The Composite Index Buried in the Data

What is the Hospice Care Index?

The Hospice Care Index is a single composite score, from 0 to 10, that Medicare calculates for each certified hospice out of ten separate claims-based indicators. Each indicator has its own numerator, its own denominator, and its own passing threshold. A hospice earns exactly one point for every threshold it meets, and the index is simply the count of points earned. Higher is better 1Ref 1Muma A, Chung A, Nandi A, et al. (Abt Associates, for the Centers for Medicare & Medicaid Services) (2022).Hospice Care Index Technical Report.The defining specification of the Hospice Care Index: exactly ten claims-based indicators each with its own numerator, denominator and threshold; a 0-to-10 score in which higher is better; one point earned per indicator meeting its Index Earned Point Criterion; thresholds set from statistical analysis of national performance across eight quarters of CY2019-2021 claims; and testing for variability, validity and reliability against national performance standards with convergent evidence against CAHPS Hospice..

Nobody at the hospice fills anything out to produce it. A claims-based measure is calculated from the bills a provider already sends Medicare — no survey, no extra form, no self-report. The index is computed from Medicare fee-for-service hospice claims, which is both its strength and its ceiling: it is difficult to dress up, and it can only see what a bill records 1Ref 1Muma A, Chung A, Nandi A, et al. (Abt Associates, for the Centers for Medicare & Medicaid Services) (2022).Hospice Care Index Technical Report.The defining specification of the Hospice Care Index: exactly ten claims-based indicators each with its own numerator, denominator and threshold; a 0-to-10 score in which higher is better; one point earned per indicator meeting its Index Earned Point Criterion; thresholds set from statistical analysis of national performance across eight quarters of CY2019-2021 claims; and testing for variability, validity and reliability against national performance standards with convergent evidence against CAHPS Hospice..

That matters because hospice is now the ordinary way Americans die. About 1.72 million Medicare beneficiaries used hospice in 2022, roughly 49 percent of everyone who died on Medicare 2Ref 2National Alliance for Care at Home (formerly NHPCO) (2024).NHPCO Facts and Figures, 2024 Edition.Aggregate U.S. hospice utilisation for CY2022: approximately 1.72 million Medicare beneficiaries used hospice, about 49 percent of Medicare decedents.. Almost every family will choose a hospice, most will choose in a hurry, and until fairly recently there was very little on the public record to choose on.

The index sits inside the Hospice Quality Reporting Program, the same federal program that runs the HOPE patient assessment and the CAHPS Hospice family survey and feeds all of it into public reporting 3Ref 3Centers for Medicare & Medicaid Services (2024).Hospice Quality Reporting Program.The structure of the Hospice Quality Reporting Program, which houses the HOPE patient assessment, the CAHPS Hospice family survey and claims-based measures including a stand-alone measure of visits in the last days of life, and feeds them into public reporting.. Those instruments answer different questions. The index asks what the hospice did. The survey asks how it felt to the family. Reading one without the other gives you half the record.

What do the ten indicators actually measure?

Each of the ten indicators is a behavior that shows up in billing data: whether the hospice ever provided the higher levels of care, whether nursing visits had long gaps, how often patients left the hospice alive very early or very late in a stay, what happened after those departures, how much nursing time a patient actually received, and whether anyone came in the final days 1Ref 1Muma A, Chung A, Nandi A, et al. (Abt Associates, for the Centers for Medicare & Medicaid Services) (2022).Hospice Care Index Technical Report.The defining specification of the Hospice Care Index: exactly ten claims-based indicators each with its own numerator, denominator and threshold; a 0-to-10 score in which higher is better; one point earned per indicator meeting its Index Earned Point Criterion; thresholds set from statistical analysis of national performance across eight quarters of CY2019-2021 claims; and testing for variability, validity and reliability against national performance standards with convergent evidence against CAHPS Hospice..

