Comment: Several commenters stated that the use of pseudo-patients and simulation techniques are common in healthcare and a standard of practice in many formal nursing assistant programs. See Condition of participation: Interdisciplinary group, care planning, and coordination of services, Title 42, Chapter IV, Subchapter B, Part 418, 418.56 (https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_156) and Condition of participation: Hospice aide and homemaker services, Title 42, Chapter IV, Subchapter B, Part 418, 418.76 (https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_176). 8. While we did not propose any of these recommendations we could consider them for future rulemaking. 553 requires the agency to give interested parties the opportunity to participate in the rulemaking through public comment before the provisions of the rule take effect. We are also finalizing regulatory changes that are not directly related to PHE waivers that will clarify or align some policies that have been raised as concerns by stakeholders. This also entailed using 4 quarters of HH QRP data from CY 2019 for the all-cause hospitalization and emergency department use claims-based measures, 8 quarters of HH QRP data from CY2018 and CY2019 for Medicare spending per beneficiary (MSPB) and discharge to community (DTC) claims-based measures; and or 12 quarters from January 2017 to December 2019 for the potentially preventable readmission claims-based measure. Sections 1812(d), 1813(a)(4), 1814(a)(7), 1814(i), and 1861(dd) of the Act, and the regulations in 42 CFR part 418, establish eligibility requirements, payment standards and procedures; define covered services; and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. We will publicly report the HCI and HVLDL beginning no earlier than May 2022, and to include it in the Preview Reports no sooner than the May 2022 refresh. We refer stakeholders to the FY 2022 IPPS proposed rule for further information (86 FR 25416 through 25428). In another example, if County B has a pre-floor, pre-reclassified hospital wage index value of 0.7440, we would multiply 0.7440 by 1.15, which equals 0.8556. Full HVLDL specifications are also publicly available on the HQRP website at: https://www.cms.gov/files/document/hospice-visits-last-days-life-hvldl-measure-specifications.pdf. Our analyses suggest that the scoring criteria ensure distributions of HCI scores that allow for differentiation between hospices in any given year. Table 20 displays the original schedule for public reporting of OASIS and HH CAHPS Survey measures prior to the Q1 and Q2 2020 data impacted by the COVID-19 PHE. In the proposed rule, we proposed to introduce Star Ratings for public reporting of CAHPS Hospice Survey results on the Care Compare or successor websites no sooner than FY 2022. If, in the judgment of the hospice interdisciplinary team, which includes the hospice physician, the patient's symptoms cannot be effectively managed at home, then the patient is eligible for general inpatient care (GIP), a more medically intense level of care. Continuous home care may be covered for as much as 24 hours a day, and these periods must be predominantly nursing care, in accordance with the regulations at 418.204. If claims data are revised to include other disciplines, we may consider whether to include them in this measure. A list of the approved vendors can be found on the CAHPS Hospice Survey website: www.hospicecahpssurvey.org. This means CMS requires that hospices submit 90 percent of all required HIS records within 30-days of the event (that is, patient's admission or discharge). We count skilled nursing visits where the corresponding revenue center date overlaps with one of the days of RHC previously identified. Teno J.M., Bowman, J., Plotzke, M., Gozalo, P.L., Christian, T., Miller, S.C., Williams, C., & Mor, V. (2015). We identify the dates billed for RHC, IRC, and GIP by examining the corresponding revenue center date (which identifies the first day in the sequence of days by level of care) and the revenue center units (which identify the number of days (including the first day) in the sequence of days by level of care). You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Name and signature of the Medicare hospice beneficiary (or representative) and date signed, along with a statement that signing this addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not necessarily the beneficiary's agreement with the hospice's determinations. Comment: A commenter stated that the preview report timeframe is too short and that hospices should receive preview data at least 1 year prior to its publication in order to analyze performance and implement quality improvement. Each document posted on the site includes a link to the Overlapping inpatient claims were combined to determine the full length of a hospitalization (looking at the earliest from date and latest through date from a series of overlapping inpatient claims for a beneficiary). and publicly reported by CMS for other care settings. found that 953 hospice programs did not provide any GIP level of care services, and it was unclear if dying patients at such hospices were receiving appropriate pain control or symptoms management (a similar concern exists for hospice services at the CHC level). Hospices would need to make sure the date furnished' on the addendum is within the required timeframe (3 or 5 days, depending upon when the request was made). Information about this document as published in the Federal Register. Other commenters expressed concern that the HCI indicators do not take patient preferences into account, and that the HCI might incentivize hospices to standardize the types and amount of services provided rather than considering personal patient circumstances. [31] This pattern of transitions may lead to fragmented care and may be associated with concerning care processes. This proposed methodology assumes that the proportion of salary costs to total costs for other patient care services is consistent for each of the four levels of care. We also proposed to exclude those providers whose CHC compensation costs were greater than total CHC costs. State/County MEDICAID Rate Charts: NHPCO has prepared the . 