Hos­pice providers earn high marks on CMS sat­is­fac­tion sur­veys, but do they re­flect re­al­ity?

Modern Healthcare - - News - By Maria Castel­lucci

In­terim Health­Care has a hard time get­ting the fam­ily mem­bers of its hos­pice pa­tients to com­plete the CMS’ ex­pe­ri­ence sur­vey. The Lub­bock, Texas-based provider works with a third-party ven­dor to dis­trib­ute the sur­veys by mail to fam­i­lies after their loved ones have passed away. But In­terim con­sid­ers it­self lucky when just 25% of fam­ily mem­bers take the time to com­plete and mail back the sur­vey.

“If we send out 30 sur­veys and we get five sur­veys back, there is no telling what the re­sponses will be. Are the five great? Are three bad? It’s a crap­shoot,” said Jen­nifer Bullard, ex­ec­u­tive vice pres­i­dent for In­terim’s Texas and New Mex­ico di­vi­sion, which op­er­ates 14 hos­pice sites.

In­terim is one of more than 4,000 hos­pice providers across the coun­try required by the CMS since 2015 to send out the Con­sumer As­sess­ment of Health­care Providers and Sys­tems Hos­pice Sur- vey to fam­ily mem­bers or risk a 2% Medi­care pay­ment cut.

The re­quire­ment is part of the larger Hos­pice Qual­ity Re­port­ing Pro­gram man­dated un­der the Af­ford­able Care Act in an ef­fort to move the sec­tor to value-based pay­ment. Along with the CAHPS hos­pice sur­vey, the CMS pro­gram re­quires hos­pices to pub­licly re­port data on qual­ity mea­sures.

In late Fe­bru­ary, the CMS for the first time posted find­ings on Hos­pice Com­pare from the CAHPS hos­pice sur­veys, which were gath­ered from April 2015 to March 2017.

The re­sults at first glance are a suc­cess story. A Mod­ern Health­care anal­y­sis shows that for each of the eight mea­sures the CMS uses in the sur­vey, on av­er­age at least 75% of re­spon­dents in­di­cated they re­ceived a pos­i­tive ex­pe­ri­ence. The CMS dataset dis­plays “top box” scores to show the CAHPS re­sults, which is the per­cent­age of re­spon­dents who gave the most pos­i­tive re­sponses for each mea­sure.

But ex­perts are ques­tion­ing the value of the sur­veys for con­sumers con­sid­er­ing the over­whelm­ingly pos­i­tive re­sults and mod­est re­sponse rates. Roughly 33% of fam­ily mem­bers com­plete the CAHPS hos­pice sur­veys on av­er­age.

“It’s un­known how more than two-thirds of fam­ily mem­bers per­ceived their care,” said Dr. Kath­leen Un­roe, as­so­ciate pro­fes­sor of geri­atric medicine at In­di­ana Univer­sity. “If ev­ery­one is do­ing well, is that help­ful in­for­ma­tion? You want it to be use­ful (for pa­tients and fam­ily mem­bers), but it doesn’t feel that use­ful.”

The re­sults come after the CMS had to im­ple­ment a cor­rec­tion to the Hos­pice Com­pare site last year be­cause of in­ac­cu­rate re­port­ing re­gard­ing hos­pice lo­ca­tions and for-profit sta­tus.

The new dataset raised more ques­tions about the value of the re­sults. Ac­cord­ing to the CMS, the 2,795 hos­pices con­sid­ered in the anal­y­sis were on av­er­age strong per­form­ers in the cat­e­gories that in­volved giv­ing pa­tients and fam­ily mem­bers emo­tional and re­li­gious sup­port, with about

90% of re­spon­dents in­di­cat­ing that they got the right kind of sup­port, and 91% of re­spon­dents say­ing that the hos­pice team al­ways treated the pa­tient with re­spect.

Most fam­ily mem­bers said they would rec­om­mend the hos­pice provider, with nearly

85% of re­spon­dents say­ing they had a pos­i­tive ex­pe­ri­ence and 80% also in­di­cat­ing providers com­mu­ni­cated well.

