[Federal Register Volume 82, Number 149 (Friday, August 4, 2017)]
[Rules and Regulations]
[Pages 36638-36685]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-16294]
[[Page 36637]]
Vol. 82
Friday,
No. 149
August 4, 2017
Part III
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Part 418
Medicare Program; FY 2018 Hospice Wage Index and Payment Rate Update
and Hospice Quality Reporting Requirements; Final Rule
Federal Register / Vol. 82 , No. 149 / Friday, August 4, 2017 / Rules
and Regulations
[[Page 36638]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 418
[CMS-1675-F]
RIN 0938-AT00
Medicare Program; FY 2018 Hospice Wage Index and Payment Rate
Update and Hospice Quality Reporting Requirements
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
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SUMMARY: This final rule will update the hospice wage index, payment
rates, and cap amount for fiscal year (FY) 2018. Additionally, this
rule includes new quality measures and provides an update on the
hospice quality reporting program.
DATES: These regulations are effective on October 1, 2017.
FOR FURTHER INFORMATION CONTACT: Debra Dean-Whittaker, (410) 786-0848
for questions regarding the CAHPS[supreg] Hospice Survey.
Cindy Massuda, (410) 786-0652 for questions regarding the hospice
quality reporting program.
For general questions about hospice payment policy, please send
your inquiry via email to: [email protected].
SUPPLEMENTARY INFORMATION: Wage index addenda will be available only
through the internet on the CMS Web site at: (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html.)
Table of Contents
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Impacts
II. Background
A. Hospice Care
B. History of the Medicare Hospice Benefit
C. Services Covered by the Medicare Hospice Benefit
D. Medicare Payment for Hospice Care
1. Omnibus Budget Reconciliation Act of 1989
2. Balanced Budget Act of 1997
3. FY 1998 Hospice Wage Index Final Rule
4. FY 2010 Hospice Wage Index Final Rule
5. The Affordable Care Act
6. FY 2012 Hospice Wage Index Final Rule
7. FY 2015 Hospice Wage Index and Payment Rate Update Final Rule
8. IMPACT Act of 2014
9. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule
10. FY 2017 Hospice Wage Index and Payment Rate Update Final
Rule
E. Trends in Medicare Hospice Utilization
III. Provisions of the Final Rule
A. Monitoring for Potential Impacts--Affordable Care Act Hospice
Reform
B. FY 2018 Hospice Wage Index and Rates Update
1. FY 2018 Hospice Wage Index
2. FY 2018 Hospice Payment Update Percentage
3. FY 2018 Hospice Payment Rates
4. Hospice Cap Amount for FY 2018
C. Discussion Regarding Sources of Clinical Information for
Certifying Terminal Illness
D. Updates to the Hospice Quality Reporting Program (HQRP)
1. Background and Statutory Authority
2. General Considerations Used for Selection of Quality Measures
for the HQRP
3. Policy for Retention of HQRP Measures Adopted for Previous
Payment Determinations
4. Policy for Adopting Changes to Previously Adopted Measures
5. Previously Adopted Quality Measures for FY 2018 Payment
Determination and Future Years
6. Removal of Previously Adopted Measures
7. Measure Concepts Under Consideration for Future Years
8. Form, Manner, and Timing of Quality Data Submission
a. Background
b. Policy for New Facilities To Begin Submitting Quality Data
c. Previously Finalized Data Submission Mechanisms, Timelines,
and Deadlines
d. New Data Collection and Submission Mechanisms Under
Consideration: Hospice Evaluation & Assessment Reporting Tool
(HEART)
9. Previously Adopted APU Determination and Compliance Criteria
for the HQRP
a. Background
b. Previously Finalized HIS Data Submission Timelines and
Compliance Thresholds for FY 2018 Payment Determination and
Subsequent Years
c. CAHPS[supreg] Participation Requirements for FY 2018 APU
Determination and Determinations for Subsequent Years
10. HQRP Submission Exemption and Extension Requirements for the
FY 2019 Payment Determination and Subsequent Years
a. Extraordinary Circumstances Exemption and Extension
b. Volume-Based Exemption for CAHPS[supreg] Hospice Survey Data
Collection and Reporting Requirements
c. Newness Exemption for CAHPS[supreg] Hospice Survey Data
Collection and Reporting Requirements
11. CAHPS[supreg] Hospice Survey Participation Requirements for
the FY 2020 APU and Subsequent Years
a. Background and Description of the CAHPS[supreg] Hospice
Survey
b. Overview of Proposed Measures
c. Data Sources
i. Requirements for the FY 2020 Annual Payment Update
ii. Requirements for the FY 2021 Annual Payment Update
iii. Requirements for the FY 2022 Annual Payment Update
d. Measure Calculations
i. Composite Survey-Based Measures
ii. Global Survey-Based Measures
iii. Cohort
e. Risk Adjustment
i. Patient-Mix Adjustment
ii. Mode Adjustment
f. For Further Information About the CAHPS[supreg] Hospice
Survey
12. HQRP Reconsideration and Appeals Procedures for the FY 2018
Payment Determination and Subsequent Years
13. Confidential Feedback Reports
14. Public Display of Quality Measures and Other Hospice Data
for the HQRP
IV. Collection of Information Requirements
A. Hospice Item Set
B. Summary of CAHPS[supreg] Hospice Survey Information
Collection Requirements (OMB Control Number 0938-1257)
V. Regulatory Impact Analysis
A. Statement of Need
B. Overall Impacts
C. Anticipated Effects
D. Detailed Economic Analysis
E. Accounting Statement
F. Reducing Regulation and Controlling Regulatory Costs
G. Conclusion
Acronyms
Because of the many terms to which we refer by acronym in this
final rule, we are listing the acronyms used and their corresponding
meanings in alphabetical order:
APU Annual Payment Update
ASPE Assistant Secretary of Planning and Evaluation
BBA Balanced Budget Act of 1997
BIPA Benefits Improvement and Protection Act of 2000
BNAF Budget Neutrality Adjustment Factor
BLS Bureau of Labor Statistics
CAHPS[supreg] Consumer Assessment of Healthcare Providers and
Systems
CASPER Certification and Survey Provider Enhanced Reports
CBSA Core-Based Statistical Area
CCN CMS Certification Number
CCW Chronic Conditions Data Warehouse
CFR Code of Federal Regulations
CHC Continuous Home Care
CHF Congestive Heart Failure
CMS Centers for Medicare & Medicaid Services
COPD Chronic Obstructive Pulmonary Disease
CoPs Conditions of Participation
CPI-U Consumer Price Index-Urban Consumers
CVA Cerebral Vascular Accident
CWF Common Working File
CY Calendar Year
DME Durable Medical Equipment
DRG Diagnostic Related Group
FEHC Family Evaluation of Hospice Care
FR Federal Register
FY Fiscal Year
GAO Government Accountability Office
GIP General Inpatient Care
HCFA Healthcare Financing Administration
HEART Hospice Evaluation & Assessment Reporting Tool
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HHS Health and Human Services
HIS Hospice Item Set
HQRP Hospice Quality Reporting Program
ICD-9-CM International Classification of Diseases, Ninth Revision,
Clinical Modification
ICD-10-CM International Classification of Diseases, Tenth Revision,
Clinical Modification
ICR Information Collection Requirement
IDG Interdisciplinary Group
IMPACT Act Improving Medicare Post-Acute Care Transformation Act of
2014
IPPS Inpatient Prospective Payment System
IRC Inpatient Respite Care
LCD Local Coverage Determination
MAC Medicare Administrative Contractor
MACRA Medicare Access and CHIP Reauthorization Act of 2015
MAP Measure Applications Partnership
MedPAC Medicare Payment Advisory Commission
MFP Multifactor Productivity
MLN Medicare Learning Network
MSA Metropolitan Statistical Area
NF Long Term Care Nursing Facility
NOE Notice of Election
NOTR Notice of Termination/Revocation
NP Nurse Practitioner
NPI National Provider Identifier
NQF National Quality Forum
OIG Office of the Inspector General
OACT Office of the Actuary
OMB Office of Management and Budget
PEPPER Program for Evaluating Payment Patterns Electronic Report
PRA Paperwork Reduction Act of 1995
PRRB Provider Reimbursement Review Board
PS&R Provider Statistical and Reimbursement Report
Pub. L. Public Law
POC Plan of Care
QAPI Quality Assessment and Performance Improvement
QIO Quality Improvement Organization
QM Quality Measure
RHC Routine Home Care
RN Registered Nurse
SBA Small Business Administration
SEC Securities and Exchange Commission
SIA Service Intensity Add-on
SNF Skilled Nursing Facility
TEFRA Tax Equity and Fiscal Responsibility Act of 1982
TEP Technical Expert Panel
UHDDS Uniform Hospital Discharge Data Set
U.S.C. United States Code
I. Executive Summary
A. Purpose
This final rule updates the hospice payment rates for fiscal year
(FY) 2018, as required under section 1814(i) of the Social Security Act
(the Act). This rule also discusses new quality measures and provides
an update on the hospice quality reporting program (HQRP), consistent
with the requirements of section 1814(i)(5) of the Act. In accordance
with section 1814(i)(5)(A) of the Act, hospices that fail to meet
quality reporting requirements receive a 2 percentage point reduction
to their payments.
B. Summary of the Major Provisions
Section III.B.1 of this final rule updates the hospice wage index
with updated wage data and makes the application of the updated wage
data budget neutral for all four levels of hospice care. In section
III.B.2 of this final rule, we discuss the FY 2018 hospice payment
update percentage of 1.0 percent. Sections III.B.3 and III.B.4 of this
final rule update the hospice payment rates and hospice cap amount for
FY 2018 by the hospice payment update percentage discussed in section
III.B.2 of this final rule.
In section III.C of this final rule, we discuss comments on the
appropriate source(s) of the required clinical information for
certification of a medical prognosis of a life expectancy of 6 months
or less.
Finally, in section III.D of this final rule, we discuss updates to
HQRP, including changes to the Consumer Assessment of Healthcare
Providers and Systems (CAHPS)[supreg] Hospice Survey measures as well
as the possibility of utilizing a new assessment instrument to collect
quality data. We also discuss the enhancements to the current Hospice
Item Set (HIS) data collection instrument to be more in line with other
post-acute care settings. The new data collection instrument would be a
comprehensive patient assessment instrument, rather than the current
chart abstraction tool. Finally, we discuss our plans for sharing HQRP
data publicly later in calendar year (CY) 2017, as well as plans to
provide public reporting via a Compare Site in CY 2017 and future
years.
C. Summary of Impacts
The overall economic impact of this final rule is estimated to be
$180 million in increased payments to hospices during FY 2018.
II. Background
A. Hospice Care
Hospice care is a comprehensive, holistic approach to treatment
that recognizes that the impending death of an individual, upon his or
her choice, warrants a change in the focus from curative care to
palliative care for relief of pain and for symptom management. The goal
of hospice care is to help terminally ill individuals continue life
with minimal disruption to normal activities while remaining primarily
in the home environment. A hospice uses an interdisciplinary approach
to deliver medical, nursing, social, psychological, emotional, and
spiritual services through a collaboration of professionals and other
caregivers, with the goal of making the beneficiary as physically and
emotionally comfortable as possible. Hospice is compassionate
beneficiary and family/caregiver-centered care for those who are
terminally ill.
Medicare regulations define ``palliative care'' as patient and
family-centered care that optimizes quality of life by anticipating,
preventing, and treating suffering. Palliative care throughout the
continuum of illness involves addressing physical, intellectual,
emotional, social, and spiritual needs and to facilitate patient
autonomy, access to information, and choice (42 CFR 418.3). Palliative
care is at the core of hospice philosophy and care practices, and is a
critical component of the Medicare hospice benefit. For more
information, see ``Medicare and Medicaid Programs: Hospice Conditions
of Participation'' final rule (73 FR 32088, June 5, 2008). The goal of
palliative care in hospice is to improve the quality of life of
beneficiaries and their families and caregivers through early
identification and management of pain and other issues associated with
a life limiting condition. The hospice interdisciplinary group works
with the beneficiary, family, and caregivers to develop a coordinated,
comprehensive care plan; reduce unnecessary diagnostics or ineffective
therapies; and maintain ongoing communication with individuals and
their families about changes in their condition. The beneficiary's care
plan will shift over time to meet the changing needs of the individual,
family, and caregiver(s) as the individual approaches the end of life.
Medicare hospice care is palliative care for individuals with a
prognosis of living 6 months or less if the terminal illness runs its
normal course. When a beneficiary is terminally ill, many health
problems are related to the underlying condition(s), as bodily systems
are interdependent. In the 2008 Hospice Conditions of Participation
final rule, we stated that ``the [hospice] medical director must
consider the primary terminal condition, related diagnoses, current
subjective and objective medical findings, current medication and
treatment orders, and information about unrelated conditions when
considering the initial certification of the terminal illness'' (73 FR
32176). As referenced in our regulations at Sec. 418.22(b)(1), to be
eligible for Medicare hospice services, the patient's attending
physician (if any)
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and the hospice medical director must certify that the individual is
``terminally ill,'' as defined in section 1861(dd)(3)(A) of the Act and
our regulations at Sec. 418.3; that is, the individual's prognosis is
for a life expectancy of 6 months or less if the terminal illness runs
its normal course. The regulations at Sec. 418.22(b)(3) require that
the certification and recertification forms include a brief narrative
explanation of the clinical findings that support a life expectancy of
6 months or less.
While the goal of hospice care is to allow the beneficiary to
remain in his or her home, circumstances during the end of life may
necessitate short-term inpatient admission to a hospital, skilled
nursing facility (SNF), or hospice facility for necessary pain control
or acute or chronic symptom management that cannot be managed in any
other setting. These acute hospice care services ensure that any new or
worsening symptoms are intensively addressed so that the beneficiary
can return to his or her home. Limited, short-term, intermittent,
inpatient respite care (IRC) is also available because of the absence
or need for relief of the family or other caregivers. Additionally, an
individual can receive continuous home care (CHC) during a period of
crisis in which an individual requires continuous care to achieve
palliation or management of acute medical symptoms so that the
individual can remain at home. 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 our regulations at Sec. 418.204. 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 (Sec. 418.302(e)(4)).
Hospices are expected to comply with all civil rights laws,
including the provision of auxiliary aids and services to ensure
effective communication with patients and patient care representatives
with disabilities consistent with section 504 of the Rehabilitation Act
of 1973 and the Americans with Disabilities Act. Additionally, they
must provide language access for such persons who are limited in
English proficiency, consistent with Title VI of the Civil Rights Act
of 1964. Further information about these requirements may be found at
http://www.hhs.gov/ocr/civilrights.
B. History of the Medicare Hospice Benefit
Before the creation of the Medicare hospice benefit, hospice
programs were originally operated by volunteers who cared for the
dying. During the early development stages of the Medicare hospice
benefit, hospice advocates were clear that they wanted a Medicare
benefit that provided all-inclusive care for terminally-ill
individuals, provided pain relief and symptom management, and offered
the opportunity to die with dignity in the comfort of one's home rather
than in an institutional setting.\1\ As stated in the August 22, 1983
proposed rule entitled ``Medicare Program; Hospice Care'' (48 FR
38146), ``the hospice experience in the United States has placed
emphasis on home care. It offers physician services, specialized
nursing services, and other forms of care in the home to enable the
terminally ill individual to remain at home in the company of family
and friends as long as possible.'' The concept of a beneficiary
``electing'' the hospice benefit and being certified as terminally ill
were two key components of the legislation responsible for the creation
of the Medicare Hospice Benefit (section 122 of the Tax Equity and
Fiscal Responsibility Act of 1982 (TEFRA), (Pub. L. 97-248)). Section
122 of TEFRA created the Medicare Hospice benefit, which was
implemented on November 1, 1983. Under sections 1812(d) and 1861(dd) of
the Act, we provide coverage of hospice care for terminally ill
Medicare beneficiaries who elect to receive care from a Medicare-
certified hospice. Our regulations at Sec. 418.54(c) stipulate that
the comprehensive hospice assessment must identify the beneficiary's
physical, psychosocial, emotional, and spiritual needs related to the
terminal illness and related conditions, and address those needs in
order to promote the beneficiary's well-being, comfort, and dignity
throughout the dying process. The comprehensive assessment must take
into consideration the following factors: The nature and condition
causing admission (including the presence or lack of objective data and
subjective complaints); complications and risk factors that affect care
planning; functional status; imminence of death; and severity of
symptoms (Sec. 418.54(c)). The Medicare hospice benefit requires the
hospice to cover all reasonable and necessary palliative care related
to the terminal prognosis, as well as, care for interventions to manage
pain and symptoms, as described in the beneficiary's plan of care.
Additionally, the hospice Conditions of Participation (CoPs) at Sec.
418.56(c) require that the hospice must provide all reasonable and
necessary services for the palliation and management of the terminal
illness, related conditions, and interventions to manage pain and
symptoms. Therapy and interventions must be assessed and managed in
terms of providing palliation and comfort without undue symptom burden
for the hospice patient or family.\2\ In the December 16, 1983 Hospice
final rule (48 FR 56010), regarding what is related versus unrelated to
the terminal illness, we stated: ``. . . we believe that the unique
physical condition of each terminally ill individual makes it necessary
for these decisions to be made on a case by case basis. It is our
general view that hospices are required to provide virtually all the
care that is needed by terminally ill patients.'' Therefore, unless
there is clear evidence that a condition is unrelated to the terminal
prognosis, all conditions are considered to be related to the terminal
prognosis and the responsibility of the hospice to address and treat.
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\1\ Connor, Stephen. (2007). Development of Hospice and
Palliative Care in the United States. OMEGA. 56(1), p. 89-99.
\2\ Paolini, DO, Charlotte. (2001). Symptoms Management at End
of Life. JAOA. 101(10). p. 609-615.
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As stated in the December 16, 1983 Hospice final rule, the
fundamental premise upon which the hospice benefit was designed was the
``revocation'' of traditional curative care and the ``election'' of
hospice care for end-of-life symptom management and maximization of
quality of life (48 FR 56008). After electing hospice care, the
beneficiary typically returns home from an institutional setting or
remains in the home, to be surrounded by family and friends, and to
prepare emotionally and spiritually, if requested, for death while
receiving expert symptom management and other supportive services.
Election of hospice care also requires waiving the right to Medicare
payment for curative treatment for the terminal prognosis, and instead
receiving palliative care to manage pain or other symptoms.
The benefit was originally designed to cover hospice care for a
finite period of time that roughly corresponded to a life expectancy of
6 months or less. Initially, beneficiaries could receive three election
periods: Two 90-day periods and one 30-day period. Currently, Medicare
beneficiaries can elect hospice care for two 90-day periods and an
unlimited number of subsequent 60-day periods; however, at the
beginning of each period, a physician must certify that the beneficiary
has a life expectancy of 6 months or less if the terminal illness runs
its normal course.
[[Page 36641]]
C. Services Covered by the Medicare Hospice Benefit
One requirement for coverage under the Medicare Hospice benefit is
that hospice services must be reasonable and necessary for the
palliation and management of the terminal illness and related
conditions. Section 1861(dd)(1) of the Act establishes the services
that are to be rendered by a Medicare-certified hospice program. These
covered services include: Nursing care; physical therapy; occupational
therapy; speech-language pathology therapy; medical social services;
home health aide services (now 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.
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,
that 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 (described in section
1861(dd)(2)(B) of the Act). The services offered under the Medicare
hospice benefit must be available to beneficiaries as needed, 24 hours
a day, 7 days a week (section 1861(dd)(2)(A)(i) of the Act). Upon the
implementation of the hospice benefit, the Congress expected hospices
to continue to use volunteer services, though these services are not
reimbursed by Medicare (see section 1861(dd)(2)(E) of the Act). As
stated in the August 22, 1983 Hospice proposed rule, the hospice
interdisciplinary group should comprise paid hospice employees as well
as hospice volunteers (48 FR 38149). This expectation supports the
hospice philosophy of community based, holistic, comprehensive, and
compassionate end-of-life care.
Before the Medicare hospice benefit was established, the Congress
requested a demonstration project to test the feasibility of covering
hospice care under Medicare.\3\ The National Hospice Study was
initiated in 1980 through a grant sponsored by the Robert Wood Johnson
and John A. Hartford Foundations and the Centers for Medicare &
Medicaid Services (CMS) (then, the Health Care Financing Administration
(HCFA)). The demonstration project was conducted between October 1980
and March 1983. The project summarized the hospice care philosophy and
principles as the following:
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\3\ Greer, D., Mor, V., Sherwood, S. (1983) National hospice
study analysis plan. Journal of Chronic Diseases, Vol 36, 11, 737-
780. https://doi.org/10.1016/0021-9681(83)90069-3.
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Patient and family know of the terminal condition.
Further medical treatment and intervention are indicated
only on asupportive basis.
Pain control should be available to patients as needed to
prevent rather than to just ameliorate pain.
Interdisciplinary teamwork is essential in caring for
patient and family.
Family members and friends should be active in providing
support during thedeath and bereavement process.
Trained volunteers should provide additional support as
needed.
The cost data and the findings on what services hospices provided
in the demonstration project were used to design the Medicare hospice
benefit. The identified hospice services were incorporated into the
service requirements under the Medicare hospice benefit. Most
importantly, in the August 22, 1983 Hospice proposed rule, we stated
``the hospice benefit and the resulting Medicare reimbursement is not
intended to diminish the voluntary spirit of hospices'' (48 FR 38149).
D. Medicare Payment for Hospice Care
Sections 1812(d), 1813(a)(4), 1814(a)(7), 1814(i), and 1861(dd) of
the Act, and our regulations in 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. Part 418, subpart
G, provides for a per diem payment in one of four prospectively-
determined rate categories of hospice care (routine home care (RHC),
continuous home care (CHC), inpatient respite care (IRC), and general
inpatient care (GIP)), based on each day a qualified Medicare
beneficiary is under hospice care (once the individual has elected).
This per diem payment is to include all of the hospice services and
items needed to manage the beneficiary's care, as required by section
1861(dd)(1) of the Act. There has been little change in the hospice
payment structure since the benefit's inception. The per diem rate
based on level of care was established in 1983, and this payment
structure remains today with some adjustments, as noted below.
1. Omnibus Budget Reconciliation Act of 1989
Section 6005(a) of the Omnibus Budget Reconciliation Act of 1989
(Pub. L. 101-239) amended section 1814(i)(1)(C) of the Act and provided
for the following two changes in the methodology concerning updating
the daily payment rates: (1) Effective January 1, 1990, the daily
payment rates for RHC and other services included in hospice care were
increased to equal 120 percent of the rates in effect on September 30,
1989; and (2) the daily payment rate for RHC and other services
included in hospice care for fiscal years (FYs) beginning on or after
October 1, 1990, were the payment rates in effect during the previous
federal FY increased by the hospital market basket percentage increase.
2. Balanced Budget Act of 1997
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L.
105-33) amended section 1814(i)(1)(C)(ii)(VI) of the Act to establish
updates to hospice rates for FYs 1998 through 2002. Hospice rates were
updated by a factor equal to the hospital market basket percentage
increase, minus 1 percentage point. Payment rates for FYs from 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 will be the hospital market basket percentage increase for the FY.
The Act requires us to use the inpatient hospital market basket to
determine hospice payment rates.
3. FY 1998 Hospice Wage Index Final Rule
In the August 8, 1997 FY 1998 Hospice Wage Index final rule (62 FR
42860), we implemented a new methodology for calculating the hospice
wage index based on the recommendations of a negotiated rulemaking
committee. The original hospice wage index was based on 1981 Bureau of
Labor Statistics hospital data and had not been updated since 1983. In
1994, because of disparity in wages from one geographical location to
another, the Hospice Wage Index Negotiated Rulemaking Committee was
[[Page 36642]]
formed to negotiate a new wage index methodology that could be accepted
by the industry and the government. This Committee was composed of
representatives from national hospice associations; rural, urban, large
and small hospices, and multi-site hospices; consumer groups; and a
government representative. The Committee decided that in updating the
hospice wage index, aggregate Medicare payments to hospices would
remain budget neutral to payments calculated using the 1983 wage index,
to cushion the impact of using a new wage index methodology. To
implement this policy, a Budget Neutrality Adjustment Factor (BNAF) was
computed and applied annually to the pre-floor, pre-reclassified
hospital wage index when deriving the hospice wage index, subject to a
wage index floor.
4. FY 2010 Hospice Wage Index Final Rule
Inpatient hospital pre-floor and pre-reclassified wage index
values, as described in the August 8, 1997 Hospice Wage Index final
rule, were subject to either a budget neutrality adjustment or
application of the wage index floor. Wage index values of 0.8 or
greater were adjusted by the BNAF. Starting in FY 2010, a 7-year phase-
out of the BNAF began (FY 2010 Hospice Wage Index final rule, (74 FR
39384, August 6, 2009)), with a 10 percent reduction in FY 2010, an
additional 15 percent reduction for a total of 25 percent in FY 2011,
an additional 15 percent reduction for a total 40 percent reduction in
FY 2012, an additional 15 percent reduction for a total of 55 percent
in FY 2013, and an additional 15 percent reduction for a total 70
percent reduction in FY 2014. The phase-out continued with an
additional 15 percent reduction for a total reduction of 85 percent in
FY 2015, and an additional, and final, 15 percent reduction for
complete elimination in FY 2016. We note that the BNAF was an
adjustment which increased the hospice wage index value. Therefore, the
BNAF phase-out reduced the amount of the BNAF increase applied to the
hospice wage index value. It was not a reduction in the hospice wage
index value itself or in the hospice payment rates.
5. The Affordable Care Act
Starting with FY 2013 (and in subsequent FYs), the market basket
percentage update under the hospice payment system referenced in
sections 1814(i)(1)(C)(ii)(VII) and 1814(i)(1)(C)(iii) of the Act is
subject to annual reductions related to changes in economy-wide
productivity, as specified in section 1814(i)(1)(C)(iv) of the Act. In
FY 2013 through FY 2019, the market basket percentage update under the
hospice payment system will be reduced by an additional 0.3 percentage
point (although for FY 2014 to FY 2019, the potential 0.3 percentage
point reduction is subject to suspension under conditions specified in
section 1814(i)(1)(C)(v) of the Act).
In addition, sections 1814(i)(5)(A) through (C) of the Act, as
added by section 3132(a) of the Affordable Care Act, require hospices
to begin submitting quality data, based on measures to be specified by
the Secretary of the Department of Health and Human Services (the
Secretary), for FY 2014 and subsequent FYs. Beginning in FY 2014,
hospices that fail to report quality data will have their market basket
percentage increase reduced by 2 percentage points.
