient population data to proactively identify those at risk of live discharge, according to Bond.

“It’s important that you’re monitoring and preventing live discharges,” said Bond at the NAHC conference. “Let the data drive where you’re looking to help your clinicians and empower them to serve your patients better. You can be the source of change within your market, impacting issues, if you leverage data to ensure you’re going to meet that quality measure.”

Providers should keep in mind that payers will likely way quality data beyond what they can see in Medicare claims or publicly-available reports, according to Mollie Gurian, vice president of home based and home- and community-based services policy at LeadingAge.

“If you’re a hospice entering some kind of relationship with a health plan, they’re likely going to ask about things not publicly reported,” Gurian told Hospice News. “It can be beneficial to collect data on things in regards to your readmission rates, ER utilization and medication management, because these are ways that help keep payer costs down and patient satisfaction up. It’s important for hospices that payers may not have a lot of context for what a quality score actually means and how it applies and translates to the overall care plan.”

Looking ahead, quality data tied to health equity improvement measures will be on payers’ radars, added Gurian. CMS and MA plans are increasingly interested in how hospices are addressing access issues within their service communities, with “some kind of quality data reporting” requirement anticipated in the near future, said Gurian.

The Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) payment model rolled out as part of the Center for Medicare & Medicaid Innovation’s (CMMI) “strategy refresh” includes a focus on health care equity in the payment model design. ACO REACH is among the first new models to use this approach, though more could be forthcoming that include diversity, equity and inclusion components.

To tie all the pieces of quality data together, hospice staff must understand their role in capturing that information and how their employer, CMS, and payers use it, said Cindy Campbell, director of operational consulting at WellSky.

Hospices need to be strategic about how they educate and train staff across the board, because the ways they document and interpret the data is just as crucial as how they gather it, she added.

“It’s thinking about the quality of what we do in hospice and whether or not that gets rewarded in a market,” said Campbell during the NAHC conference. “If you’ve got ‘dirty data’ in the outcomes, then you have a staffing issue with the assessment and understanding of how to capture patient data. You’ve got to be able to manage organizational, individual and team behaviors in order to help these metrics consistently improve and move in the right direction.”

Companies featured in this article:

, , , ,