Hos­pices did ex­pe­ri­ence com­par­a­tively lower scores—al­though still strong—for cat­e­gories about help­ing pa­tients with symp­toms and train­ing fam­i­lies to care for loved ones, with

75% of re­spon­dents say­ing they were sat­is­fied.

The Hos­pice Qual­ity Re­port­ing Pro­gram doesn’t yet ding providers if they per­form be­low av­er­age com­pared with their peers, though it likely will soon. If hos­pices don’t re­port qual­ity mea­sures in this fis­cal year, which ends Sept. 30, they will see a 2% re­duc­tion in re­im­burse­ment, ac­cord­ing to the most re­cent CMS re­im­burse­ment fi­nal rule.

In the dataset, there are 1,633 hos­pices that were not in­cluded in the CMS anal­y­sis, but the rea­sons for their ex­clu­sion were not pro­vided. The CMS doesn’t yet know how many hos­pices will re­ceive a penalty.

This pe­riod “gives hos­pices a chance to get fa­mil­iar with the qual­ity mea­sures and im­prove on them prior to be­ing held fi­nan­cially ac­count­able for per­for­mance,” said Re­becca An­hang Price, a se­nior pol­icy re­searcher at the RAND Corp.

Providers ar­gue that the sur­vey re­sults are so strong be­cause the CMS has only just started to gather them. More time is prob­a­bly needed to an­a­lyze the data for trends and vari­a­tion in per­for­mance, said Judi Lund Per­son, vice pres­i­dent of reg­u­la­tory and com­pli­ance at the Na­tional Hos­pice and Pal­lia­tive Care Or­ga­ni­za­tion.

“I think as we get a lit­tle bit fur­ther into the CAHPS sur­veys, we will start to see which ques­tions are pop­ping up” that have more vari­a­tion, she said. “It might not al­ways be rosy. I think it’s go­ing to take some time.”

But the sur­veys are only use­ful in­di­ca­tors of pa­tient ex­pe­ri­ence if the pop­u­la­tions that com­plete them are large enough and di­verse, which ev­i­dence in­di­cates rarely oc­curs.

A re­cent study by Un­roe on the Fam­ily Eval­u­a­tion of Hos­pice Care, a sur­vey hos­pice providers used vol­un­tar­ily be­fore the CAHPS sur­vey, shows that whites are more likely to re­turn the sur­vey than blacks, as well as those with fam­ily mem­bers who were on hos­pice for longer than six months. The re­sponse rate for this sur­vey was also low in the study, 27%. Un­roe said it’s im­por­tant for the CMS to be trans­par­ent about the pop­u­la­tions rep­re­sented and those un­der­rep­re­sented in the sur­veys. “How are they go­ing to com­pen­sate (for the un­der­rep­re­sented pa­tients)? Is there go­ing to be ad­di­tional out­reach?” she added.

A CMS spokes­woman said the agency con­tin­ues to eval­u­ate the find­ings from the CAHPS hos­pice sur­veys “and wel­comes sug­ges­tions that can make the sur­vey re­sults more mean­ing­ful for our ben­e­fi­cia­ries.”

The CMS also an­nounced last week that it’s look­ing to add new qual­ity mea­sures to the Hos­pice Qual­ity Re­port­ing Pro­gram “that ad­dress ad­di­tional iden­ti­fied gaps in hos­pice qual­ity mea­sure­ment.” The agency is tak­ing sug­ges­tions from stake­hold­ers un­til April 25.

Un­roe said the CMS should not only mon­i­tor the sur­veys for vari­a­tion in the re­sults but also

pro­vide as much in­for­ma­tion as pos­si­ble about the sur­vey re­spon­dents and their loved ones. “Peo­ple are in hos­pice for dif­fer­ent rea­sons and di­ag­noses. … It’s im­por­tant to have as much in­for­ma­tion as pos­si­ble to guide pa­tients and fam­i­lies to the right de­ci­sions for them,” she said.

How­ever, Price at RAND said she thinks con­sumers likely see vari­a­tion be­tween hos­pices when they use Hos­pice Com­pare be­cause they are only com­par­ing one or two providers in­stead of a large dataset. “CAHPS sur­veys have been shown to re­li­ably dis­tin­guish the per­for­mance be­tween hos­pices,” she said.

