In the FY 2022 Hospice Wage Index and Rate Update final rule ( 86 FR 42532 through 42539 ), we finalized a policy to rebase and revise the labor shares for CHC, RHC, IRC and GIP using Medicare cost report (MCR) data for freestanding hospices (collected via CMS Form 1984-14, OMB NO. Furthermore, we expect that hospices will have processes in place when they are obtaining a signed addendum from a beneficiary or representative. Then, for each level of care separately, we further trimmed the sample of cost reports. Denominator: The number of beneficiaries with at least 1 day of hospice during the last 3 days of life within a reporting period. 48. CMS Publishes Final Hospice Payments Rule for FY 2022 Chapter 12: Hospice Services. We proposed that the calculation and display of the CAHPS Hospice Survey Star Ratings be similar to that of other CAHPS Star Ratings programs such as Hospital CAHPS and Home Health CAHPS. However, in its comment, MedPAC concluded that the aggregate level of payments could be reduced and would still be sufficient to cover hospice providers' costs and preserve beneficiaries' access to care. Therefore, MedPAC recommended a zero percent update for FY 2022 for all hospice providers. The division will pay the hospice in accordance with the usual Medicaid reimbursement for physician services (such as direct patient care services) when these services are provided by hospice employees or physicians under agreement with the hospice. 20. In addition, MedPAC's Report to Congress: Medicare Payment Policy[9] Live discharges occur when the patient discharge status code does not equal a value from the following list: 30, 40, 41, 42, 50, 51. Thus, we do not anticipate service refusals to be concentrated among particular hospices, and as such do not expect refused visits to have an outsized effect on any hospice's performance on this measure. Response: We appreciate the opportunity to provide clarification. Payment rates for FYs since 2002 have been updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update to the payment rates for subsequent FYs must be the inpatient market basket percentage increase for that FY. For questions regarding home health public reporting, contact Charles Padgett (410) 786-2811. To: NHPCO Provider and State Members From: NHPCO Regulatory Team Date: September 29, 2021 . Table 7 indicates the number of hospice days, hospice claims, beneficiaries enrolled in hospices and hospices with at least one claim represented in each year of our analysis. The commenter claimed that the proposed methodology only captures salaries and benefits of physicians, nurse practitioners, RNs and hospice aides. Part 418, subpart G, provides for a per diem payment based on one of four prospectively-determined rate categories of hospice care (routine home care (RHC), CHC, IRC, and GIP), based on each day a qualified Medicare beneficiary is under hospice care (once the individual has elected). PDF Medicare Program; FY 2023 Hospice Wage Index and Payment Rate - NHPCO Hospices can review and correct their HIS data before the Data Correction Deadline; for claims data, hospices will be able to ensure that the data are accurate through the end of the 90-day run-off period. The date of the visit is recorded in the corresponding revenue center date. Medicare fee-for-service (FFS) hospice claims with through dates on and between October 1, 2016 and September 30, 2019 to determine information such as hospice days by level of care, provision of visits, live discharges, hospice payments, and dates of hospice election. Along with nine HIS-based quality measures, the CAHPS Hospice Survey measures are publicly reported on a designated CMS website that is currently Care Compare. Response: We recognize commenters' concern that HQRP measures reflect quality of care rather than program integrity issues. Since FY 2014, hospices that fail to report quality data have their market basket percentage increase reduced by 2 percentage points. Indicators reflect practices or outcomes hospices should pursue, thereby awarding points based on the criterion. 4. One commenter strongly encouraged CMS not to revise the labor share using the 2018 MCR for freestanding hospices. The quality, utility, and clarity of the information to be collected. 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. In the FY 2022 Hospice Wage Index and Payment Rate Update proposed rule (86 FR 19720), we proposed the market basket percentage increase of 2.5 percent for FY 2022 using the most current estimate of the inpatient hospital market basket (based on IHS Global Inc.'s fourth-quarter 2020 forecast with historical data through the third quarter 2020). As part of developing the HCI, we conducted reportability, variability, and validity testing using claims data from FY 2019. While we consider how best to address these potential scenarios in a consistent and thoughtful manner, we reiterate that our policy principles with regard to the wage index include generally using the most current data and information available and providing that data and information, as well as any approaches to addressing any significant effects on Medicare payments resulting from these potential scenarios, in notice and comment rulemaking. 