Then, using the same FY 2020 data, we apply the FY 2022 wage index and the current labor share values to simulate FY 2022 payments and compare simulated payments using the FY 2022 wage index and the proposed revised labor shares. HQRP Compliance Checklist illustrates the APU and timeliness threshold requirements. Response: We appreciate MedPAC's comments; however, we are required by law to update the hospice cap amount from the preceding year by the hospice payment update percentage, in accordance with section 1814(i)(2)(B)(ii) of the Act. (2020). In addition to the publicly-reported quality measure data, in 2019 we added to public reporting, information about the hospices' characteristics, taking raw data available from the Medicare Public Use File and other publicly-available government data sources and making them more consumer friendly and accessible for people seeking hospice care for themselves or family members, (83 FR 38649). https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf. Indicator Four: Late Live Discharges, (5). A gap of at least 1 day without hospice ends the sequence. We understand the possibility of conflating the differences between the ABN and the hospice election statement addendum. They stated that in many healthcare systems someone from the accounting department completed the cost report form with very little input from the hospice program. Update on the Hospice Visits in the Last Days of Life (HVLDL) and Hospice Item Set V3.00, 5. County Name CBSA Urban/Rural . Other commenters stated that denying the whole hospice claim when the addendum is furnished late is excessive. 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. The MAP conditionally supported the HCI for rulemaking contingent on NQF endorsement. The payment rate updates are subject to changes in economy-wide productivity as specified in section 1886(b)(3)(B)(xi)(II) of the Act. 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. 804(2). They requested a justification for using this number. Comment: One commenter requested that clarification as to how CMS will adjust the labor share if certain types of hospices are found to provide more services and thus, likely have a larger labor share but contribute fewer cost reports. The hospice is required to furnish the addendum in writing in an accessible format, so the beneficiary (or representative) can understand the information provided, make treatment decisions based on that information, and share such information with non-hospice providers rendering un-related items and services to the beneficiary. Denominator: The total number of hospice service days provided by the hospice at any level of care within a reporting period. 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. Beginning May 2021, we will begin to display additional information from the PAC PUF on Care Compare. Hospice providers suggested that claims may lack sufficient information to adequately reflect individual patient Start Printed Page 42565needs or the full array of hospice practices. Comment: A commenter suggested that CMS should not use claims data from a time period before a measure is finalized through rulemaking. The public's familiarity with a 1 through 5 star rating system, given its use by other programs, is also a benefit to using this system. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. These visits can be made by either the RN, the medical social worker, or both. (2013). Response: We appreciate commenters' concerns that hospice providers do not believe they could replicate the indicators without more information. One commenter stated that given the survey response rate, a hospice would have more than 200 completed surveys in order for star ratings to be displayed. The specifications for Indicator Eight, Skilled Nurse Care Minutes per RHC Day, are as follows: Our regulations at 418.100(c)(2) require that [n]ursing services, physician services, and drugs and biologicals . The specifications for Indicator Nine, Skilled Nursing Minutes on Weekends, are as follows: The end of life is typically the period in the terminal illness trajectory with the highest symptom burden. 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. The commenter questioned how CMS is determining that the inpatient costs are related solely to a freestanding inpatient unit on Worksheet A-4. Federal Register. However, in light of the COVID-19 PHE, we plan to monitor the upcoming MCR Start Printed Page 42534data to see if a more frequent revision to the hospice labor shares is necessary in order to reflect the most recent cost structures of hospice providers. We sought public comment on methods, instruments, or brief summaries on hospice quality initiatives related to goal attainment, patient preferences, spiritual needs, psychosocial needs, and medication management. Given that HCI is scored relative to the national average, scores will be accounted for as part of the measure calculation. 46. Comment: Several commenters expressed concern regarding the impact of COVID-19 on labor costs. Specifically, we used historical data to calculate HIS-based quality measures under two scenarios: The HIS Comprehensive Assessment Measure is based on the receipt of care processes at the time of admission. In the proposed rule, we stated that we have subsequently received this question from stakeholders post implementation, and therefore, clarified that if a patient or representative refuses to sign the addendum, the hospice must document clearly in the medical record (and on the addendum itself) the reason the addendum is not signed in order to mitigate a claims denial for this condition for payment. Accessible via: http://www.medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf?sfvrsn=0. 