To be eligible for the Medicare hospice benefit, an individual must be eligible for Medicare Part A (which covers inpatient care) and be medically certified as having a terminal illness with a life expectancy of 6 months or less if the illness runs it normal course. For individuals to receive care from a Medicare-approved hospice program, they must elect the hospice benefit by signing a statement indicating they are waiving their rights to Medicare payment for services related to curative treatment of their terminal illness. When enrolling in Medicare hospice care, beneficiaries can receive several different types of services in various settings. Most hospice beneficiaries receive hospice care in their own home, but they can also receive care in other settings, such as a nursing home, assisted living facility, hospice facility, or hospital. The Medicare hospice benefit covers a variety of services and supplies for the palliation and management of the terminal illness, including physician and nursing services, medical equipment and supplies including drugs for pain and symptom management, hospice aide and homemaker services, physical and occupational therapy, and spiritual and grief and loss counseling. A hospice interdisciplinary team (in collaboration with the beneficiary’s primary care provider, if any) works with the beneficiary, family, and caregiver(s) to develop a plan of care that addresses the physical, psychosocial, spiritual, and emotional needs of the beneficiary, family members, and caregiver(s). The hospice provider must make all services under the Medicare hospice benefit available to beneficiaries as needed, 24 hours a day, 7 days a week. Although hospice care is designed for beneficiaries with a life expectancy of 6 months or less, beneficiaries can receive hospice care beyond 6 months if they continue to meet hospice eligibility requirements. In addition, beneficiaries can disenroll from the hospice benefit at any time and re-enroll in hospice care at a later time. CMS pays hospices based on the level of hospice care provided to beneficiaries on a given day. There are four levels of hospice care, which are paid at either a daily rate or an hourly rate depending on the location and intensity of services provided. (See table 1.) Each care level has a payment rate that is adjusted for geographic differences in wages, and CMS updates these payment rates annually. The most common level of care is called routine home care (accounting for 98 percent of all Medicare hospice care in 2017), and hospices receive the routine home care payment daily rate regardless of whether beneficiaries receive any services on a given day. In addition, CMS imposes two payment limitations (referred to as caps) on Medicare payment for hospice services—one that limits a hospice’s number of inpatient days and one that limits a hospice’s total Medicare payments in a given year. In response to requirements in the Patient Protection and Affordable Care Act, CMS established the Hospice Quality Reporting Program, which currently includes two sets of data to assess the quality of hospice providers’ care; CMS publishes these data on its Hospice Compare website. Medicare hospice providers are required to submit these data to CMS for all patients regardless of payer source (e.g., Medicare, Medicaid, or private insurance). The two data sets are the following: Provider-reported quality measure data. This set of data (which CMS refers to as the Hospice Item Set) is used to calculate a hospice provider’s performance on quality measures, which include seven measures that reflect the percentage of all hospice patients’ stays where the provider completed various key care processes, such as screening patients for pain and shortness of breath. CMS also recently implemented an eighth measure, called the composite measure, which calculates the percentage of patients’ hospice stays in which the hospice provider completed all seven care process quality measures. Caregivers’ experience survey data. This set of data (referred to as the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey) is a national survey that captures, from the caregiver’s (family member or friend) perspective, the patient’s experience with hospice care. The survey includes questions that are used to calculate eight quality measures based on survey responses. For example, one measure scores how well the hospice communicated with the patient’s family. CMS oversees the quality of Medicare hospice care primarily through inspections—referred to as surveys—which are conducted by state survey agencies contracted by CMS or CMS-approved national private accrediting organizations. These surveys are used to determine whether the hospice is in compliance with federal health and safety requirements detailed in Medicare’s hospice conditions of participation. A hospice must be in compliance with these conditions to participate in the Medicare program. Medicare’s hospice conditions of participation include requirements related to patient care and organizational environment (e.g., the hospice must organize, manage, and administer its resources to provide necessary care). Each condition of participation is composed of standards associated with the condition, and a standard may have associated sub-components. For example, the “patient’s rights” condition includes standards such as “notice of rights and responsibilities” and “rights of the patient.” The “rights of the patient” standard includes sub- components, such