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. documents in the last year, 84 We discuss the impact to the HIS here, and the impact to the CAHPS Hospice Survey further in section F.10.b.4. One commenter urged CMS to give special consideration to challenges faced by rural health care providers with specific attention given to the impact workforce shortages have in setting reimbursement rates related to the labor shares. Using percentile rankings derived from national performance, it is very unlikely for all hospices to receive the same score. We maintain transparency since Start Printed Page 42584stakeholders, who are interested in the seven HIS measures, will have access to the Provider Data Catalogue where they can find all HIS component measure scores. Thus, we proceeded with including Q4 2019 data in measure calculations for the October 2020 refresh. (2020). Comment: Many commenters encouraged CMS to update the model hospice election statement addendum on the CMS hospice center web page to illustrate these clarifications. We then calculated the change in the number of hospices which achieved the minimum reporting standard. The guidelines were developed by the National Consensus Project for Quality Palliative Care, comprising 16 national organizations with extensive expertise in and experience with palliative care and hospice, and were published by the National Coalition for Hospice and Palliative Care. PDF Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and The rule implemented temporary changes to the hospice payment requirements to provide broad flexibilities to furnish services using telecommunications technology in order to avoid exposure risks to health care providers, patients, and the community during the PHE. The labor shares showing the revised methodology are provided in Table 1. The RFA requires agencies to analyze options for regulatory relief of small businesses if a rule has a significant impact on a substantial number of small entities. L. 116 260), the reduction changes to 4 percentage points beginning in FY 2024. In particular, the existing HQRP measure set, calculated using data collected from the HIS and the CAHPS Hospice survey, does not assess quality of hospice care during a hospice election (between admission and discharge). The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Closing the Health Equity Gap in Post-Acute Care Quality Reporting ProgramsRequest for Information, VI. the material on FederalRegister.gov is accurately displayed, consistent with We note that simulated payments are based on utilization in FY 2020 as seen on Medicare hospice claims (accessed from the CCW in May 2021) and only include payments related to the level of care and do not include payments related to the service intensity add-on. We encourage hospices to use this website at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Reporting-Training-Training-and-Education-Library. Standard Public Reporting (SPR) Scenario: We used data from the four quarters of CY 2019, which represent CY 2020 public reporting in the absence of the temporary exemption from the submission of PAC quality data, as the basis for comparing simulated alternatives. Because the Medicare hospice benefit pays a per diem rate, an important determinant of per-beneficiary spending is the length of election. CMS has traditionally used a reportability threshold of 70 percent, meaning at least 70 percent of HHAs are able to report at least 20 episodes for a given measure, as the standard to determine whether a measure should be publicly reported. Existing hospices had the option of having their cap calculated through the original streamlined methodology, also within certain limits. Application of the COVID-19 PHE Affected Reporting (CAR) Scenario To Publicly Display Certain HH QRP Measures (Beginning in January 2022 Through July 2024), 6. A few commenters stated that these changes should be implemented as quickly as possible, and once they are in place CMS should undertake a recalculation of the labor shares. Several commenters stated that basing the hospice labor shares on recent MCR data for hospice providers will improve payment accuracy. One commenter requested a minimum of 6 months from the date final specifications are available for EMR and other vendors to respond to any changes in the HQRP. Teno J.M., Bowman, J., Plotzke, M., Gozalo, P.L., Christian, T., Miller, S.C., Williams, C., & Mor, V. (2015). 