In addition, the HCI and HOPE will complement each other, providing related but distinct information to providers and consumers to compare hospices. https://oig.hhs.gov/oei/reports/oei-02-10-00490.pdf. 50. 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). Finally, CMS is providing updates regarding its development of a new Hospice Outcome and Patient Evaluation (HOPE) assessment instrument. Section 1814(a)(7)(B) of the Act requires that a written plan for providing hospice care to a beneficiary who is a hospice patient be established before care is provided by, or under arrangements made by, the hospice program; and that the written plan be periodically reviewed by the beneficiary's attending physician (if any), the hospice medical director, and an interdisciplinary group (section 1861(dd)(2)(B) of the Act). The Department may not cite, use, or rely on any guidance that is not posted The commenter stated that they are forced to outsource many nursing functions at high cost, along with paying retention bonuses to current staff. Some commenters mentioned there was confusion regarding billing when an addendum is furnished late. https://www.qualityforum.org/Projects/c-d/Cost_and_Resource_Project/2158.aspx. In this proposed rule, we are continuing to provide updates for both HOPE-based and claims-based quality measure development. The results also show that th e HIS Comprehensive Assessment Measure's ICC for CAR and SPR scenarios are similar, with only a 0.02 difference. Final Decision: We are finalizing our proposal to publicly report the most-recently available 8 quarters of CAHPS data starting with the February 2022 refresh and going through the May 2023 refresh on Care Compare because we cannot publicly report Q1 2020 and Q2 2020 data due to the COVID-19 PHE. Addition of a Claims-Based Index Measure, the Hospice Care Index, b. de la Cruz, M., et al. 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. 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. 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. The specifications for Indicator Five, Burdensome Transitions Type 1, are as follows: Death in a hospital following live discharge in another concerning pattern in hospice use. One commenter also stated that they were interested in how the percentage of hospices that operate inpatient facilities can be increased and all costs, including contracted costs, can be included. Finally, we proposed to publish the details of the Star Ratings methodology on the CAHPS Hospice Survey website, www.hospicecahpssurvey.org. Such information shall include any inspection report made by such survey agency or body with respect to such survey or certification, any enforcement actions taken as a result of such survey or certification, and any other information determined appropriate by the Secretary. Because November 2020 refresh data will become increasingly out-of-date and thus less useful for consumers, we analyzed whether it would be possible to use fewer quarters of data for the last refresh affected by the exemption (February 2022) and thus more quickly resume public reporting with updated quality data. The prior MCR did not collect total costs by level of care or detailed costs by level of care (such as labor and nonlabor). The CAHPS Hospice Survey measures received NQF endorsement on October 26, 2016 and was re-endorsed November 20, 2020 (NQF #2651). 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. The median reliability scores for the HIS Comprehensive Assessment Measure are also very similar in both CAR and SPR scenarios. These comments also suggested including these disciplines in future claims-based measures to recognize the multi-disciplinary nature of hospice care. This simulation included Q2 through Q4 of 2019, which crosses the flu season. Comment: A few commenters stated that while they understand the desire and rationale for using hospice data to revise the hospice labor shares (and to make other policy changes), they believe it is important to recognize that the data inputs utilized must be appropriate to the task. We outline our proposed trimming methodology using CHC as an example. We only consider the days within the period being examined. The base payments are adjusted for geographic differences in wages by multiplying the labor share, which varies by category, of each base rate by the applicable hospice wage index. Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on state and local governments, preempts state law, or otherwise has Federalism implications. In the FY 2019 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements final rule (83 FR 38622), we finalized plans to publicly post information from the Medicare Provider Utilization and Payment Data: Hospice Public Use File (PUF) and other publicly-available CMS data to Hospice Compare or another CMS website. Comment: A few commenters stated that the survey is too long. The ADA does not directly or indirectly practice medicine or dispense dental services. This is a result of the 2.7 percent market basket percentage increase reduced by a 0.7 percentage point productivity adjustment. but we will consider addressing this policy in future rulemaking. This indicator identifies whether a hospice is below the 90th percentile in terms of how often hospice stays of at least 30 days contain at least one gap of eight or more days without a nursing visit. We would note that Medicare days, in aggregate, account for over 80 percent of total facility days. Despite the COVID-19 PHE, we would expect that hospices would still provide comprehensive care to hospice patients during the pandemic, and believe that telehealth visits are not full substitutes for care provided in person, particularly in the case of the visits measured in the HVLDL and HCI measures. Aides are usually trained by an employer, such as a hospice, HHA or nursing home and may already be certified as an aide prior to being hired. The AMA is a third party beneficiary to this license. On Thursday, July 29, 2021 the FY 2022 Hospice Wage Index and Payment Update Final Rule went on display on the Federal Register website for public inspection. This feature is not available for this document. We encourage providers to report their cost report data accurately and timely. Additionally, other provider types, such as IPPS hospitals, home health agencies (HHAs), SNFs, IRFs, and the dialysis facilities all use CBSAs to define their labor market areas. 