29. Note: The comment period closes on August 27, 2021. 37. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Certain events may limit the scope or accuracy of our impact analysis, because such an analysis is susceptible to forecasting errors due to other changes in the forecasted impact time period. Read More News March 15, 2023 L. 96-354), section 1102(b) of the Social Security Act, section 202 of the Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care. We plan to continue working with other agencies and stakeholders to coordinate and to inform our Start Printed Page 42599transformation to dQMs leveraging health IT standards. This addressed five of the six COVID-19 PHE-affected quarters for HIS-based measures, and five of the 11 COVID-19 PHE-affected quarters of CAHPS-based measures. We further refined the HCI based on this feedback, focusing on those indicators with the strongest consistency with CAHPS Hospice scores and/or which quality experts have identified as salient issues for measurement and observation. U.S. Department of Health & Human Services Finally, we requested feedback from stakeholder as to whether the hospice election statement addendum has changed the way hospices make care decisions and how the addendum is used to prompt discussions with beneficiaries and non-hospice providers to ensure that the care needs of beneficiaries who have elected the hospice benefit are met. L. 113-185). Response: As stated in section III F(3)(e). Several hospice providers expressed support for the measure's ability to demonstrate greater variation in hospice performance than the component indicators taken individually. To assess performance in these scenarios, we calculated the reportability as the percent of HHAs meeting the 20-case minimum for public reporting (the public reporting threshold, or PRT). Similarly, we proposed to clarify at 418.24(d)(5) that in the event that a beneficiary requests the addendum and the hospice furnishes the addendum within 3 or 5 days (depending upon when the request for the addendum was made), but the beneficiary dies, revokes, or is discharged prior to signing the addendum, a signature from the individual (or representative) is no longer required. The intention in doing so is to provide a simple, easy to understand, method for summarizing CAHPS scores. This indicator helps the HCI to capture patients' receipt of skilled nursing visits and direct patient care, which is an important aspect of hospice care. (2020). The commenter stated that other acceptable cost reporting methods may be applicable; however, a Level 1 edit is not currently produced if costs are reported in one of the two acceptable locations. We appreciate the support for HOPE and reiterate our commitment to providing updates and engaging stakeholders through sub-regulatory means. Chapter 12: Hospice Services. Therefore, the format of the addendum must be usable for the beneficiary and/or representative. The median reliability scores for the HIS Comprehensive Assessment Measure are also very similar in both CAR and SPR scenarios. Refer Yourself, a Loved One, or a Patient to McLaren Hospice. Paragraph (b)(2) would require collection of Administrative Data, such as Medicare claims data, used for hospice quality measures to capture services throughout the hospice stay. We note that certain changes to wage index policy may significantly affect Medicare payments. We stated that in some instances, this may mean that the hospice must furnish the addendum prior to completion of the comprehensive assessment. that agencies use to create their documents. Comments specific to HCI noted that abnormalities due to the COVID-19 PHE would affect all of the indicators, while those for HVLDL indicated that the number of in-person visits likely fell during the COVID-19 PHE due to patient and caregiver preferences, with implications for quality measurement. PDF IHCP bulletin - Indiana Medicaid Upon the implementation of the hospice benefit, the Congress also expected hospices to continue to use volunteer services, though Medicare Start Printed Page 42530does not pay for these volunteer services (section 1861(dd)(2)(E) of the Act). We then apply a budget neutrality adjustment so that the aggregate simulated payments do not increase or decrease due to changes in the labor share values. Under authority of section 319 of the Public Health Service (PHS) Act, the Secretary declared a PHE effective as of January 27, 2020. Proposal for Public Reporting of CAHPS Hospice Survey-based Measures Due to COVID-19 PHE Exemption, c. Quality Measures To Be Displayed on Care Compare in FY 2022 and Beyond, (1). Our testing indicates that claims data from the COVID-19 PHE are generally stable. We received several comments regarding the updates to the Hospice Visits in the Last Days of Life (HVLDL) and Hospice Item Set V3.00. FY2022 PROPOSED Routine Home Care Rate 1-60 days October 1, 2021 - September 30, 2022 FY2022 PROPOSED Routine Home Care Rate 61 + days October 1, 2021- September 30, 2022 FY2022 PROPOSED Service