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.. The comments pointed out that the process for providers to adapt to the new tool requires at least 6 months or more. 43. Although these measures represent the first time that hospices are held accountable for visits information in claims, the measures reflect ideas about best practice and compliance that hospices have already known. Section III.C of this rule updates the hospice wage index and makes the application of the updated wage data budget neutral for all four levels of hospice care and discusses the FY 2022 hospice payment update percentage of 2.0 percent, updates to the hospice payment rates, as well as the updates to the hospice cap amount for FY 2022 by the hospice payment update percentage of 2.0 percent. We propose no changes to this exemption. The survey received its initial NQF endorsement on October 26, 2016 (NQF #2651). Comment: We received a comment that we are making many updates in this rule and the resources for them are significant, especially during the COVID-19 Public Health Emergency (PHE). Finally, the NQF Measures Application Partnership (MAP) met on January 11, 2021 and provided input to CMS. The final rule also finalizes a Home Health Quality Reporting Program (HH QRP) policy that becomes effective on October 1, The final rule (CMS-1754-F) can be downloaded from the, https://www.federalregister.gov/public-inspection, This rule also finalizes the addition of the Consumer Assessment of Healthcare Providers and Systems, The final rule ([CMS-1754-F)can be downloaded from the, https://www.federalregister.gov/public-inspection/current. In such instances, the removal of a measure will be formally announced in the next annual rulemaking cycle. We also discussed that there may be instances in which the beneficiary or representative requests the addendum and the beneficiary dies, revokes, or is discharged prior to signing the addendum (86 FR 19725). Therefore, for accounting years that end after September 30, 2016 and before October 1, 2030, the hospice cap amount is updated by the hospice payment update percentage rather than using the CPI-U. The Future of Hospice and Medicare Advantage Organizations Hospice providers will be increasingly impacted by the growth of Medicare Advantage Organizations and their evolving ability to offer hospice benefits to patients. An official website of the State of Georgia. Specifically, 5 U.S.C. . Another exclusion was made prior to reporting the numbers in Table B.1. Also, the relatively high number of hospices that meet the public reporting threshold in the CAR scenario, relative to the SPR scenario, with just 3 quarters of data justify the use of 3 quarters in the unusual circumstances of the COVID-19 PHE and its associated exemptions. We believe that a signed addendum indicates the hospice discussed the addendum and its contents with the beneficiary (or representative). CHC is provided during a period of patient crisis to maintain the patient at home; IRC is short-term care to allow the usual caregiver to rest and be relieved from caregiving; and GIP is to treat symptoms that cannot be managed in another setting. Variability analyses confirmed that HCI demonstrates sufficient ability to differentiate hospices. The points are earned without weighting to recognize the tradeoffs for each indicator's specifications. In that final rule, we noted that the procedures for HHAs to review and correct their data on a quarterly basis is performed through CASPER along with our procedure to post the data for the public on our Care Compare website. For these reasons the HCI includes one indicator for per-beneficiary spending; lower rates of per beneficiary spending may identify hospices that provide efficient care at a lower cost to Medicare. As finalized in the FY 2019 Hospice Wage Index and Payment Update final rule (83 FR 38622), we also improved access to publicly-available information about hospices' compliance with Hospice QRP requirements. First, we evaluated measure correlation using the Pearson and Spearman correlation coefficients, which assess the alignment of hospices' HIS Comprehensive Assessment Measure scores between scenarios. These salaries reflecting all levels of care are reported on Worksheet A, column 1, lines 38 through 46 and then are further disaggregated for CHC, RHC, IRC, and GIP on Worksheets A-1, A-2, A-3, and A-4, respectively, on column 1 (salaries), lines 38 through 46. An official website of the State of Georgia. Several commenters stated that the addendum has not changed their practices for determining what is related or unrelated under the hospice benefit, but has enhanced the upfront communication with patients and representatives during the admission process. HQRP Compliance Checklist illustrates the APU and timeliness threshold requirements. Response: Star Ratings are easy for consumers to understand and interpret and are used in a variety of settings. publication in the future. This could include not only a beneficiary refusing to sign, but also death, discharge, or revocation prior to the hospice obtaining the signature. Response: We appreciate commenters' concerns regarding the administrative burden in quality reporting. (2020). Hospice rates were to be updated by a factor equal to the inpatient hospital market basket percentage increase set out under section 1886(b)(3)(B)(iii) of the Act, minus 1 percentage point. