Socioeconomic Disparities in

the Medicare Hospice Care

Index (HCI) Indicators

Authors:
Michael Plotzke
T.J. Christian
Zinnia Harrison
Catherine Hersey
Mariana Sarango Cancel

AcademyHealth 2023 Annual Research Meeting

June 2023
Acknowledgements
• The funding for this project was provided by the Centers for
Medicare & Medicaid Services under contract number
75FCMC18D0014, Home Health and Hospice Quality Reporting
Program Quality Measures and Assessment

• The content of this presentation does not necessarily reflect the

views or policies of the Department of Health and Human Services,
nor does the mention of trade names, commercial products, or
organizations imply endorsement by the U.S. Government

• The authors assume full responsibility for the accuracy and

completeness of the ideas presented.

2
Background
• The Hospice Care Index (HCI) is a
quality measure implemented in the
Centers for Medicare & Medicaid
Services (CMS) Hospice Quality
Reporting Program
– Publicly reported starting in fiscal year
2022
• An HCI score is assigned to each
hospice using a composite of ten claims-
based indicators characterizing hospice
service provision

3
Claims-Based Indicators Contributing to the
Hospice Care Index
*Burdensome transitions - Type 1: Live
Gaps in
discharges from hospice followed by
Skilled nurse
nursing visits
Nurse
hospitalization and subsequent hospice
visits on minutes per readmission
weekends RHC

**Burdensome transitions – Type 2: Live

Live
Provided CHC discharge in discharges from hospice followed by
& GIP the first 7
days hospitalization with the patient dying in the
Hospice
hospital
Care
Index Live
Per- discharges More detailed information about the HCI can
beneficiary after 180
spending days
be found in the Hospice Quality Reporting
Program Quality Measure Specifications
Visits near Burdensome
User’s Manual
the end of transitions
life Burdensome (Type 1)*
https://www.cms.gov/medicare/quality-initiatives-
transitions
(Type 2)** patient-assessment-instruments/hospice-quality-
reporting/current-measures 4
Research Objective
• Prior research has shown that end-of-life services vary by race and markers for
socioeconomic status (SES), potentially resulting in poorer experiences of care

Higher rates of hospice

Increased Less aggressive end of life care
SES
Higher rates of advance directives

• The number of care transitions in the last six months of life tend to be higher for African
Americans versus whites (Wang et al, 2019)

• The objective of this research is to measure disparities among the HCI indicators
and discuss their impact on interpreting the HCI
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Methodology
• Data: Beneficiary level HCI outcomes (FY2020 – FY2021)

• Approach: We examined the relationship between hospice services and

markers for socioeconomic status and social risk factors by estimating an
ordinary least squares (OLS) regression
– Using the results of the regression model, we estimated predicted scores for each HCI
indicator for each of the socioeconomic status and social risk factor indicators
– The goal of this analysis was to observe if there were disparities in indicator scores across
patient-level characteristics

• Dependent Variable: Each of the 10 HCI indicators are modeled separately

– We report results for those indicators showing the largest differences by the main
independent variables of interest

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Methodology
• Main Independent Variables of
Interest– Socioeconomics and
Social Risk Factors
 Patient race/ethnicity (White,
Black, Asian, Hispanic, North
American Native, other,
unknown)
 Area deprivation index (quartiles)
 Patient lives in a rural CBSA
 Patient was dual eligible prior to
hospice election 7
Methodology
• Independent Variables: Additional patient characteristics included as control
variables in the model but for which we do not report results
– Primary diagnosis on hospice claim
– Gender
– Patient age
– Site of service on last day of hospice in the data
– Level of care on last day of hospice in the data
– Length of stay (quartiles)
– Medicare Advantage enrollment
– Day of week of last day of hospice in the data
– Month of last day of hospice in the data
– Whether hospice claim lists an attending physician
• Independent Variable: Provider characteristics
– Hospice-specific fixed effect term that controls for characteristics that are invariant across
the different patients seen by a hospice (e.g., ownership type, hospice age, geographic
location, and size)

8
Methodology
• We estimated a series of ordinary least squares
regression models with the dependent and independent
variables listed previously
– For certain models, we included a hospice level fixed
effect term to control for hospice characteristics
• After we estimated each model, we constructed
predicted values for each HCI indicator based on the
socioeconomic variables of interest and using the
average value of the other independent variables in the
model
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Results – At Least one GIP/CHC Day
Predicted Probabilities for HCI Indicators (At Least one GIP/CHC Day)
At Least One GIP/CHC Day
Controls for Patient Characteristics Y Y N
Controls for Provider Characteristics Y N N
Patient is White 20.7% 20.6% 20.5%
Patient is Black 21.0% 21.3% 23.0%
Patient race is listed as "Other" 20.6% 20.6% 19.0%
Patient is Asian 20.7% 20.5% 18.5%
Patient is Hispanic 20.9% 22.9% 22.6%
Patient North American Native 20.9% 19.2% 15.7%
Patient race is listed as "Unknown" 20.6% 21.6% 27.0%