as the patient has the right to receive effective pain management and symptom control. There are three main types of survey inspections—an initial certification survey when a provider first seeks to participate in Medicare; a re- certification survey to ensure ongoing compliance; and surveys to investigate complaints or incidents related to federal requirements. If a hospice is found to be out of compliance with hospice health and safety requirements during a survey, CMS cites the provider for non- compliance—referred to as a deficiency. These deficiencies are categorized at one of two levels: Condition-level deficiencies. These deficiencies are the most serious. A condition-level deficiency is one in which the provider violates one or more standards and the deficiencies are of such character as to substantially limit the provider’s capacity to furnish adequate care or which adversely affect the health and safety of patients. When a hospice provider is cited for a condition-level deficiency, CMS places the provider on a 90-day termination track (or 23 days if the situation is determined to pose “immediate jeopardy” to beneficiaries) within which the provider must correct the issue(s) and the correction must be confirmed via a follow-up survey visit. If this does not happen within 90 days of the survey date, CMS terminates the hospice’s Medicare provider agreement; termination is an enforcement remedy CMS uses to ensure compliance. Standard-level deficiencies. These deficiencies are less serious. A hospice provider that has a standard-level deficiency can be certified or re-certified only if the provider has submitted an acceptable plan of correction for achieving compliance within a reasonable period of time. According to CMS officials, standard-level deficiencies must also have follow-up to ensure correction, although the type of follow-up depends on the nature of the deficiency. If a standard-level deficiency is very minor and does not place any beneficiaries at risk, the follow-up may be handled through email or telephone instead of a follow-up visit. According to CMS officials, if a provider fails to submit or implement an acceptable plan of correction within a reasonable period of time acceptable to CMS, the provider is placed on the 90-day termination track noted above. For-profit and non-profit hospices served roughly the same percentage of the approximately 1.5 million Medicare hospice beneficiaries in 2017, even though for-profit hospices make up about two-thirds of all hospice providers. According to our analysis of CMS data, for-profit providers treated about 50 percent of those beneficiaries and non-profit providers treated about 48 percent in 2017. This distribution has been about the same in each year from 2014 through 2017. For example, for these years, the percentages of beneficiaries treated by for-profit providers ranged from 48.7 percent to 50.2 percent (see additional details in app. I, table 7). When comparing the beneficiary populations treated by for-profit and non- profit hospice providers, we found that they generally had similar demographic characteristics. We identified two primary exceptions to this general finding: (1) non-profit hospices had slightly higher percentages of white beneficiaries, and (2) for-profit hospices had a greater proportion of patients enrolled in both Medicare and Medicaid. See table 2 (for more detailed data, see app. I, table 8). While beneficiary demographic characteristics were generally similar, we found differences in beneficiary diagnoses between for-profit and non- profit hospices. Specifically, for-profit hospices had, on average, a greater percentage of patients with non-cancer diagnoses—77 percent of for-profit hospice beneficiaries compared to 69 percent of non-profit hospice beneficiaries in 2017. Our analysis found that for-profit providers received a higher proportion of Medicare hospice payments than did non-profit providers. For 2017, about $10.4 billion (58 percent) of the $17.9 billion dollars in Medicare payments were made to for-profit providers and $7.2 billion (40 percent) of payments were to non-profit providers. Our analysis found this same pattern in each year from 2014 through 2017. One reason for-profit hospices received a higher portion of Medicare hospice payments for the period we reviewed is because (as previously noted) they had, on average, a greater percentage of beneficiaries with non-cancer diagnoses, and we found non-cancer beneficiaries, on average, had longer lengths of stay. (See table 3.) Since hospices are typically paid a set amount per day of a hospice stay, longer stays generally result in higher payments. Beneficiaries with non-cancer diagnoses can often have longer lengths of stay compared to other beneficiaries because the progression of these diseases (such as dementia) can be harder to predict; this may result in beneficiaries being enrolled in hospice earlier than appropriate (meaning that their projected life expectancy may actually be longer than 6 months). For instance, one study noted that dementia beneficiaries’ decline may include periods of stabilization where their health stays the same or even improves, which differs from a constant and predictable decline in most beneficiaries with terminal cancer. There are likely other factors beyond a greater percentage of beneficiaries with non-cancer diagnoses that contributed to for-profit providers’ higher portion of Medicare hospice payments. We found that for-profit providers