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf. Comment: The majority of commenters supported the clarifications and proposed regulation text changes regarding the election statement addendum. The specifications for Indicator Two, Gaps in Skilled Nursing Visits, are as follows: Prior work has identified various concerning patterns of live discharge from hospice. For this reason, we proposed to calculate CAHPS Hospice star ratings using top-box scores. In addition to the Preview Report, we will also include claims-based measure scores in the Hospice Agency-Level QM Report in CASPER. For further information about the CAHPS Hospice Survey, we encourage hospices and other entities to visit: https://www.hospiceCAHPSsurvey.org. [4] Montgomery County belongs in a separate CBSA from the areas defined in the Washington-Arlington-Alexandria, DC-VA CBSA. PPACA, required, effective January 1, 2011, that a hospice physician or nurse practitioner have a face-to-face encounter with the beneficiary to determine continued eligibility of the beneficiary's hospice care prior to the 180th day recertification and each subsequent recertification, and to attest that such visit took place. In the FY2018 Hospice Wage Index & Payment Rate proposed rule (82 FR 20750), we solicited public comment on two high-priority claims-based measure concepts being considered at the time, one which looked at transitions from hospice and another which examined access to higher levels of hospice care. On March 13, 2020, the President declared a national state of emergency under the Stafford Act, effective March 1, 2020, allowing the Secretary to invoke section 1135(b) of the Act (42 U.S.C. documents in the last year, by the International Trade Commission One way to approach this would be to use state survey data to identify hospices that are deficient and do not have contracts to provide GIP. A list of the approved vendors can be found on the CAHPS Hospice Survey website: www.hospicecahpssurvey.org. We do not have a policy for `exceptional circumstances' (that is floods, hurricanes, etc.) 20-01, OMB announced one new Micropolitan Statistical Area, one new component of an existing Combined Statistical Are and changes to New England City and Town Area (NECTA) delineations. To accommodate the excepted HH QRP of 2020 Q1 and Q2, we resume public reporting using 3 out of 4 quarters of data for the January 2022 refresh. Prior to the COVID-19 PHE, we reported the most recent 8 quarters of data on the basis of a rolling average, with the most recent quarter of data being added and the oldest quarter of data removed from the averages for each data refresh. IHCP bulletin BT202194 OCTOBER 21, 2021 Page 2 of 6 In FFY 2021, the updated hospice wage . However, we do not agree with the commenter who suggested including a statement on Care Compare regarding the inclusion of data from the COVID-19 PHE because such an announcement will not help consumers distinguish between HHAs in their region. As noted by the commenter, salaries and benefit costs for employed Medical Directors would be reported in Worksheet A, column 1, line 15 (salaries) and Worksheet B, column 3, line 15 (benefits), which are both included in our proposed methodology as these expenses are reported in overhead salaries and overhead benefits. Hospices can develop processes (including how to document such requests from non-hospice providers and Medicare contractors) to address circumstances in which the non-hospice provider or Medicare contractor requests the addendum, and the beneficiary or representative does not, as a means of demonstrating that the addendum was furnished to a non-hospice provider and/or Medicare contractor upon request. Specifically, a hospice's HCI score is based on its collective performance for the ten performance indicators detailed earlier, all of which must be included to calculate the score and meaningfully distinguish between hospices' relative performance. The individual measures show performance for only one process and do not demonstrate whether the hospice provides high-quality care overall, as an organization. Hospice providers were required to begin using this survey for hospice patients as of 2015. Comment: A few commenters requested more details about if and how we will include patient-mix adjustment. The commenter stated that this would better allow CMS to isolate the costs of those facilities that truly operate an inpatient unit. We will also consider opportunities to communicate through webinars, Open Door Forums, and other resources as relevant. Third, we are finalizing our proposal to calculate claims-based measure scores based on one or more years of data. Applications are available at the, Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. We will continue to evaluate the impact of the COVID-19 PHE. Given these findings, we are finalizing our proposal to use 2 years of data to publicly report HCI and HVLDL in 2022. We were also interested in feedback regarding whether including facility-level quality measure results stratified by social risk factors and social determinants of health (and relevant proxies, such as dual eligibility for Medicare and Medicaid, and race) in confidential feedback reports could allow facilities to identify gaps in the quality of care they provide. In the FY 2021 Hospice Wage Index final rule (85 FR 47070) we stated that if appropriate, we