Section 1814(a)(7)(D)(i) of the Act, as added by section 3132(b)(2)
of the Affordable Care Act, requires, 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. When implementing this provision, we finalized in the CY 2011
Home Health Prospective Payment System final rule (75 FR 70435) that
the 180th-day recertification and subsequent recertifications would
correspond to the beneficiary's third or subsequent benefit periods.
Further, section 1814(i)(6) of the Act, as added by section
3132(a)(1)(B) of the Affordable Care Act, authorizes the Secretary to
collect additional data and information determined appropriate to
revise payments for hospice care and other purposes. The types of data
and information suggested in the Affordable Care Act could capture
accurate resource utilization, which could be collected on claims, cost
reports, and possibly other mechanisms, as the Secretary determined to
be appropriate. The data collected could be used to revise the
methodology for determining the payment rates for RHC and other
services included in hospice care, no earlier than October 1, 2013, as
described in section 1814(i)(6)(D) of the Act. In addition, we were
required to consult with hospice programs and the Medicare Payment
Advisory Commission (MedPAC) regarding additional data collection and
payment revision options.
6. FY 2012 Hospice Wage Index Final Rule
When the Medicare Hospice benefit was implemented, the Congress
included an aggregate cap on hospice payments, which limits the total
aggregate payments any individual hospice can receive in a year. The
Congress stipulated that a ``cap amount'' be computed each year. The
cap amount was set at $6,500 per beneficiary when first enacted in 1983
and has been adjusted annually by the change in the medical care
expenditure category of the consumer price index for urban consumers
from March 1984 to March of the cap year (section 1814(i)(2)(B) of the
Act). The cap year was defined as the period from November 1st to
October 31st. In the August 4, 2011 FY 2012 Hospice Wage Index final
rule (76 FR 47308 through 47314) for the 2012 cap year and subsequent
cap years, we announced that subsequently, the hospice aggregate cap
would be calculated using the patient-by-patient proportional
methodology, within certain limits. We allowed existing hospices the
option of having their cap calculated via the original streamlined
methodology, also within certain limits. As of FY 2012, new hospices
have their cap determinations calculated using the patient-by-patient
proportional methodology. The patient-by-patient proportional
methodology and the streamlined methodology are two different
methodologies for counting beneficiaries when calculating the hospice
aggregate cap. A detailed explanation of these methods is found in the
August 4, 2011 FY 2012 Hospice Wage Index final rule (76 FR 47308
through 47314). If a hospice's total Medicare payments for the cap year
exceed the hospice aggregate cap, then the hospice must repay the
excess back to Medicare.
7. FY 2015 Hospice Wage Index and Payment Rate Update Final Rule
When electing hospice, a beneficiary waives Medicare coverage for
any care for the terminal illness and related conditions except for
services provided by the designated hospice and attending physician.
The FY 2015 Hospice Wage Index and Payment Rate Update final rule (79
FR 50452) finalized a requirement that requires the Notice of Election
(NOE) be filed within 5 calendar days after the effective date of
hospice election. If the NOE is filed beyond this 5-day period, hospice
providers are liable for the services furnished during the days from
the effective date of hospice election to the date of NOE filing (79 FR
50474).
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Similar to the NOE, the claims processing system must be notified of a
beneficiary's discharge from hospice or hospice benefit revocation.
This update to the beneficiary's status allows claims from non-hospice
providers to be processed and paid. Late filing of the NOE can result
in inaccurate benefit period data and leaves Medicare vulnerable to
paying non-hospice claims related to the terminal illness and related
conditions and beneficiaries possibly liable for any cost-sharing of
associated costs. Upon live discharge or revocation, the beneficiary
immediately resumes the Medicare coverage that had been waived when he
or she elected hospice. The FY 2015 Hospice Wage Index and Payment Rate
Update final rule also finalized a requirement that requires hospices
to file a notice of termination/revocation within 5 calendar days of a
beneficiary's live discharge or revocation, unless the hospices have
already filed a final claim. This requirement helps to protect
beneficiaries from delays in accessing needed care (Sec. 418.26(e)).
A hospice ``attending physician'' is described by the statutory and
regulatory definitions as a medical doctor, osteopath, or nurse
practitioner whom the beneficiary identifies, at the time of hospice
election, as having the most significant role in the determination and
delivery of his or her medical care. Over time, we have received
reports of problems with the identification of the person's designated
attending physician and a third of hospice patients had multiple
providers submit Part B claims as the ``attending physician,'' using a
claim modifier. The FY 2015 Hospice Wage Index and Payment Rate Update
final rule finalized a requirement that the election form include the
beneficiary's choice of attending physician and that the beneficiary
provide the hospice with a signed document when he or she chooses to
change attending physicians (79 FR 50479).
Hospice providers are required to begin using a Hospice Experience
of Care Survey for informal caregivers of hospice patients as of 2015.
The FY 2015 Hospice Wage Index and Payment Rate Update final rule
provided background and a description of the development of the Hospice
Experience of Care Survey, including the model of survey
implementation, the survey respondents, eligibility criteria for the
sample, and the languages in which the survey is offered. The FY 2015
Hospice Wage Index and Payment Rate Update final rule also set out
participation requirements for CY 2015 and discussed vendor oversight
activities and the reconsideration and appeals process for entities
that failed to win CMS approval as vendors (79 FR 50496).
Finally, the FY 2015 Hospice Wage Index and Payment Rate Update
final rule required providers to complete their aggregate cap
determination not sooner than 3 months after the end of the cap year,
and not later than 5 months after, and remit any overpayments. Those
hospices that fail to timely submit their aggregate cap determinations
will have their payments suspended until the determination is completed
and received by the Medicare Administrative Contractor (MAC) (79 FR
50503).
8. IMPACT Act of 2014
The Improving Medicare Post-Acute Care Transformation Act of 2014
(Pub. L. 113-185) (IMPACT Act) became law on October 6, 2014. Section
3(a) of the IMPACT Act mandated that all Medicare certified hospices be
surveyed every 3 years beginning April 6, 2015 and ending September 30,
2025. In addition, section 3(c) of the IMPACT Act requires medical
review of hospice cases involving beneficiaries receiving more than 180
days care in select hospices that show a preponderance of such
patients; section 3(d) of the IMPACT Act contains a new provision
mandating that the cap amount for accounting years that end after
September 30, 2016, and before October 1, 2025 be updated by the
hospice payment update rather than using the consumer price index for
urban consumers (CPI-U) for medical care expenditures.
9. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2016 Hospice Wage Index and Payment Rate Update final
rule, we created two different payment rates for RHC that resulted in a
higher base payment rate for the first 60 days of hospice care and a
reduced base payment rate for subsequent days of hospice care (80 FR
47172). We also created a Service Intensity Add-on (SIA) payment
payable for services during the last 7 days of the beneficiary's life,
equal to the CHC hourly payment rate multiplied by the amount of direct
patient care provided by a registered nurse (RN) or social worker that
occurs during the last 7 days (80 FR 47177).
In addition to the hospice payment reform changes discussed, the FY
2016 Hospice Wage Index and Payment Rate Update final rule implemented
changes mandated by the IMPACT Act, in which the cap amount for
accounting years that end after September 30, 2016 and before October
1, 2025 is updated by the hospice payment update percentage rather than
using the CPI-U. This was applied to the 2016 cap year, starting on
November 1, 2015 and ending on October 31, 2016. In addition, we
finalized a provision to align the cap accounting year for both the
inpatient cap and the hospice aggregate cap with the fiscal year for FY
2017 and later (80 FR 47186). This allows for the timely implementation
of the IMPACT Act changes while better aligning the cap accounting year
with the timeframe described in the IMPACT Act.
Finally, the FY 2016 Hospice Wage Index and Payment Rate Update
final rule clarified that hospices must report all diagnoses of the
beneficiary on the hospice claim as a part of the ongoing data
collection efforts for possible future hospice payment refinements.
Reporting of all diagnoses on the hospice claim aligns with current
coding guidelines as well as admission requirements for hospice
certifications.
10. FY 2017 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2017 Hospice Wage Index and Payment Rate Update final
rule, we finalized several new policies and requirements related to the
HQRP. First, we codified our policy that if the National Quality Forum
(NQF) makes non-substantive changes to specifications for HQRP measures
as part of the NQF's re-endorsement process, we will continue to
utilize the measure in its new endorsed status, without going through
new notice-and-comment rulemaking (81 FR 52160). We will continue to
use rulemaking to adopt substantive updates made by the NQF to the
endorsed measures we have adopted for the HQRP; determinations about
what constitutes a substantive versus non-substantive change will be
made on a measure-by-measure basis. Second, we finalized two new
quality measures for the HQRP for the FY 2019 payment determination and
subsequent years: Hospice Visits when Death is Imminent Measure Pair
and Hospice and Palliative Care Composite Process Measure-Comprehensive
Assessment at Admission (81 FR 52173). The data collection mechanism
for both of these measures is the HIS, and the measures are effective
April 1, 2017. Regarding the CAHPS[supreg] Hospice Survey, we finalized
a policy that hospices that receive their CMS Certification Number
(CCN) after January 1, 2017 for the FY 2019 Annual Payment Update (APU)
and January 1, 2018 for the FY 2020 APU will be exempted from the
Hospice CAHPS[supreg] requirements due to newness (81 FR 52182). The
exemption is
[[Page 36644]]
determined by CMS and is for 1 year only.
E. Trends in Medicare Hospice Utilization
Since the implementation of the hospice benefit in 1983, and
especially within the last decade, there has been substantial growth in
hospice benefit utilization. The number of Medicare beneficiaries
receiving hospice services has grown from 513,000 in FY 2000 to nearly
1.4 million in FY 2016. Similarly, Medicare hospice expenditures have
risen from $2.8 billion in FY 2000 to approximately $16.5 billion in FY
2016. Our Office of the Actuary (OACT) projects that hospice
expenditures are expected to continue to increase, by approximately 7
percent annually, reflecting an increase in the number of Medicare
beneficiaries, more beneficiary awareness of the Medicare Hospice
Benefit for end-of-life care, and a growing preference for care
provided in home and community-based settings.
There have also been changes in the diagnosis patterns among
Medicare hospice enrollees. Specifically, as described in Table 2,
there have been notable increases between 2002 and 2016 in
neurologically-based diagnoses, including diagnoses of Alzheimer's
disease. Additionally, there have been significant increases in the use
of non-specific, symptom-classified diagnoses, such as ``debility'' and
``adult failure to thrive.'' In FY 2013, ``debility'' and ``adult
failure to thrive'' were the first and sixth most common hospice
claims-reported diagnoses, respectively, accounting for approximately
14 percent of all diagnoses. Effective October 1, 2014, hospice claims
are returned to the provider if ``debility'' and ``adult failure to
thrive'' are coded as the principal hospice diagnosis as well as other
ICD-9-CM (and as of October 1, 2015, ICD-10-CM) codes that are not
permissible as principal diagnosis codes per ICD-9-CM (or ICD-10-CM)
coding guidelines. In the FY 2015 Hospice Wage Index and Payment Rate
Update final rule (79 FR 50452), we reminded the hospice industry that
this policy would go into effect and claims would start to be returned
to the provider effective October 1, 2014. As a result of this, there
has been a shift in coding patterns on hospice claims. For FY 2016, the
most common hospice principal diagnoses were Alzheimer's disease, Heart
Failure, Chronic Obstructive Pulmonary Disease, Lung Cancer, and Senile
Degeneration of the Brain, which constituted approximately 30 percent
of all claims-reported principal diagnosis codes reported in FY 2016
(see Table 2).
Table 2--The Top Twenty Principal Hospice Diagnoses, FY 2002, FY 2007, FY 2013, FY 2016
----------------------------------------------------------------------------------------------------------------
ICD-9/Reported principal
Rank diagnosis Count Percentage
----------------------------------------------------------------------------------------------------------------
Year: FY 2002
----------------------------------------------------------------------------------------------------------------
1........................ 162.9 Lung Cancer................. 73,769 11
2........................ 428.0 Congestive Heart Failure.... 45,951 7
3........................ 799.3 Debility Unspecified........ 36,999 6
4........................ 496 COPD........................ 35,197 5
5........................ 331.0 Alzheimer's Disease......... 28,787 4
6........................ 436 CVA/Stroke.................. 26,897 4
7........................ 185 Prostate Cancer............. 20,262 3
8........................ 783.7 Adult Failure To Thrive..... 18,304 3
9........................ 174.9 Breast Cancer............... 17,812 3
10....................... 290.0 Senile Dementia, Uncomp..... 16,999 3
11....................... 153.0 Colon Cancer................ 16,379 2
12....................... 157.9 Pancreatic Cancer........... 15,427 2
13....................... 294.8 Organic Brain Synd Nec...... 10,394 2
14....................... 429.9 Heart Disease Unspecified... 10,332 2
15....................... 154.0 Rectosigmoid Colon Cancer... 8,956 1
16....................... 332.0 Parkinson's Disease......... 8,865 1
17....................... 586 Renal Failure Unspecified... 8,764 1
18....................... 585 Chronic Renal Failure (End 8,599 1
2005).
19....................... 183.0 Ovarian Cancer.............. 7,432 1
20....................... 188.9 Bladder Cancer.............. 6,916 1
----------------------------------------------------------------------------------------------------------------
Year: FY 2007
----------------------------------------------------------------------------------------------------------------
1........................ 799.3 Debility Unspecified........ 90,150 9
2........................ 162.9 Lung Cancer................. 86,954 8
3........................ 428.0 Congestive Heart Failure.... 77,836 7
4........................ 496 COPD........................ 60,815 6
5........................ 783.7 Adult Failure To Thrive..... 58,303 6
6........................ 331.0 Alzheimer's Disease......... 58,200 6
7........................ 290.0 Senile Dementia Uncomp...... 37,667 4
8........................ 436 CVA/Stroke.................. 31,800 3
9........................ 429.9 Heart Disease Unspecified... 22,170 2
10....................... 185 Prostate Cancer............. 22,086 2
11....................... 174.9 Breast Cancer............... 20,378 2
12....................... 157.9 Pancreas Unspecified........ 19,082 2
13....................... 153.9 Colon Cancer................ 19,080 2
14....................... 294.8 Organic Brain Syndrome NEC.. 17,697 2
15....................... 332.0 Parkinson's Disease......... 16,524 2
16....................... 294.10 Dementia In Other Diseases w/ 15,777 2
o Behavior. Dist.
17....................... 586 Renal Failure Unspecified... 12,188 1
18....................... 585.6 End Stage Renal Disease..... 11,196 1
19....................... 188.9 Bladder Cancer.............. 8,806 1
20....................... 183.0 Ovarian Cancer.............. 8,434 1
----------------------------------------------------------------------------------------------------------------
[[Page 36645]]
Year: FY 2013
----------------------------------------------------------------------------------------------------------------
1........................ 799.3 Debility Unspecified........ 127,415 9
2........................ 428.0 Congestive Heart Failure.... 96,171 7
3........................ 162.9 Lung Cancer................. 91,598 6
4........................ 496 COPD........................ 82,184 6
5........................ 331.0 Alzheimer's Disease......... 79,626 6
6........................ 783.7 Adult Failure to Thrive..... 71,122 5
7........................ 290.0 Senile Dementia, Uncomp..... 60,579 4
8........................ 429.9 Heart Disease Unspecified... 36,914 3
9........................ 436 CVA/Stroke.................. 34,459 2
10....................... 294.10 Dementia In Other Diseases w/ 30,963 2
o Behavioral Dist.
11....................... 332.0 Parkinson's Disease......... 25,396 2
12....................... 153.9 Colon Cancer................ 23,228 2
13....................... 294.20 Dementia Unspecified w/o 23,224 2
Behavioral Dist..
14....................... 174.9 Breast Cancer............... 23,059 2
15....................... 157.9 Pancreatic Cancer........... 22,341 2
16....................... 185 Prostate Cancer............. 21,769 2
17....................... 585.6 End-Stage Renal Disease..... 19,309 1
18....................... 518.81 Acute Respiratory Failure... 15,965 1
19....................... 294.8 Other Persistent Mental Dis.- 14,372 1
classified elsewhere.
20....................... 294.11 Dementia In Other Diseases w/ 13,687 1
Behavioral Dist..
----------------------------------------------------------------------------------------------------------------
Year: FY 2016
----------------------------------------------------------------------------------------------------------------
1........................ G30.9 Alzheimer's disease, 162,845 11
unspecified.
2........................ I50.9 Heart failure, unspecified.. 84,088 6
3........................ J44.9 Chronic obstructive 74,131 5
pulmonary disease,
unspecified.
4........................ C34.90 Malignant Neoplasm Of Unsp 57,077 4
Part Of Unsp Bronchus Or
Lung.
5........................ G31.1 Senile degeneration of 55,305 4
brain, not elsewhere
classified.
6........................ G20 Parkinson's disease......... 37,245 2
7........................ I25.10 Atherosclerotic heart 33,647 2
disease of native coronary
art without angina pectoris.
8........................ J44.1 Chronic obstructive 32,851 2
pulmonary disease with
(acute) exacerbation.
9........................ G30.1 Alzheimer's disease with 29,223 2
late onset.
10....................... I67.2 Cerebral atherosclerosis.... 27,629 2
11....................... C61 Malignant neoplasm of 24,576 2
prostate.
12....................... N18.6 End stage renal disease..... 22,261 1
13....................... C18.9 Malignant neoplasm of colon, 22,203 1
unspecified.
14....................... I51.9 Heart disease, unspecified.. 21,868 1
15....................... C25.9 Malignant neoplasm of 20,400 1
pancreas, unspecified.
16....................... I63.9 Cerebral infarction, 18,546 1
unspecified.
17....................... I67.9 Cerebrovascular disease, 14,879 1
unspecified.
18....................... C50.919 Malignant neoplasm of 14,022 1
unspecified site of
unspecified female breast.
19....................... A41.9 Sepsis, unspecified organism 12,723 1
20....................... I50.22 Chronic systolic 12,083 1
(congestive) heart failure.
----------------------------------------------------------------------------------------------------------------
Note(s): The frequencies shown represent beneficiaries that had a least one claim with the specific ICD-9-CM/ICD-
10 code reported as the principal diagnosis. Beneficiaries could be represented multiple times in the results
if they have multiple claims during that time period with different principal diagnoses.
Source: FY 2002 and 2007 hospice claims data from the Chronic Conditions Data Warehouse (CCW), accessed on
February 14 and February 20, 2013. FY 2013 hospice claims data from the CCW, accessed on June 26, 2014, and FY
2016 hospice claims data from the CCW, accessed and merged with ICD-10 codes on January 9, 2017.
While there has been a shift in the reporting of the principal
diagnosis as a result of diagnosis clarifications, a significant
proportion of hospice claims (49 percent) in FY 2014 only reported a
single principal diagnosis, which may not fully explain the
characteristics of Medicare beneficiaries who are approaching the end
of life. To address this pattern of single diagnosis reporting, the FY
2015 Hospice Wage Index and Payment Rate Update final rule (79 FR
50498) reiterated ICD-9-CM coding guidelines for the reporting of the
principal and additional diagnoses on the hospice claim. We reminded
providers to report all diagnoses on the hospice claim for the terminal
illness and related conditions, including those that affect the care
and clinical management for the beneficiary. Additionally, in the FY
2016 Hospice Wage Index and Payment Rate Update final rule (80 FR
47201), we provided further clarification regarding diagnosis reporting
on hospice claims. We clarified that hospices will report all diagnoses
identified in the initial and comprehensive assessments on hospice
claims, whether related or unrelated to the terminal prognosis of the
individual, effective October 1, 2015. Analysis of FY 2016 hospice
claims show that 100 percent of hospices reported one diagnosis, 86
percent submitted at least two diagnoses, and 77 percent included at
least three diagnoses.
III. Provisions of the Final Rule
On May 3, 2017, we published the FY 2018 Hospice Wage Index and
Payment Rate Update and Hospice Quality Reporting Requirements proposed
rule in the Federal Register (82 FR 20750 through 20792) and provided a
60 day comment period. In that proposed rule, we proposed to update the
hospice wage index, payment rates, and cap amount for fiscal year (FY)
2018. In addition, we
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proposed changes to the hospice quality reporting program. The proposed
rule also solicited feedback on an enhanced data collection instrument
and described plans to publicly display quality measures and other
hospice data beginning in the middle of 2017. We received approximately
89 public comments on the proposed rule, including comments from
MedPAC, hospice agencies, national provider associations, patient
organizations, nurses, and advocacy groups.
In this final rule, we provide a summary of each proposed
provision, a summary of the public comments received and our responses
to them, and the policies we are finalizing for the FY 2018 Hospice
Payment Rate Update and Hospice Quality Reporting Requirements.
Comments related to the paperwork burden are addressed in section IV
``Collection of Information Requirements'' of this final rule. Comments
related to the impact analysis are addressed in section V ``Regulatory
Impact Analysis'' of this final rule.
A. Monitoring for Potential Impacts--Affordable Care Act Hospice Reform
In the FY 2018 Hospice Wage Index and Payment Rate Update proposed
rule (82 FR 20750), we provided a summary of analysis conducted on
hospice length of stay, live discharge rates, skilled visits in the
last days of life, and non-hospice spending. Additionally, we discussed
initial analyses of data from recently revised cost reports. We will
continue to monitor the impact of future payment and policy changes and
will provide the industry with periodic updates on our analysis in
future rulemaking and/or announcements on the Hospice Center Web page
at: https://www.cms.gov/Center/Provider-Type/Hospice-Center.html.
We received several comments on the analysis and CMS's plans for
future monitoring efforts with regards to hospice payment reform
outlined in the proposed rule.
The comments and our responses are set forth below.
Comment: Many commenters expressed continued support for our plans
to monitor the impact of hospice payment reform and suggested the use
of monitoring results in order to better target program integrity
efforts. Commenters suggested CMS ensure hospices with a high number of
live discharges receive the appropriate training on hospice eligibility
requirements, which may help reduce their number of live discharges to
a threshold more aligned with other hospices with similar demographics.
With regards to skilled visits during the last days of life, a few
commenters stated that hospices continue to take their cues from
patients and families, who should always have the option to decline a
visit. As such, decisions regarding visits made by the patient and
family ought to be considered and/or reflected in the data. With
regards to the initial analysis of newly-revised cost report data,
several commenters encouraged CMS to approach further analysis in a
deliberate fashion, taking into account the ``newness'' of the data
collected, further educate providers on appropriate completion of the
cost report forms, and audit cost reports before moving forward with
any further research. Several commenters suggested that CMS take action
to educate other Medicare provider types to increase understanding of
benefits coverage and claims processing after a beneficiary has elected
hospice and encouraged Medicare systems changes that could shorten the
time frame for updates to the beneficiary's status in all systems.
Several commenters recommended that CMS make more data available to the
hospice providers and other stakeholders, especially with regards to
Part D billing, and consider clarifying the responsibilities for
prescription medications to decrease Part D non-hospice spending.
Response: We appreciate these comments on the ongoing analysis
presented and we will continue to monitor hospice trends and
vulnerabilities within the hospice benefit, while also investigating
the means by which we can educate the provider community regarding the
hospice benefit and appropriate billing practices. We will also
consider these suggestions for future monitoring efforts and for
potential policy or payment refinements. We are currently working on a
process to allow NOEs to be submitted via electronic data interchange
while simultaneously working on a redesign of hospice benefit period
data in our systems. Allowing NOEs to be submitted via an electronic
data interchange and the hospice benefit period data redesign should
help with more timely beneficiary status updates in the Medicare
systems.
B. FY 2018 Hospice Wage Index and Rate Update
1. FY 2018 Hospice Wage Index
The hospice wage index is used to adjust payment rates for hospice
agencies under the Medicare program to reflect local differences in
area wage levels, based on the location where services are furnished.
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. Our regulations at Sec. 418.306(c) require each
labor market to be established using the most current hospital wage
data available, including any changes made by Office of Management and
Budget (OMB) to the Metropolitan Statistical Areas (MSAs) definitions.
We use the previous FY's hospital wage index data to calculate the
hospice wage index values. For FY 2018, the hospice wage index will be
based on the FY 2017 hospital pre-floor, pre-reclassified wage index.
This means that the hospital wage data used for the hospice wage index
is not adjusted to take into account any geographic reclassification of
hospitals including those in accordance with section 1886(d)(8)(B) or
1886(d)(10) of the Act. The appropriate wage index value is applied to
the labor portion of the payment rate based on the geographic area in
which the beneficiary resides when receiving RHC or CHC. The
appropriate wage index value is applied to the labor portion of the
payment rate based on the geographic location of the facility for
beneficiaries receiving GIP or IRC.
There exist some geographic areas where there were no hospitals,
and thus, no hospital wage index data on which to base the calculation
of the hospice wage index. In the FY 2008 Hospice Wage Index final rule
(72 FR 50214), we implemented a methodology to update the hospice wage
index for such areas. In cases where there was a rural area without
rural hospital wage data, we use the average pre-floor, pre-
reclassified hospital wage index data from all contiguous Core-Based
Statistical Areas (CBSAs), to represent a reasonable proxy for the
rural area. The term ``contiguous'' means sharing a border (72 FR
50217). Currently, the only rural area without a hospital from which
hospital wage data could be derived is Puerto Rico. However, for rural
Puerto Rico, we would not apply this methodology due to the distinct
economic circumstances that exist there (for example, due to the close
proximity to one another of almost all of Puerto Rico's various urban
and non-urban areas, this methodology would produce a wage index for
rural Puerto Rico that is higher than that in half of its urban areas);
instead, we would continue to use the most recent wage index previously
available for that area. For FY 2018, we will continue to use the most
recent pre-floor, pre-reclassified hospital wage index value available
for Puerto Rico, which is 0.4047.
[[Page 36647]]
In the FY 2010 Hospice Wage Index final rule (74 FR 39386), we
adopted the policy that for urban labor markets without a hospital from
which hospital wage index data could be derived, all of the CBSAs
within the state would be used to calculate a statewide urban average
pre-floor, pre-reclassified hospital wage index value to use as a
reasonable proxy for these areas. For FY 2018, the only CBSA without a
hospital from which hospital wage data can be derived is 25980,
Hinesville-Fort Stewart, Georgia.
