DEPARTMENT OF HEALT H AND HUMA.l~ SERVIC ES 
OFFICE OF INSPECTOR GENERAL 
WASHI NGTON , DC  2020 1 
MAY 0 3 2013 
TO: 	 Marilyn Tavenner 
Acting Administrator 
Centers for Medicare & Medicaid Services 
FROM:  Stuart Wright: 
Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Memorandum Report:  Medicare Hospice :  Use ofGenerallnpatient 
Care, OEI-02-1 0-00490 
This memorandum report describes the use of hospice general inpatient care in 2011.  It 
is part of ongoing work by the Office of Inspector General (OIG) on the Medicare 
hospice benefit.  A companion report will look at the appropriateness ofhospice general 
inpatient care provided to beneficiaries. 
SUMMARY 
Hospice general inpatient care (GIP) is for pain control or symptom management 
provided in an inpatient facility that cannot be managed in other settings.  The care is 
intended to be short-term and is the second most expensive level of hospice care.  GIP 
may be provided in one of three settings:  a Medicare-certified hospice inpatient unit, a 
hospital, or a skilled nursing facility (SNF). 
Centers for Medicare & Medicaid Services (CMS) staff have expressed concerns about 
possible misuse of GIP, such as care being billed for but not provided, long lengths of 
stay, and beneficiaries receiving care unnecessarily. In addition, the Federal govenunent 
recently reached a $2.7 million settlement with a hospice for allegedly billing Medicare 
for GIP when beneficiaries actually received routine home care, which has a lower 
reimbursement rate . 1 
We found that Medicare paid $1 .1 billion for GIP in 2011, most of which was provided in 
hospice inpatient units, as opposed to hospitals or SNFs.  Twenty-three percent of 
1 U .S. Department of Justice, "Hospice Home Care to Pay $2,700,000 Settlement in Medicare Fraud Case," 

December 9, 2011.  Accessed at 

http://www.j usti~~~Q_y/usao/are/news/2011/Dec;ember/Hospice quita[!Ljlf.ttle  12091l.html on April22, 

2013 . 
 Page 2  Marilyn Tavenner 
 
Medicare hospice beneficiaries received GIP during the year.  One-third of beneficiaries 
GIP stays exceeded 5 days, with 11 percent lasting 10 days or more.  The hospices that 
used inpatient units provided GIP to more of their beneficiaries and for longer periods of 
time than hospices that used other settings.  We also found that 953 hospices, or 
27 percent of Medicare hospices, did not provide any GIP to Medicare beneficiaries in 
2011 and that 429 of these hospices did not provide any level of hospice care other than 
routine home care. 
 
These results raise several questions about GIP.  Long lengths of stay and the use of GIP 
in inpatient units need further review to ensure that hospices are using GIP as intended 
and providing the appropriate level of care.  OIG is committed to looking into these 
issues further and will conduct a medical record review that will assess the 
appropriateness of GIP provided in different settings.  CMS should also focus on these 
issues as it considers options for hospice payment reform and for developing hospice 
quality measures.  In particular, CMS should focus on hospices that do not provide GIP 
and ensure that these hospices are providing beneficiaries access to needed levels of care 
at the end of their lives.  One option is for CMS to adopt a quality measure regarding 
hospices ability to provide all hospice services. 
   
BACKGROUND 
 
The goals of hospice care are to help terminally ill beneficiaries continue life with 
minimal disruption and to support beneficiaries families and other caregivers throughout 
the process.  The care may be provided to individuals and their families in various 
settings, including a hospice inpatient unit, the home, or other places of residence, such as 
a SNF or other nursing facility.  In 2011, Medicare paid $13.7 billion for hospice care for 
1.2 million beneficiaries. 
 