Area Deprivation Index

Quartile 1 (Most Advantaged) 20.8% 20.4% 15.9%
Quartile 2 20.7% 20.8% 20.3%
Quartile 3 20.7% 20.9% 22.6%
Quartile 4 (Least Advantaged) 20.7% 20.4% 22.6%

Patient is not in a Rural CBSA 20.8% 21.0% 22.9%

Patient is in a Rural CBSA 20.1% 19.2% 8.9%

Patient was not Dual Eligible Prior to Hospice Election 20.8% 20.7% 21.0% 10
Patient was Dual Eligible Prior to Hospice Election 20.5% 20.9% 20.0%
Results – At Least one GIP/CHC Day
Predicted Probabilities for HCI Indicators (At Least one GIP/CHC Day)
At Least One GIP/CHC Day
Controls for Patient Characteristics Y Y N
Controls for Provider Characteristics Y N N
Patient is White 20.7% 20.6% 20.5%
Patient is Black 21.0% 21.3% 23.0%
Patient race is listed as "Other" 20.6% 20.6% 19.0%
Patient is Asian 20.7% 20.5% 18.5%
Patient is Hispanic 20.9% 22.9% 22.6%
Patient North American Native 20.9% 19.2% 15.7%
Patient race is listed as "Unknown" 20.6% 21.6% 27.0%

Area Deprivation Index

Quartile 1 (Most Advantaged) 20.8% 20.4% 15.9%
Quartile 2 20.7% 20.8% 20.3%
Quartile 3 20.7% 20.9% 22.6%
Quartile 4 (Least Advantaged) 20.7% 20.4% 22.6%

Patient is not in a Rural CBSA 20.8% 21.0% 22.9%

Patient is in a Rural CBSA 20.1% 19.2% 8.9%

Patient was not Dual Eligible Prior to Hospice Election 20.8% 20.7% 21.0% 11
Patient was Dual Eligible Prior to Hospice Election 20.5% 20.9% 20.0%
Results – At Least one GIP/CHC Day
Predicted Probabilities for HCI Indicators (At Least one GIP/CHC Day)
At Least One GIP/CHC Day
Controls for Patient Characteristics Y Y N
Controls for Provider Characteristics Y N N
Patient is White 20.7% 20.6% 20.5%
Patient is Black 21.0% 21.3% 23.0%
Patient race is listed as "Other" 20.6% 20.6% 19.0%
Patient is Asian 20.7% 20.5% 18.5%
Patient is Hispanic 20.9% 22.9% 22.6%
Patient North American Native 20.9% 19.2% 15.7%
Patient race is listed as "Unknown" 20.6% 21.6% 27.0%

Area Deprivation Index

Quartile 1 (Most Advantaged) 20.8% 20.4% 15.9%
Quartile 2 20.7% 20.8% 20.3%
Quartile 3 20.7% 20.9% 22.6%
Quartile 4 (Least Advantaged) 20.7% 20.4% 22.6%

Patient is not in a Rural CBSA 20.8% 21.0% 22.9%

Patient is in a Rural CBSA 20.1% 19.2% 8.9%

Patient was not Dual Eligible Prior to Hospice Election 20.8% 20.7% 21.0% 12
Patient was Dual Eligible Prior to Hospice Election 20.5% 20.9% 20.0%
Results – At Least one GIP/CHC Day
Predicted Probabilities for HCI Indicators (At Least one GIP/CHC Day)
At Least One GIP/CHC Day
Controls for Patient Characteristics Y Y N
Controls for Provider Characteristics Y N N
Patient is White 20.7% 20.6% 20.5%
Patient is Black 21.0% 21.3% 23.0%
Patient race is listed as "Other" 20.6% 20.6% 19.0%
Patient is Asian 20.7% 20.5% 18.5%
Patient is Hispanic 20.9% 22.9% 22.6%
Patient North American Native 20.9% 19.2% 15.7%
Patient race is listed as "Unknown" 20.6% 21.6% 27.0%

Area Deprivation Index

Quartile 1 (Most Advantaged) 20.8% 20.4% 15.9%
Quartile 2 20.7% 20.8% 20.3%
Quartile 3 20.7% 20.9% 22.6%
Quartile 4 (Least Advantaged) 20.7% 20.4% 22.6%