Intensity Add-On . Indeed, they noted that Questions such as How often did your family member get the help he or she needed for trouble breathing or How often did your family member get the help he or she needed for constipation are difficult for family members to answer if their loved one did not experience issues with those symptoms.. These refreshes for claims-based measures, OASIS-based measures, and for HH CAHPS Survey measures are outlined in Table 20. We received many comments about the use of standardized patient assessment data in the hospice setting to assess health equity and social determinants of health (SDOH). The size exemption is only valid for the year on the size exemption request form. Response: We appreciate the support for this comment and agree that a targeted approach is both more efficient and will permit greater focus on remediating the deficient skills. A summary of these comments and our responses appear below: Comments: Several commenters encouraged CMS to thoughtfully consider the implementation timeline for HOPE and the collection demographic and social risk factor data. We are revising the provisions at 418.306(b)(2) to change the payment reduction for failing to meet hospice quality reporting requirements from 2 to 4 percentage points. While the transition from the HIS to HOPE will eventually enable the HQRP to be more robust, we should not wait to seek improvement on this composite measure as an indicator of quality. For these analyses, we exclude claims from hospices with 19 or fewer discharges[14] If you want to request a wider IP range, first request access for your current IP, and then use the "Site Feedback" button found in the lower left-hand side to make the request. Response: We also believe in the importance of using simple language on Care Compare to ensure consumers can easily use and appropriately interpret quality information that we provide for their decision-making. Hospices should update the addendum to include such conditions, items, services, and drugs they determine to be unrelated throughout the course of a hospice election. Fast Healthcare Interoperability Resources (FHIR) in Support of the Hospice Quality Reporting Program RFI. Section 4410(a) of the Balanced Budget Act of 1997 (Pub. FY 2020 Hospice Wage Index and Payment Rate Update Final Rule, 12. Some commenters suggested that the measure should allow for two visits occurring on the same day to meet the measure qualifications, as visits on the same day could address different patient needs, representing meaningful care on the part of the hospice. We appreciate commenters' concern for provider and vendor burden in implementing a new tool and encourage all key stakeholders to continue to stay informed and engaged through the HQRP Forums, Quarterly Updates, and listserv notifications. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. Thus, quarterly updates would not necessarily provide meaningful support to hospices seeking to improve their quality of care. These commenters stated that the impact of COVID-19 on the labor component of the rates cannot be captured in cost report data that is at least 2 years old. We note that hospices should be able to receive timely reports and data directly from their survey vendors. Our regulations at 418.306(c) require each labor market to be established using the most current hospital wage data available, including any changes made by the Office of Management and Budget (OMB) to the Metropolitan Statistical Areas (MSAs) definitions. Comment: Several commenters expressed concern about the public's ability to understand the meaning of the HIS Comprehensive Measure without being able to see the seven component measures. For FY 2019 this removes 5,212,319 hospice days that come from 218,420 claims and 33,009 beneficiaries. This decision was communicated to the public in a Public Reporting Tip Sheet, which is located at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices. We previously finalized a one-time newness exemption for hospices that meet the criteria as stated in the FY 2017 Hospice Wage Index and Payment Rate Update final rule (81 FR 52181). Star ratings benefit the public in that they can be easier for some to understand than absolute measure scores, and they make comparisons between hospices more straightforward. Numerator: Total sum of minutes provided by the hospice during skilled nursing visits during RHC services days occurring on Saturdays or Sunday within a reporting period. In the March 27, 2020 CMS Guidance Memo, we granted an exception to the HH QRP reporting requirements under the HH QRP exceptions and extension requirements for Quarter 4 (Q4) 2019 (October 1, 2019 through December 31, 2019), Q1 2020 (January 1, 2020 through March 30, 2020), and Q2 2020 (April 1, 2020 through June 30, 2020). Commenters thanked CMS for these regulatory changes, stating that these clarifications will facilitate administration of the addendum and reduce hospice burden. (2) For accounting years that end after September 30, 2016, and before October 1, 2030, the cap amount is the cap amount for the preceding accounting year updated by the percentage update to payment rates for hospice care for services furnished during the fiscal year beginning on the October 1 preceding the beginning of the accounting year as determined pursuant to section 1814(i)(1)(C) of the Act (including the application of any productivity or other adjustments to the hospice percentage update). However, patterns of variation across providers could signal less service provider availability and access for patients on weekends. as patients and their