To be eligible for Medicare hospice care, a beneficiary must be entitled to Part A of 
Medicare and be certified as having a terminal illness with a life expectancy of 6 months 
or less if the disease runs its normal course.2  Upon a beneficiarys election of hospice 
care, the hospice agency assumes the responsibility for medical care related to the 
beneficiarys terminal illness and related conditions.  This care is palliative, rather than 
curative.  It includes, among other things, nursing care, medical social services, hospice 
aide services (sometimes referred to as home health aide services), medical supplies 
(including drugs and biologicals), and physician services.  The beneficiary waives all 
rights to Medicare payment for services related to the curative treatment of the terminal 
condition or related conditions but retains rights to Medicare payment for services to treat 
conditions unrelated to the terminal illness.3  Beneficiaries may revoke their election of 
hospice care and return to standard Medicare coverage at any time.4 
 
2 Social Security Act,  1814(a)(7)(A) and 1861(dd)(3)(A), 42 U.S.C.  1395f(a)(7)(A) and 
1395x(dd)(3)(A); 42 CFR  418.20 and 418.22.  Certification is based on the physicians or medical 
directors clinical judgment regarding the normal course of the individuals illness. 
3 Social Security Act,  1812(d)(2)(A) and 1861(dd)(1), 42 U.S.C.  1395d(d)(2)(A) and 1395x(dd)(1); 
42 CFR  418.24(d). 
4 Social Security Act,  1812(d)(2)(B), 42 U.S.C.  1395d(d)(2)(B); 42 CFR  418.28. 
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 3  Marilyn Tavenner 
 
Beneficiaries are entitled to receive hospice care for two 90-day periods, followed by an 
unlimited number of 60-day periods.5  The periods need not be consecutive.  At the start 
of each period of care, an attending physician must certify that the beneficiary is 
terminally ill and has a life expectancy of 6 months or less.  For care to be covered under 
Part A, hospices must be certified by Medicare.6  In 2011, there were 3,585 Medicare 
hospices.  Of these, 2,071 were for-profit, 1,237 were nonprofit, and 185 were 
government owned.7   
 
The Medicare hospice benefit is currently undergoing some changes.  Per the Patient 
Protection and Affordable Care Act (ACA), CMS must reform the hospice payment 
system.8  Also, CMS must develop quality measures for hospices and hospices must 
report quality data.  CMS is currently using two quality measures.  The first relates to 
pain management and the second relates to how hospices track patient care.  Beginning in 
2014, hospices must report these measures or face reduced Medicare payments.9   
 
Hospice General Inpatient Care 
The Medicare hospice benefit has four levels of care.10  Each level has an all-inclusive 
daily rate that is paid through Part A.  The rate is paid to the hospice for each day that a 
beneficiary is in hospice care, regardless of the number of services furnished.  The rates 
are adjusted based on the beneficiarys geographic location. 
 
GIP is the second most expensive level of hospice care.  As with all covered hospice 
services, hospices are required to provide GIP if the beneficiary needs it.11  GIP is for 
pain control or symptom management that cannot be managed in other settings, such as 
the beneficiarys home.12  GIP is intended to be short-term and may be provided in one of 
three settings:  a Medicare-certified hospice inpatient unit, a hospital, or SNF.13  A 
Medicare-certified hospice inpatient unit can be freestanding or in space shared with 
another health care facility.  Medicare-certified hospices with inpatient units must comply 
with a number of Federal regulations, ranging from staffing to the dispensing of drugs.14 
 
The other three levels of care are routine home care, continuous home care, and inpatient 
respite care.  Routine home care is the most common.  Medicare reimburses the hospice 
at this rate for each day that the beneficiary is under the care of the hospice and is not 
receiving one of the other levels of care.  Continuous home care is allowed only during 
 