As described in the August 8, 1997 Hospice Wage Index final rule
(62 FR 42860), the pre-floor and pre-reclassified hospital wage index
is used as the raw wage index for the hospice benefit. These raw wage
index values are subject to application of the hospice floor to compute
the hospice wage index used to determine payments to hospices. Pre-
floor, pre-reclassified hospital wage index values below 0.8 are
adjusted by a 15 percent increase subject to a maximum wage index value
of 0.8. For example, if County A has a pre-floor, pre-reclassified
hospital wage index value of 0.3994, we would multiply 0.3994 by 1.15,
which equals 0.4593. Since 0.4593 is not greater than 0.8, then County
A's hospice wage index would be 0.4593. 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. Because 0.8556 is
greater than 0.8, County B's hospice wage index would be 0.8.
On February 28, 2013, OMB issued OMB Bulletin No. 13-01, announcing
revisions to the delineation of MSAs, Micropolitan Statistical Areas,
and Combines Statistical Areas, and guidance on uses of the delineation
in these areas. In the FY 2016 Hospice Wage Index and Payment Rate
Update final rule (80 FR 47178), we adopted the OMB's new area
delineations using a 1-year transition. Also, in the FY 2016 Hospice
Wage Index and Payment Rate Update final rule, we stated that beginning
October 1, 2016, the wage index for all hospice payments would be fully
based on the new OMB delineations. The most recent bulletin (No. 15-01)
concerning the revised delineations was published by the OMB on July
15, 2015.
A summary of the comments we received regarding the wage index and
our responses to those comments appears below.
Comment: Several commenters expressed concern that hospices in
Montgomery County and Frederick County, Maryland, which are included in
CBSA 43524 (Silver Spring-Frederick-Rockville, MD), are reimbursed at a
lower rate than hospices in the greater Washington DC area that are
included in CBSA 47894 (Washington-Arlington-Alexandria, DC-VA-MD-WV).
The commenters request that CMS reconsider CBSA 43524 (Silver Spring-
Frederick-Rockville, MD).
Response: We refer readers of this final rule to the FY 2016
Hospice Wage Index and Payment Rate Update (80 FR 47179 through 47180)
wherein we provided a detailed response to this comment.
Comment: A commenter stated that another complicating factor
related to the wage index value for CBSA 43524 (Silver Spring-
Frederick-Rockville, MD) is the Maryland Federal Waiver and global
budget. In all other states, cost reports drive reimbursement for
hospitals and accurate reporting of wages is key to reimbursement
rates. The commenter believes that since the data on cost reports does
not relate to their reimbursement, hospitals in Maryland have no
incentive to report their wages accurately. The commenter asserts that
there are two hospitals in CBSA 43524 that have not reported their
nursing wages accurately. The cost report data drives the rates for
post-acute Medicare services such as hospice; this difference should be
taken into consideration.
Response: We would like to thank the commenter for her comment. We
disagree with the commenter's statement that hospitals in Maryland have
no incentives for ensuring the accuracy of their cost reports and that
the cost report data are inaccurate and not representative of the costs
that the hospitals actually incur. Hospitals' cost reports, including
those of hospitals in Maryland, are required to be certified by the
Officer or Administrator of the hospital. The hospital Medicare Cost
Report (MCR) Form (CMS-2552-10) states the following:
``I HEREBY CERTIFY that I have read the above statement and that I
have examined the accompanying cost report and the Balance Sheet and
Statement of Revenue and Expenses prepared by _____ (provider name(s)
and number(s) for the cost report beginning ___ and ending ___ and to
the best of my knowledge and belief, this report and statement are
true, correct, complete and prepared from the books and records of the
provider in accordance with applicable instructions, except as noted. I
further certify that I am familiar with the laws and regulations
regarding the provision of health care services, and that the services
identified in this cost report were provided in compliance with such
laws and regulations.''
We also note that the hospital Medicare cost report referenced
statement above includes the following:
``Misrepresentation or falsification of any information
contained in this cost report may be punishable by criminal, civil
and administrative action, fine and/or imprisonment under federal
law. Furthermore, if services identified in this report were
provided or procured through the payment directly or indirectly of a
kickback or were otherwise illegal, criminal, civil and
administrative action, fines and/or imprisonment may result.''
As always, we encourage providers to fill out the Medicare cost
reports as accurately as possible.
Comment: A commenter stated that no hospice should receive a wage
index below the hospital rural floor. The commenter stated that in some
small CBSAs, hospices receive a wage index that is below the rural
floor which severely impacts their ability to deliver high-quality
hospice care. CMS should mandate that no hospice receive a wage index
below the rural floor.
Response: The hospice wage index does not contain a rural floor
provision. Section 4410(a) of the Balanced Budget Act of 1997 (Pub. 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. This rural floor provision is specific to hospitals. Because the
hospital rural floor applies only to hospitals, and not to hospices, we
continue to believe the use of the previous year's pre-floor and pre-
reclassified hospital wage index results in the most appropriate
adjustment to the labor portion of the hospice payment rates. This
position is longstanding and consistent with other Medicare payment
systems (for example, SNF PPS, IRF PPS, and HH PPS). The hospice floor
is applicable to all CBSAs, both rural and urban. Pre-floor, pre-
reclassified hospital wage index values below 0.8 are adjusted by a 15
percent increase subject to a maximum wage index value of 0.8.
Comment: A commenter requested that CMS make adjustments to the
methodology used to calculate the wage index for rural Puerto Rico. The
commenter stated that the proposed ruling for the FY 2018 Hospice Wage
Index Update states that ``in cases where there was a rural area
without rural hospital wage data, we use the average pre-floor, pre-
reclassified hospital wage index data from all contiguous Core-Based
Statistical Areas (CBSAs), to represent a reasonable proxy for the
[[Page 36648]]
rural area.'' Currently, the only rural area without a hospital from
which hospital wage data could be derived is Puerto Rico. The commenter
notes that CMS chose not to use this proxy for Puerto Rico and
continued using the most recent wage index previously available for
that rural area. The commenter does not believe that this represents a
``reasonable proxy for the rural area'' in comparison with other
jurisdictions, and it still does not justify applying lower wage
indices to urban areas in Puerto Rico.
The commenter proposes that CMS should use the wage index defined
for the neighboring U.S. Virgin Islands for CY 2018, as this would be
in harmony with the policy defined for Part B GPCIs, by providing more
consistency across the payment policies among neighboring Territories.
Alternatively, the commenter proposes that Puerto Rico wage indices in
Hospice care should not be lower than the average ratio of Puerto Rico
wages to U.S. wages, using the data from the OES. The Puerto Rico
average wage is at 58 percent of the national average, the commenter
considers that the Hospice wage index should be at least equal to that
ratio.
Response: We will take these comments under consideration for any
future policy changes that may be considered for Puerto Rico. The wage
index value for rural Puerto Rico is increased by 15 percent in
accordance with the hospice floor provision. There was an error in the
Proposed FY 2018 Hospice Wage Index file. The value for rural Puerto
Rico was listed as 0.4047. The correct value is 0.4654.
Comment: A commenter expressed dissatisfaction with the wage index
value for Madera County, California in relation to the wage index value
for Fresno County, which is adjacent to Madera County.
Response: As stated earlier in this final rule, we use OMB's
geographic area delineations to differentiate between labor markets.
Based on the most recent list of MSA definitions contained in OMB
Bulletin No. 15-01, published on July 15, 2015 and available at https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/bulletins/2015/15-01.pdf, Madera County is associated with a different MSA than Fresno
County. Therefore, for payment purposes we calculate these two counties
wage indices separately, based on data gathered from the cost reports
of the Inpatient Prospective Payment System (IPPS) hospitals in those
counties.
Comment: One commenter expressed concern that the proposed FY 2018
hospice wage index will be fully based on the new OMB geographic area
wage delineations. The commenter was particularly concerned with the
New York City CBSA and the fact that the CBSA contains counties from
New Jersey where labor costs are lower.
Response: We responded to this comment in the FY 2017 Hospice Wage
Index and Payment Rate Update final rule (81 FR 52154). We continue to
believe that the OMB's geographic area delineations are a reasonable
and appropriate method of defining geographic areas for the purposes of
wage adjusting the hospice payment rates.
Comment: A commenter was concerned with the continued use of the
pre-floor, pre-reclassified hospital wage index to adjust the hospice
payment rates and states his belief that this causes continued
volatility of the hospice wage index from one year to the next. The
commenter believes that the volatility is often based on inaccurate or
incomplete hospital cost report data.
Response: We addressed this comment in the FY 2017 Hospice Wage
Index and Payment Rate Update final rule (81 FR 52154). We continue to
believe that the annual changes in the wage index reflect real
variations in costs of providing care in various geographic locations.
We utilize efficient means to ensure and review the accuracy of the
hospital cost report data and resulting wage index. The hospice wage
index is derived from the pre-floor, pre-reclassified wage index, which
is calculated based on cost report data from hospitals. All IPPS
hospitals must complete the wage index survey (Worksheet S-3, Parts II
and III) as part of their Medicare cost reports. Cost reports will be
rejected if Worksheet S-3 is not completed. In addition, our Medicare
contractors perform desk reviews on all hospitals' Worksheet S-3 wage
data, and we run edits on the wage data to further ensure the accuracy
and validity of the wage data. We believe that our review processes
result in an accurate reflection of the applicable wages for the areas
given. In addition, we believe that our policy of utilizing a hospice
wage index standardization factor, which was proposed and finalized in
FY 2017 rulemaking, provides a safeguard to the Medicare program as
well as to hospices because it will mitigate fluctuations in the wage
index by ensuring that wage index updates and revisions are implemented
in a budget neutral manner.
Comment: A commenter was concerned with the lack of parity between
different health care sectors, each of which utilizes some form of a
hospital wage index, that experience differing wage index values for
specific geographic areas. The commenter also stated that hospital
reclassifications create labor market distortions in areas in which
hospice costs are not reclassified.
Response: We responded to this comment in the FY 2017 Hospice Wage
Index and Payment Rate Update final rule (81 FR 52154) and believe that
it is important to reiterate that the regulations and statutes that
govern hospice payments do not provide a mechanism for allowing
hospices to seek geographic reclassification. The reclassification
provision is found in section 1886(d)(10) of the Act. Section
1886(d)(10)(C)(i) of the Act states, ``The Board shall consider the
application of any subsection (d) hospital requesting that the
Secretary change the hospital's geographic classification . . .'' This
provision is only applicable to hospitals as defined in section 1886(d)
of the Act. In addition, we do not believe that using hospital
reclassification data would be appropriate, as these data are specific
to the requesting hospitals and they may or may not apply to a given
hospice in a given instance. In addition, several post-acute care
payment systems utilize the pre-floor, pre-reclassified hospital wage
index as the basis for their wage indices (for example, the Home Health
Prospective Payment System (HH PPS), the Skilled Nursing Facility
Prospective Payment System (SNF PPS) and the Inpatient Rehabilitation
Facility Prospective Payment System (IRF PPS)).
Final Decision: After considering the comments received in response
to the proposed rule and for the reasons discussed above, we are
finalizing our proposal to use the pre-floor, pre-reclassified hospital
inpatient wage index as the wage adjustment to the labor portion of the
hospice rates. For FY 2018, the updated wage data are for hospital cost
reporting periods beginning on or after October 1, 2012 and before
October 1, 2013 (FY 2013 cost report data).
The wage index applicable for FY 2018 is available on our Web site
at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html. The hospice wage index for FY 2018 will be
effective October 1, 2017 through September 30, 2018.
2. FY 2018 Hospice Payment Update Percentage
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L.
105-33) amended section 1814(i)(1)(C)(ii)(VI) of the Act to establish
updates to
[[Page 36649]]
hospice rates for FYs 1998 through 2002. 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. 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.
The Act historically required us to use the inpatient hospital market
basket as the basis for the hospice payment rate update.
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 statute defines the productivity adjustment to be equal to the 10-
year moving average of changes in annual economy-wide private nonfarm
business multifactor productivity (MFP). In addition to the MFP
adjustment, section 3401(g) of the Affordable Care Act also mandated
that in FY 2013 through FY 2019, the hospice payment update percentage
would be reduced by an additional 0.3 percentage point (although for FY
2014 to FY 2019, the potential 0.3 percentage point reduction is
subject to suspension under conditions specified in section
1814(i)(1)(C)(v) of the Act).
Prior to the enactment of the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16,
2015), which amended section 1814(i)(1)(C) of the Act, the proposed
hospice update percentage for FY 2018 would have been based on the
estimated inpatient hospital market basket update of 2.7 percent (based
on IHS Global Inc.'s second quarter 2017 forecast with historical data
through the first quarter of 2017 of the 2014-based IPPS market
basket). Due to the requirements at section 1886(b)(3)(B)(xi)(II) of
the Act prior to enactment of the MACRA, the estimated FY 2018
inpatient hospital market basket update of 2.7 percent would have been
reduced by a MFP adjustment as mandated by Affordable Care Act
(currently estimated to be 0.6 percentage point for FY 2018) and a 0.3
percentage point reduction as mandated by section 1814(i)(1)(C)(v) of
the Act. In effect, the hospice payment update percentage for FY 2018
would be 1.8 percent. However, section 411(d) of the MACRA amended
section 1814(i)(1)(C) of the Act, such that for hospice payments for FY
2018, the market basket percentage increase is required to be 1
percent.
Currently, the labor portion of the hospice payment rates is as
follows: For RHC, 68.71 percent; for CHC, 68.71 percent; for General
Inpatient Care, 64.01 percent; and for Respite Care, 54.13 percent. The
non-labor portion is equal to 100 percent minus the labor portion for
each level of care. Therefore, the non-labor portion of the payment
rates is as follows: For RHC, 31.29 percent; for CHC, 31.29 percent;
for General Inpatient Care, 35.99 percent; and for Respite Care, 45.87
percent. Beginning with cost reporting periods starting on or after
October 1, 2014, freestanding hospice providers are required to submit
cost data using CMS Form 1984-14 (https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports/Hospice-2014.html). We are currently analyzing this data for possible
use in updating the labor portion of the hospice payment rates. Any
changes to the labor portions will be proposed in future rulemaking and
will be subject to public comments.
A summary of the comments we received regarding the payment update
and our responses to those comments appear below.
Comment: Several commenters stated that the FY 2018 payment update
of 1 percent is inadequate. One of the commenters stated that the
update does not appropriately keep pace with the cost of providing
hospice care to beneficiaries and does not match the increasing costs
associated with data collection requirements and reporting, technology,
workforce and training.
Response: We appreciate the commenter's concerns; however, the 1
percent payment update for FY 2018 is mandated by section 411(d) of the
MACRA.
Comment: A commenter noted that in MedPAC's March 2017 Report to
Congress, MedPAC concluded that indicators of payment adequacy for
hospice providers are generally positive. In 2015, the number of
hospices increased about 2.6 percent because of continued entry of for-
profit providers. The aggregate Medicare margin was 8.2 percent in 2014
and MedPAC projected a 2017 aggregate Medicare margin of 7.7 percent.
Based on their assessment of these and other payment adequacy
indicators, MedPAC concluded that hospices should be able to
accommodate cost changes in 2018 without an update to the 2017 base
payment rate. The commenter also acknowledged that CMS is required by
statute to update the FY 2018 hospice payment rates by 1 percent.
Response: We thank the commenter for noting that hospices' Medicare
margins appear to be adequate and no update to the per diem amounts is
needed for FY 2018. We further thank the commenter for acknowledging
that we do not have the authority to eliminate the payment update for
FY 2018.
3. FY 2018 Hospice Payment Rates
There are four payment categories that are distinguished by the
location and intensity of the services provided. 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. A hospice is paid the RHC rate for each day the
beneficiary is enrolled in hospice, unless the hospice provides CHC,
IRC, or GIP. 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.
As discussed in the FY 2016 Hospice Wage Index and Payment Rate
Update final rule (80 FR 47172), we implemented two different RHC
payment rates, one RHC rate for the first 60 days and a second RHC rate
for days 61 and beyond. In addition, in the final rule, we adopted a
Service Intensity Add-on (SIA) payment for RHC for when direct patient
care is provided by a RN or social worker during the last 7 days of the
beneficiary's life. The SIA payment is equal to the CHC hourly rate
multiplied by the hours of nursing or social work provided (up to 4
hours total) that occurred on the day of service, if certain criteria
are met. In order to maintain budget neutrality, as required under
section 1814(i)(6)(D)(ii) of the Act, the new RHC rates were adjusted
by a SIA budget neutrality factor.
As discussed in the FY 2016 Hospice Wage Index and Payment Rate
Update final rule (80 FR 47177), we will continue to make the SIA
payments budget neutral through an annual determination of the SIA
budget neutrality factor (SBNF), which will then be applied to the RHC
payment rates. The SBNF will be calculated for each FY using the most
current and complete FY utilization data available at the time of
rulemaking. For FY 2018, we calculated the SBNF using FY 2016
utilization data. We examined skilled nursing and social work visit
data for the last 7 days of life where RHC was billed and found that,
from January 1
[[Page 36650]]
through September 30, 2016, approximately 86 percent of nursing visits
were identified as RN visits (using G0299) and 14 percent of nursing
visits were identified as Licensed Practical Nurse (LPN) visits (using
G0300). Because the differentiated nursing visit G-codes were not
implemented until January 1, 2016, for skilled nursing visits during
the last 7 days of life where RHC was billed and that occurred between
October 1 and December 31, 2015, we estimated that 86 percent of the
line item visits reported using G0154 were RN and 14 percent were LPN
using statistics generated for the 2016 time period where data were
available. For FY 2018, the budget neutrality adjustment that would
apply to days 1 through 60 is calculated to be 1.0017. The budget
neutrality adjustment that would apply to days 61 and beyond is
calculated to be 1.0005.
In the FY 2017 Hospice Wage Index and Payment Rate Update final
rule (81 FR 52156), we initiated a policy of applying a wage index
standardization factor to hospice payments in order to eliminate the
aggregate effect of annual variations in hospital wage data. In order
to calculate the wage index standardization factor, we simulate total
payments using the FY 2018 hospice wage index and compare it to our
simulation of total payments using the FY 2017 hospice wage index. By
dividing payments for each level of care using the FY 2018 wage index
by payments for each level of care using the FY 2017 wage index, we
obtain a wage index standardization factor for each level of care (RHC
days 1-60, RHC days 61+, CHC, IRC, and GIP). The wage index
standardization factors for each level of care are shown in the tables
below.
Lastly, the hospice payment rates for hospices that submit the
required quality data would be increased by the FY 2018 hospice payment
update percentage of 1.0 percent as discussed in section III.B.2 of
this final rule. The FY 2018 RHC rates are shown in Table 12. The FY
2018 payment rates for CHC, IRC, and GIP are shown in Table 13.
Table 12--FY 2018 Hospice RHC Payment Rates
----------------------------------------------------------------------------------------------------------------
SIA budget Wage index FY 2018
Code Description FY 2017 neutrality standardization hospice FY 2018
payment rates factor factor payment update payment rates
----------------------------------------------------------------------------------------------------------------
651......... Routine Home $190.55 x 1.0017 x 1.0000 x 1.01 $192.78
Care (days 1-
60).
651......... Routine Home 149.82 x 1.0005 x 1.0001 x 1.01 151.41
Care (days
61+).
----------------------------------------------------------------------------------------------------------------
Table 13--FY 2018 Hospice CHC, IRC, and GIP Payment Rates
----------------------------------------------------------------------------------------------------------------
Wage index FY 2018
Code Description FY 2017 standardization hospice FY 2018
payment rates factor payment update payment rates
----------------------------------------------------------------------------------------------------------------
652................. Continuous Home Care; $964.63 x 1.0022 x 1.01 $976.42
Full Rate = 24 hours
of care; $40.68 = FY
2018 hourly rate.
655................. Inpatient Respite Care. 170.97 x 1.0006 x 1.01 172.78
656................. General Inpatient Care. 734.94 x 1.0017 x 1.01 743.55
----------------------------------------------------------------------------------------------------------------
Sections 1814(i)(5)(A) through (C) of the Act require that hospices
submit quality data, based on measures to be specified by the
Secretary. In the FY 2012 Hospice Wage Index final rule (76 FR 47320
through 47324), we implemented a Hospice Quality Reporting Program
(HQRP) as required by section 3004 of the Affordable Care Act. Hospices
were required to begin collecting quality data in October 2012, and
submit that quality data in 2013. Section 1814(i)(5)(A)(i) of the Act
requires that beginning with FY 2014 and each subsequent FY, the
Secretary shall reduce the market basket update by 2 percentage points
for any hospice that does not comply with the quality data submission
requirements with respect to that FY. The FY 2018 rates for hospices
that do not submit the required quality data would be updated by the FY
2018 hospice payment update percentage of 1 percent minus 2 percentage
points. These rates are shown in Tables 14 and 15.
Table 14--FY 2018 Hospice RHC Payment Rates for Hospices That Do Not Submit the Required Quality Data
----------------------------------------------------------------------------------------------------------------
FY 2018
hospice
FY 2017 SIA budget Wage index payment update FY 2018
Code Description payment rates neutrality standardization of 1% minus 2 payment rates
factor factor percentage
points = -1.0%
----------------------------------------------------------------------------------------------------------------
651......... Routine Home $190.55 x 1.0017 x 1.0000 x 0.99 $188.97
Care (days 1-
60).
651......... Routine Home 149.82 x 1.0005 x 1.0001 x 0.99 148.41
Care (days
61+).
----------------------------------------------------------------------------------------------------------------
[[Page 36651]]
Table 15--FY 2018 Hospice CHC, IRC, and GIP Payment Rates for Hospices That DO NOT Submit the Required Quality
Data
----------------------------------------------------------------------------------------------------------------
FY 2018
hospice
FY 2017 Wage index payment update FY 2018
Code Description payment rates standardization of 1% minus 2 payment rates
factor percentage
points = -1.0%
----------------------------------------------------------------------------------------------------------------
652................. Continuous Home Care; $964.63 x 1.0022 x 0.99 $957.08
Full Rate = 24 hours
of care; $39.88 = FY
2018 hourly rate.
655................. Inpatient Respite Care. 170.97 x 1.0006 x 0.99 169.36
656................. General Inpatient Care. 734.94 x 1.0017 x 0.99 728.83
----------------------------------------------------------------------------------------------------------------
4. Hospice Cap Amount for FY 2018
As discussed in the FY 2016 Hospice Wage Index and Payment Rate
Update final rule (80 FR 47183), we implemented changes mandated by the
Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT
Act). Specifically, for accounting years that end after September 30,
2016 and before October 1, 2025, the hospice cap is updated by the
hospice payment update percentage rather than using the consumer price
index for urban consumers (CPI-U). The hospice cap amount for the 2018
cap year will be $28,689.04, which is equal to the 2017 cap amount
($28,404.99) updated by the FY 2018 hospice payment update percentage
of 1.0 percent.
A summary of the comments we received regarding the hospice cap
amount and our responses to those comments appears below.
Comment: One commenter noted that the hospice cap is a uniform
amount meaning that each CBSA has the same cap amount. The commenter
ascertains that in certain CBSAs, the hospice per diem rate is
significantly higher than the national average. The commenter believes
that since the cap amount does not adjust relative to CBSA, Medicare
beneficiaries in CBSAs with higher wage indices have significantly
fewer potential days of hospice care available to them relative to
beneficiaries who reside in CBSAs with a lower wage indices.
Accordingly, the commenter recommends that, in fairness to providers
located in CBSAs with higher than average wage indices, CMS adjust the
hospice cap amount by CBSA.
Response: We appreciate the commenter's suggestion that CMS wage-
adjust the annual cap amount. However, the restriction set forth in
section 1814(i)(2)(B), as amended by section 3(d) of the IMPACT Act,
does not give us discretion to adjust the cap amount.
C. Discussion Regarding Sources of Clinical Information for Certifying
Terminal Illness
In accordance with the regulations at Sec. 418.20, a patient must
be certified as terminally ill in order to be eligible to elect the
Medicare Hospice benefit. Furthermore, hospice admission is predicated
on the certification of terminal illness that determines eligibility.
In reaching a decision to certify, Sec. 418.25 requires a hospice
medical director to consider the diagnosis of the terminal condition of
the patient, other health conditions (whether related or unrelated to
the terminal condition), and current clinically relevant information
supporting all diagnoses. In the FY 2018 Hospice Wage Index and Payment
Rate Update proposed rule, we discussed a potential proposal for a
regulatory text change at Sec. 418.25, clarifying that the
documentation used for the initial certification must come from the
referring physician's or acute/post-acute care facility's medical
records (84 FR 20771). We also discussed the potential benefit of an
initial face-to-face visit by the hospice medical director or physician
designee, if needed, to support the clinical documentation required to
accompany the certification of terminal illness. Although we did not
propose this regulatory change, we requested public input on the
possible amendment. We solicited comments on current processes used by
hospices to ensure comprehensive clinical review to support
certification, and encouraged submission of any alternate suggestions
for supporting clinical documentation sources that ensure appropriate
hospice admission.
Comment: A few commenters expressed support for the potential
regulations text change, and stated that they consider ``obtaining and
analyzing medical records from the referring provider'' to be ``best
practice.'' Additionally, commenters indicated that their processes for
certification already include review of the referring source's clinical
documentation, which one commenter noted includes review of ``pathology
reports, blood work reports, x-rays, kidney function, heart function,
PPS assessment, mental assessment, medications, goals of care,
diagnosis, nutritional assessment, weight loss, BMI and any other
hospital report available that would indicate the patient has 6 months
or less to live.'' A few commenters specifically noted that the
regulations at Sec. 418.22(b) specify that clinical information and
other documentation that supports the patient's prognosis must
accompany the certification and that hospices receive clinical
information from a variety of sources; therefore, a change in the
regulations at Sec. 418.25 is not needed.
Response: We thank commenters for their support. We understand from
commenters that hospices already obtain and analyze clinical
information from a variety of sources, including referring providers,
and we agree that the regulations at Sec. 418.22(b) require such
information to accompany the certification of terminal illness. While
we are not proposing a change in the regulations at this time, we plan
to work with our Medicare Administrative Contractors (MACs) to confirm
whether they are requesting such information when claims are selected
for medical review and, if not, whether such information should be
included in any additional documentation requests. We continue to
encourage providers to use the full range of clinical documentation
when certifying terminal illness in order to ensure physician
engagement and accountability.
Comment: The majority of commenters expressed concerns that
obtaining clinical documentation from outside physicians or facilities
would delay hospice admission and services. In addition, commenters
expressed concern that CMS was considering requiring hospice physicians
to perform a face-to-face visit within the 2 day
[[Page 36652]]
certification time frame in order to certify terminal illness.