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. Hospice providers must bill the correct rate for the appropriate period of routine home care days. 804(2)). In those final rules, we referenced the measure removal factors in the preamble but inadvertently omitted them from the regulations text. If additional data points become available, CMS will consider modifying the measure in light of the new data. How you know. However, as discussed in the CMS-10390 Supporting Statement published October 23, 2020 and HIS V3.00 approved by OMB on February 16, 2021, our analysis comparing HVWDII and HVLDL with CAHPS would recommend scores demonstrates that HVLDL results in higher validity and variability testing results compared to HVWDII. Hospices' scores on the HCI can range from zero to ten. A few commenters stated that if data from the hospice cost report is to be used for calculating the labor component by level of care, revisions to the cost report should be proposed to address current inconsistent, but acceptable, reporting practices. Denominator: The total number of RHC days provided by a hospice within a reporting period. Consequently, we determined to freeze the data displayed, that is, holding data constant after the October 2020 refresh without subsequently updating the data through October 2021. An official website of the State of Georgia. Hospice Payment Rates Calculator FY 2023 (Oct 2022 - Sept 2023) Wage Index Hospice Rates FY 2022 (Oct 2021 - Sept 2022) We tabulate the resulting payments according to the classifications (for example, provider type, geographic region, facility size), and compare the difference between current and future payments to determine the overall impact. Response: We appreciate the commenters request for future changes to the hospice cost report to allow us to better isolate costs of those facilities that operate an inpatient unit. The specifications for Indicator One, CHC or GIP services provided, are as follows: The OIG has found instances of infrequent visits by nurses to hospice patients. We appreciate the concern that consumers may not know about the component measure scores in the Provider Data Catalogue. We believe that using the most current OMB delineations provides a more accurate representation of geographic variation in wage levels and do not believe it would be appropriate to allow hospices to be assigned a higher CBSA designation or to allow 1-year limited increase in hospice wage index payments for hospices only in the Montgomery County Metropolitan Divisions. This indicates that scores estimated using 3 quarters of data continue to capture provider-level differences and that admission-level scores remain consistent within hospices. HOPE will include key items from the HIS and demographics like gender and race. Our analyses showed that the HCI as currently defined does differentiate between hospices, as the range of HCI scores across hospices was found to be sufficiently large to highlight very high performing hospices, as well as identify the need for improvement in others. The FY 2022 hospice payment rates are effective for care and services provided on or after October 1, 2021, through September 30, 2022. This could increase the speed of performing competency testing and would allow new aides to begin serving patients more quickly while still protecting patient health and safety. Response: We will not include data from Q1 and Q2 2020 in Star Rating calculations, as hospices were exempted from submitting these quarters of data to CMS due to the COVID-19 PHE. Based on the OMB's current delineations, Montgomery County belongs in a separate CBSA from the areas defined in the Washington-Arlington-Alexandria, DC-VA CBSA. Information about the TEP feedback on these quality measures concepts and future measure concepts can be obtained via: https://www.cms.gov/files/document/2020-hqrp-tep-summary-report.pdf. 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. The commenter stated that they would become concerned, for instance, if data indicates that some providers offer significantly fewer hours of professional interdisciplinary team (IDT) care yet make up a disproportionate percentage of providers filing cost reports. We believe that a signed addendum indicates the hospice discussed the addendum and its contents with the beneficiary (or representative). The candidate measure Timely Reduction of Pain Impact reports the percentage of patients who experienced a reduction in the impact of moderate or severe pain. The data must be submitted in a form, manner, and at a time specified by the Secretary. endstream endobj 600 0 obj <. This approach aligns with what we are doing for the other PAC setting Quality Reporting Programs, including home health (see section III.G). The commenter stated that this would better allow CMS to isolate the costs of those facilities that truly operate an inpatient unit. We encourage all key stakeholders to continue to stay