5 Social Security Act,  1812(a)(4), 42 U.S.C.  1395d(a)(4).  Prior to 1990, Medicare provided hospice 
coverage for a maximum of 210 days. 
6 Social Security Act,  1814(a) and 1866, 42 U.S.C.  1395f(a) and 1395cc; 42 CFR  418.116(a).   
7 We did not have information on ownership status for 92 hospices. 
8 Patient Protection and Affordable Care Act (ACA), P.L. 111-148  3132. 
9 ACA, P.L. 111-148  3004; 76 Fed. Reg. 47302, 4732526 (Aug. 4, 2011). 
10 42 CFR  418.302. 
11 Social Security Act,  1861(dd)(2)(A)(i), 42 U.S.C.  1395x(dd)(2)(A)(i). 
12 42 CFR  418.302(b)(4). 
13 42 CFR  418.108(a) and (b).  For GIP, Medicare regulations do not specify what is meant by short 
term. 
14 42 CFR  418.110. 
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 4  Marilyn Tavenner 
 
brief periods of crisis in which a beneficiary requires continuous care to achieve 
palliation or management of acute medical symptoms.  Inpatient respite care is short-term 
inpatient care provided to the beneficiary when necessary to relieve the beneficiarys 
caregiver(s).  It may not be provided consecutively for more than 5 days at a time.15  See 
Table 1 for the unadjusted payment rates for each level of care in fiscal year (FY) 2011. 
 
Table 1:  Unadjusted Daily Medicare Hospice Payment  
Rates by Level of Care, FY 2011 
Unadjusted  
Level of Care 
FY 2011 Rate 
Routine Home Care  $146.63 
Continuous Home Care  $855.79 
General Inpatient Care  $652.27 
Inpatient Respite Care  $151.67 
Source:  CMS, Update to Hospice Payment Rates, Hospice Cap, Hospice Wage  
Index, and the Hospice Pricer for FY 2011, Change Request 7077, July 23, 2010. 
 
Inpatient care is subject to an annual cap.  Medicare limits the total number of days of 
inpatient care (the sum of GIP and inpatient respite care days) for which a hospice may 
be reimbursed.  The cap is set at 20 percent of the hospices total patient care days.16 
 
Related Work 
This report is part of OIGs continuing work related to Medicare hospice care.  Another 
study involving a medical record review of general inpatient claims from 2012 will 
follow this memorandum report.  In 2011, OIG issued a report that found that hospices 
with a high percentage of their Medicare beneficiaries residing in nursing facilities 
received more Medicare payments per beneficiary and served beneficiaries who spent 
more time in hospice care.17  Another report determined that Medicare paid an average of 
$960 per week for hospice care for each beneficiary in a nursing facility.18  This care 
most commonly included nursing, home health aide, and medical social services.  
Hospices provided an average of 4.2 visits per week for these 3 services combined.   
 
OIG also has conducted several studies identifying inappropriate Medicare payments in 
hospice.  OIG found that 82 percent of hospice claims for beneficiaries in nursing 
facilities did not meet Medicare coverage requirements.19  In addition, OIG identified a 
number of cases in which the use of inpatient respite care for beneficiaries in nursing 
facilities may have been inappropriate.20  OIG also found instances in which Medicare 
 
15 42 CFR  418.302(e)(5). 
16 Social Security Act,  1861(dd)(2)(A)(iii), 42 U.S.C.  1395x(dd)(2)(A)(iii); 42 CFR  418.302(f).  
Excess inpatient care days are reimbursed at the routine home care rate.  
17 OIG, Medicare Hospices That Focus on Nursing Facility Residents, OEI-02-10-00070, July 2011. 
18 OIG, Medicare Hospice Care:  Services Provided to Beneficiaries Residing in Nursing Facilities,  
OEI-02-06-00223, September 2009.  Payment for physician services was not included in the analysis.   
19 OIG, Medicare Hospice Care for Beneficiaries in Nursing Facilities:  Compliance With Medicare 
Coverage Requirements, OEI-02-06-00221, September 2009.  
20 OIG, Hospice Beneficiaries Use of Respite Care, OEI-02-06-00222, March 2008. 
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 5  Marilyn Tavenner 
 
paid physicians for services related to a beneficiarys terminal illness under Part B, while 
also paying for physicians services for the terminal illness under Part A.21 
 
In addition, OIG is conducting a study that focuses on discharges from acute care 
hospitals to hospice care.22  It will address how a hospital transfer payment policy for 
early discharges to hospice care would financially affect the Medicare Part A program 
and hospitals. 
 