Response: The discussion in the FY 2018 Hospice Wage Index and
Payment Rate Update proposed rule was meant only to solicit comments on
clarifying the source of the clinical information already required to
be reviewed by the hospice medical director upon the initial
certification. Therefore, this clinical information can be obtained
orally from the referring entity and documented in the patient's chart
within the 2 day time-frame needed for certification. We stated in the
November 22, 2005 Hospice Care Amendments final rule that the clinical
information may initially arrive verbally and is documented in the
patient's medical record as part of the hospice's assessment of
eligibility for hospice. The referring entity's clinical documentation
may arrive later for retention in the patient's medical record (70 FR
70539). We believe that clinical information and documentation are
critical to the certification decision and this information is needed
for the hospice's interdisciplinary group (IDG) to develop the initial
plan of care for the new patient and, therefore we would expect the
information to accompany, in some fashion, the certification. Likewise,
the requirement that the medical documentation that accompanies the
initial written certification be obtained prior to submitting a claim
remains unchanged and should not impede services. The hospice admission
assessment can also accompany the initial written certification;
however, this information should further substantiate rather than
provide the basis for certification.
We would also like to clarify that the hospice medical director or
physician designee would not be required to perform a face-to-face
visit before the third benefit period recertification, as currently
required by the regulations at Sec. 418.22(a)(4). Rather, the intent
of the discussion and solicitation of comments in the FY 2018 Hospice
Wage Index and Payment Rate Update proposed rule was to determine
whether such optional visits could be useful to augment the referral
source's clinical documentation to support a medical prognosis of 6
months or less.
We appreciate and thank all commenters for providing feedback on
this discussion. We will carefully consider all comments for any future
rulemaking proposals, if needed, regarding the sources of clinical
information to support the certification of terminal illness.
D. Updates to the Hospice Quality Reporting Program (HQRP)
1. Background and Statutory Authority
Section 3004(c) of the Affordable Care Act amended section
1814(i)(5) of the Act to authorize a quality reporting program for
hospices. Section 1814(i)(5)(A)(i) of the Act requires that beginning
with FY 2014 and each subsequent FY, the Secretary shall reduce the
market basket update by 2 percentage points for any hospice that does
not comply with the quality data submission requirements for that FY.
Depending on the amount of the annual update for a particular year, a
reduction of 2 percentage points could result in the annual market
basket update being less than 0 percent for a FY and may result in
payment rates that are less than payment rates for the preceding FY.
Any reduction based on failure to comply with the reporting
requirements, as required by section 1814(i)(5)(B) of the Act, would
apply only for the particular year involved. Any such reduction would
not be cumulative or be taken into account in computing the payment
amount for subsequent FYs. Section 1814(i)(5)(C) of the Act requires
that each hospice submit data to the Secretary on quality measures
specified by the Secretary. The data must be submitted in a form,
manner, and at a time specified by the Secretary.
2. General Considerations Used for Selection of Quality Measures for
the HQRP
Any measures selected by the Secretary must be endorsed by the
consensus-based entity, which holds a contract regarding performance
measurement, including the endorsement of quality measures, with the
Secretary under section 1890(a) of the Act. This contract is currently
held by the National Quality Forum (NQF). However, section
1814(i)(5)(D)(ii) of the Act provides that in the case of a specified
area or medical topic determined appropriate by the Secretary for which
a feasible and practical measure has not been endorsed by the
consensus-based entity, the Secretary may specify measures that are not
so endorsed as long as due consideration is given to measures that have
been endorsed or adopted by a consensus-based organization identified
by the Secretary. Our paramount concern is the successful development
of a HQRP that promotes the delivery of high quality healthcare
services. We seek to adopt measures for the HQRP that promote person-
centered, high quality, and safe care. Our measure selection activities
for the HQRP take into consideration input from the Measure
Applications Partnership (MAP), convened by the NQF, as part of the
established CMS pre-rulemaking process required under section 1890A of
the Act. The MAP is a public-private partnership comprised of multi-
stakeholder groups convened by the NQF for the primary purpose of
providing input to CMS on the selection of certain categories of
quality and efficiency measures, as required by section 1890A(a)(3) of
the Act. By February 1st of each year, the NQF must provide that input
to CMS. Input from the MAP is located at: http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx.
We also take into account national priorities, such as those
established by the HHS Strategic Plan (http://www.hhs.gov/secretary/about/priorities/priorities.html), the National Strategy for Quality
Improvement in Healthcare, (http://www.ahrq.gov/workingforquality/reports/annual-reports/nqs2015annlrpt.htm) and the CMS Quality Strategy
(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html). To
the extent practicable, we have sought to adopt measures endorsed by
member organizations of the National Consensus Project (NCP) (http://www.nationalconsensusproject.org/Default.aspx), recommended by multi-
stakeholder organizations, and developed with the input of providers,
purchasers/payers, and other stakeholders.
In the FY 2018 Hospice proposed rule (82 FR 20773 through 20774),
we discussed accounting for social risk factors in the HQRP. We stated
that we consider related factors that may affect measures in the HQRP.
We understand that social risk factors such as income, education, race
and ethnicity, employment, disability, community resources, and social
support (certain factors of which are also sometimes referred to as
socioeconomic status (SES) factors or socio-demographic status (SDS)
factors) play a major role in health. One of our core objectives is to
improve beneficiary outcomes including reducing health disparities, and
we want to ensure that all beneficiaries, including those with social
risk factors, receive high quality care. In addition, we seek to ensure
that the quality of care furnished by providers and suppliers is
assessed as fairly as possible under our programs while ensuring that
beneficiaries have adequate access to excellent care.
[[Page 36653]]
We have been reviewing reports prepared by the Office of the
Assistant Secretary for Planning and Evaluation (ASPE) \4\ and the
National Academies of Sciences, Engineering, and Medicine on the issue
of measuring and accounting for social risk factors in CMS' quality
measurement and payment programs, and considering options on how to
address the issue in these programs. On December 21, 2016, ASPE
submitted a Report to Congress on a study they were required to conduct
under section 2(d) of the Improving Medicare Post-Acute Care
Transformation (IMPACT) Act of 2014. The study analyzed the effects of
certain social risk factors of Medicare beneficiaries on quality
measures and measures of resource use used in one or more of nine
Medicare value-based purchasing programs.\5\ The report also included
considerations for strategies to account for social risk factors in
these programs. In a January 10, 2017, report released by The National
Academies of Sciences, Engineering, and Medicine, that body provided
various potential methods for measuring and accounting for social risk
factors, including stratified public reporting.\6\ In addition, the NQF
undertook a 2-year trial period in which new measures, measures
undergoing maintenance review, and measures endorsed with the condition
that they enter the trial period were assessed to determine whether
risk adjustment for selected social risk factors was appropriate for
these measures. This trial entailed temporarily allowing inclusion of
social risk factors in the risk-adjustment approach for these measures.
The trial has concluded and NQF will issue recommendations on the
future inclusion of social risk factors in risk adjustment for quality
measures.
---------------------------------------------------------------------------
\4\ https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
\5\ https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
\6\ National Academies of Sciences, Engineering, and Medicine.
2017. Accounting for social risk factors in Medicare payment.
Washington, DC: The National Academies Press.
---------------------------------------------------------------------------
As we continue to consider the analyses and recommendations from
these reports and await the recommendations of the NQF trial on risk
adjustment for quality measures, we are continuing to work with
stakeholders in this process. As we have previously communicated, we
are concerned about holding providers to different standards for the
outcomes of their patients with social risk factors because we do not
want to mask potential disparities or minimize incentives to improve
the outcomes for disadvantaged populations. Keeping this concern in
mind, while we sought input on this topic previously, we continue to
seek public comment on whether we should account for social risk
factors in measures in the HQRP, and if so, what method or combination
of methods would be most appropriate for accounting for social risk
factors. Examples of methods include: Confidential reporting to
providers of measure rates stratified by social risk factors, public
reporting of stratified measure rates, and potential risk adjustment of
a particular measure as appropriate based on data and evidence.
In addition, in the proposed rule, we sought public comment on
which social risk factors might be most appropriate for reporting
stratified measure scores and/or potential risk adjustment of a
particular measure. Examples of social risk factors include, but are
not limited to, dual eligibility/low-income subsidy, race and
ethnicity, and geographic area of residence. We also sought comments on
which of these factors, including current data sources where this
information would be available, could be used alone or in combination,
and whether other data should be collected to better capture the
effects of social risk. We will take commenters' input into
consideration as we continue to assess the appropriateness and
feasibility of accounting for social risk factors in the HQRP. We note
that any such changes would be proposed through future notice and
comment rulemaking.
We look forward to working with stakeholders as we consider the
issue of accounting for social risk factors and reducing health
disparities in CMS programs. Of note, implementing any of the above
methods would be taken into consideration in the context of how this
and other CMS programs operate (for example, data submission methods,
availability of data, statistical considerations relating to
reliability of data calculations, among others), so we sought comment
on operational considerations. We are committed to ensuring that its
beneficiaries have access to and receive excellent care, and that the
quality of care furnished by providers and suppliers is assessed fairly
in our programs.
We received many comments in response to our request for public
comment on whether we should account for social risk factors in the
Hospice Quality Reporting Program.
Comment: Commenters were supportive of CMS accounting for social
risk factors however, the majority of the commenters cautioned that
social risk factors should be used to inform only outcome quality
measures. Specifically, they were not supportive of identifying social
risk factors for process measures or direct impacts of care under the
hospice's control. Several commenters were concerned about quality
measures for items that a hospice has minimal control over and many of
these items are under discussion for risk adjustment.
Regarding methodology for adjustment, overall, commenters were
supportive of risk adjustment in general, but a few commenters
indicated preference for stratification or peer grouping, due to the
minimal measure-level research required and low impact on provider
incentives to improve care when their adjusted performance is
transparent. One commenter suggested using standard statistical
methodology and adopting the approach used for adjusting CAHPS[supreg]
data. Prior to conducting social risk factor stratification, however, a
few commenters noted that they would like for CMS to evaluate and
disseminate the testing results from the NQF and solicit provider
comment on the results. Several commenters encouraged CMS to determine
the feasibility and appropriateness of identifying social risk factors,
and a couple commenters recommended involving hospice providers in
determining appropriate social risk factors and associated outcome
measures. One commenter recommended piloting the outcome measures with
social risk factors in advanced care planning pilot instead of
incorporating them with current hospice measures. However, several
commenters expressed concern that risk adjusting may lead to the
unintended consequences of discouraging providers from admitting
patients with identified social risk factors, and enabling providers to
deliver sub-optimal care to disadvantaged populations. One commenter
noted providers wishing to maintain or improve scores on quality
measures may consider exclusively admitting patients who will
demonstrate positive care outcomes. Another commenter emphasized that
patients impacted by many social risk factors require intensified,
complex care at end of life, so CMS should not unfairly penalize
providers when taking these patient needs and challenges into account
in the quality measurement process. Additionally, commenters offered
specific suggestions for types of social risk factors to identify and
recommended ways CMS could manage the testing, data collection, and
reporting. In commenters' discussion of suggested social risk factors,
a few
[[Page 36654]]
commenters drew attention to how adjustment should be conducted on a
measure-specific basis, as different social risk factors affect
different outcomes such as caregiver satisfaction and care delivery. In
addition to support for CMS's suggested categories of race and
ethnicity, dual eligibility status, and geographical location, many
commenters emphasized adjusting for family dynamics, such as the
patient's relationship with the family, accessibility/availability of
an adequate caregiver, history of substance abuse in the family, and
psychosocial acuity. Other commenters promoted education level,
literacy and health literacy levels, mental health, rurality and
English as a second language. A few commenters highlighted adjusting
for Medicaid-covered services in the area and income-subsidy levels.
Some emphasized that core-based statistical area (CBSAs), geographical
location of patient residence, and driving distance to home locations
are important because they impact timeliness of care delivery. One
commenter noted adequate and safe housing impacts the hospice's ability
to deliver care. A few commenters suggested adjusting for length of
stay, as patient needs will require differing acuities of care for
short and long stays. One commenter requested that extraction of social
risk factors pose low burden for providers. A few commenters discussed
public display of data adjusted for social risk factors. One commenter
suggested displaying both unadjusted and adjusted data in confidential
feedback reports as a means of provider performance improvement before
publicly reporting adjusted data to be used for determining
reimbursement.
Response: As we have previously stated, we are concerned about
holding providers to different standards for the outcomes of their
patients with social risk factors, because we do not want to mask
potential disparities. We believe that the path forward should
incentivize improvements in health outcomes for disadvantaged
populations while ensuring that beneficiaries have adequate access to
excellent care. We will consider all suggestions as we continue to
assess each measure and the overall program. We intend to explore
options including but not limited to measure stratification by social
risk factors in a consistent manner across programs, informed by
considerations of stratification methods described in the upcoming FY
2018 Inpatient Prospective Payment System/Long-Term Care Hospital
Prospective Payment System (IPPS/LTCH PPS) final rule, which is
expected to publish in the Federal Register shortly after this final
rule. We thank commenters for this important feedback and will continue
to consider options to account for social risk factors that would allow
us to view disparities and potentially incentivize improvement in care
for patients and beneficiaries. We will also consider providing
feedback to providers on outcomes for individuals with social risk
factors in confidential reports.
3. Policy for Retention of HQRP Measures Adopted for Previous Payment
Determinations
For the purpose of streamlining the rulemaking process, we
finalized our policy in the FY 2016 Hospice Wage Index final rule (80
FR 47187) that when we adopt measures for the HQRP beginning with a
payment determination year, these measures would automatically be
adopted for all subsequent years' payment determinations, unless we
proposed to remove, suspend, or replace the measures. Quality measures
would be considered for removal by us for reasons including, but not
limited to the following:
Measure performance among hospices was so high and
unvarying that meaningful distinction in improvements in performance
could no longer be made.
Performance or improvement on a measure did not result in
better patient outcomes.
A measure did not align with current clinical guidelines
or practice.
A more broadly applicable measure (across settings,
populations, or conditions) for the particular topic was unavailable.
A measure that was more proximal in time to desired
patient outcomes for the particular topic was not available.
A measure that was more strongly associated with desired
patient outcomes for the particular topic was not available.
Collection or public reporting of a measure led to
negative unintended consequences.
For any such removal, the public would be given an opportunity to
comment through the annual rulemaking process. However, if there was
reason to believe continued inclusion of a measure in the HQRP would
encourage delivery of care that raised potential safety concerns, we
would take immediate action to remove the measure from the HQRP and not
wait for the annual rulemaking cycle. The measures would be promptly
removed and we would immediately notify hospices and the public of such
a decision through the CMS HQRP Web site, listserv messages via the
Post-Acute Care Quality Reporting Program listserv,\7\ Medicare
Learning Network (MLN) Connects[supreg] National Provider Calls &
Events, MLN Connects[supreg] Provider eNews. Following immediate
removal of the measures, we would also notify the public of any such
removal in the next annual rulemaking cycle. CMS expects immediate
removal of a measure due to safety concerns to be an unlikely event,
given the rigorous testing and analysis all measures undergo prior to
adoption in the HQRP.
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\7\ CMS, Post-Acute Care QRP listerv, available at: https://public-dc2.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12265.
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4. Policy for Adopting Changes to Previously Adopted Measures
To further streamline the rulemaking process, we finalized in the
FY 2017 Hospice Wage Index final rule (81 FR 52159) that if measures in
the HQRP undergo non-substantive changes in specifications as part of
their NQF re-endorsement process, we would subsequently utilize the
measure with their new endorsed status in the HQRP without going
through new notice-and-comment rulemaking. As mentioned previously,
quality measures selected for the HQRP must be endorsed by the NQF
unless they meet the statutory criteria for exception under section
1814(i)(5)(D)(ii) of the Act. The NQF is a voluntary consensus
standard-setting organization with a diverse representation of
consumer, purchaser, provider, academic, clinical, and other healthcare
stakeholder organizations. The NQF was established to standardize
healthcare quality measurement and reporting through its consensus
measure development process (http://www.qualityforum.org/About_NQF/Mission_and_Vision.aspx). The NQF undertakes review of: (a) New quality
measures and national consensus standards for measuring and publicly
reporting on performance, (b) regular maintenance processes for
endorsed quality measures, (c) measures with time-limited endorsement
for consideration of full endorsement, and (d) ad hoc review of
endorsed quality measures, practices, consensus standards, or events
with adequate justification to substantiate the review. Through NQF's
or the measure steward's measure maintenance process, measures are
sometimes updated to incorporate changes that we believe do not
substantively change the intent of the measure. Examples of such
changes may include updated diagnosis or procedure codes or changes to
[[Page 36655]]
exclusions to the patient population or definitions. While we address
such changes on a case-by case basis, we generally believe these types
of maintenance changes are distinct from substantive changes to
measures that result in what are considered new or different measures.
Additionally, since the NQF endorsement and measure maintenance process
is one that ensures transparency, public input, and discussion among
representatives across the healthcare enterprise,\8\ we believe that
the NQF measure endorsement and maintenance process itself is
transparent, scientifically rigorous, and provides opportunity for
public input. Thus, we finalized our proposal to codify at Sec.
418.312 that if the NQF makes only non-substantive changes to
specifications for HQRP measures in the NQF's re-endorsement process,
we would continue to utilize the measure in its new endorsed status (81
FR 52159 through 52160). If NQF-endorsed specifications change and we
do not adopt those changes, then we would propose the measure as a
modification. A modification of a NQF-endorsed quality measure is
utilized in instances when we have identified a need to use a NQF
endorsed measure in a QRP but need to use it with one or more
modifications to the quality measure's specifications. These
modifications pertain to, but are not limited to, one or more of the
following aspects of a NQF endorsed quality measure: (a) Numerator, (b)
denominator, (c) setting, (d) look-back period, (e) calculation period,
(f) risk adjustment, and (g) revisions to data elements used to collect
the data required for the measure, etc. CMS may adopt a quality measure
for the HQRP under section 1814(i)(5)(D)(ii) of the Act, which states,
``[i]n the case of a specified area or medical topic determined
appropriate by the Secretary for which a feasible and practical measure
has not been endorsed by [the NQF], the Secretary may specify a measure
that is not so endorsed as long as due consideration is given to
measures that have been endorsed or adopted by a consensus organization
identified by the Secretary.'' Reasons for not adopting changes in
measure specifications to a measure may include any of the
aforementioned criteria in the prior section, including that the new
specification does not align with clinical guidelines or practice or
that the new specification leads to negative unintended consequences.
---------------------------------------------------------------------------
\8\ ``NQF: How Endorsement Happens--National Quality Forum.''
2010. 26 Jan. 2016 http://www.qualityforum.org/Measuring_Performance/ABCs/How_Endorsement_Happens.aspx.
---------------------------------------------------------------------------
Finally, we will continue to use rulemaking to adopt substantive
updates made by the NQF to the endorsed measures we have adopted for
the HQRP. We continue to make these determinations about what
constitutes a substantive versus non-substantive change on a measure-
by-measure basis. A change would be deemed substantive if the intent of
the measure changes, the facility/setting changes, the data sources
changes, the level of analysis changes, and/or the measure is removed.
We will continue to provide updates about changes to measure
specifications as a result of NQF endorsement or maintenance processes
through the CMS HQRP Web site, listserv messages on the Post-Acute Care
QRP listserv, MLN Connects[supreg] National Provider Calls & Events,
MLN Connects[supreg] Provider eNews and announcements on Open Door
Forums and Special Open Door Forums.
5. Previously Adopted Quality Measures for FY 2018 Payment
Determination and Future Years
In the FY 2014 Hospice Wage Index final rule (78 FR 48257), and in
compliance with section 1814(i)(5)(C) of the Act, we finalized the
specific collection of data items that support the following 7 NQF-
endorsed measures for hospice:
NQF #1617 Patients Treated with an Opioid who are Given a
Bowel Regimen,
NQF #1634 Pain Screening,
NQF #1637 Pain Assessment,
NQF #1638 Dyspnea Treatment,
NQF #1639 Dyspnea Screening,
NQF #1641 Treatment Preferences,
NQF #1647 Beliefs/Values Addressed (if desired by the
patient).\6\
We finalized the following two additional measures in the FY 2017
Hospice Wage Index final rule effective April 1, 2017. Data collected
will, if not reported, affect payments for FY 2019 and subsequent
years. (81 FR 52163 through 52173):
Hospice Visits when Death is Imminent
Hospice and Palliative Care Composite Process Measure--
Comprehensive Assessment at Admission
We finalized the HIS effective July 1, 2014 (78 FR 48258). The HIS
is the data collection mechanism for all of the aforementioned
measures. To meet the quality reporting requirements for hospices for
the FY 2016 payment determination and each subsequent year, we require
regular and ongoing electronic submission of the HIS data for each
patient admission to hospice after July 1, 2014, regardless of payer or
patient age (78 FR 48234 through 48258). For the two measures finalized
in the FY 2017 Hospice Wage Index final rule, we require regular and
ongoing electronic submission for each patient admission to hospice
after April 1, 2017. We finalized a requirement in the FY 2014 Hospice
Wage Index final rule (78 FR 48258) that hospice providers collect data
on all patients to ensure that all patients regardless of payer or
patient age are receiving the same care and that provider metrics
measure performance across the spectrum of patients. Table 16 provides
a summary of measures previously finalized affecting the FY 2019 APU,
data collection mechanism, and data submission deadline.
Hospices are required to complete and submit a HIS-Admission and a
HIS-Discharge record for each patient admission. Hospices failing to
report quality data via the HIS for patient admissions occurring in
2017 will have their market basket update reduced by 2 percentage
points in FY 2019 (beginning in October 1, 2018). In the FY 2015
Hospice Wage Index final rule (79 FR 50485 through 50487), we finalized
the proposal to codify the HIS submission requirement at Sec. 418.312.
The System of Record (SOR) Notice entitled ``Hospice Item Set (HIS)
System,'' SOR number 09-70-0548, was published in the Federal Register
on April 8, 2014 (79 FR 19341).
The 7 NQF endorsed HIS measures adopted in FY 2014 Hospice Wage
Index final rule successfully underwent NQF Endorsement Maintenance in
2016.\9\ We recognize that the NQF endorsement process is an important
part of measure development and plan to submit the two measures
finalized in the FY 2017 Hospice Wage Index final rule for NQF
endorsement once sufficient measure data are available and we conduct
the analyses necessary to support NQF submission for endorsement (for
example, reliability and validity analyses). Typically, we need at
least 4 quarters worth of data to conduct the necessary analyses and
establish measure reliability and validity. Because the Hospice and
Palliative Care Composite Process Measure--Comprehensive Assessment at
Admission did not require any new data collection and can be calculated
using existing data, CMS's measure development contractor, RTI
[[Page 36656]]
International, has already conducted the analyses necessary to support
submission of the measure for NQF endorsement. We have already
submitted the Hospice and Palliative Care Composite Process Measure for
consideration for endorsement at NQF (NQF #3235); the measure is
currently under review. Data for the Hospice Visits when Death is
Imminent measure pair will be collected using new items added to the
HIS V2.00.0, effective April 1, 2017. Once data collection for the
measure pair begins, we will need at least 4 quarters of reliable data
to conduct the necessary analyses to support submission to NQF. We will
also need to assess the quality of data submitted in the first quarter
of item implementation to determine whether they can be used in the
analyses. Pending analysis, we will submit the Hospice Visits when
Death is Imminent measure pair to NQF for endorsement review in
accordance with NQF project timelines and call for measures. In the FY
2015 Hospice Wage Index final rule (79 FR 50491 through 50496), we also
finalized the Consumer Assessment of Healthcare Providers and Systems
(CAHPS[supreg]) Hospice Survey to support quality measures based on
patient and family experience of care. We refer readers to section
III.D.11 of the May 3, 2017 proposed rule (82 FR 20750 through 20792)
for details regarding the CAHPS[supreg] Hospice Survey, including
public reporting of selected survey measures.
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\9\ National Quality Forum, NQF Palliative and End-of-Life Care
2015-2016 Report, available at: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=84242.
Table 16--Previously Finalized Quality Measures Affecting the FY 2019
Payment Determination and Subsequent Years
------------------------------------------------------------------------
Year the measure was
NQF No. Hospice item set first adopted for use in
quality measure APU determination
------------------------------------------------------------------------
1641................. Treatment Preferences FY 2016
1647................. Beliefs/Values FY 2016
Addressed (if
desired by the
patient).
1634................. Pain Screening....... FY 2016
1637................. Pain Assessment...... FY 2016
1639................. Dyspnea Screening.... FY 2016
1638................. Dyspnea Treatment.... FY 2016
1617................. Patients Treated with FY 2016
an Opioid Who Are
Given a Bowel
Regimen.
N/A.................. Hospice and FY 2019
Palliative Care
Composite Process
Measure--Comprehensi
ve Assessment at
Admission.
N/A.................. Hospice Visits When FY 2019
Death is Imminent
Measure Pair.
------------------------------------------------------------------------
The comment and our response are set forth below.
Comment: We received several comments on previously adopted quality
measures, including measure refinement suggestions for the Hospice
Visits when Death is Imminent Measure Pair. One commenter suggested
that CMS include a way to capture whether visits were offered but
declined. Another commenter noted that frequent visits by hospice staff
may not be necessary or desired by all patients and encouraged CMS to
include evidence of a need or desire for these visits in the measure
specifications. We received one comment recommending risk adjustment
for the Visits Measure Pair.
Response: The Visits when Death is Imminent Measure Pair is a
measure that was previously proposed and finalized in the HQRP. We
refer readers to the FY 2017 Hospice Wage Index final rule (81 FR 52162
through 52169) for a detailed discussion of measure specifications for
this measure pair, including discussion of why refused visits were not
included in measure specifications, as well as discussion on risk
adjustment. We invite the public to submit questions or suggestions
about previously finalized and currently implemented proposals through
sub-regulatory communication channels, including the Hospice Quality
Help Desk at [email protected], and through other
communication channels such as Open Door Forums and Special Open Door
Forums.
6. Removal of Previously Adopted Measures
We did not propose to remove any of the current HQRP measures at
this time. Any future proposals regarding removal, suspension, or
replacement of measures will be proposed here in this preamble of
future rules. As stated in section III.D.3 of the FY 2018 Hospice Wage
Index proposed rule (82 FR 20750), a quality measure that is adopted
and implemented in the HQRP will be retained for all subsequent years,
unless the measure is proposed for removal, suspension, or replacement
by CMS. Policies and criteria for removing a measure were also
discussed.
