Background: What Is the SSVI?

In the FY 2027 Hospice Proposed Rule (CMS-1851-P), CMS introduced the Service and Spending Variation Index (SSVI) — a composite scoring tool that flags hospice agencies whose patterns of care and Medicare spending diverge meaningfully from peer norms. CMS released an accompanying agency-level dataset covering 6,642 hospices in FY2025 and 6,735 hospices in FY2024, offering the most granular view of variation across the hospice benefit that CMS has published to date.

The SSVI has two components:

• Non-Hospice Spending Score (0–8): Captures Medicare spending occurring outside the hospice benefit for an agency's enrolled beneficiaries — a proxy for whether patients are receiving services that arguably should be managed within hospice. There are 8 spending tiers based on annual expenditures.
• Utilization Score (0–8): Flags outlier patterns across eight service-delivery indicators, including live discharge rates, length of stay, skilled nursing intensity, weekend visit rates, and end-of-life visit patterns. Utilization scores are based on percentile thresholds (25th or 75th percentiles).

The two scores combine into a total SSVI of 0–16, with higher scores indicating greater deviation from expected norms.

The Score Landscape: Where Do Hospices Fall?

Across the 6,600+ hospices scored in each year, the distribution is roughly bell-shaped and centered in the mid-range.

The average SSVI was effectively flat year over year — 6.42 in FY2025 against 6.40 in FY2024 — and the median is 7 in both years. Only four hospices achieved a perfect score of 0 in FY2025, and the maximum observed was 15 out of 16.

At the upper end, 833 hospices (12.5%) in FY2025 scored 10 or above — the threshold that signals meaningful deviation on both spending and utilization. That compares to 813 hospices (12.1%) in FY2024, a small but notable uptick. Meanwhile, 1,664 hospices (25.1%) scored 4 or below in FY2025, reflecting performance well within or below typical norms.

Score Distribution Summary (FY2025):

Score Range	# of Hospices	% of Total
0–4 (Low)	1,664	25.1%
5–9 (Middle)	4,145	62.4%
10–16 (High)	833	12.5%

What Drives High SSVI Scores?

1. Non-hospice spending is the dominant driver

Among hospices with SSVI ≥ 10, the average Non-Hospice Spending Score was 7.15 of a possible 8 — nearly the maximum — against just 1.83 for low-scoring hospices. The dollar gap is even more striking: high scorers averaged $94.61 in non-hospice Medicare spending per beneficiary per day compared with $3.73 per day for low scorers — a 25-fold difference, and the most consequential single finding in the dataset. It indicates that for high-scoring hospices, beneficiaries are routing substantial Medicare claims outside the benefit through emergency visits, hospitalizations, or other services, signaling a benefit-alignment problem worth close operational review.

2. Utilization flags cluster

High-scoring hospices typically trip multiple utilization flags simultaneously rather than one in isolation. Among FY2025 hospices scoring 10 or higher:

Utilization Flag	High SSVI (≥10)	Low SSVI (≤4)
Low skilled nursing minutes per RHC day	60.9%	9.0%
Long length of stay (≥180 days for ≥46.7% of discharges)	57.4%	11.2%
Low end-of-life visit rate	53.8%	12.3%
Low weekend visit rate	49.2%	13.8%
High live discharge rate	48.6%	14.4%
High readmission within 7 days	38.7%	11.8%
≥40% of RHC days in nursing facility	13.3%	4.6%
No CHC and no GIP	48.6%	51.7%

The starkest contrast is in clinical engagement: 61% of high-SSVI hospices fall below the 25th-percentile threshold for skilled nursing minutes per routine home care day, against 9% of low-SSVI hospices. Pair that with low end-of-life visit rates — 54% of high scorers fall below the 87.5% threshold for skilled visits in the last two RHC days of life — and the picture is one of limited clinical contact at the most critical moments of care.

The high live-discharge and long-LOS flags are also notable. Hospices where live discharges exceed 33.3% of all discharges, or where 46.7% or more of discharges had a length of stay exceeding 180 days, often correlate with aggressive enrollment practices and questions about appropriate hospice eligibility.

One row in the table moves in the opposite direction: the No CHC / No GIP flag trips slightly more often among low-SSVI hospices than high-SSVI ones (51.7% vs. 48.6%). This likely reflects that many small, rural, or facility-based hospices legitimately do not provide higher levels of care; the flag is part of the SSVI scoring system but is a weaker discriminator than the other utilization measures.

3. For-profit ownership correlates strongly with high scores

Among the most significant findings: 95% of FY2025 high-SSVI hospices (scoring ≥10) are for-profit, even though for-profit hospices make up roughly 77.5% of the total agency universe. By contrast, for-profit hospices represent 60.9% of low-SSVI hospices (scoring ≤4). Nonprofits — about 16% of all agencies — account for only 3.1% of high-SSVI hospices but 20.9% of low-SSVI hospices.

