Medicare Hospice: CMS Needs to Fully Implement Statutory Provisions and Prioritize Certain Overdue Surveys
Fast Facts
Medicare is required to monitor hospices through surveys every 3 years. Surveys can find serious quality issues, raising concerns about the adequacy of care and triggering additional monitoring.
About 15% of hospices were cited with serious quality issues from 2020 through 2022. Medicare is working on, but hasn't fully implemented, enforcement tools—such as fines—to help bring hospices like these into compliance.
In addition, as of May 2023, about 10% of hospices were overdue for a survey—partly due to funding and staffing issues at the state agencies that conduct these surveys.
We recommended addressing these and other issues we found.
Highlights
What GAO Found
Federal law defines the quality standards that hospices must meet to participate in the Medicare program. The Centers for Medicare & Medicaid Services (CMS) monitors compliance with these standards through inspections—referred to as standard surveys—to be carried out at least every 3 years. Serious quality deficiencies cited on a survey indicate the hospice may not have the capacity to furnish adequate care or may adversely affect the health and safety of patients.
CMS has fully implemented five and partially implemented three of the eight provisions related to hospice oversight required through the Consolidated Appropriations Act, 2021 (CAA). For example, CMS has not issued planned internal guidance that would enable consistent use of new enforcement tools for hospices not complying with quality standards. Implementing these provisions would help ensure CMS meets its statutory obligations for hospice oversight.
GAO also found that about 15 percent of hospices that had at least one standard survey in each 3-year reporting cycle between 2017 and 2022 were cited with serious quality deficiencies, and most were cited with multiple such deficiencies. CMS policy requires that these hospices undergo additional monitoring and face termination from the Medicare program without timely resolution; according to CMS officials, 18 hospices were terminated between 2017 and 2022.
As of May 2023, about 10 percent of hospices participating in Medicare for 36 months or more were overdue for a survey. Of the hospices with overdue surveys, over one quarter had not had a standard survey in at least 5 years. In addition, 17 percent had at least one previous serious quality deficiency, and about 11 percent had a previous complaint that was severe and substantiated. CMS defines survey priorities each year, but does not provide any direction to prioritize among overdue surveys. CMS has noted that funding and staffing issues at state agencies, which conduct the surveys, as well as the COVID-19 public health emergency, have constrained the timely completion of surveys. Prioritizing among overdue standard surveys for hospices based on potential risk factors, such as previous quality issues, could help target such hospices.
Hospices with Overdue Surveys, by the Length of Time Overdue, as of May 2023
Why GAO Did This Study
In fiscal year 2022, over 1.7 million Medicare beneficiaries received hospice care. GAO and the Department of Health and Human Services' (HHS) Office of Inspector General have reported on the need to strengthen oversight to protect Medicare beneficiaries receiving hospice services.
The CAA included a provision for GAO to report on hospice quality of care and CMS's oversight of such care. This report addresses, among other things, CMS's implementation of hospice-related CAA provisions; the extent to which hospices were cited for serious quality deficiencies from 2017 through 2022; and the number of hospices with overdue surveys, and CMS's efforts to prioritize survey administration.
GAO reviewed CMS documentation and interviewed CMS officials, provider and consumer groups, and surveyors. GAO also analyzed CMS data on hospice surveys from 2017 through 2022 for hospices that had at least one standard survey in each of the two 3-year reporting cycles during this time. To count the number of hospices with overdue surveys, GAO reviewed data provided by CMS as of May 2023.
Recommendations
GAO is making four recommendations to CMS, including that the agency fully implement the remaining three CAA provisions, and prioritize completion of standard surveys for those hospices that are overdue based on potential risk factors. HHS agreed with three recommendations, but disagreed with prioritizing survey completion based on risk factors. GAO continues to believe this recommendation is warranted.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Medicare & Medicaid Services | The CMS Administrator should fully implement the new enforcement tools, including issuing planned internal guidance, to enable the agency to use these tools to address hospices out of compliance with Medicare quality standards. (Recommendation 1) |
In May 2024, CMS issued guidance for surveyors to assist and promote consistency in applying remedies for hospices that are determined to be out of compliance with Medicare requirements. The guidance includes factors to consider for enforcement tool selection, as well as tool-specific considerations and procedures.
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| Centers for Medicare & Medicaid Services | The CMS Administrator should make hospice survey results publicly available on Care Compare such that the information is prominent, easily accessible, and readily understandable. (Recommendation 2) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Centers for Medicare & Medicaid Services | The CMS Administrator should fully implement efforts to measure and reduce inconsistency in survey results among all surveyors, including SAs and AOs. (Recommendation 3) |
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
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| Centers for Medicare & Medicaid Services | The CMS Administrator should instruct SAs and AOs to prioritize the completion of standard surveys for hospices that are overdue for a survey based on potential risk factors, which could include the amount of time overdue or evidence of past quality issues. (Recommendation 4) |
CMS disagreed with this recommendation. However, in June 2024, the agency shared that it had recently received supplemental funding to assist with the overdue hospice standard surveys and was exploring ways to use contracted surveyors to assist the SAs with the backlog by prioritizing the states with hospices that are most at risk for not complying with health and safety standards. As of July 2024, CMS had not yet instructed SAs and AOs to prioritize the completion of their overdue hospice surveys based on potential risk factors, and we consider this recommendation open. We will continue to monitor agency action in this area.
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