As part of the Consolidated Appropriations Act of 2021, the Department of Health and Human Services was authorized to develop a Special Focus Program (SFP) for hospice agencies which aims to address issues that place hospice beneficiaries at risk. Last fall, CMS convened a Technical Expert Panel (TEP) to provide feedback to inform the development of the SFP. CMS stated in the FY2024 Hospice Wage Index proposed rule, that regulatory proposals to implement the SFP would be in the CY2024 Home Health Proposed Rule. A new report summarizes the TEP conversations and feedback.

LeadingAge participated in one of the listening sessions hosted by Abt Associates and provided feedback based on considerations for our nonprofit, mission driven membership. Both the TEP and stakeholders engaged in the listening sessions acknowledged the challenges of developing and implementing an SFP. Stakeholders acknowledged this report represents a starting point and as new data (including quality metrics and program integrity regulations) becomes available and the hospice industry changes over time, the experience gained during SFP implementation will continue to refine the program and improve quality for Medicare hospice beneficiaries nationwide.

The following were identified as key findings in the report:

• SFP Algorithm: The TEP supported the use of an algorithm that incorporates the Hospice Care Index, CAHPS® Hospice Survey data, surveyor-cited Quality of Care Condition Level Deficiencies, and substantiated complaints. The TEP agreed that no stratification, size quartile stratification, or CMS Location stratification were preferred to a state-based stratification approach. Overall, the TEP felt that all hospices should be held to the same standards regardless of their size or geographic location.
• SFP Survey Frequency: The TEP agreed that hospices in the SFP should be surveyed once every six months while in the program with most TEP participants suggesting these more frequent surveys be conducted by state survey agencies only, as opposed to accrediting organizations. The group also suggested including a transition period, whereby after a hospice graduates from the SFP, the hospice is surveyed annually before returning to the standard hospice survey frequency of once every three years.
• SFP Technical Assistance: The TEP urged that technical assistance (TA) be provided to all hospices in the SFP, with CMS setting the guidelines and metrics for TA agencies to follow. The TEP indicated that these TA agencies should not be the surveying entities, but third parties to ensure objectivity and timeliness/availability of TA. Ideas for financing the TA included using funds from civil monetary penalties or monthly claims reconciliation methods.
• SFP Graduation Criteria: The TEP suggested that to graduate from the SFP, hospices should have no condition level deficiencies for two consecutive six-month surveys, no substantiated complaints, and less than a certain number of standard level deficiencies. Once graduated, SFP hospices could then enter a transition period where they would be subject to annual surveys before returning to the three-year survey period.
• SFP Termination Criteria: The TEP generally agreed that the SFP should use progressive enforcement, starting with actions such as civil monetary penalties and/or denial of a percentage of Medicare payments. If, after 18 to 24 months, a hospice did not improve enough to graduate from the SFP, the hospice would be placed on the termination track.
• Public Reporting: The TEP would like the SFP clearly defined on Care Compare’s hospice page, and SFP hospices marked with a noticeable icon. There was also agreement that a hospice’s individual page should include additional information about the SFP and the hospice’s full survey information. The information should be easy-to-understand and not require consumers to have to search the website for pertinent information.

In addition to the overall key findings from the TEP and listening sessions, the TEP also made recommendations for future consideration:

• Consider additional indicators for the SFP as new measures are added to the HQRP;
• Standardize SA and AO surveyor training to ensure consistency when identifying condition-level and standard-level deficiencies;
• Consider ways to encourage the dissemination of a hospice’s SFP status to consumers (e.g., via enforced provider disclosure, consumer advocacy groups, trade organizations, etc); and
• Consider creating an informal dispute resolution process and/or expanding the list of corrective actions available for SFP hospices

LeadingAge will continue to monitor the implementation of the SFP for hospice and notify members of the eventual regulatory proposals.