had, on average, longer lengths of stay for both cancer and non-cancer beneficiaries compared to non-profit providers. (See table 3.) For example, non-cancer beneficiaries at for-profit providers had an average length of stay of 108 days, while non-cancer beneficiaries at non- profit providers had an average length of stay of 67 days. This suggests other factors besides beneficiary diagnosis contributed to longer average length of stay for for-profit providers. (For more detailed beneficiary diagnosis data from 2014 to 2017, see app. I, table 9.) For-profit and non-profit hospice providers had similar scores on CMS’s current quality measures (provider-reported measures and caregivers’ experience measures assessed through a survey of the beneficiaries’ caregiver). CMS uses these measures to assess the quality of care provided by hospices. In addition to CMS’s current quality measures, researchers we interviewed noted that there are other care indicators that can also be used to assess the quality of care provided by hospices. According to CMS documents, CMS is working to account for other care indicators by developing additional quality measures. We assessed hospice providers’ performance on these indicators and found that performance varied between for-profit and non-profit hospices. Our review of CMS data found that for 2017, both for-profit and non-profit hospices, on average, had similar scores on the seven quality measures that are provider-reported and that CMS currently uses to assess the quality of hospice care. (See table 4.) For six of the seven measures, for-profit and non-profit hospices had average scores of 94.7 percent or better. We also found that for-profits and non-profits had similar scores (83.6 percent and 87.0 percent, respectively) on a new composite measure that CMS implemented in 2017. This composite measure was designed to provide a more comprehensive evaluation of the hospice’s care by determining whether the hospice provider completed all of the applicable parts of hospice care that are measured by the seven quality measures. When looking at the subset of providers with the lowest scores on the composite quality measure, we found that for-profit hospices were more often in this subset, even when accounting for differences in the number of for-profit and non-profit providers: For the composite measure, there were 329 providers (261 for-profits and 68 non-profits) in the 10th percentile of scores or lower, meaning that the providers had a composite measure score of 64.3 percent or lower. Among these providers, we found that for-profits were more likely to be within this grouping, with about 12 percent of all for-profit providers having scores in the 10th percentile or lower compared to 6 percent of all non-profit providers. We also assessed the subset of these 329 providers that had composite measure scores below 50 percent, meaning that they only completed all of CMS’s seven quality measures for half or fewer of the beneficiaries they treated. We found that 130 providers (112 for-profits and 18 non-profits) had scores below 50 percent on this measure. These providers treated over 24,000 beneficiaries. In addition to the provider-reported quality measures, CMS also uses the caregivers’ experience survey to assess quality of care. We analyzed CMS data on caregivers’ experience surveys for 2016 to 2017 and found that caregivers’ reported experience with hospice care was generally similar for both for-profits and non-profits. The survey assesses care in a number of areas, such as communication, training, and help with pain and symptoms. See table 5 (for more detailed data, see app. I, table 10). Although for-profit and non-profit providers’ average scores on the caregivers’ experience survey were generally similar, we found that for- profit providers were more often among those providers with the lowest scores on certain caregivers’ experience measures than were non-profit providers. For example, on the rating measure that asks caregivers to give an overall rating of the hospice, 290 providers (248 for-profit providers and 42 non-profits) had scores at the 10th percentile or lower, meaning that their score was 72 percent or lower. For this measure, lower scores mean that fewer caregivers provided a rating of 9 or 10 on a 10- point scale, with 10 being the highest possible rating. We found that 15 percent of for-profit providers were among providers with scores in the 10th percentile or lower compared to 4 percent of non-profit providers. We used Medicare claims data to calculate certain measures researchers told us could be indicators of quality of care in hospice settings. (As noted previously, CMS is working to account for other care indicators by developing additional quality measures.) These indicators fall into two categories: (1) the number of beneficiaries discharged prior to death (often referred to as the live discharge rate) and (2) provider visits to provide medical and emotional support to the beneficiary and caregivers near the end of a beneficiary’s life. Researchers told us that such measures can fill gaps in assessing the quality of care provided by hospices, and show greater variability across hospices than CMS’s current quality measures; as previously noted, our data analysis found that providers’ quality measure scores were generally very high. According to researchers we interviewed and studies we reviewed, some discharges from hospice care prior to death should be expected because, for