2) The SIApayment is in addition to the per diem RHC rate when all the following criteria are met: (a) The day is an RHC level of care day. Commenters also encouraged CMS to provide early testing and education for providers on HIT and to provide a structured FHIR transition framework for key stakeholders. County Number CBSA FFY 2022 Hospice Wage Index Continuous Home Care Inpatient Respite Care General Inpatient Care Routine Home Care (days 1-60) Routine Home Care (days 61+) Service The sub-regulatory Quality Measure Users' Manual will be posted on the HQRP Current Measures web page to provide measure specifications. The addendum must list those items, services, and drugs the hospice has determined to be unrelated to the terminal illness and related conditions, increasing coverage transparency for beneficiaries under a hospice election. This revision to our labor share methodology results in upward revisions to the proposed labor shares for each of the levels of care (between 0.6 percentage point and 1.1 percentage point). The commenters stated that many of these hospices providers have some of the best accounting records in the industry and the proposed methodology for calculating the labor components eliminates the costs of these facilities from consideration. along with the publication of this FY 2022 Hospice Wage Index and Payment Rate Update final rule. In chapter 6 of the June 2007 Report to Congress, MedPAC recommended the new wage index should: Use wage data from all employers and industry-specific occupational weights, adjust for geographic differences in the ratio of benefits to wages, adjust at the county level and smooth large differences between counties, and be implemented so that large changes in wage index values are phased in over a transition period. This measure includes 10 indicators of quality that are calculated from claims data. It is our hope to provide additional stratified information to providers related to race and ethnicity if feasible. Hospice care is a comprehensive, holistic approach to treatment that recognizes the impending death of a terminally ill individual and warrants a change in the focus from curative care to palliative care for relief of pain and for symptom management. In this section, we presented three proposals related to calculating and reporting claims-based measures, with specific application to HVLDL and HCI. Conversely, the HIS Comprehensive Assessment Measure, which is a single composite measure, differentiates hospices by holding them accountable for completing all seven process measures to ensure these core hospice services are completed for all patients. These process measures may support or complement the outcome measures. In the home health setting, for example, national median scores for OASIS-based measures tend to increase, while the acute care hospitalization measure remains steady (Figure 3). Therefore, we are finalizing the non-labor portion of the payment rates to be as follows: For CHC, 24.8 percent; RHC, 34 percent; for GIP, 36.5 percent; and For IRC, 39.0 percent. We outline our proposed trimming methodology using CHC as an example. Before we publicly report this measure, we will provide resources to aid the public in interpreting publicly displayed quality data. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Items, Services, and Drugs Related and Unrelated to the Terminal Illness and Related Conditions, 2. Accessible via: https://oig.hhs.gov/oei/reports/oei-02-10-00491.asp. Some stakeholders raised concerns that claims data may not adequately express the quality of care provided, and may be better suited as an indicator for program integrity or compliance issues. The addendum must be titled Patient Notification of Hospice Non-Covered Items, Services, and Drugs; 3. CMS will take these comments under advisement for future consideration of quality measures and the Meaningful Measures System Blueprint. Comment: A few commenters supported the proposal to rebase the labor share for the four levels of care based on the 2018 MCR data. See Special coverage requirements, Title 42, Chapter IV, Subchapter B, Part 418, 418.204. https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_1204. We believe HCI does reflect hospice quality because the HCI indicators were identified as quality issues by the Office of Inspector General,[38,39,40] Addition of a Claims-Based Index Measure, the Hospice Care Index, b. Comment: Many commenters questioned the weighting of the components of the star ratings, particularly the decision to weigh the two global questions (Overall Rating and Willingness to Recommend) at 50 percent of the weight for each composite measure. Comment: Several commenters stated that the HCI should focus on whether hospices are prepared to provide key services, rather than whether claims for those services were billed during a given reporting period. Since 0.4593 is not greater than 0.8, then County A's hospice wage index would be 0.4593. However, due to the COVID-19 PHE, we looked at using the previous fiscal year's hospice claims data (FY 2019) to determine if there were significant differences between utilizing 2019 and 2020 claims data. During measure testing, we observed that hospices achieved scores between three and ten. As part of developing the HCI, we conducted reportability, variability, and validity testing using claims data from FY 2019. For more than 30 years, McLaren Hospice has supported the physical, emotional, and spiritual needs of thousands through their most difficult moments. Comment: Commenters recommended using simple language to describe HVLDL on Care Compare, to ensure that the average consumer will understand it. L. 111-148), required hospices to begin submitting quality data, based on measures specified by the Secretary of the Department of Health and Human Services (the Secretary), for FY 2014 and subsequent FYs. 