METHODOLOGY 
 
We based this memorandum report on an analysis of Medicare Part A hospice claims.  
To conduct this analysis, we extracted all Medicare Part A hospice claims from CMSs 
National Claims History file that included service dates for hospice care in 2011 and 
2010.  Part A hospice claims typically cover a 1-month period but could be for shorter 
periods of time.  The level of hospice care, such as GIP, was indicated by a code on the 
claim. 
 
We analyzed the claims data to identify the hospice beneficiaries who received GIP 
during 2011, the number of days that each beneficiary received this care, and the setting 
in which the care was provided.  We also determined from the claims data the terminal 
illness of each beneficiary.  For beneficiaries receiving care at the beginning of 2011, we 
used hospice claims from 2010 to determine the level of care they received when they 
started hospice care. 
 
In addition, we identified all of the Medicare-certified hospices that provided hospice 
care in 2011.  For each hospice, we determined the number of Medicare hospice 
beneficiaries it served, the number of hospice beneficiaries for whom it provided GIP, 
the settings in which it provided GIP, the number of beneficiaries for whom it provided 
other levels of hospice care, and the reimbursements it received for GIP and for all 
hospice care.  We determined each hospices profit status by using Certification and 
Survey Provider Enhanced Reports (CASPER).  If CASPER did not show a 
classification of for-profit, nonprofit, or government owned for a hospice, we used 
information available in the Healthcare Cost Report Information System to determine the 
hospices status. 
 
We grouped hospices according to the number of Medicare beneficiaries each hospice 
served during the year.  We considered a hospice to be large if it provided care to more 
than 320 Medicare beneficiaries in 2011.  We considered a hospice to be small if it 
provided care to 90 or fewer beneficiaries.23 
 
 
21 OIG, Questionable Billing for Physician Services for Hospice Beneficiaries, OEI-02-06-00224, 
September 2010. 
22 OIG, Medicare Could Save Millions by Implementing a Hospital Transfer Payment Policy for Early 
Discharges to Hospice Care, A-01-12-00507, (forthcoming). 
23 Large hospices were those in the top 30th percentile, whereas small hospices were in the bottom 30th 
percentile. 
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 6  Marilyn Tavenner 
 
For the purposes of this memorandum, we use the term GIP stay to refer to the 
continuous days in which a beneficiary received GIP from the same hospice in the same 
setting.  To determine the continuous days a beneficiary received care, we combined 
claims for GIP when they were for the same beneficiary in the same setting, from the 
same hospice, and the start date of a subsequent claim was the same day or the next day 
as the ending date of the previous claim. 
 
Standards 
This study was conducted in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
 
Limitations 
We based this memorandum report on an analysis of Medicare hospice claims.  We did 
not conduct a medical record review and did not determine whether services provided 
were medically necessary. 
   
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 7  Marilyn Tavenner 
 
RESULTS 
 
Medicare Paid More Than $1 Billion for Hospice General Inpatient Care in 2011, 
Most of Which Was Provided in Hospices Inpatient Units, as Opposed to Hospitals 
or SNFs 
Medicare paid $1.1 billion for GIP in 2011.  This is 8 percent of the total $13.7 billion 
that Medicare spent for all hospice care during the year.   
 
Most GIP was provided in hospice inpatient units.  Fifty-eight percent of GIP stays were 
in hospice inpatient units, compared to 33 percent in hospitals and 8 percent in SNFs.24  
In addition, GIP stays in hospice inpatient units accounted for more than two-thirds of the 
total amount Medicare spent on GIP during the year.  In 2011, Medicare paid 
$738 million for GIP provided in hospice inpatient units, $280 million for GIP provided 
in hospitals, and $86 million for this care in SNFs.  These amounts accounted for 
67 percent, 25 percent, and 8 percent of all GIP spending, respectively.  See Figure 1. 
 