example, patients change their mind about receiving hospice care or their condition improves and they are no longer eligible for hospice care. However, a high live discharge rate could in some cases be an indicator of poor quality of care provided or of provider misuse of the benefit, in that they may be enrolling beneficiaries who are not eligible for hospice. See text box. Live Discharges In some cases, a beneficiary may be discharged alive from hospice care prior to their death. This could be for reasons unrelated to the quality of care provided. For example, beneficiaries may reconsider their decision to start palliative treatment, and therefore leave hospice care to re-start curative treatments. In other instances, a live discharge may indicate quality of care issues. For example, a beneficiary may be unhappy with the quality of care she is receiving from her hospice provider and therefore she leaves that hospice provider to seek treatment from a different hospice provider. Given the various reasons for live discharges, we expect that hospices will have some live discharges, but interpret a high rate of live discharges as potentially suggestive of quality of care issues. We found that for-profits had higher rates of live discharges than non- profits, with 22.1 percent of beneficiaries served by for-profits being discharged alive compared to 12.0 percent of beneficiaries served by non-profits in 2017. This disparity remained true after accounting for whether beneficiaries had a cancer or non-cancer diagnosis. (See table 6; for more detailed data from 2014 to 2017, see app. I, table 11.) We found that 472 hospice providers (462 for-profit and 10 non-profit providers) had live discharge rates of 50 percent or more in 2017, meaning that half or more of their beneficiaries were discharged from hospice care prior to death. These providers provided care to about 6 percent of all beneficiaries discharged alive in 2017. According to researchers we interviewed and one of the studies we reviewed, provider visits near the end of a hospice beneficiary’s life are critical to providing quality care, including for emotional support and for training the beneficiary’s family members or other caregivers on the signs and process of dying. Assessing the number of visits near the end of life may provide insight into the quality of a hospice provider’s care; fewer visits in that time period could indicate poor quality of hospice care. CMS is currently developing a quality measure that assesses the frequency of provider visits at the beneficiary’s end of life. When analyzing CMS claims data, we found that for-profit and non-profit hospices, on average, provided a similar number of provider visits (such as nurse, doctor, social worker, or hospice aide visits) within the last 7 days of a beneficiary’s life. Specifically, in 2017, for-profits and non-profits both averaged about 6 provider visits within the last 7 days of life. We also looked at the average percentage of hospice beneficiaries who received different types of provider visits either within the last 3 days of life or last 7 days of life (consistent with CMS’s new quality measure) and found performance varied among for-profit and non-profit providers: 77 percent of for-profit beneficiaries and 85 percent of non-profit beneficiaries received at least one visit from registered nurses, physicians, or nurse practitioners in the last 3 days of life. 68 percent of for-profit beneficiaries and 57 percent of non-profit beneficiaries received at least two visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life. We also found more for-profits than non-profits among a subset of hospices that did not provide any visits during the last 3 or 7 days of life in 2017. Specifically, our analysis shows that 83 hospice providers (80 for- profits and 3 non-profits) did not provide any visits in 2017 from registered nurses, physicians, or nurse practitioners in the beneficiaries’ last 3 days of life. This means that all of the 800 hospice beneficiaries treated by these providers did not receive these types of provider visits at the end of life. In addition, we found that 58 providers (55 for-profits and 3 non- profits) did not provide any visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life in 2017; all of the 613 beneficiaries treated by these providers did not receive these specific provider visits at the end of life. In our review of CMS’s oversight of hospice providers, we found CMS does not instruct surveyors to review, prior to surveying hospice providers, providers’ performance on CMS quality measures (those based on provider-reported quality data or caregivers’ experience surveys) or other indicators of quality that could identify potential areas of concern. CMS issues guidance that surveyors use when conducting surveys to assess a hospice provider’s compliance with federal health and safety requirements. According to this guidance, surveyors are to prepare for hospice surveys by reviewing documents of record including licensure records, previous survey findings and complaints, media reports, and other publicly available information about the provider. A representative for an association representing state surveyors confirmed that this is the type of information surveyors typically review prior to a hospice provider survey. However, according to CMS officials and the surveyor association, CMS does not instruct surveyors to review other information such as providers’ performance on CMS quality