7. Measure Concepts Under Consideration for Future Years
Although we did not propose any HIS-based measures, we have measure
concepts under consideration for future years. Our paramount concern is
to develop quality measures that promote care that is person-centered,
high quality, and safe. We continue to work with our measure
development contractor, RTI International, to identify measure concepts
for future implementation in the HQRP. In identifying priority areas
for future measure enhancement and development, we take into
consideration input from numerous stakeholders, including the MAP, the
MedPAC, Technical Expert Panels (TEP), and national priorities, such as
those established by the Department of Health and Human Services (HHS)
Strategic Plan, the National Strategy for Quality Improvement in
Healthcare, and the CMS Quality Strategy. In addition, we take into
consideration vital feedback and input from research published by our
payment reform contractor. The current HQRP measure set is also an
important consideration for future measure development areas; future
measure development areas should complement the current HQRP measure
set, including current HIS measures and CAHPS[supreg] Hospice Survey
measures, without creating unnecessary burden or redundant reporting.
Based on input from stakeholders, we identified two high priority areas
that will be addressed by claims-based measure development. Developing
quality measures using claims does not require new data collection,
thus minimizing provider burden and expediting implementation.
[[Page 36657]]
Priority Area 1: Potentially Avoidable Hospice Care Transitions
The concept of a claims-based measure focusing on transitions of
care was first introduced in the FY 2016 Hospice Wage Index final rule
(80 FR 47188 through 47189). Comments received during this rule were
overall supportive of our efforts to develop more robust quality
measures that capture hospice performance and show links to patient and
family outcomes. We refer readers to the FY 2016 Hospice Wage Index
final rule (80 FR 47188 through 47189) and for additional details:
https://www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-19033.pdf.
Potentially avoidable hospice care transitions at end of life are
burdensome to patients, families, and the health care system at large,
because they are associated with adverse health outcomes, lower patient
and family satisfaction, higher health care costs, and fragmentation of
care delivery.10 11 12 13 14 By encouraging hospice
providers to assess and manage patients' risk of care transitions, this
measure concept has the potential to improve quality care at the end of
life by reducing potentially avoidable hospice care transitions.
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\10\ Aldridge MDP, MBA; Epstein, Andrew J. Ph.D.; Brody, Abraham
A. RN, Ph.D.; Lee, Eric J. MPH; Cherlin, Emily Ph.D., MSW; Bradley,
Elizabeth H. Ph.D. The Impact of Reported Hospice Preferred
Practices on Hospital Utilization at the End of Life Medical Care.
2016;54(7):657-663.
\11\ Wang S-Y, Aldridge MD, Gross CP, et al. Transitions Between
Healthcare Settings of Hospice Enrollees at the End of Life. Journal
of the American Geriatrics Society. 2016;64(2):314-322.
\12\ Carlson MDA, Herrin J, Du Q, et al. Impact of Hospice
Disenrollment on Health Care Use and Medicare Expenditures for
Patients With Cancer. Journal of Clinical Oncology.
2010;28(28):4371-4375.
\13\ Teno JM, Bowman J, Plotzke M, et al. Characteristics of
Hospice Programs With Problematic Live Discharges. Journal of Pain
and Symptom Management. 2015;50(4):548-552.
\14\ Prsic E, Plotzke M, Christian TJ, Gozalo P, Teno JM. A
National Study of Live Hospice Discharges between 2000 and 2012.
Journal of Palliative Medicine. 2016;19(9):987-990.
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Priority Area 2: Access to Levels of Hospice Care
The Medicare Hospice Benefit covers four levels of care to meet
patients' and families' clinical needs: Routine home care (RHC),
continuous home care (CHC), general inpatient care (GIP), and inpatient
respite care. The goal of this measure concept is to assess the rates
at which hospices provide different levels of hospice care. The measure
has the potential to improve access to various levels of care for
patients and caregivers. Appropriate use of CHC and GIP increases the
likelihood of a hospice patient dying in his or her location of choice,
decreases health resource utilization resulting in potential cost
savings, and increases patient and caregiver
satisfaction.15 16 Measuring use of levels of care will
encourage hospice providers to continuously assess patient and
caregiver needs and provide the appropriate level of care to meet these
needs. These two measure concepts are under development, and details
regarding measure definitions, specifications and timeline for
implementation will be communicated in future rulemaking.
---------------------------------------------------------------------------
\15\ Barclay, J., et al., Association of hospice patients'
income and care level with place of death. JAMA Internal Medicine,
2013. 173(6): p. 450-456.
\16\ Casarett, D., et al., Does Continuous Hospice Care Help
Patients Remain at Home? Journal of Pain and Symptom Management,
2015. 50(3): p. 297-304.
---------------------------------------------------------------------------
We solicited comments regarding high priority measure areas for
future measure development including two specific measures under
consideration related to: (1) Potentially avoidable hospice care
transitions, and (2) access to levels of hospice care.
The comments and our responses have been grouped below: (1)
Comments applying to both high priority measure areas, (2) comments
specific to the potentially avoidable hospice care transitions measure
area, (3) comments specific to the access to levels of hospice care
measure area, and (4) other comments and suggestions regarding future
HQRP measure development.
Comment: Many commenters agreed that these measure areas were
important.
Response: We appreciate the commenters' support of these measure
areas as high priority areas for future HQRP measure development.
Comment: Many commenters expressed concerns with the limitations of
using claims data for quality measure development. Specifically,
commenters were concerned with the limited range of data elements
available in claims data. Many commenters stated that claims data do
not capture sufficient information about the clinical condition of
patients, the preferences and needs of patients and families, or
various other factors that influence care planning and decision-making.
Several commenters believed that claims do not provide sufficient
information to adequately reflect hospice practice. In general,
commenters were concerned that, in the absence of these data elements,
providers would be unfairly penalized should these measures be
implemented.
Response: We recognize that administrative data are not collected
for the purpose of quality measure development and thus, claims data
lack certain data elements that might be important to consider in
constructing quality measures. For example, we agree that patient and
family preferences and clinical needs are important factors in
determining whether a specific care transition or use of certain level
of hospice are appropriate in a specific scenario. We acknowledge the
limitations of claims data in capturing this information. However, we
would like to clarify that quality measures are not intended to
determine whether each individual experience of a care transition or
use of a certain level of hospice care, is clinically appropriate.
Instead, the measures will present provider-level rates of the process
and outcome in the two proposed measure areas, comparing providers to
their peers with relevant and available patient-level and hospice-level
factors taken into account. Despite the inability to control for
certain relevant factors such as patient and family preferences, these
factors tend to distribute evenly across hospices. In other words, each
hospice may serve patients and families with varying levels of
preference for care. As such, the inability to control for these
factors does not necessarily disadvantage certain hospices. Regardless,
given the limitations of claims data noted above, we are placing
careful emphasis on how we construct the specifications of the measure
and are using claims data to examine the patient factors that are
available and related to the hospice's performance in these measure
areas. In addition, we believe that the advantages of using claims
data, including minimized burden to providers and expedited
implementation, outweigh the limitations of this data source. We will
continue to consider the limitations of claims data as we develop
specifications for these measure areas. We continue to engage
stakeholders in developing measures that provide meaningful information
about hospice quality. We will also continue to engage stakeholders and
conduct analyses to inform the specifications of these measures.
Comment: Several commenters expressed concerns with the public's
ability to understand these measure areas and easily discern their
connection to quality. Commenters recommended CMS to ensure that
claims-based measures are understandable to the public prior to public
reporting.
Response: We appreciate the commenters' concerns regarding public
reporting of measures that use claims as a data source. We agree that
it is critical
[[Page 36658]]
to ensure that quality measures are understandable to the public,
especially prior to public reporting of measures. As such, all measures
developed and implemented in the HQRP, including claims-based measures,
undergo rigorous user testing to ensure that they are understandable to
providers and patients and families. For both high priority measure
areas, we continue to engage stakeholders including a technical expert
panel, caregiver workgroup and clinical users in measure development to
ensure that these measures are both meaningful and understandable to
the public. In addition, prior to public reporting of these measures,
we will provide resources through the Hospice Compare Web site to aid
the public in interpreting publicly displayed quality data.
Comment: We received several comments focused on the burden
associated with future implementation of the two high priority measure
areas. Although most of these commenters applauded CMS for developing
measures based on claims data because of the minimal burden for
providers associated with their data collection and submission and
measure calculation and reporting, one commenter encouraged CMS to
carefully consider the burden associated with other aspects of
implementing these measure concept areas.
Response: We appreciate the comments regarding the burden
associated with the two high priority measure areas. It is our goal to
minimize burden for providers when considering any new measure for
implementation in the HQRP. Claims-based measures require no additional
data collection and submission and thus, minimize burden for providers.
We recognize that the implementation of these measures may compel some
providers to establish internal systems for monitoring care patterns
captured by these measure concepts and are aware that some providers
are already doing so. We will consider these internal monitoring and
performance improvement efforts within the scope of Quality Assessment
and Performance Improvement (QAPI) requirements and other current
hospice conditions of participation. We believe such systems may
facilitate the appropriate provision of care and prevent unnecessary
transitions, thus improving quality of care provided by the hospice.
However, we would like to remind providers that no new measures are
being proposed in this year's rule, so there will be no additional
burden placed on providers.
Comment: Several commenters noted that only a small proportion of
hospice patients are discharged alive from hospice. Similarly, they
noted that only 2 to 3 percent of billed days in hospice are for levels
of care other than Routine Home Care.
Response: We recognize that the two high priority measure areas
will capture lower-frequency events. However, studies have demonstrated
considerable variation across hospice providers in both measures areas,
indicating that some hospices are having a substantially higher rate of
live discharges \17\ or provide very little or no GIP or CHC care to
their patients compared to other providers.18 19 This
signals performance gaps and, by developing and implementing these
measures, we hope to capture these important quality issues.
Additionally, low-frequency events can still reveal important quality
issues and gaps in care that hospices should address and consumers
should be aware of. Thus, measurement of low-frequency events is still
important. Hospice patients are likely to need these services as their
care needs change, especially as they approach the end of life, so
monitoring access to these services will help encourage providers to
continually assess patient need.
---------------------------------------------------------------------------
\17\ Wang S-Y, Aldridge MD, Gross CP, et al. Transitions Between
Healthcare Settings of Hospice Enrollees at the End of Life. Journal
of the American Geriatrics Society. 2016;64(2):314-322.
\18\ Stevenson DG, Grabowski DC, Keating NL, et al. Effect of
ownership on hospice service use: 2005-2011. J Am Geriatr Soc. 2016
May;64(5):1024-31. doi: 10.1111/jgs.14093. PMID: 27131344.
\19\ Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life
care for Medicare beneficiaries: site of death, place of care, and
health care transitions in 2000, 2005, and 2009. JAMA. 2013 Feb
6;309(5):470-7. doi: 10.1001/jama.2012.207624. PMID: 23385273.
---------------------------------------------------------------------------
Moreover, both measure concepts show relationship with patient and
family outcomes. Care transitions from hospice including live discharge
can result in adverse health outcomes, lower patient and family
satisfaction, higher health care costs, and fragmentation of care
delivery.20 21 22 23 24 In regards to the access to levels
of hospice care measure, though only about 2 percent of days are billed
as higher intensity levels of care (for example, CHC and GIP), a higher
proportion of patients use at least one of these higher intensity
levels of care at some point during their stay. Appropriate use of CHC
and GIP increases the likelihood of a hospice patient dying in his or
her location of choice, decreases health resource utilization resulting
in potential cost savings, and increases patient and caregiver
satisfaction.25 26 27 Given the potentially severe
consequences of receiving suboptimal care in these areas, we believe
that it is appropriate to develop these measures even though they
capture relatively lower frequency, but important events. It is our
goal to ensure that all hospice patients and families are receiving
high quality of care and having their needs met.
---------------------------------------------------------------------------
\20\ Aldridge MDP, MBA; Epstein, Andrew J. Ph.D.; Brody, Abraham
A. RN, Ph.D.; Lee, Eric J. MPH; Cherlin, Emily Ph.D., MSW; Bradley,
Elizabeth H. Ph.D. The Impact of Reported Hospice Preferred
Practices on Hospital Utilization at the End of Life Medical Care.
2016;54(7):657-663.
\21\ Wang S-Y, Aldridge MD, Gross CP, et al. Transitions Between
Healthcare Settings of Hospice Enrollees at the End of Life. Journal
of the American Geriatrics Society. 2016;64(2):314-322.
\22\ Carlson MDA, Herrin J, Du Q, et al. Impact of Hospice
Disenrollment on Health Care Use and Medicare Expenditures for
Patients With Cancer. Journal of Clinical Oncology.
2010;28(28):4371-4375.
\23\ Teno JM, Bowman J, Plotzke M, et al. Characteristics of
Hospice Programs With Problematic Live Discharges. Journal of Pain
and Symptom Management. 2015;50(4):548-552.
\24\ Prsic E, Plotzke M, Christian TJ, Gozalo P, Teno JM. A
National Study of Live Hospice Discharges between 2000 and 2012.
Journal of Palliative Medicine. 2016;19(9):987-990.
\25\ Barclay, J., et al., Association of hospice patients'
income and care level with place of death. JAMA Internal Medicine,
2013. 173(6): p. 450-456.
\26\ Casarett, D., et al., Does Continuous Hospice Care Help
Patients Remain at Home? Journal of Pain and Symptom Management,
2015. 50(3): p. 297-304.
\27\ Holland JM, Keene JR, Kirkendall A, et al. Family
evaluation of hospice care: examining direct and indirect
associations with overall satisfaction and caregiver confidence.
Palliat Support Care. 2015 Aug;13(4):901-8. doi: 10.1017/
S1478951514000595. PMID: 24992378.
---------------------------------------------------------------------------
Comment: In the context of both high priority measure areas,
several commenters expressed concerns that these measure areas are more
suitable as utilization measures rather than quality measures. For
example, several commenters stated that performance measures should not
be implemented as a means to discourage or correct undesirable
organizational practices. Several commenters noted that information
about these two measure areas is available via Program for Evaluating
Payment Patterns Electronic Report (PEPPER) reports. While some
believed Hospice PEPPER reports, alone, were sufficient to monitor
access to levels of hospice care and potentially avoidable hospice care
transitions, others felt that information from the PEPPER report is
distinct from information provided by the quality measurement areas,
and that the two quality measure areas thus represent value-added for
the HQRP and providers.
Response: We appreciate commenters' comments regarding the
distinction between utilization indicators and quality measures and
similarities between the two high priority measure
[[Page 36659]]
areas and PEPPER measures. We would like to clarify that quality
measures are distinct from utilization indicators, such as those
included in the PEPPER reports. Utilization measures report statistics
on services provided and billed to Medicare, and have a primary goal of
protecting the Medicare program. That said, certain practice areas may
be related to the integrity of the Medicare program and have
significant implications on patient and family care outcomes and
experience. Developing quality measures around those areas is a more
effective strategy to ultimately promote quality improvement. The two
high priority measure areas described in this rule measure areas that
have been shown in the literature to impact quality of care through
some structure, process, or outcome of
care.28 29 30 31 32 33 34 35 As such, these 2 measure
concept areas have a direct link to quality of care. Each measure
concept's relationship to quality of care is addressed in greater
detail in section 7. Measure Concepts Under Consideration for Future
Years of this final rule, on comments specific to the potentially
avoidable hospice care transitions measure area, and the section on
comments specific to the access to levels of hospice care measure area.
We continue to solicit input from stakeholders, including a TEP, a
hospice caregiver workgroup, and a clinical user's panel to supplement
evidence of this link in the literature.
---------------------------------------------------------------------------
\28\ Aldridge MDP, MBA; Epstein, Andrew J. Ph.D.; Brody, Abraham
A. RN, Ph.D.; Lee, Eric J. MPH; Cherlin, Emily Ph.D., MSW; Bradley,
Elizabeth H. Ph.D. The Impact of Reported Hospice Preferred
Practices on Hospital Utilization at the End of Life Medical Care.
2016;54(7):657-663.
\29\ Wang S-Y, Aldridge MD, Gross CP, et al. Transitions Between
Healthcare Settings of Hospice Enrollees at the End of Life. Journal
of the American Geriatrics Society. 2016;64(2):314-322.
\30\ Carlson MDA, Herrin J, Du Q, et al. Impact of Hospice
Disenrollment on Health Care Use and Medicare Expenditures for
Patients With Cancer. Journal of Clinical Oncology.
2010;28(28):4371-4375.
\31\ Teno JM, Bowman J, Plotzke M, et al. Characteristics of
Hospice Programs With Problematic Live Discharges. Journal of Pain
and Symptom Management. 2015;50(4):548-552.
\32\ Prsic E, Plotzke M, Christian TJ, Gozalo P, Teno JM. A
National Study of Live Hospice Discharges between 2000 and 2012.
Journal of Palliative Medicine. 2016;19(9):987-990.
\33\ Barclay, J., et al., Association of hospice patients'
income and care level with place of death. JAMA Internal Medicine,
2013. 173(6): p. 450-456.
\34\ Casarett, D., et al., Does Continuous Hospice Care Help
Patients Remain at Home? Journal of Pain and Symptom Management,
2015. 50(3): p. 297-304.
\35\ Holland JM, Keene JR, Kirkendall A, et al. Family
evaluation of hospice care: examining direct and indirect
associations with overall satisfaction and caregiver confidence.
Palliat Support Care. 2015 Aug;13(4):901-8. doi: 10.1017/
S1478951514000595. PMID: 24992378.
---------------------------------------------------------------------------
Comment: Regarding measurement priority area 1 (Potentially
Avoidable Hospice Care Transitions), many commenters agreed that care
transitions at the end of life can be burdensome for patients and
families. They noted that transitions out of hospice can often be
prevented through diligent symptom management, patient and family
education, and other aspects of care delivered by the hospice during
the patient's stay. Thus, many of these commenters supported the
importance of this measure area and its relationship to quality of
care. Several commenters, including MedPAC, supported a measure related
to potentially avoidable hospice care transitions. Others expressed
concerns regarding potential measure specifications but were generally
supportive of the concept. A few commenters recommended that CMS not
pursue the development of this measure and shared their concerns.
Response: We thank the commenters for their support of a future
HQRP measure related to potentially avoidable hospice care transitions.
We also appreciate comments offering conditional support of the
measure, with suggestions for how to define and specify this measure
such that it meaningfully reflects hospice quality. These suggestions,
in addition to the concerns of those who did not support continued
development of this measure, are addressed in detail in the paragraph
below.
Comment: In addition to the general comments regarding the
limitations of claims data detailed earlier in the preamble, we also
received comments expressing concerns about using claims as a data
source for this measure area, specifically. Many commenters were
concerned that patient and family needs and preferences are not
captured in claims data and thus, the measure might penalize providers
whose patients choose to disenroll from hospice. For example,
commenters stated that patients may revoke the hospice benefit because
they decide to pursue aggressive treatment for their terminal condition
or to seek care from a hospital that is not contracted with the
hospice. Several commenters noted that, even if a hospice provided
adequate education to patients and families, they would still want to
seek acute care for various reasons unrelated to the quality of care
provided by the hospice. Several commenters emphasized that patients
have the right to revoke the hospice benefit at any time and that these
decisions are sometimes outside of the hospice's control. Commenters
described other scenarios in which they believed that discharges from
hospice and subsequent care transitions were outside the control of the
hospice. For example, a few commenters mentioned payment and policy
factors or local market-level factors that may trigger transitions from
hospice to acute care. A few described instances in which a nearby
hospital refuses to contract with them for providing GIP care, forcing
them to discharge patients should they need GIP care. Several
commenters believed that claims did not provide sufficient information
to adequately reflect hospice practice. Specifically, commenters were
concerned with using claims data to identify potentially avoidable
hospice care transitions or distinguish between appropriate and
inappropriate live discharges. Commenters discussed the situation in
which a patient's clinical condition improved as an example of an
appropriate live discharge. Several commenters requested that CMS
provide examples of potentially avoidable hospice care transitions.
Lastly, commenters suggested that claims data be supplemented with
other data sources, such as the HEART tool in the future, in order to
provide that contextual information necessary to determine whether a
transition was appropriate or indicative of poor quality provided by a
hospice.
Response: As previously stated, we acknowledge the limitations of
claims data in capturing this information and would also like to
clarify that this measure is not intended to determine whether each
individual care transition or live discharge is appropriate. Instead,
the measures will present provider-level rates of the process and
outcome in the two proposed measure areas, comparing providers to their
peers with relevant and available patient-level and hospice-level
factors taken into account. Given the limitations of claims data to
measure this area, we are examining information about care patterns and
subsequent outcomes that are available in claims data to identify
transitions that might be reflective of suboptimal quality provided by
a hospice during a patient's stay (that is, failure to meet the needs
of patients and their families). These transitions represent
disruptions in continuity of care at a time when patients and families
are extremely vulnerable. We agree that patient and family needs and
preferences are an important factor in determining whether a hospice
provider should be held accountable for a care transition and the
related outcomes and that this information is not fully captured in
claims data. However, research has demonstrated provider- and state-
level
[[Page 36660]]
variation in proportion of hospice users experiencing care transitions,
which signifies that market factors and hospice characteristics (that
is, factors other than patient/family needs and preferences) influence
transitions. We also agree that there are situations in which live
discharges may be appropriate--for example, when a patient's clinical
condition improves and they are no longer deemed to have a prognosis of
6 months or less. This measure area is not intended to suggest that
live discharge is inappropriate for any individual patient but rather,
to identify hospices with substantially higher rates of live discharges
followed by either death or acute care use during a short period of
time. Substantially higher rates of live discharge with these
subsequent outcomes may indicate that providers are not meeting patient
needs, signaling poor quality.\36\
---------------------------------------------------------------------------
\36\ MedPAC, Report to the Congress: Medicare Payment Policy.
March 2017. http://www.medpac.gov/docs/defaultsource/reports/mar17_medpac_ch12.pdf?sfvrsn=0.
---------------------------------------------------------------------------
In response to commenters' requests that we provide examples of
potentially avoidable hospice care transitions, we would like to
reiterate that this measure is currently in development and thus, its
specifications have not yet been finalized. As previously stated, this
measure is intended to address lack of continuity of care during a
vulnerable time for patients and families. Thus, measure specifications
will focus on live discharges from hospice followed by either death or
acute care use during a short period of time. We will continue to
carefully examine patterns of care for live discharge and consider them
in measure development. We will continue to solicit and consider
stakeholder input before finalizing measure definitions and
specifications. The public will have the opportunity to comment on
proposed measures and their specifications if and when these measure
concepts are proposed in future rulemaking cycles.
Comment: Commenters offered suggestions for how to specify a
measure examining potentially avoidable hospice care transitions.
Several commenters recommended that CMS to look at live discharge
followed by readmission to hospice, hospitalization, or death within a
short time frame. One commenter suggested incorporating data elements
from providers transferring patients to hospice. Several commenters
cautioned against setting a benchmark for acceptable rates of live
discharge.
Response: This measure is currently under development so its
specifications have not yet been finalized. We appreciate the
commenters' suggestions and will continue to take stakeholder input
into consideration before finalizing measure specifications. This
measure is intended to address lack of continuity of care by assessing
transitions that may reflect poor quality on the part of the hospice.
Thus, in line with the suggestions of commenters, measure
specifications will focus on live discharges from hospice followed by
either death or acute care use during a short period of time. We will
carefully examine patterns of care for live discharge and consider them
in measure development. We also appreciates commenters' concerns
regarding the identification of a threshold or benchmark for this
measure area. We acknowledge that some live discharges and care
transitions are to be expected and appropriate, and agree that a
threshold should not be set initially without careful analysis of
national data and measure trends. We will also continue to engage
stakeholders and conduct analyses to inform the specifications of this
measure.
Comment: Several commenters questioned the relationship between
this high priority measure and quality.
Response: We appreciate the commenters' concerns regarding this
measure area's relationship to quality of care. The linkage between
potentially avoidable hospice care transitions and outcomes for
patients and families is demonstrated in the literature
37 38 39 40 41 with evidence suggesting that substantially
higher rates of live discharge may signal poor quality.\42\ For
example, failures on the part of the hospice in advanced care planning,
symptom management, responsiveness, and family education could drive
patients and families to seek acute care. Furthermore, stakeholders
support the importance of this measure and its relationship to quality.
Overall, TEP members agreed on the importance of this measure concept
and supported its continued development and future implementation. In
addition, input solicited from hospice patients and caregivers suggests
that this measure concept is important and meaningful to patients and
families.
---------------------------------------------------------------------------
\37\ Aldridge MDP, MBA; Epstein, Andrew J. Ph.D.; Brody, Abraham
A. RN, Ph.D.; Lee, Eric J. MPH; Cherlin, Emily Ph.D., MSW; Bradley,
Elizabeth H. Ph.D. The Impact of Reported Hospice Preferred
Practices on Hospital Utilization at the End of Life Medical Care.
2016;54(7):657-663.
\38\ Wang S-Y, Aldridge MD, Gross CP, et al. Transitions Between
Healthcare Settings of Hospice Enrollees at the End of Life. Journal
of the American Geriatrics Society. 2016;64(2):314-322.
\39\ Carlson MDA, Herrin J, Du Q, et al. Impact of Hospice
Disenrollment on Health Care Use and Medicare Expenditures for
Patients With Cancer. Journal of Clinical Oncology.
2010;28(28):4371-4375.
\40\ Teno JM, Bowman J, Plotzke M, et al. Characteristics of
Hospice Programs With Problematic Live Discharges. Journal of Pain
and Symptom Management. 2015;50(4):548-552.
\41\ Prsic E, Plotzke M, Christian TJ, Gozalo P, Teno JM. A
National Study of Live Hospice Discharges between 2000 and 2012.
Journal of Palliative Medicine. 2016;19(9):987-990.
\42\ MedPAC, Report to the Congress: Medicare Payment Policy.
March 2017. http://www.medpac.gov/docs/defaultsource/reports/mar17_medpac_ch12.pdf?sfvrsn=0.
---------------------------------------------------------------------------
Comment: In addition to the general concerns regarding public
reporting of the two high priority measure areas, we received a few
comments specific to public reporting of the potentially avoidable
hospice care transitions measure area. One commenter expressed concerns
regarding hospice provider access to information that would enable them
to internally monitor their performance on this measure (that is,
claims for acute care stays occurring after hospice live discharge;
information allowing them to compare their performance on this measure
to the performance of other hospices). They recommended CMS to refrain
from public reporting until hospice providers have access to this
information.
Response: We appreciate the commenter's concerns regarding the
ability of hospice providers to internally monitor their performance in
this measure area. Though this measure would consider patient care
transitions after hospice discharge, the intention is to capture
performance gaps during the hospice stay that leads to the risk of
transition. Thus, hospice's provision of high quality care during a
patient's hospice stay should minimize the risk of those transitions.
For example, adequate symptom management and responsiveness on the part
of the hospice might prevent unnecessary transitions from occurring.