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. CMS also finalized a service intensity add-on (SIA) payment payable for certain services during the last 7 days of the beneficiary's life. Update on Use of Q4 2019 Data and Data Freeze for Refreshes in 2021, (3). This indicator identifies hospices that provided at least Start Printed Page 42559one day of hospice care under the CHC or the GIP levels of care during the period examined. CMS Publishes Final Hospice Payments Rule for FY 2022 The commenters stated that the hospice cost report in its current form does not suit all data purposes for hospice policy changes, and does not fully support calculation of the hospice payment rate labor shares. 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. There is one rate for the first 60 days of care and another rate for care beyond 60 days. Hospice care offers holistic support and relief from pain and other symptoms of the terminal illness. A minimum of 8 hours of nursing care, or nursing and aide care, must be furnished on a particular day to qualify for the continuous home care rate (418.302(e)(4)). The HQRP seeks to align with the other settings. hb```b> cc`az?8C\{ This is a result of the 2.7 percent market basket percentage increase reduced by a 0.7 percentage point productivity adjustment. Accessed June 13, 2021. This contract is currently held by the National Quality Forum (NQF). The scope of this license is determined by the AMA, the copyright holder. This repetition of headings to form internal navigation links Index Earned Point Criterion: Hospices earn a point towards the HCI if their individual hospice score for Type 2 burdensome transitions falls below the 90th percentile ranking among hospices nationally. Additionally, we summarize the comments on the requests for information (RFI) on advancing to digital quality measurement and the use of FHIR and on addressing the White House Executive Order related to health equity in the HQRP. L. 79-404), 5 U.S.C. documents in the last year, by the International Trade Commission Response: We are mindful of the burden related to our updates. Call: (800) 862-3132. 22. headings within the legal text of Federal Register documents. We received a comment indicating some hospice agencies never hit the cap amount and recommend for CMS to utilize available claims and quality data to target hospices with questionable practices to avoid exceeding the cap amount. Additionally, we did not propose to expand billing codes for telehealth services or patient preferences, and as such cannot include such services in the HCI. Section 3401(g) of the Affordable Care Act mandated that, starting with FY 2013 (and in subsequent FYs), the hospice payment update percentage would be annually reduced by changes in economy-wide productivity as specified in section 1886(b)(3)(B)(xi)(II) of the Act. The commenter stated that it appears that the percentage of hospice cost reports used for determining GIP and respite total costs and labor-component costs is based on a small population of hospice providers with a significant risk of error; therefore, the commenter recommended that CMS rethink its approach for GIP and respite labor costs. An official website of the United States government. For this indicator, we first determine if a beneficiary was in hospice for at least 1 day during their last 3 days of life by comparing days of hospice enrollment from hospice claims to their date of death. One commenter stated concern that due to hospice MCRs not being audited, as well as some sections of the cost report offering multiple methods of reporting, there is a general lack of consistency in the way that the reports are completed by hospice providers that will necessarily distort the average labor figures. Therefore, we proposed to clarify in regulation that the date furnished must be within the required timeframe (that is, 3 or 5 days of the beneficiary or representative request, depending on when such request was made), rather than the signature date. The ABN transfers potential financial liability to the Medicare beneficiary in certain instances, whereas the addendum (upon request) informs terminally ill beneficiaries (or their representative) only of items, services, or drugs the hospice will not be providing because the hospice has determined them to be unrelated to the terminal illness and related conditions. The Medicaid reimbursement is based on the status of the member's eligibility days and a hospice lock-in span. Table 24 summarizes this discussion. We then need to generate and check the calculations before posting for confidential reporting. 