measures or other indicators of quality that surveyors could use to identify potential areas of concern that they could focus on more closely during a survey. For example, it might be helpful for surveyors to know if a hospice provided no visits during beneficiaries’ last days of life. According to CMS officials, CMS does not use such information to target hospices for additional survey review. Several studies we reviewed and researchers we interviewed noted CMS could strengthen its survey process by incorporating additional information into the survey process, such as information on how hospice providers perform on CMS quality measures or other potential indicators of quality. For example, one study suggested that hospices with poor reported beneficiary experiences based on caregivers’ experience survey data could be identified for more frequent surveys and that such information could be used to identify care processes for closer review during surveys. Another study we reviewed concluded that claims- based measures could help guide surveyors to more closely review key processes of care to ensure Medicare beneficiaries receive high quality hospice care. In addition, a researcher we interviewed suggested when claims data show no visits during the last 2 days of life, the survey team could interview the deceased patients’ families to see if there was any harm done by the lack of visits at the end of life. And, in July 2019, the Department of Health and Human Services’ Office of the Inspector General (HHS OIG) reiterated recommendations from prior HHS OIG work that CMS analyze claims and deficiency data to identify specific patterns identified by the HHS OIG that could indicate potential issues— such as hospices that infrequently provide physician services—and that CMS instruct surveyors to pay special attention to these areas during surveys. In contrast to hospice surveys, home health agency surveyors utilize information in addition to survey findings and complaints to identify potential areas of concern. According to CMS officials and the surveyor association we interviewed, home health surveyors review certain CMS quality measures to focus the survey on specific areas of concern or to identify beneficiaries who experienced potential care issues for a more detailed survey review. According to CMS officials, the agency is considering making changes to the survey process but has not yet made any decisions. CMS officials told us they last updated the survey process in 2010, and since then, they have implemented quality measures for hospice providers (provider- reported measures in 2014 and caregivers’ experience survey measures in 2015). They also said that CMS is “currently monitoring the implementation of these programs and considering the potential benefit of incorporating review of the data into the survey process.” According to federal standards of internal control, agencies must identify, analyze, and respond to risks related to achieving objectives. By not utilizing additional information in the survey process that would allow it to identify providers and areas where risk of noncompliance is greatest, CMS is missing an opportunity to strengthen its ability to identify and respond to such risks and ensure the quality of care that hospice beneficiaries receive. CMS is limited to one hospice enforcement remedy—termination of the Medicare provider agreement. By law, to qualify for payment under the Medicare program, hospice providers must meet the program’s conditions of participation. If the agency finds a provider is not complying with the program’s conditions of participation, CMS may terminate the provider’s participation in the program. In the Medicare program, termination of a provider is the most significant action CMS can take to address provider non-compliance. As a result, CMS generally only terminates a hospice provider on the basis of a deficiency when the provider fails to correct a condition-level deficiency (the most severe) within the required time frame. Our review of CMS hospice survey data found termination happens rarely. Specifically, 19 hospices were involuntarily terminated from 2014 through 2017. This is less than half of 1 percent of the total number of hospices operating during this time period. In contrast to hospice care, where CMS’s enforcement authority is limited to termination, Congress has given the agency authority to impose additional enforcement remedies for other provider types. Additional statutory and regulatory penalties for home health agencies and nursing homes include civil money penalties, denial of payment for all new Medicare and Medicaid admissions, and imposition of training requirements for situations where it is determined that education will likely lead to provider compliance (referred to as directed in-service training). Such remedies, if available, could enable the agency to more effectively address a broader range of hospice risks. For example, additional remedies could be used in situations that warrant a remedy other than termination or that could further incentivize providers to comply with health and safety requirements or improve their quality of care. According to federal standards of internal control, agencies must identify, analyze, and respond to risks related to achieving objectives. Because CMS lacks the authority to establish such additional remedies, the agency’s ability to respond to risks and ensure quality of care for beneficiaries is limited. The HHS OIG and one