Figure 1:  Percentages of GIP Stays and Medicare Spending on GIP  
by Setting, Calendar Year 2011 
100%
90%
g 
n
di 80%
n
e
Sp 70% 67% 
d 
s an 60% 58% 
y
a
St 50%
P 
GI
40%
of  33% 
e 
g 30% 25% 
a
nt
ce 20%
r
e
P 8%  8% 
10%
0%
GIP Stays Dollars Spent on GIP
Hospice Inpatient Units Hospitals SNFs
 
Source:  OIG analysis of CMS data, 2012. 
 
Twenty-three percent of Medicare hospice beneficiaries received GIP in 2011.  
Seventy-one percent of these beneficiaries received GIP at the start of their time in 
hospice care.  The most common terminal illnesses of beneficiaries who received GIP 
were cancer, circulatory disease, respiratory disease, ill-defined conditions, and mental 
disorders.  These terminal illnesses were also the most common in the general hospice 
population. 
 
 
24 Because of rounding, these figures do not add to 100 percent. 
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 8  Marilyn Tavenner 
 
One-Third of GIP Stays Lasted Longer Than 5 Days 
Thirty-three percent of GIP stays in 2011 were longer than 5 days, with some lasting 
much longer than 5 days.  More specifically, 11 percent of all GIP stays were 10 days or 
more.  Two percent of all GIP stays continued for over 3 weeks.  See Figure 2.  Medicare 
policy does not specify a limit on the number of days GIP is allowed, although it is 
intended to be short-term.  The other level of hospice care intended to be short-term, 
inpatient respite care is limited to 5 consecutive days.  Inpatient respite care is used to 
relieve the beneficiarys caregiver(s). 
 
Figure 2:  Percentage of GIP Stays Lasting More Than 5, 10, or 21 Days,  
Calendar Year 2011 
35% 33% 
30%
s  25%
y
a
St
P  20%
GI
All 
of  15%
e 
g 11% 
a
ent 10%
c
r
e
P
5%
2% 
0%
More than 5 days More than 10 days More than 21 days
Length of Stay 
 
Source:  OIG analysis of CMS data, 2012. 
 
GIP stays were much less likely to begin on Sunday or Saturday than on a weekday.  
Eight percent of all GIP stays started on Sundays and 11 percent started on Saturdays, 
whereas at least 16 percent of GIP stays started on each of the other days of the week.  
Because GIP is meant for pain control or symptom management that cannot be managed 
in other settings, we would expect that the percentages of GIP starts during weekend days 
and those during weekdays to be similar.25  In each of the three settings, the lowest 
percentage of GIP stays started on Sundays.  The difference between Sunday and other 
days was greatest in SNFs, where 5 percent of GIP stays started on Sundays and 
19 percent started on Fridays.  See Appendix A. 
 
Unlike the starts of GIP stays, the ends of GIP stays were generally steady throughout the 
week.  Fourteen percent of GIP stays ended on Sundays and 13 percent on Saturdays.  
Thirteen to 16 percent of GIP stays ended on each of the other days of the week.  
 
25 Hospices must make physician and nursing services available (as needed) on a 24-hour basis.  Social 
Security Act,  1861(dd)(2)(A)(i), 42 U.S.C.  1395x(dd)(2)(A)(i).  
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 9  Marilyn Tavenner 
 
 
Hospices That Used Inpatient Units Provided GIP to More of Their Beneficiaries 
and for Longer Periods of Time Than Hospices That Used Other Settings 
Twenty-three percent of all Medicare hospices (809 hospices) provided GIP in inpatient 
units.  Sixty percent of all Medicare hospices (2,163 hospices) provided GIP in hospitals, 
and 27 percent (978 hospices) provided GIP in SNFs.26 
 