Hin­der­ing the re­sponse rate

Hos­pice providers said if the sur­veys could be done by fam­ily mem­bers elec­tron­i­cally, it might boost re­sponse rates. Right now, the third-party ven­dors send sur­veys by mail, over the phone or both.

“If we could move up in tech­nol­ogy and email the sur­vey, or text it, I think we’d get a much higher re­turn rate—I throw away a lot of mail,” said Dr. Michael Rof­fers, chief med­i­cal of­fi­cer for In­terim’s op­er­a­tions in Texas and New Mex­ico.

The CMS said it’s cur­rently eval­u­at­ing al­ter­na­tive modes of CAHPS sur­vey ad­min­is­tra­tion, in­clud­ing email.

The CMS also doesn’t al­low the ven­dors to put the logo of the hos­pice provider on the mailed pack­age, so fam­ily mem­bers can eas­ily throw away the sur­vey by mis­take.

The length of the sur­vey, 47 ques­tions, also could be a con­trib­u­tor to the low re­sponse rates, Bullard said.

She added that the ques­tions can eas­ily be con­fus­ing for fam­ily mem­bers if they don’t read them care­fully. The sur­vey has sim­i­lar ques­tions phrased in dif­fer­ent ways as a tac­tic to elicit con­sis­tent re­sponses. Bullard won­ders if some­times peo­ple just mis­un­der­stand how ques­tions are worded and an­swer in­cor­rectly.

But hos­pice providers can’t fol­low up with fam­ily mem­bers to fur­ther dis­cuss their an­swers. The CMS re­quires ven­dors to de-iden­tify the re­spon­dents when they send the re­sults back to the hos­pice providers.

“There are a very spe­cific set of rules by the CMS,” said Tony Kud­ner, vice pres­i­dent of Sea­sons Hos­pice and Pal­lia­tive Care, based in Rose­mont, Ill. “You have to be very com­pli­ant and care­ful.”

De­spite the lim­i­ta­tions, providers say the sur­vey re­sults can still help them im­prove care.

For in­stance, Sea­sons Hos­pice used the sur­veys to im­prove how it treats pa­tients’ pain after re­sponses showed some fam­ily mem­bers weren’t sat­is­fied.

After re­view­ing its scores, Sea­sons in late 2016 im­ple­mented SNAP, which stands for short­ness of breath, nau­sea, anx­i­ety and pain. Each hos­pice team mem­ber is now trained to check for each of th­ese things through con­ver­sa­tions with the pa­tient or fam­ily mem­ber dur­ing ev­ery visit.

Sea­sons also ramped up its use of qual­ity im­prove­ment spe­cial­ists shortly after the Hos­pice Qual­ity Re­port­ing Pro­gram went into place.

“We have a di­rec­tor and vice pres­i­dent of qual­ity, and then we have folks at ev­ery one of our sites who are re­spon­si­ble for mon­i­tor­ing and in­ter­pret­ing the re­sults so we can put some spe­cific plans in place—con­tin­u­ing to do the good stuff or work­ing on the stuff where folks are say­ing there is room for im­prove­ment,” Kud­ner said.

The 2% re­duc­tion in Medi­care pay­ment is a “huge mo­ti­va­tion” for hos­pices to re­port and re­view their sur­veys, Per­son at NHPCO said, es­pe­cially be­cause hos­pices only re­ceived a 1% bump in Medi­care pay­ments in 2018, down from the 2.1% in­crease they re­ceived in 2017.

At In­terim, there’s a grow­ing fo­cus on fol­low­ing up with the fam­ily mem­bers dur­ing treat­ment to en­sure all their needs are be­ing met. Bullard said the new in­for­ma­tion on Hos­pice Com­pare has been es­pe­cially help­ful.

“I do love it be­cause you can see how you’re do­ing next to your com­peti­tors,” Bullard said. “We can say all day long we give great care, but if our num­bers don’t add up, it doesn’t

● mean much.”

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