researcher we interviewed have recommended CMS seek statutory authority to establish additional enforcement remedies for hospices, explaining that less severe remedies could help address performance problems that may not merit termination and incentivize agencies to improve quality of care. CMS agreed with this recommendation in March 2016 and stated it would consider submitting a request that would seek legislative authority to establish additional enforcement remedies through the President’s annual budget proposal to Congress. In a July 2018 HHS OIG report, the HHS OIG again recommended CMS seek this authority. CMS neither agreed nor disagreed with this recommendation and stated again that it would consider this recommendation when developing the agency’s proposals for the President’s annual budget. However, a request for such legislative authority was not included in the President’s fiscal year 2017, 2018, or 2019 budget proposals. The HHS OIG reiterated this recommendation in two July 2019 reports. Since 2000, the number of Medicare hospice beneficiaries has almost tripled to nearly 1.5 million in fiscal year 2017. In addition, the number of hospice providers has doubled. Given this growth, it is imperative that CMS’s oversight of the quality of Medicare hospice care keeps pace with changes so that the agency can ensure the health and safety of these terminally ill beneficiaries. While recent steps have been taken to strengthen CMS’s hospice quality oversight, including the requirement that hospices be re-certified every 3 years and CMS’s ongoing development of new quality measures, we identified additional opportunities to strengthen CMS’s oversight. Specifically, our review found that CMS could strengthen oversight by using additional information—based on currently available data—to identify potential quality issues that could focus and enhance the survey process. We also found that CMS’s lack of authority to establish additional enforcement remedies before termination, which CMS rarely uses, limits its ability to ensure hospice providers’ compliance with health and safety requirements and quality of care for beneficiaries. Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. (Matter for Consideration 1) The Administrator of CMS should incorporate the use of additional information, such as quality measures or other information that could identify potential quality of care issues, into its survey process for overseeing hospice providers. (Recommendation 1) We provided a draft of this report to HHS for review and comment. HHS provided written comments, which are reprinted in appendix II. HHS concurred with our recommendation. HHS stated that it recognizes that meaningful quality measures can also serve as key indicators of provider quality and it will look into ways to incorporate the use of these data into the hospice survey process. In its comment letter, HHS also noted the importance of monitoring patient safety and quality of care to HHS’s hospice oversight efforts and the agency provided an overview of the key efforts it has in place to perform such monitoring. For example, in addition to survey and quality measure requirements, HHS requires hospices to implement a data-driven quality assessment and performance improvement program, intended to have hospices take a proactive approach in improving their performance using objective data. HHS also provided technical comments, which we incorporated into the report as appropriate. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the Secretary of Health and Human Services, the CMS administrator, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. Hospice team treated patient with respect Amount of emotional and religious support provided by the hospice team The patient got the help they needed for pain and symptoms Caregiver received the training they needed Caregiver rating of hospice agency on 10-point scale with 10 being the best hospice care possible Caregiver would recommend the hospice Non-profit hospice providers’ average scores Hospice team treated patient with respect Amount of emotional and religious support provided by the hospice team The patient got the help they needed for pain and symptoms Caregiver received the training they needed Caregiver rating of hospice agency on 10-point scale with 10 being the best hospice care possible Caregiver would recommend the hospice Government-owned hospice providers’ average scores Hospice team treated patient with respect Amount of emotional and religious support provided by the hospice team The patient got the help they needed for pain and symptoms Caregiver received the training they needed Caregiver rating of hospice agency on 10-point scale with 10 being the best hospice care possible Caregiver would recommend the hospice 2.5 survey within three categories (top scores, middle scores, and bottom scores). These data were not available for all hospice providers; our analysis of CMS caregivers’ experience survey quality measure data was for the 2,832 hospice providers that had data for the caregivers’ survey. In general, the top-box scores represent the percentage of caregivers that selected the response of “always” for the particular measure. For the rating measure, the top-box score represents caregivers that rated the hospice provider as a 9 or 10 on a 10-point scale with 10 being the highest rating. For the recommendation measure, the top-box score represents caregivers that responded that they “would definitely recommend the hospice provider.” In general, the middle-box scores represent the percentage of caregivers that selected the response of “usually” for the particular measure. For the rating measure, the middle-box score represents caregivers that rated the hospice provider as a 7 or 8 on a 10-point scale with 10 being the highest rating. For the recommendation measure, the middle-box score represents caregivers that responded that they “would probably recommend the hospice provider.” In addition to the contact named above, Gregory Giusto, Assistant Director; Christie Enders, Analyst-in-Charge; Todd Anderson, Leia Dickerson, Rob Dougherty, Krister Friday, Barbara Hansen, Jennifer Whitworth, and Chris Wickham made key contributions to this report.