15. We are also considering developing hybrid quality measures that would be calculated using claims, assessment (HOPE), or other data sources. The estimated compensation costs related to medical supply and pharmacy costs would be reflected in the Other Patient Care Salaries, Overhead Salaries, and Overhead Benefits categories. 4. Hospices which do not report HIS data used for the HIS Comprehensive Assessment Measure will not meet the requirements for compliance with the HQRP. Federal Register provide legal notice to the public and judicial notice These results indicate that a hospice's HCI scores would not normally fluctuate a great deal from one year to the next, and that they will fluctuate even less from quarter to quarter. As described in the proposed rule (86 FR 19718) and above, we include a proportion overhead salaries and overhead benefits in the compensation cost weights for each level of care. The signed addendum is only acknowledgement of the beneficiary's (or representative's) receipt of the addendum (or its updates) and the payment requirement is considered met if there is a signed addendum (and any signed updates) in the requesting beneficiary's medical record with the hospice. We obtained the hospice claims and the Medicare beneficiary summary file in May 2020, and the inpatient data in August 2020. Accessible via: https://oig.hhs.gov/oas/reports/region9/91803022.pdf. While hospices in rural areas will experience, on average, 2.2 percent increase in estimated payments compared to FY 2021. We did not exclude providers based on the reporting of contracted inpatient days as reported on Worksheet S-1. Our analysis, however, found that many providers were not reporting salaries on the detailed level of care worksheets (A-1, A-2, A-3, A-4, column 1), but rather reporting total costs (reflecting salary and nonsalary costs) for these services for each level of care on Worksheets A-1, A-2, A-3, A-4, column 7. However, patterns of variation across providers could signal less service provider availability and access for patients on weekends. The revisions and additions read as follows: (c) Content of hospice election statement addendum. One commenter stated that the hospice per diem structure severely limits the amounts they can spend on staff. We encourage providers to report their cost report data accurately and timely. Simulation means a training and assessment technique that mimics the reality of the homecare environment, including environmental distractions and constraints that evoke or replicate substantial aspects of the real world in a fully interactive fashion, in order to teach and assess proficiency in performing skills, and to promote decision making and critical thinking. For HIS-based measures, we used quarters Q1 through Q4 2019. The commenter asked whether any consideration was made regarding this inconsistency or other common inconsistencies in the nature of the expenses. These changes will expire at the end of the COVID-19 PHE. Because beneficiaries may choose to revoke hospice for a variety of reasons, which in some cases are related to the hospice provider's business practices or quality of care, we include revocations in our analysis.. documents in the last year, 887 We will make explanatory information available to consumers, while recognizing that keeping the interface as streamlined as possible improves the usability of the site for consumers. In particular, family caregivers stated that there might be a need for several HCI indicators, such as nursing availability on weekends and average Medicare per-beneficiary spending, to be included on Care Compare as additional information. While using more years of data would allow us to report measures for even more hospices, it would involve sharing data that are no longer relevant, and display scores that do not reflect recent hospice improvement efforts. To further support the hospice community, we will also provide education, training, and additional opportunities for hospices to receive information about the measures through open door forums or other venues. Report to the Congress: Medicare Payment Policy | March 2020. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf?sfvrsn=0. One commenter also expressed a desire to include permanent telehealth provisions in the QRP, as that would help improve rural healthcare access. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf. 0938-0758) for 2018. Our reweighted compensation cost weights for IRC and GIP were similar (less than one percentage point in absolute terms) to our proposed compensation cost weights for IRC and GIP (as shown in Table 1) and, therefore, we believe our sample is representative of freestanding hospices providing inpatient hospice care. This rule rebases the hospice labor shares and clarifies certain aspects of the hospice election statement addendum requirements. Some commenters were concerned about the comparative nature of CAHPS star ratings and a few called for an alternative methodology that would rate hospices against a benchmark. For hospice elections beginning on or after October 1, 2020, in the event that the hospice determines there are conditions, items, services, or drugs that are unrelated to the individual's terminal illness and related conditions, the individual (or representative), non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement.
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