Though hospice providers might not have access to claims from acute
care stays occurring after they discharge a patient alive, this should
not affect their ability to take steps to ensure the provision of high
quality care to prevent these transitions and thus, should not affect
their ability to perform well on this measure. Before the onset of any
public reporting for any new quality measure, we provide confidential
feedback reports (that is, Certification and Survey Provider Enhanced
Reports (CASPER) Quality Measure (QM) reports, confidential to the
extent permissible by federal law) to providers that allow them to
compare their performance to national averages.
[[Page 36661]]
Comment: Several commenters were concerned that this measure may
result in unintended consequences for patients and families. For
example, a few commenters worried that it may encourage providers to
approach care decisions with less attention towards patient and family
wishes.
Response: We appreciate commenters' concerns regarding potential
unintended consequences of a measure examining potentially avoidable
hospice care transitions. With the development of any new quality
measures, it is a priority of CMS to minimize any potential unintended
consequences. Thus, we will work closely with the hospice industry and
other stakeholder groups to ensure that this measure does not
inadvertently impede a patients' choice to make a desired transition or
have any other unintended consequence.
Comment: Regarding measure development priority area 2 (Access to
Levels of Hospice Care), most commenters, including MedPAC, supported
the ``access to levels of hospice care'' measure area. Several
commented on its potential to encourage providers to better meet the
needs of patients and families as well as its potential usefulness for
Medicare beneficiaries and their families. Some commenters, though they
had concerns with potential specifications for this measure, generally
agreed that access to levels of hospice care is an important aspect of
hospice care for patients and families.
Response: We thank the commenters for their support of a future
HQRP measure related to access to levels of hospice care. We also
appreciate comments offering conditional support of the measure, with
suggestions for how to define and specify this measure such that it
meaningfully reflects hospice quality. These suggestions are addressed
in detail in the paragraph below.
Comment: In addition to the general comments regarding the
limitations of claims data detailed above, we also received comments
expressing concerns about using claims as a data source for this
measure area, specifically, commenters noted that claims data would not
provide information about when higher intensity levels of hospice care
were needed, such as information about patient acuity. One commenter
stated that claims data would not reflect situations in which GIP or
CHC were offered but refused by patients and families. Several
commenters were concerned that claims data would not reflect instances
in which a patient didn't receive a higher intensity level of care
because the hospice was able to get their symptoms under control
without escalating the patient to GIP or CHC. A few commenters worried
that their performance on this measure might be lower because their
hospices focused on preemptively mitigating the need for higher
intensity levels of care through diligent symptom management and
patient and family education. Some commenters cautioned against judging
access to and availability of GIP and CHC by delivery of such care.
Several commenters suggested linking claims data with survey data that
demonstrates a hospice's ability to provide higher intensity levels of
care (for example, contracts with inpatient facilities).
Response: We agree that patient and caregiver needs and preferences
for certain levels of care can impact the use of more intensive levels
of hospice care and recognize that claims only provide information
about what level of care was provided, not what level of care was
needed or desired. However, research has demonstrated provider- and
state-level variation in proportion of hospice users receiving higher
intensity levels of hospice care, which signifies that market factors
and hospice characteristics (that is, factors other than patient/family
needs and preferences) influence GIP and CHC provision. This measure
concept is not intended to suggest that a higher intensity level of
care is appropriate or needed for any given individual; the purpose of
this measure concept is to ensure that patients and families have
access to these higher intensity levels of care if needed. Furthermore,
there will be risk adjustment for this measure, which will
statistically account for patient case-mix differences across hospices
so that the outcome rates can be more accurately compared despite the
differences in patient case-mix. We acknowledge the limitations of
claims data and thus, the inability to control for certain relevant
factors such as patient and family preferences and refusal of care.
However, these factors tend to distribute evenly across hospices. In
other words, each hospice may serve patients and families with varying
level of preference for higher intensity levels of hospice care. As
such, the inability to control for these factors does not necessarily
disadvantage certain hospices. We encourage hospice providers to take
measures to preemptively meet the symptom management and other needs of
patients and applaud those who are doing so. However, we also recognize
that there will be instances in which, despite a hospice's best
efforts, certain patients will require higher intensity levels of
hospice care. The focus of this measure area is to ensure that these
patients have access to the care that they need, and to encourage
hospices to continually assess patients and provide different levels of
care as needed. We also thank commenters for their suggestions
regarding supplementing claims data with other data sources. We will
consider the benefit of doing such in the context of the potential
burden associated with data collection and measure calculation and
reporting. We will also consider opportunities to incorporate other
data sources into future HQRP measure development efforts.
Comment: Several commenters cautioned against setting a threshold
or benchmark for GIP and CHC provision in the absence of evidence
regarding where this threshold should lie.
Response: We appreciate the commenters' concerns regarding the
identification of a threshold or benchmark for this measure area. We
agree that thresholds should not be set arbitrarily, without rigorous
information gathering and measure testing. We will continue to engage
stakeholders and conduct claims data analyses to inform the
specifications of this measure.
Comment: Several commenters questioned the relationship between
this high priority measure area and quality.
Response: This measure area's relationship with quality of care is
supported by the literature. Appropriate use of CHC and GIP increases
the likelihood of a hospice patient dying in his or her location of
choice, decreases health resource utilization resulting in potential
cost savings, and increases patient and caregiver
satisfaction.43 44 45 This linkage between appropriate use
of higher intensity levels of hospice care and outcomes for patients
and families is further supported by a technical expert panel and other
stakeholder groups thus far engaged in the development of this measure.
Overall, TEP members agreed on the importance of this measure concept
and supported its relationship to quality. Additionally, input
solicited from hospice caregivers has suggested that this measure
concept
[[Page 36662]]
is important and meaningful to patients and families.
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\43\ Barclay, J., et al., Association of hospice patients'
income and care level with place of death. JAMA Internal Medicine,
2013. 173(6): p. 450-456.
\44\ Casarett, D., et al., Does Continuous Hospice Care Help
Patients Remain at Home? Journal of Pain and Symptom Management,
2015. 50(3): p. 297-304.
\45\ Holland JM, Keene JR, Kirkendall A, et al. Family
evaluation of hospice care: examining direct and indirect
associations with overall satisfaction and caregiver confidence.
Palliat Support Care. 2015 Aug;13(4):901-8. doi: 10.1017/
S1478951514000595. PMID: 24992378.
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Comment: Several commenters expressed concern with the feasibility
of certain hospices providing all four levels of care and described
factors that may lower their performance on a measure examining access
to higher intensity levels of hospice care. For example, some
commenters discussed staffing challenges associated with providing CHC
and GIP, particularly for smaller hospices. Several commenters noted
challenges related to the CHC billing requirement that at least 8 hours
of continuous care be provided within one calendar day. They described
situations in which the continuous care they are providing is not
reflected as CHC in claims data because it did not meet the 8 hour
threshold within 1 calendar day. Others described market factors
influencing a hospice's ability to provide GIP, including issues with
contracting with nearby hospitals.
Response: While we acknowledge that some hospice providers may face
unexpected challenges in providing higher intensity levels of hospice
care, according to the Hospice Conditions of Participation (CoPs) all
hospice agencies regardless of size, location or other organizational
or market characteristics must be able to provide all four levels of
hospice care. We will continue to discuss these issues with a technical
expert panel and other stakeholder groups and conduct analyses to
better understand sources of variation in GIP and CHC provision across
hospices. These discussions and analyses will inform the specifications
for this measure. Though we do acknowledge the challenges that
commenters raised, it is our expectation that all hospices meet the
requirements set forth in the Hospice (CoPs) and demonstrate the
capacity to meet the needs of patients and families.
Comment: A few commenters expressed concerns with the access to
levels of hospice care measure promoting overutilization of GIP and
CHC. They added that the intent of this quality measure conflicts with
efforts to discourage overutilization of these higher intensity, more
costly levels of hospice care.
Response: We appreciate these commenters raising one potential
unintended consequence of this measure area. It is our goal to minimize
the unintended consequences of any new quality measure. The purpose of
this measure area is not to encourage GIP or CHC for any individual
patient or to encourage very high rates of GIP or CHC use within
hospices. Rather, the focus of this measure area is to assess whether
patients have access to these levels of care if they need it, and to
encourage hospices to continually assess patients and provide different
levels of care as needed. With that said, we will provide educational
opportunities for providers and the public to clearly explain the
intent of this measure and its relationship to quality of care.
Provider education will emphasize that the purpose of this measure is
to promote access, not to encourage increased use of GIP or CHC for any
given patient. We will also coordinate this measure and relevant
utilization measures reported under the PEPPER to design a balanced
incentive for hospices to provide the level of GIP and CHC care to meet
patient and family needs.
Comment: In addition to offering comments about the two high
priority measure development areas, several commenters stated their
general support for future HQRP measure development efforts. Commenters
noted the importance of developing quality measures that reflect the
holistic and comprehensive care provided by hospice and measures that
recognize that the unit of hospice care is composed of both the patient
and their family. Several commenters recommended CMS to turn attention
towards the development of outcome measures for the HQRP to supplement
current measures, many of which are process measures. Additionally,
several commenters recommended CMS to ensure that all future measures
are clearly defined and undergo rigorous testing prior to
implementation in the HQRP. Commenters emphasized the importance of
stakeholder engagement in all measure development efforts. Several
commenters specifically noted the importance of patient and family
engagement to develop new HQRP measures, including measures that
capture patient experience. Several commenters suggested that CMS
engage with NQF and the MAP in determining priority areas for future
measurement. One commenter pointed specifically to the PEACE Project, a
CMS project that developed a set of quality measures, with complete
specifications, and data collection tools for use by hospice and
palliative care providers in quality improvement, and the 2012 MAP
Performance Measurement Coordination Strategy for Hospice and
Palliative Care as resources from which to pull measures and measure
concepts.
Response: We thank the commenters for their support and suggestions
for future quality measurement efforts as part of the HQRP. We agree
that quality measures should capture the aspects of care that set
hospice apart from many other types of care, including the provision of
holistic interdisciplinary care and the recognition of both the patient
and their family as the unit of care. Further, we agree with commenters
that the development of outcome measures should be prioritized in
future HQRP measure development. It is our goal to supplement existing
HIS and CAHPS[supreg] measures to develop a more comprehensive measure
set that captures key domains of hospice care. With the development of
any new QRP measure, we follow a rigorous process for measure
development which includes measure conceptualization, measure
specification, and measure testing prior to measure implementation.
Each of these stages of development incorporates ample opportunity for
stakeholder engagement. We consider the perspective of clinicians,
patients and caregivers, and other stakeholder groups integral to the
development process. We will continue to engage with the NQF and the
MAP to identify priority measure concepts. We would like to note that
all measures undergo review by the MAP prior to implementation in the
HQRP. Further, where possible, CMS seeks NQF endorsement for any new
HQRP measures that are not already endorsed by NQF. For more details
regarding our measure development process, please refer to the
Blueprint for CMS Measures Management System Version 13: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MMS-Blueprint.html.
Comment: Commenters offered suggestions for future measure concepts
to consider for implementation in the HQRP including:
Congruence of place of death and patient wishes;
Psychological, psychiatric, and psychosocial aspects of
care;
Spiritual well-being;
Bereavement services offered by a hospice;
Volunteer services offered by a hospice;
Occupational therapy outcomes;
Provider commitment to credentialing their staff;
Care planning (for example, regular review of patient and
family goals; shared decision making);
Timely communication of patient's goals across all
providers;
Cost of care; and
Care coordination among providers.
In addition, commenters suggested measures specific to certain
subpopulations of hospice patients including:
Pediatric patients;
[[Page 36663]]
Patients with a diagnosis of Alzheimer's or Dementia;
Patients with a short length of stay; and
Patients receiving hospice care in a nursing facility or
assisted living facility.
Response: We thank the commenters for their suggestions regarding
potential future quality measures. We agree that these are important
areas of hospice and will consider these suggestions in future HQRP
measure development efforts.
8. Form, Manner, and Timing of Quality Data Submission
a. Background
Section 1814(i)(5)(C) of the Act requires that each hospice submit
data to the Secretary on quality measures specified by the Secretary.
Such data must be submitted in a form and manner, and at a time
specified by the Secretary. Section 1814(i)(5)(A)(i) of the Act
requires that beginning with the FY 2014 and for each subsequent FY,
the Secretary shall reduce the market basket update by 2 percentage
points for any hospice that does not comply with the quality data
submission requirements for that FY.
b. Policy for New Facilities To Begin Submitting Quality Data
In the FY 2015 Hospice Wage Index final rule (79 FR 50488), we
finalized a policy stating that any hospice that receives its CMS
Certification Number (CCN) (also known as the Medicare Provider Number)
notification letter dated on or after November 1 of the preceding year
involved is excluded from any payment penalty for quality reporting
purposes for the following FY. This requirement was codified at Sec.
418.312.
In the FY 2016 Hospice Wage Index final rule (80 FR 47189), we
further clarified and finalized our policy for the timing of new
providers to begin reporting data to CMS. The clarified policy
finalized in the FY 2016 Hospice Wage Index final rule (80 FR 47189)
distinguished between when new hospice providers are required to begin
submitting HIS data and when providers will be subject to the potential
2 percentage point annual payment update (APU) reduction for failure to
comply with HQRP requirements. In summary, the policy finalized in the
FY 2016 Hospice Wage Index final rule (80 FR 47189 through 47190)
clarified that providers must begin submitting HIS data on the date
listed in the letterhead of the CCN Notification letter received from
CMS but will be subject to the APU reduction based on whether the CCN
Notification letter was dated before or after November 1 of the
reporting year involved. Thus, beginning with the FY 2018 payment
determination and for each subsequent payment determination, we
finalized our policy that a new hospice be responsible for HQRP quality
data submission beginning on the date of the CCN notification letter;
we retained our prior policy that hospices not be subject to the APU
reduction if the CCN notification letter was dated after November 1 of
the year involved. For example, if a provider receives their CCN
notification letter and the date in the letterhead is November 5, 2017,
that provider will begin submitting HIS data for patient admissions
occurring after November 5, 2017. However, since the CCN notification
letter was dated after November 1st, they would not be evaluated for,
or subject to any payment penalties for, the relevant FY APU update
(which in this instance is the FY 2019 APU, which is associated with
patient admissions occurring January 1, 2017 through December 31,
2017).
This policy allows us to receive HIS data on all patient admissions
on or after the date a hospice receives their CCN notification letter,
while at the same time allowing hospices flexibility and time to
establish the necessary accounts for data submission before they are
subject to the potential APU reduction for a given reporting year.
Currently, new hospices may experience a lag between Medicare
certification and receipt of their actual CCN Number. Since hospices
cannot submit data to the QIES ASAP system without a valid CCN Number,
we finalized that new hospices begin collecting HIS quality data
beginning on the date noted on the CCN notification letter. We believe
this policy provides sufficient time for new hospices to establish
appropriate collection and reporting mechanisms to submit the required
quality data to CMS. Requiring quality data reporting beginning on the
date listed in the letterhead of the CCN notification letter aligns our
policy requirements for new providers with the functionality of the HIS
data submission system (QIES ASAP).
c. Previously Finalized Data Submission Mechanisms, Timelines, and
Deadlines
In the FY 2015 Hospice Wage Index final rule (79 FR 50486), we
finalized our policy requiring that hospices complete and submit HIS
records for all patient admissions to hospice after July 1, 2014. For
each HQRP program year, we require that hospices submit data on each of
the adopted measures in accordance with the reporting requirements
specified in sections III.C.9.b through III.C.9.c of the FY 2015
Hospice final rule (79 FR 50486) for the designated reporting period.
This requirement applies to previously finalized and adopted measures,
as well as new measures proposed through the rulemaking process.
Electronic submission is required for all HIS records. Although
electronic submission of HIS records is required, hospices do not need
to have an electronic medical record to complete or submit HIS data. In
the FY 2014 Hospice Wage Index final rule (78 FR 48258), we finalized a
provision requiring that providers use either the Hospice Abstraction
Reporting Tool (HART) (which is free to download and use) or vendor-
designed software to complete HIS records. HART provides an alternative
option for hospice providers to collect and maintain facility, patient,
and HIS Record information for subsequent submission to the QIES ASAP
system. Once HIS records are complete, electronic HIS files must be
submitted to CMS via the QIES ASAP system. Electronic data submission
via the QIES ASAP system is required for all HIS submissions; there are
no other data submission methods available. Hospices have 30 days from
a patient admission or discharge to submit the appropriate HIS record
for that patient through the QIES ASAP system. We will continue to make
HIS completion and submission software available to hospices at no
cost. We provided details on data collection and submission timing
under the downloads section of the HIS Web page on the CMS.gov Web site
at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html.
The QIES ASAP system provides reports upon successful submission
and processing of the HIS records. The final validation report may
serve as evidence of submission. This is the same data submission
system used by nursing homes, inpatient rehabilitation facilities, home
health agencies, and long-term care hospitals for the submission of
Minimum Data Set Version 3.0 (MDS 3.0), Inpatient Rehabilitation
Facility-patient assessment instrument (IRF-PAI), Outcome Assessment
Information Set (OASIS), and Long-Term Care Hospital Continuity
Assessment Record & Evaluation Data Set (LTCH CARE), respectively. We
have provided hospices with information and details about use of the
HIS through postings on the HQRP Web site, Open Door Forums,
announcements in the CMS
[[Page 36664]]
MLN Connects[supreg] Provider e-News (E-News), and provider training.
Hospices are evaluated for purposes of the quality reporting
program based on whether or not they submit data, not on their
substantive performance level for the required quality measures. In
order for us to appropriately evaluate the quality reporting data
received by hospice providers, it is essential HIS data be received in
a timely manner. The submission date is the date on which the completed
record is submitted and accepted by the QIES ASAP system. In the FY
2016 Hospice Wage Index final rule (80 FR 47191), we finalized our
policy that beginning with the FY 2018 payment determination, hospices
must submit all HIS records within 30 days of the event date, which is
the patient's admission date for HIS-Admission records or discharge
date for HIS-Discharge records. For HIS-Admission records, the
submission date must be no later than the admission date plus 30
calendar days. The submission date can be equal to the admission date,
or no greater than 30 days later. The QIES ASAP system will issue a
warning on the Final Validation Report if the submission date is more
than 30 days after the patient's admission date. For HIS-Discharge
records, the submission date must be no later than the discharge date
plus 30 calendar days. The submission date can be equal to the
discharge date, or no greater than 30 days later. The QIES ASAP system
will issue a warning on the Final Validation Report if the submission
date is more than 30 days after the patient's discharge date.
The QIES ASAP system validation edits are designed to monitor the
timeliness of submission and ensure that providers' submitted records
conform to the HIS data submission specifications. Providers are
notified when timing criteria have not been met by warnings that appear
on their Final Validation Reports. A standardized data collection
approach that coincides with timely submission of data is essential to
establish a robust quality reporting program and ensure the scientific
reliability of the data received.
In the FY 2016 Hospice Wage Index final rule (80 FR 47191), we also
clarified the difference between the completion deadlines and the
submission deadlines. Current sub-regulatory guidance produced by CMS
(for example, HIS Manual, HIS trainings) states that the completion
deadlines for HIS records are 14 days after the Event Date for HIS
Admission records and 7 days after the Event Date for HIS Discharge
records. Completion deadlines continue to reflect CMS guidance only;
these guidelines are not statutorily specified and are not designated
through regulation. These guidelines are intended to offer clear
direction to hospice agencies in regards to the timely completion of
HIS-Admission and HIS-Discharge records. The completion deadlines
define only the latest possible date on which a hospice should complete
each HIS record. This guidance is meant to better align HIS completion
processes with clinical workflow processes; however, hospices may
develop alternative internal policies to complete HIS records. Although
it is at the discretion of the hospice to develop internal policies for
completing HIS records, we will continue to recommend that providers
complete and attempt to submit HIS records early, prior to the
previously finalized submission deadline of 30 days, beginning in FY
2018. Completing and attempting to submit records early allows
providers ample time to address any technical issues encountered in the
QIES ASAP submission process, such as correcting fatal error messages.
Completing and attempting to submit records early will ensure that
providers are able to comply with the 30 day submission deadline. HQRP
guidance documents, including the CMS HQRP Web site, HIS Manual, HIS
trainings, Frequently Asked Questions, and Fact Sheets, continue to
offer the most up-to-date CMS guidance to assist providers in the
successful completion and submission of HIS records. Availability of
updated guidance will be communicated to providers through the CMS HQRP
Web site, listserv messages via the Post-Acute Care QRP listserv, MLN
Connects[supreg] National Provider Calls & Events, MLN Connects[supreg]
Provider eNews and announcements on Open Door Forums and Special Open
Door Forums.
The comment and our response are below.
Comment: We received a few comments on the previously finalized
data submission mechanism, the HIS. One commenter offered several
suggestions for potential revisions to the HIS V2.00.0, including
suggested edits to items in Section A and Section J of the HIS-
Admission record. The commenter offered suggestions for response
options or items that could be potentially eliminated, and offered
suggestions for refinements to coding guidance provided in the HIS
Manual for these items. Another commenter requested CMS include
additional examples in the HIS Manual; specifically, examples that had
greater clinical relevance for a broader range of hospice providers.
Response: The HIS V2.00.0 was previously proposed and finalized as
a data collection mechanism for the HQRP. We refer readers to the FY
2017 Hospice Wage Index final rule (81 FR 52167 through 52192) for a
detailed discussion of the HIS V2.00.0. We invite the public to submit
questions or suggestions about previously finalized and currently
implemented proposals through sub-regulatory communication channels,
including the Hospice Quality Help Desk at
[email protected], and through other communication
channels such as Open Door Forums and Special Open Door Forums. These
can be found at the CMS Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Spotlight.html. Requests such as including additional examples in the
HIS Manual can be addressed at the Hospice Quality Help Desk. We are
always seeking ways to make the HIS Manual more user-friendly and will
consider adding examples that provide more clinical relevance for a
broader range of hospice providers. By writing to the Hospice Quality
Help Desk, we can communicate to be sure we understand the issue to
most appropriately address it.
d. New Data Collection and Submission Mechanisms Under Consideration:
Hospice Evaluation & Assessment Reporting Tool (HEART)
We have made great progress in implementing the objectives set
forth in the quality reporting and data collection activities required
by sections 3004 of the Affordable Care Act. To date, we have
established the HQRP, which includes clinical quality measures from the
HIS and patient experience of care measures from the CAHPS[supreg]
Hospice Survey. We have also finalized payment reform measures,
including changes to the RHC payment rate and the implementation of a
Service Intensity Add-On (SIA) payment, effective January 1st, 2016.
As discussed in the FY 2017 Hospice Wage Index final rule (81 FR
52177), to facilitate continued progress towards the requirements set
forth in section 3004 of the Affordable Care Act, we are in the early
stages of the development of a new data collection mechanism for use by
hospices. This new data collection mechanism would be a hospice patient
assessment tool, which would serve two primary objectives concordant
with the Affordable Care Act legislation: (1) To provide the quality
data necessary for HQRP requirements and the current function of the
HIS; and
[[Page 36665]]
(2) provide additional clinical data that could inform future payment
refinements. In the FY 2017 Hospice Wage Index final rule (81 FR
52143), we solicited input from the public on the development of a
hospice patient assessment tool that would collect quality, clinical,
and other data with the ability to be used to inform future payment
refinement efforts. Overall, feedback from the public was supportive of
the move towards a standardized patient assessment instrument, and
commenters offered some guiding principles for CMS to keep in mind in
the development of a patient assessment tool, given the unique nature
of hospice care. For a detailed discussion of the public comments and
responses, as well as our guiding principles and motivation behind the
development of a hospice patient assessment tool, we refer readers to
the FY 2017 (81 FR 52143). As noted in the FY 2017 Hospice Wage Index
final rule, we envision the hospice patient assessment tool itself as
an expanded HIS. The hospice patient assessment tool would include
current HIS items, as well as additional clinical items that could also
be used for payment refinement purposes or to develop new quality
measures. The hospice patient assessment tool would not replace
existing requirements set forth in the Medicare Hospice CoPs (such as
the initial and comprehensive assessment), but would be designed to
complement data that are collected as part of high-quality clinical
care. The new data collection effort would replace the current HIS, but
would not replace other HQRP data collection efforts (that is, the
CAHPS[supreg] Hospice Survey), nor would it replace regular submission
of claims data. We envision that patient assessment data would be
collected upon a patient's admission to and discharge from any
Medicare-certified hospice provider; additional interim data collection
efforts are also possible.
We did not propose a hospice patient assessment tool at this time;
we are still in the early stages of development of an assessment tool
to determine the appropriate content and feasibility of such a tool. As
such, we have made progress over the past year in the development of a
hospice patient assessment tool, preliminarily called the Hospice
Evaluation & Assessment Reporting Tool (HEART). CMS's measure
development contractor, RTI International, has begun preliminary HEART
development activities, including: Conducting environmental scans and
engaging clinical experts to determine which domains of care are
important to capture in a hospice patient assessment; posting a
national provider call and forming a Clinical Committee comprised of
hospice organizations from across the United States to participate in
the early development of an assessment; and collaborating within CMS to
assess various stakeholder needs and encourage collaboration within CMS
and across other HHS agencies. As we move forward with the development
of the HEART patient assessment tool, we will continue to keep the
public informed of our progress and solicit input as we establish and
finalize domains of care to include in the assessment, and as we move
towards specific item wording and development. Once we move past the
preliminary phases of development and conceptualization, we will
communicate a timeline for the HEART development, testing, and proposed
implementation in future rulemaking cycles.
As mentioned in the FY 2017 Hospice Wage Index final rule (81 FR
52143), it is important for CMS to develop a hospice patient assessment
tool that is scientifically rigorous and clinically appropriate for the
hospice population, thus we believe that continued and transparent
involvement of stakeholders is critical. We will continue to receive
stakeholder input from MedPAC and ongoing input from the provider
community, Medicare beneficiaries, and technical experts. Additionally,
it is important for CMS to minimize data collection burden on providers
in the development of HEART. We will ensure that hospice patient
assessment data items are not duplicative or overly burdensome to
providers, patients, caregivers, or their families. We will also work
with the public and other stakeholders to ensure that HEART takes into
account the unique aspects of hospice care delivery including symptom
burden and psychosocial needs, patient and family preferences, care of
imminently dying patients, and the complexity of providing hospice care
in multiple settings and at multiple intensity levels.
The comments and our responses are set forth below.