Summary: Since 2000, there has been substantial growth in Medicare payments for hospice services and the number of Medicare beneficiaries using hospice. This growth has been accompanied by an increase in the number of providers (primarily an increase in for-profit providers), reaching approximately 4,500 providers by 2017. GAO was asked to review aspects of Medicare's hospice program. This report, among other things, (1) compares quality scores and other potential indicators of quality for for-profit and non-profit hospices; and (2) examines opportunities for strengthening CMS's oversight of hospice providers. GAO analyzed CMS data on hospice care for 2014 through 2017—the latest years for which full-year data were available at the time of GAO's analysis—and reviewed research on hospice care. GAO interviewed CMS officials, researchers, provider associations, a survey agency association, and a non-generalizable sample of hospice providers selected in part through referrals from other stakeholders. GAO also reviewed relevant statutes, regulations, documents, and enforcement data. Medicare's hospice benefit provides palliative care to beneficiaries with terminal illnesses and a life expectancy of 6 months or less. GAO's review of 2017 data from the Centers for Medicare & Medicaid Services (CMS) found that for-profit and non-profit hospices had, on average, similar scores on CMS's current quality measures that indicate hospice performance in areas such as pain assessment and discussion of beneficiary treatment preferences. However, for-profits were more often among the subset of providers with the lowest scores on certain quality measures GAO reviewed. In addition to analyzing providers' scores on CMS quality measures, GAO analyzed provider performance on other indicators, identified by researchers, that could signal quality issues and found performance varied among for-profit and non-profit hospices. One of the other quality indicators GAO analyzed was the rate of beneficiaries discharged from hospice prior to death, which in some cases could indicate dissatisfaction with care leading to the beneficiary's decision to leave the hospice provider. In addition, GAO examined the number of provider visits to give medical and emotional support within the last few days of a beneficiary's life. With regard to these indicators, for 2017, GAO found the following, among other things: 472 hospice providers (462 for-profits and 10 non-profits) had a high rate of discharging beneficiaries prior to death (50 percent or more were discharged). According to research, a high discharge rate could, in some cases, be an indicator of poor quality of care or of provider misuse of the benefit, in that the hospice may be enrolling beneficiares who are not eligible for hospice care. 83 providers (80 for-profits and 3 non-profits) did not have hospice staff (such as nurses, physicians, or nurse practitioners) visit beneficiaries within the last 3 days of their life—a critical time in providing quality care, according to researchers GAO interviewed. CMS's oversight of the quality of care provided by hospice providers consists primarily of inspections—called surveys—of hospice providers. GAO found that, while CMS instructs surveyors to review previous survey findings and complaints, CMS does not instruct surveyors to use information on providers' performance on quality measures or other potential indicators of quality as part of the survey process. For example, CMS does not instruct surveyors to consider whether a hospice provided staff visits during beneficiaries' last week of life. According to research, this information could be used to enhance the survey process. GAO also found that CMS is limited to one enforcement option—termination of the Medicare provider agreement—which CMS uses rarely and generally only when providers fail to correct within the required time frame the most serious violations of federal health and safety requirements. According to two researchers, additional remedies, such as civil monetary penalties, could enhance CMS's oversight by addressing performance problems that do not merit termination and incentivize agencies to improve quality of care. CMS uses a range of remedies for other provider types, such as home health agencies and nursing homes, but lacks authority to impose such additional sanctions on hospices. CMS should incorporate the use of additional information that could be used to identify quality of care issues into its survey process for hospice oversight. Congress should consider giving CMS authority to establish additional enforcement remedies for hospices that do not meet federal health and safety requirements. The Department of Health and Human Services concurred with GAO's recommendation.