Average SSVI by Ownership (FY2025):

Ownership Type	Avg SSVI	Median SSVI
For-profit	6.81	7.0
Nonprofit	5.53	6.0
Government	3.89	4.0
Other / Unknown	~4.1	4.0

Government-operated hospices averaged the lowest SSVI at 3.89 — nearly three points below their for-profit peers.

4. Urban, freestanding agencies score higher

Urban hospices average an SSVI of 6.58 against 5.30 for rural. Freestanding hospices average 6.82, while facility-based hospices average 4.27. These structural differences likely reflect both patient population composition and competitive market dynamics.

What Characterizes Low-Scoring Hospices?

Agencies with SSVI ≤ 4 present a consistent and instructive profile:

• Low non-hospice spending: an average of just $3.73/day in outside Medicare spending, indicating beneficiaries are largely managed within the hospice benefit.
• Higher nonprofit and government representation: nearly a third of low scorers are nonprofit or government-operated.
• Rural concentration: rural hospices make up 21.2% of low scorers, compared with 4.9% of high scorers.
• Facility-based care models: hospital and facility-integrated hospices appear more likely to maintain tighter clinical protocols.
• Strong clinical engagement: low scorers average 16.1 skilled nursing minutes per RHC day, against 9.7 minutes for high scorers — a 66% difference in direct care intensity.
• Lower live-discharge rates: 23.5% on average, versus 49.3% for high scorers.

In aggregate, low-scoring agencies look like what the hospice benefit is designed to be: clinically intensive care for patients with a defined prognosis, delivered within the benefit.

Geographic Patterns

State-level variation is pronounced. Among states with at least 20 reporting hospices, the highest average SSVI scores cluster in parts of the South and Northeast:

State	Avg SSVI	# Agencies
Florida	8.28	58
Mississippi	7.45	82
New Jersey	7.34	61
Oklahoma	7.29	134
Texas	7.26	998
Ohio	7.01	162
Massachusetts	7.00	75

California and Texas alone account for 66% of all high-SSVI hospices nationally (312 in California, 237 in Texas) — a function of both market size and historically high concentrations of for-profit, freestanding hospice providers.

At the lower end of average scores:

State	Avg SSVI	# Agencies
Oregon	4.20	66
Montana	4.29	31
Puerto Rico	4.29	41
Nebraska	4.74	42
Idaho	4.75	55

Western and upper-Midwestern states consistently appear at the lower end of the average-SSVI distribution, likely reflecting different market compositions and longer-standing nonprofit hospice infrastructure.

Implications for Hospice Providers

Several practical takeaways for providers preparing their response to the proposed rule:

1. Non-hospice spending is the highest-leverage exposure

Utilization flags can often be mitigated through operational changes; outsized non-hospice Medicare spending is harder to explain and points squarely to a benefit-alignment problem. Hospices should start their internal review here. One methodology note worth keeping in mind: the SSVI's spending score is built from aggregate non-hospice spending across an agency's enrolled beneficiaries, not per-day figures, so reducing daily costs without addressing total volume of outside services will not move the score.

2. Flags travel together

A compliance review focused on a single flag — say, live discharge rates — risks missing the broader pattern CMS is targeting. Look at the full set of utilization indicators in tandem.

3. Ownership type does not determine outcome

While the aggregate statistics are unfavorable for for-profit providers, many for-profit hospices fall in the low-score range. The SSVI is measuring practice patterns, not corporate structure.

4. Patient mix and structure influence scores

Rural and facility-embedded hospices score lower on average, suggesting that referral patterns and patient population are part of what the index captures. Providers should account for this when benchmarking against peers.

5. Track your problem utilization scores in real time

For scores near or above the percentile thresholds, SHP's analytics tools allow agencies to track similar utilization measures in real time. Check out our new Hospice Scorecard Percentiles report recently released. Pair that visibility with a focused QAPI initiative on the specific flags driving your score, then monitor performance over time.

Conclusion

The SSVI is CMS's most data-driven attempt yet to separate high-value hospice care from patterns it views as inappropriate utilization. The FY2025 data reveals a hospice landscape in which a meaningful minority of providers — concentrated in for-profit, urban, freestanding settings, with low clinical intensity and high outside spending — diverge sharply from the rest of the field.

The wide variance within each ownership category shows the SSVI is measuring practice patterns, not just business models. But the concentration of high scores among for-profit freestanding hospices — 95% of the highest scorers — will make it difficult to argue that the index is capturing anything other than what CMS intends. Providers should benchmark their own performance against the public dataset, identify which specific flags are driving their score, and — for those in the at-risk range — develop a documented response strategy now.

Data source: CMS Service and Spending Variation Index (SSVI) file, released April 16, 2026, associated with the FY 2027 Hospice Proposed Rule (CMS-1851-P). Analysis covers 6,642 hospices in FY2025 and 6,735 hospices in FY2024.