The ten, in plain terms:

• Continuous home care or general inpatient care provided — whether the hospice delivered either crisis level of care at all. Of the four levels of hospice care, these are the two that exist for a bad night; a hospice that never bills for continuous and inpatient care has, in effect, only one gear.
• Gaps in skilled nursing visits — how often patients went long stretches with no nurse.
• Early live discharges — patients discharged alive shortly after admission.
• Late live discharges — patients discharged alive after a long enrollment.
• Burdensome transitions, type one — a live discharge followed by a hospital admission and then a return to hospice.
• Burdensome transitions, type two — a live discharge followed by a hospital admission in which the patient died in the hospital.
• Per-beneficiary spending — what the hospice spends on a patient relative to other hospices.
• Nurse care minutes per routine home care day — how much nursing time an average day actually contains.
• Skilled nursing minutes on weekends — whether coverage holds up on a Saturday and a Sunday.
• Visits near death — nursing and social-work visits at the very end of life. The same quality program separately reports a stand-alone measure of visits in last days of life 3Ref 3Centers for Medicare & Medicaid Services (2024).Hospice Quality Reporting Program.The structure of the Hospice Quality Reporting Program, which houses the HOPE patient assessment, the CAHPS Hospice family survey and claims-based measures including a stand-alone measure of visits in the last days of life, and feeds them into public reporting..

Read as a group rather than one at a time, the ten describe three things. Intensity: is anyone actually coming, and for how long. Continuity: does the coverage hold at night, on weekends, at the end. And enrollment pattern: do people stay, or are they discharged alive at conspicuous moments. A live discharge is not automatically wrong — some people stabilize and leave hospice alive, and that is a good outcome. It is the pattern across hundreds of patients, not any single discharge, that this index is built to see.

How does a hospice earn each point?

A hospice earns one point for each indicator whose score meets or exceeds that indicator's Index Earned Point Criterion, which is the technical name for its passing threshold. There is no partial credit and no weighting — the tenth indicator counts exactly as much as the first — so the published index is a whole number equal to the count of criteria met, and a perfect score is a 10 1Ref 1Muma A, Chung A, Nandi A, et al. (Abt Associates, for the Centers for Medicare & Medicaid Services) (2022).Hospice Care Index Technical Report.The defining specification of the Hospice Care Index: exactly ten claims-based indicators each with its own numerator, denominator and threshold; a 0-to-10 score in which higher is better; one point earned per indicator meeting its Index Earned Point Criterion; thresholds set from statistical analysis of national performance across eight quarters of CY2019-2021 claims; and testing for variability, validity and reliability against national performance standards with convergent evidence against CAHPS Hospice..

The thresholds come in two kinds 1Ref 1Muma A, Chung A, Nandi A, et al. (Abt Associates, for the Centers for Medicare & Medicaid Services) (2022).Hospice Care Index Technical Report.The defining specification of the Hospice Care Index: exactly ten claims-based indicators each with its own numerator, denominator and threshold; a 0-to-10 score in which higher is better; one point earned per indicator meeting its Index Earned Point Criterion; thresholds set from statistical analysis of national performance across eight quarters of CY2019-2021 claims; and testing for variability, validity and reliability against national performance standards with convergent evidence against CAHPS Hospice.. Some are normative: the service was either provided or it was not, and any amount above zero clears the bar. Others are relative, set against a percentile of national hospice performance, so passing means sitting on the right side of what the rest of the country does. Every one of them was set from statistical analysis of national performance, using eight quarters of claims spanning calendar years 2019 through 2021 1Ref 1Muma A, Chung A, Nandi A, et al. (Abt Associates, for the Centers for Medicare & Medicaid Services) (2022).Hospice Care Index Technical Report.The defining specification of the Hospice Care Index: exactly ten claims-based indicators each with its own numerator, denominator and threshold; a 0-to-10 score in which higher is better; one point earned per indicator meeting its Index Earned Point Criterion; thresholds set from statistical analysis of national performance across eight quarters of CY2019-2021 claims; and testing for variability, validity and reliability against national performance standards with convergent evidence against CAHPS Hospice..