informed and engaged through the HQRP Forums, Open Door Forums, Quarterly Updates, and listserv notifications.Start Printed Page 42571. Teno J.M., Bowman, J., Plotzke, M., Gozalo, P.L., Christian, T., Miller, S.C., Williams, C., & Mor, V. (2015). AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. The BNAF phase-out reduced the amount of the BNAF increase applied to the hospice wage index value, but was not a reduction in the hospice wage index value itself or in the hospice payment rates. Other commenters suggested using a 1-year time frame, so as to make the measure score more reflective of current operations and performance, and thus more understandable and useful for providers and consumers. Medicare fee-for-service inpatient claims with through dates on and between January 1, 2016 and December 31, 2019 to determine dates of hospitalization. These comments along with our responses are summarized below. Update to the Public Display of HH CAHPS Measures Due to the COVID-19 PHE Exception, A. The fourth column shows the effect of the final rebased labor shares. FY2022 Hospice Wage Index PROPOSED Rates Wage Index values posted on CMS Website - April 8, 2021 . Response: We thank the commenter for these recommendations. Indicators reflect practices or outcomes hospices should pursue, thereby awarding points based on the criterion. Therefore, we stated that we expect that hospices already have processes and procedures in place to ensure that required signatures are obtained, either from the beneficiary, or from the representative in the event the beneficiary is unable to sign, and we anticipate that hospices would use the same procedures for obtaining signatures on the addendum. Clinical Signs of Impending Death in Cancer Patients. The agency is finalizing its proposal to use three quarters rather than four quarters of data for the January 2022 refresh affecting OASIS-based measures. It will be published in the Federal Register on August 4, 2021. While we did not propose any of these recommendations we could consider them for future rulemaking. On March 27, 2020, we sent a guidance memorandum under the subject title, Exceptions and Extensions for Quality Reporting Requirements for Acute Care Hospitals, PPS-Exempt Cancer Hospitals, Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, Ambulatory Surgical Centers, Renal Dialysis Facilities, and MIPS Eligible Clinicians Affected by COVID-19[48] To date we have not received reports of claims denials resulting from the implementation of the election statement addendum and the current regulations at 418.24. As stated previously, we will continue to monitor the labor shares over time and propose revisions to these shares to reflect a more recent cost structure and mix of providers. In addition, to help hospices understand the HCI and their hospice's performance, we will revise the confidential QM report to include claims-based measure scores, including agency and national rates through the Certification and Survey Provider Enhanced Reports (CASPER) or its replacement system. Payments are based upon the location of the beneficiary for routine and continuous home care or the location of the facility for respite and general inpatient care. Based on the caregivers' feedback, we proposed reporting the HCI as a single score to report on Care Compare, while providing the indicator scores in the Provider Data Catalog (PDC). The difference between using FY 2019 and FY 2020 hospice claims data was minimal. Applications are available at the AMA website. Therefore, hospice providers with larger costs (reflecting larger utilization) would have a larger weight in the proposed labor shares. Response: Although Care Compare already notes that for Hospice CAHPS the user is comparing . For more information about HQRP Requirements, please visit the frequently-updated HQRP website and especially the Best Practice, Education and Training Library, and Help Desk web pages at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Start Printed Page 42577Quality-Reporting. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. In fact, on weekends, patients' caregivers are more likely to be around and could prefer privacy from hospice staff. Comment: Many commenters offered suggestions to modify specific HCI indicators and expressed concerns about specific indicators rather than the HCI as a whole. This implies high internal reliability of the measure in both scenarios. the current document as it appeared on Public Inspection on be made routinely available on a 24-hour basis seven days a week. Days billed as CHC require more than half the hours provided be nursing hours. documents in the last year, 84 documents in the last year, 9 We will continue to monitor the HIS Comprehensive Assessment Measure performance and consider if removal or refinements would be appropriate in the future. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf. Medicare spending per beneficiary is then calculated by dividing the total payments by the total number of unique beneficiaries. We proposed that hospice star ratings for each measure be assigned based on where the hospice-level measure score falls within these cut-points. 