Comment: Many commenters were supportive of the continued
development of a patient assessment tool, HEART. Commenters believed
that--beyond currently available CMS data sources--a tool such as HEART
would enable a broader picture of the quality of care provided by
hospice agencies, as well as a more comprehensive picture of patient
need and service delivery. Commenters also agreed with CMS that this
enhanced patient assessment tool could be useful for quality purposes
and potential payment purposes. MedPAC supported HEART, noting that a
patient assessment instrument would gather more detailed clinical
information on hospice patients (for example, patients' symptom
burden), facilitate the development of more meaningful quality
measures, and be helpful for payment policy purposes. Many commenters
offered their support to CMS in the development of HEART, noting that
transparent involvement of stakeholders would be crucial for ensuring
HEART is scientifically rigorous, clinically appropriate, addresses the
needs of individual patients, and sets the foundation for data
collection that more accurately reflects the needs of patients served.
In addition to voicing general support for HEART, commenters also
offered several suggestions and considerations for CMS to keep in mind
as we move forward with the development of HEART. Suggestions focused
on the following themes: Intended use of HEART, Content of HEART,
Processes for HEART development, HEART Policies and Procedures, and
Burden. Beyond these major themes, commenters also offered suggestions
for HEART's relationship to quality and payment and cross-setting
considerations.
Response: First, we thank commenters for their support of the
development of a patient assessment tool, HEART. We agree that enhanced
data collection would further the goals of the HQRP and the Medicare
Hospice Benefit by providing data that could be useful for development
of future quality measures and potential future payment refinements.
Second, we appreciate the input and recommendations from the hospice
community. The input received from commenters are invaluable as we move
forward with the development of HEART; we look forward to continued
collaboration with our stakeholders and the hospice community. We
address specific comments received in greater detail in paragraph
below.
Comment: CMS received a few comments regarding the utility of HEART
and CMS's vision for how HEART would be used for quality and payment
purposes. A couple of commenters recommend CMS to ``move cautiously'',
particularly in the area of payment refinement. One commenter suggested
that CMS make a concerted effort to--in future rulemaking cycles--
separate payment refinements from the expanded quality data that HEART
would offer.
[[Page 36666]]
Response: We would like to take this opportunity to further clarify
our vision for HEART and HEART's ultimate utility. At this time, we
envision HEART as a patient assessment tool that would replace the HIS.
HEART would provide richer data to offer a broader, more comprehensive
picture of quality of care received by hospice patients and their
families. We believe HEART may provide data that could inform future
payment refinements, we would like to clarify that HEART's role in
future payment refinements is not definite. We realize that before a
patient assessment can be used for payment purposes, it must undergo
rigorous testing to investigate whether data items are reliable and
valid predictors of resource utilization. We acknowledge and appreciate
that extensive testing of HEART data items will need to occur before we
can make a final determination about whether HEART will prove useful in
informing future payment refinements. This analysis would be in
addition to the analyses that will be conducted to determine the
scientific soundness of the data items themselves, as well as in
addition to analyses conducted to inform the development of future
quality measures. Thus, at this time, we cannot say definitively
whether HEART will be used for payment refinements. Furthermore, any
changes to the hospice payment methodology would be subject to the
rulemaking process, which allows for public comment on any payment
proposal. Although this is a potential use of the data, until extensive
analysis and testing is conducted, we cannot make a final determination
on the role HEART may play in future payment refinements. We would also
like to take this opportunity to reassure the public of our timeline
for development and testing of HEART. We appreciate the need to use a
rigorous process in the development of testing and HEART; we assure the
public that we will work on a timeline that allows for iterative
testing and refinements, and provides ample opportunity to solicit the
feedback of technical experts and the hospice community. Further
details on our timeline and processes for development and testing of
HEART are discussed further on in the preamble.
Comment: Many commenters offered recommendations on the content of
HEART. Many commenters noted the unique nature of hospice care and
offered considerations for designing HEART to ensure it would reflect
the comprehensive and holistic aspects of hospice care. Specifically,
commenters recommended that CMS ensure HEART: (1) Reflects the holistic
and comprehensive nature of hospice care, including physical,
psychosocial, and spiritual components; (2) recognizes the importance
of an individualized approach to care; (3) includes the patient and
family's right to refuse or defer offered services; (4) accommodates
the delivery of care in various settings, including nursing homes,
assisted living facilities, hospitals, hospice facilities, and the
patient's home; and (5) recognizes that the assessment must be
interdisciplinary. These commenters also encouraged CMS to ensure that
data gathered through HEART is easily and readily usable for
development of and updates to the plan of care. In addition to
accommodating the facets of care noted above, a few commenters
discussed the importance of ensuring flexibility in HEART to
accommodate care of the imminently dying patient. Commenters noted that
patients who are imminently dying at the time of admission to hospice
need the hospice to immediately address high priority patient and
family needs; completing assessment forms such as HEART could interfere
with providing immediate clinical and psychosocial support for
vulnerable patients and families who are facing imminent death. One
commenter believed that requiring completion of all HEART data
elements, regardless of patient status, would obligate hospices to
complete regulatory requirements at the expense of addressing urgent
patient and family needs for patients who are close to death upon
admission to hospice. This commenter believed hospices should have the
discretion to complete only those aspects of assessment that are most
critical to the needs of the patient and family, and that to promote
this discretion, CMS should allow flexibility in completing HEART items
for these patients. CMS received a couple of comments regarding the
inclusion of standardized tools in HEART. One commenter was supportive
of including validated, standardized instruments in HEART (for example,
standardized pain scales, symptom management assessment tools). This
commenter believed that the inclusion of standardized tools would
reduce duplication with assessments that hospices already complete as
part of usual care. On the other hand, another commenter cautioned
against prescribing the use of specific validated, standardized tools.
This commenter believed that it would be important for CMS to preserve
the integrity of the hospice philosophy by allowing hospice clinicians
to individualize assessments and care based on clinical judgment, and
that prescribing specific standardized tools may restrict clinical
judgment and practice. One commenter recommended including HEART data
elements that would capture social risk factors. Another commenter
suggested CMS to include patient preferences in HEART data elements.
Response: We appreciate commenters' considerations on what should
be included in the content of HEART. We wholeheartedly agree with
commenters regarding the unique nature of hospice care, and we will
continue to keep the hospice philosophy as the foundation of the HEART
patient assessment. We seek to develop an assessment that reflects the
distinctive aspects of hospice care, including the team-based, multi-
disciplinary approach that is essential to hospice. We agree with the
points raised by commenters about the overall focus of HEART and aims
to develop a tool that addresses the holistic nature of hospice,
incorporating medical, psychosocial, spiritual, and other aspects of
care that are important for patients and their caregivers. We also
appreciate commenters' specific suggestions regarding the need for a
flexible assessment, which would incorporate input from various members
of the IDT and accommodate circumstances unique to hospice, such as
care of patients who are imminently dying, patients' and caregivers'
right to decline services or treatment, and the fact that hospice is
delivered in multiple settings. We appreciate commenters' suggestions
about including items to capture other important facets of care,
including suggestions about the inclusion of standardized tools, the
suggestion to incorporate patient preference into HEART, and the
suggestion to consider data collection on social risk factors. We will
keep these considerations in mind as we move forward with HEART
development.
Comment: CMS received many suggestions from commenters regarding
the process for continued development of HEART. All of these commenters
encouraged CMS to engage stakeholders and the hospice community in the
development process, and appreciated CMS's commitment to a transparent
and collaborative development process. Commenters believed that
extensive stakeholder engagement would lead to meaningful data that is
truly reflective of quality of care delivered by hospices. Due to the
magnitude, complexity, and importance of HEART, one commenter
encouraged CMS to go beyond traditional opportunities for input (for
example, TEPs) and employ widespread
[[Page 36667]]
processes for gathering provider input. Another commenter encouraged
CMS to broaden the definition of relevant stakeholders and include EMR
vendors as a stakeholder in the HEART development process. This
commenter believed that many of the difficulties encountered in
implementation of new requirements stem from the complexity of
integrating data collection into EMR systems, and that inclusion of EMR
vendors in the development process may result in a smoother
implementation of HEART. In addition to offering suggestions for
stakeholder engagement, many commenters offered suggestions for testing
and refinement of HEART. Several commenters encouraged CMS to use an
iterative testing approach; commenters encouraged CMS to conduct
several phased pilot tests, which would allow for the iterative and
ongoing refinement of HEART. A few commenters recommended CMS include a
range of hospice agencies in pilot tests, including hospices of varying
sizes, locations, and organizational structure. One commenter asked if
CMS could share any progress or materials on the development of HEART,
such as the structure of the assessment. Finally, many commenters
offered their support to CMS throughout the development process,
volunteering to provide feedback and participate in pilot initiatives.
Response: We are appreciative commenters continued support and
engagement throughout the development process; and we look forward to
opportunities for continued collaboration and input. We have already
begun to engage the public and other stakeholders in our development
process. We have formed a Clinical Committee comprised of hospice
organizations from across the United States, and we have begun
conversations with hospice clinical experts and other stakeholders with
CMS and across HHS. We look forward to continuing these discussions and
engaging in additional opportunities for stakeholder input. We agree
that input from the hospice industry will be invaluable and assure
commenters that our process for development and testing of HEART will
allow ample opportunity to refine and improve HEART based on
stakeholder input. We plan to hold TEPs to inform the development,
testing, and refinement of the patient assessment. We also plan to
provide other opportunities for stakeholders to provide input through
venues such as Special Open Door Forums and other regular HQRP
communication channels. We will also consider additional mechanisms for
soliciting input from the public to further enhance opportunities for
input.
We are committed to a development process that will ensure rigorous
and iterative testing of the patient assessment tool in hospices with
varying organizational characteristics, patient populations, settings
of care delivery, and levels of care. As with the development of
patient assessment instruments in other care settings, tentative
development processes may include holding TEPs to gather input from
hospice clinicians and researchers, conducting small-scale pilot tests
to determine feasibility of a patient assessment instrument for
hospice, conducting a larger, national test to establish reliability
and validity of items and determine appropriate use of each item,
providing ongoing opportunities for input and engagement from the
hospice community. Only after completion of a thorough development
process over the next several years would CMS consider proposing HEART
through rulemaking for implementation in the HQRP. We believe our
tentative development process to be aligned with commenters'
recommendations for a thorough and iterative testing approach, allowing
ample opportunity for the refinement of HEART prior to implementation.
Further details on HEART development and testing will be communicated
in future rulemaking cycles and through sub-regulatory communication
channels. We will also announce opportunities for stakeholder input and
participation regularly through sub-regulatory communication channels
(for example, MLN eNews ListServs, ODFs, SODFs). Regarding the
commenter's request for information on the current draft version of
HEART, we are still in the early, initial phases of HEART development;
we look forward to sharing our progress with the provider community as
developments become available.
Comment: Several commenters offered suggestions to CMS regarding
policies and procedures for HEART data collection and submission,
including feedback on data collection intervals, modes and timing for
data collection and submission, and implementation of HEART. Commenters
had differing opinions as to whether HEART data should be collected at
admission and discharge only, or if data should be collected at
additional interim time points beyond admission and discharge.
Commenters who supported interim data collection efforts noted the
importance of measuring care throughout a patient's stay to fully
understand quality of care delivered to patients over the course of
their length of stay. Commenters who supported admission and discharge
data collection believed interim data collection efforts only would
prove overly burdensome for providers. Regarding data completion and
submission, one commenter encouraged CMS to implement data collection
and submission timeframes that are reasonable and clear.
Several commenters offered suggestions regarding the implementation
of HEART. Commenters encouraged CMS to provide advanced notice prior to
any final implementation date in order to allow ample time for
infrastructure and IT system development, as well as clinician
training. Several commenters recommended CMS use a phased
implementation or dry run approach, which would ensure adequate time
(that is, at least 1 year) for EMR vendors to incorporate HEART into
their software; for hospices to initiate and thoroughly test HEART data
collection processes; and, to train staff and ensure competency in use.
One commenter noted that issues experienced with the implementation of
prior HQRP data collection efforts (for example, NQF #0209 measure)
might have been alleviated with longer implementation and dry run
periods. Several commenters underscored the importance of adequately
training clinicians and other staff on HEART data collection, coding
rules, and definitions to ensure accurate data collection. These
commenters recommended CMS to provide ample and ongoing educational
opportunities to support HEART implementation. Commenters encouraged
CMS to include clear definitions for each data element included in
HEART. These commenters believed that clear definitions that are
readily understood are imperative to the success of any patient
assessment data collection effort. One commenter noted that although
CMS training materials for the HIS are thorough and comprehensive,
proving useful for staff responsible for HIS data submission, the level
of detail included in CMS materials is often too great for clinical
staff. This commenter recommended that, in addition to providing
traditional educational and training materials, CMS consider developing
streamlined educational materials geared towards clinical staff.
Finally, a few commenters touched on the information technology (IT)
burden related to potential implementation of HEART. These commenters
noted the
[[Page 36668]]
time and effort associated with upgrading EMR vendor systems and
training staff on functionality of updated systems. One commenter
recommended CMS to ``include sufficient protections for small
hospices'' and keep in mind how IT burden affects these organizations.
This commenter also suggested that CMS ensure new quality reporting
requirements are tenable for small hospice programs, given their
limited health IT resources.
Response: We appreciate commenters' input on processes and policies
for HEART data collection and submission. We appreciate commenters'
feedback on intervals for HEART data collection, as well as commenters'
recommendations regarding data collection and submission timeframes,
systems for data submission, and timeline for implementation of HEART.
We agree that having data submission timeframes and policies that align
with clinical workflow and are clear to providers is very important. We
also agree that a longer or phased implementation approach could help
facilitate a smooth transition to HEART and minimize burden, allowing
ample time for upgrading IT and EMR systems, with minimal disruption of
provider workflow and increased quality of data submitted. We also
agree that educational materials and ample opportunity for training--
including clear and understandable definitions for each data element--
will be critical to the success of HEART. Finally, we understand and
appreciate commenters' concerns about the complexity of upgrading EMR
and IT systems to accommodate new data collection efforts. With respect
to commenters' suggestions about clear and understandable definitions
for each data element, our hope is that our phased, iterative pilot
testing approach will offer rich information on how hospices interpret
HEART data elements, yielding definitions that are reflective of the
reality of hospice care and are readily understood by providers.
Regarding commenters' concerns about health IT and the complexity of
upgrading EMR systems, we understand the concerns about the time
required for vendors to upgrade EMR systems and for hospices to be
trained. In addition, we would like to note that we anticipate making
data completion and submission software available to providers at no
cost so that providers can complete and submit HEART data free of
charge, without the need to purchase an EMR or vendor software. This
would be analogous to the HART and QIES ASAP systems currently used for
HIS data completion and submission.
Comment: Although commenters were generally supportive of HEART,
many commenters cautioned CMS against the creation of a patient
assessment that would be overly burdensome. Commenters applauded CMS's
commitment to the development of a tool that is minimally burdensome
and not duplicative. In their comments related to burden, commenters
discussed the consideration of burden to the hospice provider, as well
as potential burden to the patient and family. Commenters encouraged
CMS to be cognizant of potential burden that additional data collection
could place on patients and families. Commenters stated that the
initial portion of a patient's stay in hospice is a time when
clinicians and staff are developing a relationship with the patient and
family and noted that in usual practice, hospices must balance the
collection of important data necessary to deliver care with the need to
not overwhelm the patient and family unit during this time. One
commenter noted that this consideration is even more critical when
caring for an imminently dying patient. This commenter believed that
standardized data collection has the potential to be burdensome to the
patient and family and delay initiation of timely care to address high
priority needs. Commenters encouraged CMS to keep this balance in mind
when developing HEART.
Regarding burden to the provider, commenters cautioned CMS against
designing an assessment that would be overly burdensome for providers,
noting that the move to a more comprehensive patient assessment would
require investments in chart review and other data completion
activities. One commenter recommended CMS to accurately account for any
potential increases in burden and cost in calculations of burden and
costs of regulatory impacts. Commenters mentioned collaboration with
the provider community and efficiencies from EMR software as potential
ways to reduce burden. One commenter raised the relationship between
HEART and existing CoP requirements and. questioned how CMS envisioned
this tool being minimally burdensome when CMS stated in the proposed
rule that HEART would not replace initial or comprehensive assessment
requirements.
Finally, several commenters noted the tradeoff between time spent
on assessment tools and regulatory requirements and time spent
delivering care and addressing patient and family needs. Commenters
recommended CMS to ensure that HEART data elements are overall
meaningful and contribute to care planning, and cautioned CMS against
the creation of a patient assessment tool that would simply be an
exercise in ``filling out forms'' and ``checking off boxes''.
Commenters noted that time spent completing HEART would be time spent
away from providing direct care and implored CMS to keep this tradeoff
in mind in the development of HEART.
Response: We appreciate commenters concerns about burden of data
collection efforts for both hospice providers and for hospice patients
and their families. Regarding burden to patients and families, we agree
with commenters that HEART should not impose burden on patients and
families, especially during this early time in hospice care, and in
instances where hospice patients are admitted close to death. It is our
objective to ensure that HEART aligns with clinical practices so that
collection of data for HEART poses no additional burden on patients and
families beyond what hospices collect as part of usual care delivery.
To ensure this objective is met, we will solicit clinician and patient
and family caregiver input as part of HEART development process.
Finally, we recognize the potential tradeoff between data collection
and reporting requirements and time spent with the patient and family
delivering care. CMS will keep this tradeoff at the forefront of HEART
development to ensure that HEART does not detract from the primary
mission of hospice care.
Regarding burden to hospice providers, we are not including HEART
in this rule, so there is no additional burden associated with this
rule. Once the HEART assessment has been tested and is proposed in
rulemaking, CMS will provide a PRA package and burden estimates. As
noted in this rule, the HEART assessment would replace the current HIS
reporting requirement, meaning HEART would not represent an additional
reporting requirement for hospices. Although HEART would not replace
current CoP requirements for the initial and comprehensive assessment,
CMS's intent is to design HEART in a way that is complementary to the
initial and comprehensive assessment to minimize burden on providers.
Similar to how CoP requirements for the initial and comprehensive
assessment do not require hospices to use specific formats, we envision
HEART having similar levels of flexibility for providers. We believe
that a flexible patient assessment tool that allows for clinician
judgment will help minimize burden
[[Page 36669]]
and duplication of existing requirements. Moreover, any patient
assessment tool proposed through rulemaking would undergo OMB and PRA
review and approval, the purpose of which is to ensure required data
collection efforts do not impose undue burden on the public.
We will continue to collaborate with stakeholders and will ensure
that any patient assessment is minimally burdensome and not
duplicative. We consider the perspective of clinicians and patients,
and caregivers integral to the development process and will provide
ample opportunity for stakeholder input to ensure any assessment tool
is clinically appropriate and minimally burdensome. Moreover, burden
will be a focus of the pilot data collection efforts in order to ensure
we are appropriately assessing burden of data collection.
Comment: CMS received a few comments about HEART's relationship to
quality and payment, and what providers should or should not be held
accountable for. With respect to HEART's relationship to quality and
the development of future quality measures using HEART data, one
commenter stated that CMS should not hold providers accountable for
outcomes of care that are not feasible for all hospice patients. For
example, the commenter felt that providers should not be held
accountable or penalized for occurrence of skin wounds at the end of
life because organ failure and skin breakdown is a normal part of the
dying process. Similarly, the commenter also suggested CMS not hold
providers accountable for decreases in function and activities of daily
living since this is an expected trajectory among hospice patients.
Finally, the commenter requested that CMS not hold providers to
achieving complete symptom control because this is not feasible in all
patients. Another commenter encouraged CMS to appropriately risk adjust
any outcomes generated from HEART data to appropriately reflect
patients' right to refuse services, short lengths of stay in hospice,
and instances where attending physicians refuse to sign orders that
align with the patient preferences. This commenter also encouraged CMS
to capture preference-concordant care as an outcome measure in HEART.
Several commenters addressed HEART's relationship to resource
utilization and payment, offering suggestions to CMS as to how
assessment data might be useful for future payment refinements. One
commenter discussed data that HEART would need to capture if CMS moved
to a case-mix payment methodology. The commenter noted that hospices
should be paid higher rates for patients needing higher levels of
services, including patients who have pain or other symptoms that are
difficult to manage, and patients with wounds who need higher levels of
skilled care. The commenter suggested that CMS not set a payment rate
lower than the rate hospices receive under current payment policy.
MedPAC recommended CMS to ensure that elements of HEART were not unduly
subject to provider manipulation if HEART data was to be used for
payment purposes.
Response: We appreciate commenters' feedback and suggestions about
HEART's relationship to quality. We will take these suggestions into
consideration for future rulemaking and the continued development of
HEART and any associated quality measures. We recognize and agree with
the commenter that some outcomes of care are not achievable for dying
patients and will work to ensure that any future outcome measures are
appropriate for the hospice population. We also appreciate the
commenter's suggestion to consider preference-concordant care as a
future quality domain in HEART, as well as the suggestion to
appropriately risk-adjust any future outcome measures generated from
HEART data.
We also thank commenters for their suggestions regarding HEART's
relationship to resource utilization and payment. As noted earlier in
the preamble, we will need to complete extensive analysis before we
determine what--if any--utility HEART will have for future payment
refinements. That said, we recognize that resource utilization in
hospice is unique and is most often linked to patient symptomology and
service needs rather than diagnosis. As such, it is our paramount
concern to develop a patient assessment tool that appropriately
reflects the needs of patients and services provided by hospices to
meet those needs. We will continue to involve stakeholders, including
hospice organizations and clinicians, in the development process to
ensure this objective is met. We also recognize the importance of
developing patient assessment data elements that are scientifically
rigorous and are not easily manipulated by providers. We will ensure
that any data elements included in HEART undergo rigorous testing and
validation prior to implementation.
Comment: Several commenters also discussed cross-setting issues
with respect to HEART. Commenters suggested that CMS consider how HEART
would fit in with efforts to develop other patient assessment
instruments for other post-acute care settings (for example, IRFs,
SNFs, home health, and LTCHs). Commenters encouraged CMS to balance the
need between developing uniform and consistent post-acute care
assessment tools that would include post-acute settings and hospice,
with the need to ensure HEART is reflective of the unique aspects of
hospice care. Although commenters recognized cross-setting
standardization and coordination as an opportunity to develop cohesive
patient assessments that enable better longitudinal plans of care and
integration across the care continuum, commenters also stressed the
importance of ensuring that HEART reflect the interdisciplinary and
unique aspects of hospice care. One commenter also encouraged CMS to
incorporate HEART into the CMS Data Element Library (DEL).
Response: We appreciate the commenters' suggestions on cross-
setting issues. We assure commenters that we recognize the unique
nature of hospice care; it is not our intent to develop an assessment
tool that inappropriately relies on items from existing tools used in
other quality reporting programs for different patient populations. We
will work diligently with the provider community to gather information
on current assessment practices in hospice and to ensure that a hospice
assessment tool would capture the goals of hospice care and be
complementary to current clinical practice. At the same time, we also
agree that HEART is an opportunity to coordinate and harmonize with
measure and data elements from other care settings, where applicable.
Although hospice was not a care setting included in the IMPACT Act, we
are coordinating within CMS to ensure HEART promotes continuity of care
across the post-acute care continuum where feasible and appropriate.
9. Previously Adopted APU Determination and Compliance Criteria for the
HQRP
a. Background
The HQRP is currently designed as a ``pay-for-reporting'' system,
meaning that it is the act of submitting data that determines
compliance with HQRP requirements. Performance level is not a
consideration when determining market basket updates/APU. Reporting
compliance is determined by successfully fulfilling both the Hospice
CAHPS[supreg] Survey requirements and the HIS data submission
requirements.
[[Page 36670]]
b. Previously Finalized HIS Data Submission Timelines and Compliance
Thresholds for FY 2018 Payment Determination and Subsequent Years
To accurately analyze quality reporting data received by hospice
providers, it is imperative we receive ongoing and timely submission of
all HIS-Admission and HIS-Discharge records. In the FY 2016 Hospice
Wage Index final rule (80 FR 47192), we finalized the timeliness
criteria for submission of HIS-Admission and HIS-Discharge records. The
finalized timeliness criteria were in response to input from our
stakeholders seeking additional specificity related to HQRP compliance
affecting FY payment determinations and, due to the importance of
ensuring the integrity of quality data submitted.
As stated in that rule, beginning with the FY 2018 payment
determination and subsequent FY payment determinations, all HIS records
would have to be submitted within 30 days of the event date, which is
the patient's admission date or discharge date. In conjunction with the
timeliness criteria for submission of HIS-Admission and HIS-Discharge
records, in the FY 2016 Hospice Wage Index final rule (80 FR 47192) we
also finalized a policy to establish an incremental threshold for
compliance over a 3-year period. To be compliant for the FY 2018 APU
determination, hospices must submit no less than 70 percent of their
total number of HIS-Admission and HIS-Discharge records by no later
than 30 days from the event date. The timeliness threshold is set at 80
percent for the FY 2019 APU determination and at 90 percent for the FY
2020 APU determination and subsequent years. The threshold corresponds
with the overall amount of HIS records received from each provider that
fall within the established 30 day submission timeframes. Our ultimate
goal is to require all hospices to achieve a compliance rate of 90
percent or more.
To summarize, in the FY 2016 Hospice Wage Index final rule (80 FR
47193), we finalized our policy to implement the timeliness threshold
requirement beginning with all HIS-Admission and HIS-Discharge records
that occur after January 1, 2016, in accordance with the following
schedule
Beginning January 1, 2016 to December 31, 2016, hospices
must submit at least 70 percent of all required HIS records within the
30 day submission timeframe for the year or be subject to a 2
percentage point reduction to their market basket update for FY 2018.
Beginning January 1, 2017 to December 31, 2017, hospices
must submit at least 80 percent of all required HIS records within the
30 day submission timeframe for the year or be subject to a 2
percentage point reduction to their market basket update for FY 2019.
Beginning January 1, 2018 to December 31, 2018 and
thereafter, hospices must submit at least 90 percent of all required
HIS records within the 30 day submission timeframe for the year or be
subject to a 2 percentage point reduction to their market basket update
for FY 2020.
In July of 2016, we released the Hospice Timeliness Compliance
Threshold Report in the Certification and Survey Provider Enhanced
Reports (CASPER) system. This report allows providers with a QIES ASAP
User ID to check their preliminary compliance with the 70/80/90
timeliness compliance threshold described above. For more information
on the Hospice Timeliness Compliance Threshold Report, we refer readers
to the Timeliness Compliance Threshold Fact Sheet, available on the HIS
portion of the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html and Chapter 3 of the CASPER User's Manual,
available on the QTSO Web site: https://www.qtso.com/hospicetrain.html.
In the FY 2016 Hospice Wage Index final rule (80 FR 47192 through
47193), we provided clarification regarding the methodology used in
calculating the 70 percent/80 percent/90 percent compliance thresholds.
