Trends in Hospice Quality Oversight and Key Challenges to Making it More Effective, 2006-2015

Abstract

Background: Given the limited ability of hospice patients to assess, monitor, and respond to substandard care, quality oversight has an important role to play in the hospice sector. The IMPACT Act of 2014 required that agencies be recertified at least every three years, but it did not otherwise alter hospice quality oversight. Objectives: To illuminate the current hospice quality oversight process and discuss its role alongside other government monitoring and public reporting efforts. Methods: Retrospective analysis (2006-2015) concerning hospice accreditation status, deficiency trends, survey frequency and deficiency outcomes, and termination from the Medicare program. Results: The proportion of privately accredited hospice agencies increased from 15% to 39%, a trend driven largely by its increased use among for-profit agencies. The combined rate of deficiencies per agency increased 35% over the past decade, with issues around care planning, aide and homemaker services, and clinical assessment featured most prominently. Nearly half (45%) of all surveys resulted in deficiency citations; however, less than one-in-four hospice agencies were surveyed in a given year. Over the past decade, 28 agencies were terminated from the Medicare program; most of these agencies were unaccredited and operated on a for-profit basis. Conclusions: The IMPACT Act addressed one of the biggest shortcomings in hospice oversight. Our findings highlight additional reforms that could be considered. First, reporting inspection results from private and public recertification surveys could promote greater transparency and accountability. Second, making a wider range of intermediate sanctions available to oversight agencies could enhance enforcement efforts and, ideally, incentivize agencies to improve quality of care.