The 23 percent of hospices that used inpatient units were more likely than other hospices 
to provide GIP to their beneficiaries.  Hospices that used inpatient units provided GIP to 
35 percent of their beneficiaries.  In contrast, hospices that did not use inpatient units and 
provided GIP in hospitals or SNFs did so for 12 percent of their beneficiaries.  Hospices 
that used inpatient units were also more dependent on GIP dollars.  GIP represented 
13 percent of the total Medicare dollars of hospices that used hospice inpatient units.  In 
contrast, GIP represented 4 percent of the total Medicare dollars of hospices that did not 
use inpatient units and provided GIP in hospitals or SNFs. 
 
GIP stays in inpatient units were typically longer than GIP stays in other settings.  On 
average, GIP stays in inpatient units were 50 percent longer than GIP stays in hospitals 
and 29 percent longer than GIP stays in SNFs.  The average GIP length of stay in an 
inpatient unit lasted 6.1 days, whereas the average GIP length of stay in a hospital was 
4.1 days and the average in a SNF was 4.8 days.  See Figure 3.  GIP stays in inpatient 
units were much more likely than GIP stays in other settings to exceed 5 days.  Forty 
percent of all GIP stays in an inpatient unit exceeded 5 days, compared to 22 percent in 
hospitals and 27 percent in SNFs.  
 
Figure 3:  Average Length of GIP Stays by Setting, Calendar Year 2011 
7
6.1 
6
4.8 
5
y  4.1 
a
St 4
P 
GI
of  3
s 
y
a 2
D
1
0
Inpatient Units Hospitals SNFs
GIP Setting 
 
Source:  OIG analysis of CMS data, 2012.   
 
Hospices that provided GIP in inpatient units were more likely to be large than were 
other hospices that provided GIP.  We considered a hospice to be large if it provided 
 
26 Some hospices provided GIP in more than one setting. 
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 10  Marilyn Tavenner 
 
hospice care to more than 320 Medicare beneficiaries in 2011.  Sixty-two percent of 
hospices that used inpatient units were large, compared to 29 percent of other hospices.  
Hospices that provided GIP in inpatient units served an average of 774 Medicare 
beneficiaries in 2011.  Other hospices that provided GIP served an average of 
292 Medicare beneficiaries.  
 
More Than One Quarter of Hospices Did Not Provide Any General Inpatient Care 
in 2011 
A total of 953 hospices did not provide GIP in 2011.  This represents 27 percent of the 
3,585 Medicare hospices in 2011.  These 953 hospices served 92,803 Medicare hospice 
beneficiaries, but did not provide GIP to any of them during the year.  As with all 
covered hospice services, hospices are required to provide GIP if the beneficiary needs it.  
In general, the beneficiaries served by hospices that did not provide GIP had the same 
terminal illnesses as beneficiaries served by hospices that provided GIP.27  
 
Hospices that did not provide GIP often did not provide other levels of hospice care to 
beneficiaries.  Sixty-eight percent of hospices that did not provide GIP also did not 
provide continuous care, which is a level of hospice care that manages acute medical 
symptoms while the beneficiary remains at home.  Sixty-two percent of hospices that did 
not provide GIP did not provide inpatient respite care, which is short-term inpatient care 
provided to the beneficiary when necessary to relieve the beneficiarys caregiver(s).  Like 
GIP, continuous care and inpatient respite care are covered by Medicare and must be 
provided if needed.  In total, 45 percent of hospices that did not provide GIP also did not 
provide continuous care or inpatient respite care during the year.  These 429 hospices 
provided only routine hospice care to all their beneficiaries throughout 2011. 
 
The hospices that did not provide GIP were more likely than other hospices to be 
for-profit.  In 2011, 69 percent of the hospices that did not provide GIP were for-profit, as 
opposed to 54 percent of hospices that provided GIP.  
 