The index is a count of thresholds met, not an average of ten scores. Two hospices holding the same 8 can have failed entirely different things, and one of those failures may matter far more to a particular family than the other.

This is the single most useful thing to understand about the number. An 8 is not eighty percent of good care. It is eight yeses and two noes, and the two noes have names. When a hospice's index falls short of 10, the honest question to put to that hospice is which indicators it missed and what has changed since.

Where can you find a hospice's index score?

The index is published on Medicare's Care Compare, the government site that lists every Medicare-certified hospice along with its publicly reported quality results and family-survey scores. There is no login and no charge. You search by city, town, or ZIP code, open a hospice's profile, and read its measures 4Ref 4Centers for Medicare & Medicaid Services (2024).Find Healthcare Providers: Compare Care Near You (Hospice).That Medicare-certified hospices and their publicly reported quality and family-experience results can be looked up and compared by the public on Care Compare, free and without a login..

Most families arrive at care compare for hospice looking for a rating and leave confused, because hospice public quality data is not laid out the way a restaurant review is. A few habits make it readable:

• Work from a list rather than a single page. Three or four hospices serve most addresses. Open all of them.
• Write the numbers down somewhere. The site does not hold a comparison for you between sessions.
• Note the ownership type while you are there. It is on the record and it is worth knowing.
• Treat a missing number as a question rather than a verdict. A measure has to have enough underlying data before it can be reported at all.

The index is reported as its own number, alongside the other hospice quality measures on the same profile 4Ref 4Centers for Medicare & Medicaid Services (2024).Find Healthcare Providers: Compare Care Near You (Hospice).That Medicare-certified hospices and their publicly reported quality and family-experience results can be looked up and compared by the public on Care Compare, free and without a login.. Families usually go looking for hospice star ratings first, which is reasonable — but a rating summarizes how the care felt to families afterward, and the index summarizes what the hospice did while the care was happening. They are different instruments answering different questions, and the index is not folded into the rating.

What a high score does and does not tell you

A 10 means a hospice cleared all ten thresholds during the measurement period. That is genuinely meaningful, because the thresholds describe behaviors that matter enormously to a dying person: someone came, someone came at night, someone came at the end. But it is a floor-clearing score rather than a ranking, and a great many hospices earn it 1Ref 1Muma A, Chung A, Nandi A, et al. (Abt Associates, for the Centers for Medicare & Medicaid Services) (2022).Hospice Care Index Technical Report.The defining specification of the Hospice Care Index: exactly ten claims-based indicators each with its own numerator, denominator and threshold; a 0-to-10 score in which higher is better; one point earned per indicator meeting its Index Earned Point Criterion; thresholds set from statistical analysis of national performance across eight quarters of CY2019-2021 claims; and testing for variability, validity and reliability against national performance standards with convergent evidence against CAHPS Hospice..

The measure was tested for variability, validity, and reliability against national performance standards using eight quarters of claims, and its results agreed with what families independently report on the CAHPS Hospice survey 1Ref 1Muma A, Chung A, Nandi A, et al. (Abt Associates, for the Centers for Medicare & Medicaid Services) (2022).Hospice Care Index Technical Report.The defining specification of the Hospice Care Index: exactly ten claims-based indicators each with its own numerator, denominator and threshold; a 0-to-10 score in which higher is better; one point earned per indicator meeting its Index Earned Point Criterion; thresholds set from statistical analysis of national performance across eight quarters of CY2019-2021 claims; and testing for variability, validity and reliability against national performance standards with convergent evidence against CAHPS Hospice.. Convergent agreement of that kind means two measures move in the same direction. It does not mean one substitutes for the other.

What the index cannot see is most of what families actually remember. It cannot see whether the nurse sat down. It cannot see whether the aide was the same person twice, whether the chaplain was any good, whether the call at three in the morning was answered by someone who already knew the patient's name. Claims record events and durations. They do not record conduct.

A hospice with a slightly imperfect index is not a bad hospice, and a family who has already chosen one has not made a mistake. This is a screening tool for a decision ahead of you, not a verdict on care that is already underway.