would propose any updates from OMB Bulletin No. Hospice Rates for Providers that Have Submitted the Required Quality Data Federal Fiscal Year 2021 Effective October 1, 2020 County Name County Number CBSA We examined star ratings using linear means and, separately, top-box scores. We stated that we would continue to expect that the hospice would note the date furnished in the patient's medical record and on the addendum, if the hospice has already completed the addendum, as well as an explanation in the patient's medical record noting that the patient died, revoked, or was discharged prior to signing the addendum (86 FR 19725). We also solicited comments regarding skilled visits in the last week of life, particularly, what factors determine how and when visits are made as an individual approaches the end of life and how hospices make determinations as to what items, services and drugs are related versus unrelated to the terminal illness and related conditions. L. 105-33) provides that the area wage index applicable to any hospital that is located in an urban area of a state may not be less than the area wage index applicable to hospitals located in rural areas in that state. One commenter stated that their hospice revisited the way relatedness is defined, and realized that many diagnoses that were previously thought to be unrelated were related. We proposed that only the overall Star Rating be publicly reported and that hospices must have a minimum of 75 completed surveys in order to be assigned a Star Rating. We proposed that total costs Start Printed Page 42537for CHC are equal to Worksheet B, column 18, line 50, for RHC are equal to Worksheet B, column 18, line 51, for IRC are equal to Worksheet B, column 18, line 52, and for GIP are equal to Worksheet B, column 18, line 53. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". (3) If there are any changes to the plan of care during the course of hospice care, the hospice must update the addendum and provide these updates, in writing, to the individual (or representative) in order to communicate these changes to the individual (or representative). Comment: One commenter stated that many of the hospice cost reports filed in 2018 failed to report contracted GIP days and contracted IRC care days on Worksheet S-1. 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. We observed that the HIS data submission rate for Q4 2019 was in fact 1.8 percent higher than the previous CY (Q4 2018). They stated that the number of hospices that do not pass level 1 edits is also of concern. Until the ACFR grants it official status, the XML One commenter stated that their hospice utilizes general inpatient contracts, as they do not have our own facility. Proposal To Revise 418.312(b) Submission of Hospice Quality Reporting Program Data, 6. Comment: Another specific concern stated by the commenters was that the determination of the labor share for GIP and IRC is based on Worksheet A-3 and A-4; however, any hospices reporting costs on line 25 (contracted services) were not included in the sample used for setting the labor share. The HQRP seeks to align with the other settings. As measured by Pearson's correlation coefficients, the correlation between the CAHPS hospice overall rating and the HCI is +0.0675, and the correlation between the CAHPS hospice recommendation outcome and the HCI score is +0.0916. d. What additional resources or tools would post-acute care settings, including but not limited to hospices and health IT vendors find helpful to support testing, implementation, collection, and reporting of all measures using FHIR standards via secure APIs to reinforce the sharing of patient health information between care settings? Some commenters requested that LPNs count for the measure, in addition to RNs. The 2020-2021 MAP 2020 Final Recommendations can be found at: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=94893. By dividing total payments for each level of care (RHC days 1 through 60, RHC days 61+, CHC, IRC, and GIP) using the FY 2022 wage index, current labor shares and payment rates for each level of care by the total payments for each level of care using the final revised labor shares and FY 2022 wage index and payment. Our two primary objectives for HOPE are to provide quality data for the HQRP requirements through standardized data collection, and to provide additional clinical data that could inform future payment refinements. We further proposed to calculate a summary or overall CAHPS Hospice Survey Star Rating by averaging the Star Ratings across the 8 measures, with a weight of 1/2 for Rating of the Hospice, a weight of 1/2 for Willingness to Recommend the Hospice, and a weight of 1 for each of the other measures, and then rounding to a whole number. [27] We previously finalized the participation requirements for the CAHPS Hospice Survey, (84 FR 38484). We disagree with commenters that the hospice MCR data does not provide adequate or appropriate measure of labor expenses. 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. Public Health Emergency. 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