In addition, hospices that did not provide GIP were more likely than other hospices to be 
small.  We considered a hospice to be small if it provided hospice care to 90 or fewer 
Medicare beneficiaries in 2011.  Sixty-three percent of hospices that did not provide GIP 
were small while 18 percent of hospices that provided GIP were small.   
   
 
27 There were small differences in two terminal illnesses.  Twenty-four percent of beneficiaries from 
hospices that did not provide GIP had cancer, compared to 28 percent of beneficiaries from hospices that 
provided GIP.  Eight percent of beneficiaries from hospices that did not provide GIP had Alzheimers 
disease, compared to 5 percent from the other hospices.  See Appendix A. 
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 11  Marilyn Tavenner 
 
CONCLUSION 
 
GIP is an important level of care for hospice beneficiaries.  We found that Medicare paid 
$1.1 billion for GIP in 2011, most of which was provided in hospice inpatient units, as 
opposed to hospitals or SNFs.  Twenty-three percent of Medicare hospice beneficiaries 
received GIP during the year.  One-third of beneficiaries GIP stays exceeded 5 days, 
with 11 percent lasting 10 days or more.  The hospices that used inpatient units provided 
GIP to more of their beneficiaries and for longer periods of time than hospices that used 
other settings.  We also found that 953 hospices, or 27 percent of Medicare hospices, did 
not provide any GIP to Medicare beneficiaries in 2011 and that 429 of these hospices did 
not provide any level of hospice care other than routine home care.   
 
These results raise several questions about GIP.  Long lengths of stay and the use of GIP 
in inpatient units need further review to ensure that hospices are using GIP as intended 
and providing the appropriate level of care.  OIG is committed to looking into these 
issues further and will conduct a medical record review that will assess the 
appropriateness of GIP provided in different settings.  CMS should also focus on these 
issues as it considers options for hospice payment reform and for developing hospice 
quality measures.  In particular, CMS should focus on hospices that do not provide GIP 
and ensure that these hospices are providing beneficiaries access to needed levels of care 
at the end of their lives.  One option is for CMS to adopt a quality measure regarding 
hospices ability to provide all hospice services.    
 
This report is being issued directly in final form because it contains no recommendations.  
We anticipate making recommendations regarding the use of GIP in a separate report 
after we have completed our medical record review.  If you have comments or questions 
about this report, please provide them within 60 days.  Please refer to report number 
OEI-02-10-00490 in all correspondence. 
   
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 12  Marilyn Tavenner 
 
APPENDIX A  
 
Figure A-1:  Percentage of Hospice General Inpatient Care (GIP) Stays That Started on 
Each Day of the Week by Setting, Calendar Year 2011 
25%
ys  20%
a
t
S
P 
GI
15%
All 
f 
o
e 
g 10%
a
t
n
e
c
r
e 5%
P
0%
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Starting Day of the GIP Stay 
Hospice Inpatient Units Hospitals Skilled Nursing Facilities
 
Source:  Office of Inspector General analysis of Centers for Medicare & Medicaid Services data, 2012. 
 
 
 
   
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)  Page 13  Marilyn Tavenner 
 
APPENDIX B  
 
Figure B-1:  Beneficiary Diagnoses in Hospices That Provided Hospice General Inpatient 
Care (GIP) and in Hospices That Provided No GIP, Calendar Year 2011 
35%
30%
s 
e
ri 25%
a
ci
nefi 20%
e
B
of  15%
e 
g
a
ent 10%
c
r
e
P
5%
0%
Cancers Circulatory Respiratory Ill-Defined Mental Alzheimer's
Diseases Diseases Conditions Disorders Disease
Diagnosis Category of the Terminal Illness 
Hospices that provided no GIP Hospices that provided GIP
 
Source:  Office of Inspector General analysis of Centers for Medicare & Medicaid Services data, 2012.   
 
Medicare Hospice:  Use of General Inpatient Care (OEI-02-10-00490)