How does the index relate to the family survey?

The CAHPS Hospice Survey asks bereaved family caregivers, months after the death, about the care they witnessed: communication with the hospice team, help with pain and other symptoms, emotional and religious support, and whether the family was trained to give care at home. It is a standardized instrument administered the same way everywhere, which is precisely what makes one hospice's results comparable to another's 5Ref 5Agency for Healthcare Research and Quality (2024).CAHPS Hospice Survey.That the CAHPS Hospice Survey is a standardized, validated instrument surveying bereaved family caregivers across domains including communication, help with pain and symptoms, emotional and religious support, and training the family to provide care at home..

So the two numbers describe different halves of the same thing. The index measures activity — visits made, minutes delivered, levels of care used. The survey measures conduct — what it was like to be on the receiving end of that activity. A hospice can meet all ten indicators and still leave families feeling abandoned, and a hospice with warm survey results can carry a thin staffing pattern that shows up nowhere except in the claims.

Both are published under the same quality reporting program and both appear on the same public profile 3Ref 3Centers for Medicare & Medicaid Services (2024).Hospice Quality Reporting Program.The structure of the Hospice Quality Reporting Program, which houses the HOPE patient assessment, the CAHPS Hospice family survey and claims-based measures including a stand-alone measure of visits in the last days of life, and feeds them into public reporting.. Neither was designed to be read alone. When the two disagree, the disagreement is itself information, and it makes an unusually good question to put to an admissions nurse: the visits happened, so what was happening inside them?

What the index leaves out, starting with ownership

The index says nothing about who owns a hospice, and ownership turns out to predict something the claims data does not capture. A national analysis of CAHPS Hospice responses found that family caregivers reported worse care experiences at for-profit hospices than at not-for-profit ones across every domain the survey measures, and were less likely to say they would recommend the hospice 6Ref 6Anhang Price R, Parast L, Elliott MN, et al. (2023).Association of Hospice Profit Status With Family Caregivers' Reported Care Experiences.That family caregivers nationally reported worse care experiences across all CAHPS Hospice domains at for-profit hospices than at not-for-profit hospices, and were less likely to recommend them..

That is an average across an entire sector, not a verdict on any particular agency. Excellent for-profit hospices exist, and so do poor not-for-profit ones, and a family in a rural county may have one realistic option regardless of what any of this says. The useful move is to treat ownership as a question rather than an answer. It is on the public record next to everything else, and knowing it changes what is worth asking about on the phone.

The other thing the index leaves out is the specific promise a particular family needs kept. Someone with a large family and a small apartment needs to know about the crisis levels of care. Someone who lives alone needs to know how fast a nurse arrives after a call. Someone dying of a disease with a frightening ending needs to know the hospice has managed one before. None of that is in a ten-point score, and none of it should be.

Using the index when you are actually choosing

In practice, the index is one column in a short table a family builds for itself. Open Care Compare, list the hospices that serve the address, and for each one write down the index score, the family-survey results, and the ownership type 4Ref 4Centers for Medicare & Medicaid Services (2024).Find Healthcare Providers: Compare Care Near You (Hospice).That Medicare-certified hospices and their publicly reported quality and family-experience results can be looked up and compared by the public on Care Compare, free and without a login.. Three lines of notes is enough. Then call each hospice, because the table does not decide anything — it tells you what to ask about.

Worth asking, in roughly this order:

• Who answers the phone at three in the morning, and is that person a nurse?
• How often does a nurse visit in the last days, and who makes that call?
• Do you provide crisis-level care in the home, or does a bad night mean the hospital?
• What actually happens on a Saturday?
• The public data shows you missed an indicator — which one, and what has changed since?

A family choosing a hospice at nine on a Friday night, because a discharge planner asked for a decision by morning, is not going to do any of this. That is the normal case and it is not a failure. The index rewards steady, unglamorous behavior sustained over years, which is exactly the thing a single phone call cannot reveal. But a single phone call reveals other things, and a family who has already chosen can still ask every question on that list on the first day.