Nurse Sheri Juan measures a San Diego hospice patient's arm for edema, which could be a sign his congestive heart failure is worsening. Heidi de Marco, Kaiser Health News.
by Cheryl Clark, inewsource
For the first time, Medicare officials have posted online quality scores for some 3,800 hospice providers - including about two dozen in San Diego County.
The scores are on a website launched Wednesday called Hospice Compare. And most San Diego hospices did well on most measures compared with national averages.
Kate Goodrich of the Centers for Medicare and Medicaid Services said the new transparency for end-of-life care will provide "a snapshot on the quality of care delivered by each provider" that will "help consumers make informed decisions about important aspects of hospice care."
Public reporting of data encourages hospice providers to improve their services, Goodrich said.
Visitors can compare up to three hospice facilities at a time, along with national averages for each of the seven measures, and see the data in table or graph format. For profit or not-for-profit status of each hospice is also shown.
The scores rate companies that provide care to patients with six months or less to live on whether their services meet seven measures known to ease the process of dying. The scores reveal the percentage of patients who:
- Were checked for pain at the beginning of hospice care.
- Received a timely and thorough pain assessment when pain was identified as a problem.
- Were checked for shortness of breath at the beginning of hospice care.
- Received timely treatment for shortness of breath.
- Were taking opioid pain medication and who were offered care for opioid-related constipation.
- Were asked about treatment preferences such as hospitalization and resuscitation at the beginning of hospice care.
- Were asked about their beliefs and values at the start of hospice care.
The data was collected for hospice care provided between Oct. 1, 2015, to Sept. 30, 2016.
For six of the seven measures, most of the San Diego area hospices scored well above 90 percent, and most were above the national average. However, with two measures, scores for San Diego area providers showed wide variation, a gap that indicates lower scoring hospice companies have room to improve.
For example, on the measure for assessment of pain when it was identified as a problem, 11 area hospices scored under 80 percent. The lowest performing provider in the county was Bridge Hospice, with a 48.3 percent score, although CMS noted that Bridge reported for a shorter time period than required. Bridge was followed by Advantage Health Systems with 50 percent, and Gentiva Hospice with 63.1 percent. Six other hospices in the county scored under the national average of 77.7 percent.
For the other lower scoring measure, beliefs and values, four area hospices scored below 80 percent. The lowest scoring facility was Health Essentials LLC with 45.2 percent. It was followed by Seaport Hospice with 61.8 percent and Sonata Healthcare with 72.7 percent. Nine other area hospices were below the national average of 93.6 percent although two did not have enough data for the full year.
San Diego County has 27 hospices listed on the CMS website but not all of them reported their quality data to CMS and some had fewer than the required number of eligible patients to be scored.
Hospices that fail to report their results to CMS receive a 2 percent reduction in their Medicare payment. Many did not report on some or all of the categories, locally and nationally. On the pain assessment measure, for example, data was unavailable for nearly 1,400 hospices.
The new website satisfies a provision of the Affordable Care Act that required information be made public about the quality of end-of-life care. Some hospice experts, however, have criticized its implementation as not showing sufficient variation to be helpful to most viewers.
Many high performing hospices
Relatively few hospices scored lower than 80 percent on any measure, said Dr. Joan Teno, a national hospice quality expert at the University of Washington who questioned what value the website has to influence consumer choice or physician referral.
"So many hospices are scoring so highly on this, it's not going to provide consumers with actual information," Teno said Wednesday.
The March Medicare Payment Advisory Commission report called the website's data "limited," and said that for all measures except pain assessment, "at least three-quarters of hospices performed the process appropriately more than 91 percent of the time." For documentation of treatment preferences and shortness of breath screening, scores averaged 98 percent.
Hospice providers have known for several years which measures were being scored, and had a chance earlier this summer to review their data and correct errors.
Some San Diego County hospices scored consistently well. For example, Hospice of the North Coast scored 100 percent in five of the seven measures, and Advantage Health System scored 100 percent in four.
Dr. Karl Steinberg, medical director of Hospice By the Sea in Solana Beach, is on the National Quality Forum standing committee that debates and approves end of life measures for use in health care settings.
Steinberg said he hopes all of the hospices, including his own, will "see how they compare to local and national parameters, and take stock to see what quality improvements they can put in place." He acknowledged room to improve in pain assessment, treatment for patients who are short of breath and asking patients about their beliefs and values. His hospice scored from 80 percent to 84.8 percent on these measures.
Even so, Steinberg said, "I think you have to take it all with a grain of salt, especially when there's not a lot of scatter. If one hospice is 94 percent and one is 92 percent, you don't really know that one hospice is somehow a lot better."
Goodrich acknowledged during a Wednesday news conference that many of the measures do have fairly high performance scores.
"These are measures that hospices have gained a fair amount of familiarity with," she said. They've been in the program for a little while, so we knew we had - based on our own work with the data - fairly valid and reliable data, which is of course is important for anything that's going to be publicly reported," Goodrich said.
Charles Padgett, also of the CMS clinical center, added that the website is particularly helpful if one is looking at a hospice that is at the lower end of quality. "There is differentiation among facilities on the lower end," he said.
More hospice quality measures on the way
But Goodrich said more measures are needed, and some are in the works to score hospice care in other ways. The agency plans eventually to make public patient and family member responses to a survey that reflects family and patient experiences of care.
That survey asks 10 questions such as how often did the hospice workers keep you informed about when they would arrive to care for your family member? Or, how often did the hospice team explain things in a way that was easy to understand? And, how often did anyone from the hospice give you confusing or contradictory information about your family member's condition or care.
Other measures were added for hospice to start reporting in April but are at least a year away from being publicly reported.
According to the Medicare Payment Advisory Commission report, one of those new measures scores the percentage of patients who received a visit from a registered nurse, physician, nurse practitioner or physician assistant during the last three days of life. Another counts the percentage of patients receiving at least two visits from a social worker, chaplain or spiritual counselor, licensed practice nurse or hospice aide in the last seven days of life.
Those are expected to be rolled out in winter of 2018 on the Hospice Compare website.
Another measure still under consideration would score whether symptoms such as pain are brought under control within 48 hours and whether the patient has a comfortable death in the eyes of the family members and how that should be defined.
"By next winter, we're going to have a much more complete picture for consumers and payers to use," said Carol Spence, vice president of research and quality for the National Hospice and Palliative Care Organization.
Spence said measuring care for hospice services has been difficult. "It's come late to the table when it comes to quality reporting," behind scorecards for hospitals, skilled nursing homes and many other health care settings, she said, and that's in part because one-third of patients die within seven days of admission to hospice care.
That doesn't give much time to provide services covered under current measures, Spence said.
While the trend is for more Medicare beneficiaries to choose hospice care at the end of life - it grew from 47.9 percent in 2014 to 48.6 percent in 2015 - average length of stay declined from 88.2 to 86.7 days, with a median of 17 days, according to the Medicare Payment Advisory Commission.
Goodrich also said CMS is working on a composite score that will roll several hospice measures together. She hopes that will be more meaningful to patients and "will also further differentiate performance across providers."
Some hospice providers welcomed the release. Mary Zalaznik, senior vice president of VITAS, a national for-profit company with a hospice in San Diego County, said the data provides insight on how to create quality improvement plans.
"As the site matures, Hospice Compare will include measurements regarding the patient's reported experience along with quality, outcome-based measurements," Zalaznik said.
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