16. (7) Collection or public reporting of a measure leads to negative unintended consequences other than patient harm. The exception granted under the March 27, 2020 CMS Guidance Memo impacted the HH QRP public display schedule. Several commenters encouraged CMS to use quality claims-based data and other data sources for hybrid measure, consider the implications of claims-based measures to measure quality, use of survey data if feasible, explore outcome measures related to pain and other symptom management, and explore goal achievement. When deficient aide skills are noted during a supervisory visit, the RN determines the deficient skills and all related skills that may be impacted. CMS will monitor data availability as well as measure performance, and may re-specify the measure if needed. High-quality hospice care not only manages pain and symptoms of the terminal illness, but assesses non-clinical needs of the patient and family caregivers, which is a hallmark of patient-centered care. We identify RHC days by the presence of revenue code 0651 on the hospice claim. Also included in the compensation costs for each level of care, as discussed in the FY 2022 Hospice proposed rule (86 FR 19718) and below, is a proportion overhead salaries and benefits. The commenters requested consideration of the impact of COVID-19 when setting labor shares for future years. The 7 HIS measures credited hospices when any of these measures were performed regardless of the individual patient. This periodicity of updates aligns with most claims-based measures across PAC settings. 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. As discussed later in this section of the preamble, we will publicly report no earlier than May 2022. Response: CMS analyzed existing data to inform the development of star ratings in the hospice setting. Both the use of the pseudo-patient and targeted aide training align requirements between these two providers, home health and hospice, affording the opportunity for efficiency in implementation for many agencies that are Medicare certified to provide both services. Section 418.309 is amended by revising paragraphs (a)(1) and (2) to read as follows: (1) For accounting years that end on or before September 30, 2016 and end on or after October 1, 2030, the cap amount is adjusted for inflation by using the percentage change in the medical care expenditure category of the Consumer Price Index (CPI) for urban consumers that is published by the Bureau of Labor Statistics. We also rebased IRC per diem rates equal to the estimated FY Start Printed Page 425322019 average costs per day, with a reduction of 5 percent to the FY 2019 average cost per day to account for coinsurance. Notice and comment are unnecessary because we are conforming the regulation to statute and there is no discretion on the part of the Secretary. Using 3 quarters of data for the February 2022 refresh would allow us to begin displaying Q3 2020, Q4 2020, and Q1 2021 data in February 2022, rather than continue displaying November 2020 data (Q1 2019 through Q4 2019). We proposed to modify our public display schedule to display fewer quarters of data than what we previously finalized for certain HH QRP measures for the January 2022 refresh. (2013). hereafter referred to as the March 27, 2020 CMS Guidance Memorandum. These covered services include: Nursing care; physical therapy; occupational therapy; speech-language pathology therapy; medical social services; home health aide services (called hospice aide services); physician services; homemaker services; medical supplies (including drugs and biologicals); medical appliances; counseling services (including dietary counseling); short-term inpatient care in a hospital, nursing facility, or hospice inpatient facility (including both respite care and procedures necessary for pain control and acute or chronic symptom management); continuous home care during periods of crisis, and only as necessary to maintain the terminally ill individual at home; and any other item or service which is specified in the plan of care and for which payment may otherwise be made under Medicare, in accordance with Title XVIII of the Act. Response: We appreciate the commenters highlighting the use of pseudo-patients and simulation techniques in other healthcare setting and agree that the use of these techniques is standard of practice in many formal nursing assistant programs. For example, Gaps in Skilled Nursing Visits have a criterion of lower than the 90th percentile, and supports the hospice CoPs that require an assessment of the patient and caregiver needs as well as Start Printed Page 42557implementation of the plans of care. 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. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". Using a benchmark rather than the clustering approach represents a major shift from our current practice. Medicare Hospice: Use of General lnpatient Care. The specifications for Indicator Seven, Per-Beneficiary Medicare Spending, are as follows: Medicare Hospice CoPs require a member of the interdisciplinary team to ensure ongoing assessment of patient and caregiver needs. documents in the last year, 1008 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. 28. Final Decision: We are finalizing the proposal to add composite HCI measures to the HQRP as of FY 2022 and will monitor the measure. The other determinant of per-beneficiary spending is the level of care at which services are billed. 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. As discussed in the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR 47183), we implemented changes mandated by the IMPACT Act of 2014 (Pub. We believe when a deficient area(s) in the aide's care is assessed by the RN, there may be additional related competencies that may also lead to additional deficient practice areas and thus would require that those skills be included in the targeted competency evaluation. 32. 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. The scope of this license is determined by the ADA, the copyright holder. They encouraged CMS to conduct further analyses before finalizing the measure.
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