family caregivers also place value on physical symptom management and spiritual/psychosocial care as important factors at the end-of-life. This means providers seeking a size exemption for CAHPS in CY 2022 would base it on their hospice size in CY 2021. Response: We appreciate the recommendation to permit greater flexibility for hospices in regards to staffing of essential workers. The FY 1998 Hospice Wage Index final rule (62 FR 42860), implemented a new methodology for calculating the hospice wage index and instituted an annual Budget Neutrality Adjustment Factor (BNAF) so aggregate Medicare payments to hospices would remain budget neutral to payments calculated using the 1983 wage index. (8) The costs associated with a measure outweigh the benefit of its continued use in the program. Based on our estimates, OMB's Office of Information and Regulatory Affairs has determined that this rulemaking is economically significant as measured by the $100 million threshold, and hence also a major rule under Subtitle E of the Small Business Regulatory Enforcement Fairness Act of 1996 (also known as the Congressional Review Act), 5 U.S.C. Specifically, they stated that claims from the COVID-19 PHE would not reflect typical hospice services. The hospice wage index utilizes the wage adjustment factors used by the Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital wage adjustments. A summary of these comments and our responses to those comments appear below: Comment: One commenter expressed concern that hospices in Montgomery County, Maryland are at a long-term competitive disadvantage due to what they refer to as a Medicare hospice Federal payment inequity involving CBSAs specifically when Metropolitan Divisions are present. If the beneficiary (or representative) refuses to sign the addendum, the hospice must document on the addendum the reason the addendum was not signed and the addendum would become part of the patient's medical record. 7. We solicited public comment on this proposal to use 3 quarters of HIS data for the February 2022 public reporting refresh. A Rule by the Centers for Medicare & Medicaid Services on 08/04/2021. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf. The intent of these waivers was to expand healthcare system capacity while continuing to maintain public and patient safety, and to hold harmless providers and suppliers unable to comply with existing regulations after a good faith effort. 15. The labor shares for other PPS systems (for example, IPPS, SNF, IRF, IPF, and LTCH) are typically rebased every four to five years. Table 8 illustrates how a hypothetical hospice's score is determined across all ten indicators, and how the ten indicators' scores determine the overall HCI score. While nothing in the COPs prevent hospices from augmenting in-person visits with technological means, such as telehealth, these are not intended to change the standard of practice or replace in-person visits. Comment: A few commenters did not agree with the CAA 2021 provision that removes the prohibition on public disclosure of hospice surveys performed by a national accreditation agency in section 1865(b) of the Act, thus allowing the Secretary to disclose such accreditation surveys. This PDF is The commenter stated that they believe their patients and their representatives would welcome this option; however, it is unclear whether mailing the form is acceptable for CMS. We invited public comment on the following: While we stated that we would not be responding to specific comments submitted in response to this RFI in the FY 2022 Hospice Wage Index final rule, we appreciate all of the comments and interest in this topic. In addition, the overall reliability of the CAHPS scores would decline with fewer quarters of data. Medicare regulations define palliative care as patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and Then, for each level of care separately, we further trimmed the sample of cost reports. These four measures cover hospice care throughout the hospice stay. The Affordable Care Act requires physicians or other eligible providers to be enrolled in the GA Medicaid Program to order, prescribe and refer items or services for Medicaid beneficiaries. Hospice Payment Rates As such, the individual measures have a limited ability to differentiate hospices. The AMA does not directly or indirectly practice medicine or dispense medical services. This table of contents is a navigational tool, processed from the We expect that hospices would use the same methods when educating patients (or representatives) about the addendum and non-covered items, services and drugs, which the hospice has determined are not reasonable or necessary for the palliation and management of the terminal illness and related conditions. Addition of a Claims-Based Index Measure, the Hospice Care Index, b. We note that based on comments received during the CMS-1984-14; OMB NO. Comment: Several commenters expressed concern about publicly reporting claims-based measures using data from care provided during the COVID-19 PHE. Finally, in the FY 2020 Hospice Wage Index and Rate Update final rule (84 FR 38505), we finalized modifications to the hospice election statement content requirements at 418.24(b) by requiring hospices, upon request, to furnish an election statement addendum effective beginning in FY 2021. We believe that this will benefit the hospice and the patient by allowing new aide trainees and aides requiring remedial training and competency testing to begin serving patients more quickly while protecting patient health and safety.
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