Hot Topics in Hospice Regulatory and Quality Matters

– A Review of 2020 Updates

By Sherita Castille, PharmD.

Header Image



There is value in the adage “It’s not what you say, but how you say it”.  The same can be said for our actions.  Therefore, it is difficult to separate regulations (the what) from quality (the how).  NHPCO states “A successful organization’s compliance program should be made up of regulatory compliance, which includes adherence to the federal Conditions of Participation as well as regulations from CMS and those from your state.  Just as important is a quality compliance program, which includes participation in quality measures, assessment, and improvement.”  In the latter 2019 hospice providers consistently heard the buzz of rates changes with the majority being finalized October 1, 2020.   This review will outline a few of the hospice updates and more importantly provide a better understanding of the changes and how these regulatory amendments will improve the quality of care for those we serve.


HOSPICE Act would increase survey frequency, redesign surveyor training

According to Hospice News, recent legislation in the U.S. House of Representatives calls for increasing the frequency of hospice compliance surveys every two years as opposed to the current policy of every three years. Among other provisions, the bill would also take steps to improve surveyor education and training.

Under the HOSPICE act or “Helping Our Senior Population in Comfort Environments Act” national accreditation bodies would have greater public transparency.  All the information submitted will be published on the public website of the Centers for Medicare & Medicaid Services.  Each state will provide surveyors comprehensive training, no later than October 1, 2021.  After this date, all surveyors must successfully complete a training and testing program in survey and certification techniques that have been approved by the Secretary.

The HOSPICE Act is designed to bring hospice oversight in line with that of other post-acute care settings by providing the U.S. Department of Health and Human Services with new powers to oversee and penalize hospices found to have serious quality deficiencies, develop more stringent CMS and state agency surveys and improve surveyor training, as well as increase transparency for patients and families, including a requirement that states establish toll-free hotlines through which families could report abuse or neglect.

This act will empower patients and families when deciding which agency should be entrusted to navigate their loved ones end of life journey.  This partnership is profound and should never be taken lightly.  The HOSPICE Act will provide the structure to keep hospice providers honest, but more importantly, create an environment where iron sharpens iron by creating a NEW standard of excellence.


Fiscal Year 2020 Hospice Payment Rate Update Final Rule (CMS-1714-F)

CMS finalized changes to the hospice payment rates to improve payment accuracy within the system. CMS used 3 years of hospice cost report data to analyze reported costs by level of care with reimbursement rates for each level of care.  This rule finalizes the rebasing of the continuous home care (CHC), general inpatient care (GIP), and the inpatient respite care (IRC) per diem payment rates, thus closing reimbursement gaps.  These areas received a 2.6% rate increase, while routine home care (RHC) rates decreased by 2.72%.


FY2020 Rebased Rates for CHC, IRC and GIP


RHC Rates FY2020


Prior to this ruling, there was a significant gap between the average cost per day of reimbursement rates when caring for patients on Continuous Home Care (CHC), Inpatient Respite Care and General Inpatient Care. According to CMS the payment gap for these levels of care was as much as 161%.  The 2020 updates ensure that funds are more appropriately distributed among the levels of care.  The reduction in payment for Routine Home Care (RHC) is not as significant as you may think.  In fact, the reduction would only result in 19%, equating to approximately $0.37 on RHC for service Days 1 through 60 and $0.29 for service days 61+, as compared to 2019 payment rates.

The rule also finalizes modifications to the election statement by requiring hospices, upon request, to furnish an election statement addendum effective beginning in FY 2021.  The addendum will list those items, services, and drugs the hospice has determined to be unrelated to the terminal illness and related conditions, increasing coverage transparency.  The new election statement would list items, drugs, or services that will not be covered by the hospice because the hospice has determined that these items, drugs, or services are to treat a condition that is unrelated to the terminal illness and related conditions.  Beneficiaries would also receive cost‐sharing information for hospice.

Addendum Details

  • Addendum only would be furnished to beneficiaries, their representatives, non- hospice providers, or Medicare contractors who request such information.
  • If requested at the time of hospice election, the hospice must produce addendum information within 5 days from the start of hospice care
  • If requested during the course of hospice, hospice has 72 hours to provide an addendum
  • If the beneficiary requests the election statement at the time of hospice election but dies within 5 days, the hospice would not be required to furnish the addendum.

It is our obligation to be good stewards to ensure our healthcare system works well for all of us.  After all, we are equally invested.  This information will enable patients and families to make an informed decision when deciding to elect hospice.  These changes will go into effect on October 1, 2020.


The quality of our Healthcare System was on display and under the national spotlight with the passing of the Affordable Care Act in 2012.  Requirements like Hospice Quality Reporting Program (HQRP) took a closer look at hospice quality measures.  The two components that made up HQRP included Hospice Item Set (HIS) and CAHPS surveys.

  • Hospice Item Set (HIS)… A component of the HQRP for the FY 2016 APU and subsequent years. HIS is a patient-level data collection tool developed by CMS. Hospices are required to submit a HIS-­Admission record and an HIS­-Discharge record for each patient.
  • CAHPS® Hospice Survey… A component of the HQRP for the FY 2017 APU and subsequent years. CAHPS Hospice is a post-death family caregiver survey developed by CMS for the assessment of patient and family experiences with hospice care.

These surveys allowed hospices to be compared on a national level.  For the first time, patients and families could evaluate the quality of hospice services such as pain control or symptom management.

This February CMS announced that the Hospice Outcomes Patient Evaluation (HOPE) assessment program would begin the alpha testing phase.  The HOPE assessment is designed to be a centralized database to evaluate a patient’s hospice experience.  The HOPE data collected is more comprehensive.  CMS will be able to better understand how to care for patients at end-of-life, provide hospice with information to better address patient & family needs and ultimately improve the quality of services.  Because all Medicare-certified hospices will be collecting the same assessment items, CMS will be able to recognize the differences between hospices and ultimately identify opportunities for quality improvement.

Hospice Quality Resources

I’m still of the opinion that words are powerful.  They instruct us how to complete simple tasks, comfort us in times of need and inspire us to achieve great things.  But at the end of the day, nothing changes unless we are compelled to move.  It’s a movement that makes the difference.  CMS will continue to evaluate spending and seek ways to reduce waste.  CMS will continue to identify oversites and increase transparency proving ultimately actions speak louder than words.