Patient is not in a Rural CBSA 20.8% 21.0% 22.9%

Patient is in a Rural CBSA 20.1% 19.2% 8.9%

Patient was not Dual Eligible Prior to Hospice Election 20.8% 20.7% 21.0% 13
Patient was Dual Eligible Prior to Hospice Election 20.5% 20.9% 20.0%
Results – At Least one GIP/CHC Day
Predicted Probabilities for HCI Indicators (At Least one GIP/CHC Day)
At Least One GIP/CHC Day
Controls for Patient Characteristics Y Y N
Controls for Provider Characteristics Y N N
Patient is White 20.7% 20.6% 20.5%
Patient is Black 21.0% 21.3% 23.0%
Patient race is listed as "Other" 20.6% 20.6% 19.0%
Patient is Asian 20.7% 20.5% 18.5%
Patient is Hispanic 20.9% 22.9% 22.6%
Patient North American Native 20.9% 19.2% 15.7%
Patient race is listed as "Unknown" 20.6% 21.6% 27.0%

Area Deprivation Index

Quartile 1 (Most Advantaged) 20.8% 20.4% 15.9%
Quartile 2 20.7% 20.8% 20.3%
Quartile 3 20.7% 20.9% 22.6%
Quartile 4 (Least Advantaged) 20.7% 20.4% 22.6%

Patient is not in a Rural CBSA 20.8% 21.0% 22.9%

Patient is in a Rural CBSA 20.1% 19.2% 8.9%

Patient was not Dual Eligible Prior to Hospice Election 20.8% 20.7% 21.0% 14
Patient was Dual Eligible Prior to Hospice Election 20.5% 20.9% 20.0%
Results – At Least One Gap in Nursing Visits
Predicted Probabilities for HCI Indicators (At Least One Gap In Nursing Visits)
At Least One Gap In Nursing Visits
Controls for Patient Characteristics Y Y N
Controls for Provider Characteristics Y N N
Patient is White 58.9% 58.5% 58.7%
Patient is Black 60.3% 63.3% 62.4%
Patient race is listed as "Other" 60.8% 60.9% 60.0%
Patient is Asian 61.9% 62.0% 60.5%
Patient is Hispanic 60.2% 62.2% 61.7%
Patient North American Native 60.5% 59.3% 57.4%
Patient race is listed as "Unknown" 59.6% 60.3% 56.3%

Area Deprivation Index

Quartile 1 (Most Advantaged) 59.7% 61.9% 62.6%
Quartile 2 59.4% 60.6% 60.7%
Quartile 3 58.8% 57.8% 57.5%
Quartile 4 (Least Advantaged) 58.6% 55.6% 55.3%

Patient is not in a Rural CBSA 59.4% 59.9% 60.1%

Patient is in a Rural CBSA 58.0% 55.0% 54.3%

Patient was not Dual Eligible Prior to Hospice Election 58.6% 58.2% 56.9% 15
Patient was Dual Eligible Prior to Hospice Election 60.5% 61.4% 64.6%
Results – Live discharges from hospice followed by hospitalization and
subsequent hospice readmission
Predicted Probabilities for HCI Indicators (Live discharges from hospice followed by hospitalization and subsequent hospice
readmission)
At least 1 Live discharges from hospice followed by hospitalization and subsequent hospice readmission
Controls for Patient Characteristics Y Y N
Controls for Provider Characteristics Y N N
Patient is White 9.1% 9.0% 9.1%
Patient is Black 10.5% 11.4% 11.2%
Patient race is listed as "Other" 9.1% 8.3% 7.9%
Patient is Asian 8.5% 7.5% 7.3%
Patient is Hispanic 9.1% 8.1% 7.7%
Patient North American Native 9.5% 9.7% 10.5%
Patient race is listed as "Unknown" 8.9% 8.4% 9.2%

Area Deprivation Index

Quartile 1 (Most Advantaged) 8.9% 7.3% 7.3%
Quartile 2 9.1% 8.4% 8.4%
Quartile 3 9.3% 9.8% 9.8%
Quartile 4 (Least Advantaged) 9.7% 12.0% 12.0%

Patient is not in a Rural CBSA 9.4% 9.5% 9.4%

Patient is in a Rural CBSA 8.3% 7.9% 8.3%

Patient was not Dual Eligible Prior to Hospice Election 9.3% 9.5% 9.6% 16
Patient was Dual Eligible Prior to Hospice Election 9.1% 8.9% 8.7%
Conclusion
• These findings suggest that two otherwise similar beneficiaries from
different socioeconomic groups are, on average, treated similarly by
the same hospice

• Instead, observed socioeconomic disparities for some measures in

part result from beneficiaries having different patient characteristics
or through sorting into different hospices
– That is, lower quality hospices may be more likely to treat those who
are most disadvantaged
• The socioeconomic marker showing the largest disparity for a
particular HCI indicator varied across indicators

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Implications for Policy or Practice
• CMS should continue to monitor how hospice service
provision differs by socioeconomic status through the
HCI indicators and measure if differences are consistent
across different states and regions

• Understanding whether socioeconomic differences

within- or across-hospices drive differences in HCI
outcomes may help CMS minimize disparities and
ensure all patients receive adequate care

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 Questions? Contact
abtassociates.com Michael_Plotzke@abtassoc.com