In general, HIS records submitted for patient admissions and discharges
occurring during the reporting period (January 1st to December 31st of
the reporting year involved) will be included in the denominator for
the compliance threshold calculation. The numerator of the compliance
threshold calculation would include any records from the denominator
that were submitted within the 30 day submission deadline. In the FY
2016 Hospice Wage Index final rule (80 FR 47192), we also stated that
we would make allowances in the calculation methodology for two
circumstances. First, the calculation methodology will be adjusted
following the applicable reporting period for records for which a
hospice is granted an extension or exemption by CMS. Second,
adjustments will be made for instances of modification/inactivation
requests (Item A0050. Type of Record = 2 or 3). Additional helpful
resources regarding the timeliness compliance threshold for HIS
submissions can be found under the ``downloads'' section of the HIS Web
page at CMS.gov at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html. Lastly, as further details of the data submission and
compliance threshold are determined by CMS, we anticipate communicating
these details through the CMS HQRP Web site, listserv messages via the
Post-Acute Care QRP listserv, MLN Connects [supreg] National Provider
Calls & Events, MLN Connects [supreg] Provider eNews and announcements
on Open Door Forums and Special Open Door Forums.
c. CAHPS[supreg] Participation Requirements for FY 2018 APU
Determination and Determinations for Subsequent Years
In the FY 2015 Hospice Wage Index final rule, we added the
CAHPS[supreg] Hospice Survey to the Hospice Quality Reporting Program
requirements for the FY 2017 payment determination and determinations
for subsequent FY APU years (79 FR 50491).
In the FY 2017 Hospice Wage Index final rule, we finalized that to
meet the HQRP requirements for the FY 2018, FY 2019 and FY 2020 APU
payment determinations, hospices would collect survey data on a monthly
basis for the months of January 1, 2016 through December 31, 2016 to
qualify for the full FY 2018 APU; hospices would collect survey data on
a monthly basis for the months of January 1, 2017 through December 31,
2017, to qualify for the full FY 2019 APU, and hospices would collect
survey data on a monthly basis for the months of January 1, 2018
through December 31, 2018 for the full FY 2020 APU (81 FR 25529 through
25530). In the May 2017 proposed rule we proposed that in order to meet
the HQRP requirements for the FY 2021 APU payment determination,
hospices would collect survey data on a monthly basis for the months of
January 1, 2019 through December 31, 2019 to qualify for the FY 2021
APU. In addition, we proposed that in order to meet the HQRP
requirements for the FY 2022 APU payment determination, hospices would
collect survey data on a monthly basis for the months of January 1,
2020 through December 31, 2020 to qualify for the FY 2022 APU.
[[Page 36671]]
10. HQRP Submission Exemption and Extension Requirements for the FY
2019 Payment Determination and Subsequent Years
a. Extraordinary Circumstances Exemption and Extension
In the FY 2015 Hospice Wage Index final rule (79 FR 50488), we
finalized our proposal to allow hospices to request, and for CMS to
grant, exemptions/extensions for the reporting of required HIS quality
data when there are extraordinary circumstances beyond the control of
the provider. Such extraordinary circumstances may include, but are not
limited to, acts of nature or other systemic issues with our data
systems. We further finalized that hospices must request such an
exemption or extension within 30 days of the date that the
extraordinary circumstances occurred. In certain instances, however, it
may be difficult for hospices to timely evaluate the impact of
extraordinary circumstances within 30 calendar days. For other quality
reporting programs such as the Hospital Inpatient Quality Reporting (81
FR 57182), Inpatient Rehabilitation Facility Quality Reporting Program
(81 FR 52125) and the Long term Care Hospital Quality Reporting Program
(81 FR 25205), we have reevaluated our policy and subsequently
finalized through rulemaking an extension of that period of time to 90
calendar days. Therefore, we proposed to extend the deadline for
submitting an exemption or extension request to 90 calendar days from
the qualifying event which is preventing a hospice from submitting
their quality data for the HQRP. We believe that extending the deadline
to 90 calendar days would allow hospices more time to determine whether
it is necessary and appropriate to submit an exemption or extension
request and to provide a more comprehensive account of the qualifying
event in their request form to CMS. For example, if a hospice has
suffered damage due to a hurricane on January 1st, it would have until
March 31st to submit a request form to CMS via email to the HQRP
mailbox at [email protected].
Further, while we finalized our policy in the past for exception/
extension for the submission of the HIS data, we proposed to extend
this policy beyond the submission of the HIS date to submission of the
CAHPS[supreg] Hospice Survey data, given that multiple data submission
processes could be impacted by the same qualifying event. Therefore, we
proposed for FY 2019 payment determination and subsequent payment
determinations to extend the period of time a hospice may have to
submit a request for an extension or exception for quality reporting
purposes from 30 calendar days to 90 calendar days after the date that
the extraordinary circumstances occurred, by submitting a request to
CMS via email to the HQRP mailbox at
[email protected]. Exemption or extension requests
sent to us through any other channel will not be considered valid. The
request for an exemption or extension must contain all of the finalized
requirements as outlined on our Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Extensions-and-Exemption-Requests.html. If a hospice
is granted an exemption or extension, timeframes for which an exemption
or extension is granted will be applied to the new timeliness
requirement so such hospices are not penalized. If a hospice is granted
an exemption, we will not require that the hospice submit HIS and/or
CAHPS[supreg] Hospice Survey data for a given period of time. By
contrast, if we grant an extension to a hospice, the hospice will still
remain responsible for submitting data collected during the timeframe
in question, although we will specify a revised deadline by which the
hospice must submit these quality data.
This process does not preclude us from granting extensions/
exemptions to hospices that have not requested them when we determine
that an extraordinary circumstance, such as an act of nature, affects
an entire region or locale. We may grant an extension/exemption to a
hospice if we determine that a systemic problem with our data
collection systems directly affected the ability of the hospice to
submit data. If we make the determination to grant an extension/
exemption to hospices in a region or locale, we will communicate this
decision through the various means, including the CMS HQRP Web site,
listserv messages via the Post-Acute Care QRP listserv, MLN
Connects[supreg] National Provider Calls & Events, MLN Connects[supreg]
Provider eNews and announcements on Open Door Forums and Special Open
Door Forums.
We solicited comments on these proposals. The comments and our
responses are set forth below.
Comment: Commenters were unanimously supportive of CMS's proposal
to extend the deadline for submitting an exemption or extension request
to 90 calendar days from the qualifying event which is preventing a
hospice from submitting their quality data for the HQRP. One commenter
believed the change in policy will enable hospice agencies to have more
time to determine whether an emergency may warrant an extension or
exemption request. Another commenter believed the change in policy will
enhance fairness where acts of nature or a systemic problem on part of
CMS's data collection system prevents compliance. One commenter
requested clarification about form for submitting requests for
exemption and extensions; specifically, what the appropriate mode of
submission of exemption and extension requests is.
Response: We appreciate the commenters' support for the proposal to
extend the submission deadline from 30 to 90 days. We agree that the
change will be helpful for providers and maximize compliance and
participation in the HQRP. Regarding the commenter's request for
clarification on our policies for exemption and extension, including
mode of submission of these requests, as noted in this rule, we accept
requests for exemption and extension via email to the HQRP
Reconsiderations mailbox at [email protected].
Procedures for exemptions and extensions are further outlined on the
CMS HQRP Web site here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Extensions-and-Exemption-Requests.html.
Final Action: We are finalizing our proposal to implement the
change in deadline from 30 to 90 days for hospices requesting an
exemption or extension for the FY 2019 payment determination and
subsequent payment determinations.
b. Volume-Based Exemption for CAHPS[supreg] Hospice Survey Data
Collection and Reporting Requirements
We previously finalized a volume-based exemption for CAHPS[supreg]
Hospice Survey Data Collection and Reporting requirements in the FY
2017 Final Rule (81 FR 52143). Hospices that have fewer than 50 survey
eligible decedents/caregivers in the period from January 1, 2017
through December 31, 2017 are eligible to apply for an exemption from
CAHPS[supreg] Hospice Survey data collection and reporting requirements
for the FY 2020 payment determination (corresponds to the CY 2018 data
collection period). To qualify, hospices must submit an exemption
request form for the FY 2020 APU. The exemption request form is
available on the official CAHPS[supreg] Hospice Survey Web site http://www.hospiceCAHPSsurvey.org. Hospices that intend to claim the size
exemption are required to submit to
[[Page 36672]]
CMS their total unique patient count for the period of January 1, 2017
through December 31, 2017. The due date for submitting the exemption
request form for the FY 2020 APU is December 31, 2018. Small hospices
that meet the exemption for size criteria for FY 2020 must complete an
exemption form for FY 2020. Exemptions for size are active for 1 year
only. If a hospice continues to meet the eligibility requirements for
this exemption in future FY APU periods, the organization needs to
request the exemption annually for every applicable FY APU period.
Hospices that have fewer than 50 survey eligible decedents/
caregivers in the period from January 1, 2018 through December 31, 2018
are eligible to apply for an exemption from CAHPS[supreg] Hospice
Survey data collection and reporting requirements for the FY 2021
payment determination. Hospices that intend to claim the size exemption
are required to submit to CMS their total unique patient count for the
period of January 1, 2018 through December 31, 2018. The due date for
submitting the exemption request form for the FY 2021 APU is December
31, 2019. Small hospices that meet the exemption for size criteria for
FY 2021 must complete an exemption form for FY 2021.
Hospices that have fewer than 50 survey eligible decedents/
caregivers in the period from January 1, 2019 through December 31, 2019
are eligible to apply for an exemption from CAHPS[supreg] Hospice
Survey data collection and reporting requirements for the FY 2022
payment determination. Hospices that intend to claim the size exemption
are required to submit to CMS their total unique patient count for the
period of January 1, 2019 through December 31, 2019. The due date for
submitting the exemption request form for the FY 2022 APU is December
31, 2020. If a hospice continues to meet the eligibility requirements
for this exemption in future FY APU periods, the organization should
request the exemption annually for every applicable FY APU period.
c. Newness Exemption for CAHPS[supreg] Hospice Survey Data Collection
and Reporting Requirements
We previously finalized a one-time newness exemption for hospices
that meet the criteria (81 FR 52181). Accordingly, hospices that are
notified about their Medicare CCN after January 1, 2018 are exempted
from the FY 2020 APU CAHPS[supreg] Hospice Survey requirements due to
newness. No action is required on the part of the hospice to receive
this exemption. The newness exemption is a one-time exemption from the
survey. Likewise, hospices notified about their Medicare CCN after
January 1, 2019, are exempted from the FY 2021 APU CAHPS[supreg]
Hospice Survey and hospices notified about their Medicare CCN after
January 1, 2020, are exempted from the FY 2022 APU CAHPS[supreg]
Hospice Survey requirements.
11. CAHPS[supreg] Hospice Survey Participation Requirements for the FY
2020 APU and Subsequent Years
The CAHPS[supreg] Hospice Survey of CMS' Hospice Quality Reporting
Program is used to collect data on the experiences of hospice patients
and the primary caregivers listed in their hospice records. Readers who
want more information are referred to our extensive discussion of the
Hospice Experience of Care prior to our proposal for the public
reporting of measures should refer to 79 FR 50452 and 78 FR 48261.
a. Background and Description of the CAHPS[supreg] Hospice Survey
The CAHPS[supreg] Hospice Survey is the first standardized national
survey available to collect information on patients' and informal
caregivers' experience of hospice care. Patient-centered experience
measures are a key component of the CMS Quality Strategy, emphasizing
patient-centered care by rating experience as a means to empower
patients and their caregivers and improving the quality of their
care.\46\ In addition, the survey introduces standard survey
administration protocols that allow for fair comparisons across
hospices.
---------------------------------------------------------------------------
\46\ CMS National Quality Strategy 2016. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/cms-quality-strategy.pdf.
---------------------------------------------------------------------------
Details regarding CAHPS[supreg] Hospice Survey national
implementation, survey administration, participation requirements,
exemptions from the survey's requirements, hospice patient and
caregiver eligibility criteria, fielding schedules, sampling
requirements, survey instruments, and the languages that are available
for the survey, are all available on the official CAHPS[supreg] Hospice
Survey Web site, www.HospiceCAHPSsurvey.org and in the CAHPS[supreg]
Hospice Survey Quality Assurance Guidelines (QAG), which is posted on
the Web site.
b. Overview of Proposed Measures
The CAHPS[supreg] Hospice Survey was developed in line with the
U.S. Department of Health and Human Services' Transparency Initiative
to measure patient experience. Unlike the Hospital CAHPS[supreg] Survey
deployed in 2006 (71 FR 48037 through 48039) and other subsequent
CAHPS[supreg] surveys, the CAHPS[supreg] Hospice Survey is administered
after the patient is deceased and queries the decedent's primary
caregiver regarding the patient and family experience of care. National
implementation of the CAHPS[supreg] Hospice Survey commenced January 1,
2015 as stated in the FY 2015 Hospice Wage Index and Payment Rate
Update final rule (79 FR 50452).
The survey consists of 47 questions and is available (using the
mailed version) in English, Spanish, Chinese, Russian, Portuguese,
Vietnamese, Polish, and Korean. It covers topics such as access to
care, communications, getting help for symptoms, and interactions with
hospice staff. The survey also contains two global rating questions and
asks for self-reported demographic information (race/ethnicity,
educational attainment level, languages spoken at home, among others).
The CAHPS[supreg] Hospice Survey measures received NQF endorsement on
October 26th, 2016 (NQF number 2651). Measures derived from the
CAHPS[supreg] Hospice Survey include six multi-item (composite)
measures and two global ratings measures under NQF 2651. We proposed to
adopt these eight survey-based measures for the CY 2018 data collection
period and for subsequent years. We believe these survey-based measures
will be useful in assessing aspects of hospice care where the family/
primary caregiver is the most useful or only source of information, and
to allow meaningful and objective comparisons between hospice
providers. The six CAHPS[supreg] Hospice Survey composite survey-based
measures are:
Hospice Team Communication;
Getting Timely Care;
Treating Family Member with Respect;
Getting Emotional and Religious Support;
Getting Help for Symptoms; and
Getting Hospice Care Training.
Each of the six composite survey-based measures consists of two or
more questions. The two global survey-based measures are:
Rating of Hospice; and
Willingness to Recommend Hospice.
The two global survey-based measures comprise a single question
each and ask the primary caregiver of the decedent to rate the care
provided by the hospice facility and his or her willingness to
recommend the hospice to family and friends. More information about
these measures can be found on the official CAHPS[supreg] Hospice
Survey Web site, www.HospiceCAHPSsurvey.org and in
[[Page 36673]]
the CAHPS[supreg] Hospice Survey Quality Assurance Guidelines (QAG),
which is posted on the Web site.
The eight survey-based measures we proposed were included on the CY
2016 MUC \47\ list, and reviewed by the MAP.\48\ They are as follows:
---------------------------------------------------------------------------
\47\ CMS, List of Measures Under Consideration for December 1,
2016. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/Measures-under-Consideration-List-for-2016.pdf.
\48\ The National Quality Forum. MAP 2016-2017 Preliminary
Recommendations. National Quality Forum, 2016 Recommendations for
Measures Under Consideration, Jan. 2017. Available at: http://www.qualityforum.org/map/.
CAHPS[supreg] Hospice Survey: Rating of Hospice (MUC ID:
MUC16-31).
CAHPS[supreg] Hospice Survey: Hospice Team Communications
(MUC16-32).
CAHPS[supreg] Hospice Survey: Willingness to Recommend (MUC16-
33).
CAHPS[supreg] Hospice Survey: Getting Hospice Care Training
(MUC16-35).
CAHPS[supreg] Hospice Survey: Getting Timely Care (MUC16-36).
CAHPS[supreg] Hospice Survey: Getting Emotional and Religious
Support (MUC16-37).
CAHPS[supreg] Hospice Survey: Getting Help for Symptoms
(MUC16-39)
CAHPS[supreg] Hospice Survey: Treating Family Member with
Respect (MUC16-40)
The MAP supported rulemaking for all eight ``patient-reported''
measures derived from the CAHPS[supreg] Hospice Survey. We received no
comments about these items and therefore, we are adopting these
measures as final for CY 2018.
c. Data Sources
As discussed in the CAHPS[supreg] Hospice Survey Quality Assurance
Guidelines V3.0 (QAG V3.0) (http://www.hospicecahpssurvey.org/en/quality-assurance-guidelines/), the survey has three administration
methods: Mail-only, telephone only, and mixed mode (mail with telephone
follow-up of non-respondents). We previously finalized the
participation requirements for the FY 2018 and FY 2019 Annual Payment
Updates (80 FR 47194). To summarize, to meet the CAHPS[supreg] Hospice
Survey requirements for the HQRP, we proposed that hospice facilities
must contract with a CMS-approved vendor to collect survey data for
eligible patients on a monthly basis and report that data to CMS on the
hospice's behalf by the quarterly deadlines established for each data
collection period. The list of approved vendors is available at: http://www.hospicecahpssurvey.org/en/approved-vendor-list.
Hospices are required to provide lists of the patients who died
under their care, along with the associated primary caregiver
information, to their respective survey vendors to form the samples for
the CAHPS[supreg] Hospice Survey. We emphasize the importance of
hospices providing complete and accurate information to their
respective survey vendors in a timely manner. Hospices must contract
with an approved CAHPS[supreg] Hospice Survey vendor to conduct the
survey on their behalf. Hospices are responsible for making sure their
respective survey vendors meet all data submission deadlines. Vendor
failures to submit data on time are the responsibility of the hospices.
i. Requirements for the FY 2020 Annual Payment Update
To meet participation requirements for the FY 2020 annual payment
update (APU), Medicare-certified hospices must collect CAHPS[supreg]
Hospice Survey data on an ongoing monthly basis from January 2018
through December 2018 (all 12 months) in order to receive their full
payment for the FY 2020 APU. All data submission deadlines for the FY
2020 APU are in Table 17. CAHPS[supreg] Hospice Survey vendors must
submit data by the deadlines listed in Table 17 for all APU periods
listed in the table and moving forward. There are no late submissions
permitted after the deadlines, except for extraordinary circumstances
beyond the control of the provider as discussed above.
Table 17--CAHPS[supreg] Hospice Survey Data Submission Dates for the APU
in FY 2020, FY 2021, and FY 2022
------------------------------------------------------------------------
Sample months (that is, month of death Quarterly data submission
\1\) deadlines \2\
------------------------------------------------------------------------
FY 2020 APU
------------------------------------------------------------------------
January-March 2018 (Q1)................ August 8, 2018.
April-June 2018 (Q2)................... November 14, 2018.
July-September 2018 (Q3)............... February 13, 2019.
October-December 2018 (Q4)............. May 8, 2019.
------------------------------------------------------------------------
FY 2021 APU
------------------------------------------------------------------------
January-March 2019 (Q1)................ August 14, 2019.
April-June 2019 (Q2)................... November 13, 2019.
July-September 2019 (Q3)............... February 12, 2020.
October-December 2019 (Q4)............. May 13, 2020.
------------------------------------------------------------------------
FY 2022 APU
------------------------------------------------------------------------
January-March 2020 (Q1)................ August 12, 2020.
April-June 2020 (Q2)................... November 12, 2020 \3\.
July-September 2020 (Q3)............... February 10, 2021.
October-December 2020 (Q4)............. May 12, 2021.
------------------------------------------------------------------------
\1\ Data collection for each sample month initiates 2 months following
the month of patient death (for example, in April for deaths occurring
in January).
\2\ Data submission deadlines are the second Wednesday of the submission
months, which are the months August, November, February, and May.
\3\ Second Wednesday is Veterans Day Holiday.
ii. Requirements for the FY 2021 Annual Payment Update
To meet participation requirements for the FY 2021 APU, Medicare-
certified hospices must collect CAHPS[supreg] Hospice Survey data on an
ongoing monthly basis from January 2019 through December 2019 (all 12
months) in order to receive their full payment for the FY 2021 APU. All
data submission deadlines for the FY 2021 APU are in Table 17.
CAHPS[supreg] Hospice Survey vendors must submit data by the deadlines
listed in Table 17 for all APU periods listed in the table and moving
[[Page 36674]]
forward. There are no late submissions permitted after the deadlines,
except for extraordinary circumstances beyond the control of the
provider as discussed above.
iii. Requirements for the FY 2022 Annual Payment Update
To meet participation requirements for the FY 2022 APU, Medicare-
certified hospices must collect CAHPS[supreg] Hospice Survey data on an
ongoing monthly basis from January 2020 through December 2020 (all 12
months) in order to receive their full payment for the FY 2022 APU. All
data submission deadlines for the FY 2022 APU are in Table 17.
CAHPS[supreg] Hospice Survey vendors must submit data by the deadlines
listed in Table 17 for all APU periods listed in the table and moving
forward. There are no late submissions permitted after the deadlines,
except for extraordinary circumstances beyond the control of the
provider as discussed above.
d. Measure Calculations
As noted above, we proposed to adopt six composite CAHPS[supreg]
Hospice Survey-based measures and two global survey-based measures. As
with other measures adopted for HQRP, a hospice's performance for a
given payment determination year will be based upon the successful
submission of data required in accordance with the administrative,
form, manner and timing requirements established for the program.
Therefore, hospices' substantive scores on the CAHPS[supreg] Hospice
Survey-based measures will not affect whether they are subject to the
2.0 percentage point payment reduction for hospices that fail to report
data required to be submitted. Rather, the 2.0 percentage point
reduction will be applied based on whether the data were submitted in
accordance with our requirements.
We proposed that CAHPS[supreg] Hospice Survey scores for a given
hospice be displayed as ``top box'' scores, with the national average
top-box score for participating hospices provided for comparison. Top-
box scores reflect the proportion of caregiver respondents that endorse
the most positive response(s) to a given measure, such as the
proportion that rate the hospice a 9 or 10 out of 10 on a 0 to 10
scale, or the proportion that report that they ``always'' received
timely care. The top-box numerator for each question within a measure
is the number of respondents that endorse the most positive response(s)
to the question. The denominator includes all respondents eligible to
respond to the question, with one exception. The exception is the
Getting Hospice Care Training measure; for this measure, the measure
score is calculated only among those respondents who indicated that
their family member received hospice care at home or in an assisted
living facility.
For additional information on the specifications of these measures,
including details regarding top-box scoring methodology and mode and
case-mix adjustment, please refer to the CAHPS[supreg] Hospice Survey
Web page at http://www.hospicecahpssurvey.org/en/.
i. Composite Survey-Based Measures
Unadjusted hospice scores on each composite CAHPS[supreg] Hospice
Survey-based measure would be calculated by determining the proportion
of ``top-box'' responses for each question within the composite and
averaging these proportions over all the questions in the composite
measure. For example, to assess hospice performance on the composite
measure CAHPS[supreg] Hospice Survey--Hospice Team Communication, we
would calculate the proportion of top-box responses for each of the
measure's six questions, add those proportions together, and divide by
the number of questions in the composite measure (in this case, six).
As a specific example, we take a theoretical hospice facility that
had 50 surveys completed and received the proportions of ``top-box''
responses through sample calculations:
25 ``top-box'' responses out of 50 total responses on Question
One
40 ``top-box'' responses out of 50 total responses on Question
Two
50 ``top-box'' responses out of 50 total responses on Question
Three
35 ``top-box'' responses out of 50 total responses on Question
Four
45 ``top-box'' responses out of 50 total responses on Question
Five
40 ``top-box'' responses out of 50 total responses on Question
Six
Based on the above responses, we would calculate that hospice's
unadjusted measure score for public reporting as follows:
Publicly Reported Score. = ((0.5 + 0.8 + 1 + 0.7 + 0.9 + 0.8))/6)
This calculation would give this example hospice an unadjusted
score of 0.78 or 78 percent for the Hospice Team Communication measure
for purposes of public reporting. We note that an adjusted hospice
score would be calculated by adjusting the score for each question for
differences in the characteristics of decedents and caregivers across
hospices and for mode, and then averaging across questions within the
measure as described here. Further detailed information regarding
scoring and risk adjustment can be found at the CAHPS[supreg] Hospice
Survey Web site (http://www.hospicecahpssurvey.org/en/technical-specifications/).
ii. Global Survey-Based Measures
We proposed to adopt two global CAHPS[supreg] Hospice Survey
measures. CAHPS[supreg] Hospice Survey--Rating of Hospice asks the
primary caregiver of the decedent to rate the care provided by the
hospice on a scale of 0 to 10, and CAHPS[supreg] Hospice Survey--
Willingness to Recommend asks about the caregiver's willingness to
recommend the hospice to family and friends on a scale of ``Definitely
No'' to ``Definitely Yes''. Unadjusted hospice performance on each of
the two global CAHPS[supreg] Hospice Survey-based measures would be
calculated by the proportion of respondents providing high-value
responses (that is, a 9 to 10 rating or ``Definitely Yes'') to the
survey questions over the total number of respondents. For example, if
a hospice received 45 ratings of 9 or 10 points out of 50 responses,
this hospital would receive a 0.9 or 90 percent unadjusted score, which
would then be adjusted for differences in the characteristics of
decedents and caregivers across hospices and modes.
iii. Cohort
The CAHPS[supreg] Hospice Survey is administered to all eligible
patients/caregivers--or a random sample thereof--who meet the
eligibility criteria. Eligible patients, regardless of insurance or
payment, can participate.
For purposes of each survey-based measure captured in the
CAHPS[supreg] Hospice Survey, an ``eligible patient'' is a decedent 18
years or older:
With death at least 48 hours following last admission to
hospice care.
for whom there is a caregiver of record.
whose caregiver is someone other than a non-familial legal
guardian.
for whom the caregiver has a United States or United
States Territory home address.
Patients who are still alive or whose admission to the hospice
resulted in a live discharge, are not eligible to participate in the
survey. In addition, decedents/caregivers who initiate or voluntarily
request that the hospice not reveal the patient's identity; and/or not
survey the patient/caregiver (``no publicity patients/caregivers'') are
excluded from the sample.
[[Page 36675]]
e. Risk Adjustment
The CAHPS[supreg] Hospice Survey measures assess activities that
are fully under the control of hospice care professionals and/or
hospice organizations. In order to ensure fair comparisons in public
reporting, we believe it is necessary and appropriate to adjust for
factors that are not directly related to hospice performance, such as
patient mix, for these CAHPS[supreg] Hospice Survey measures. The
survey based measures are adjusted for decedent and caregiver
characteristics (including the lag time between patient death and
survey response; decedent's age, payer for hospice care, decedent's
primary diagnosis, decedent's length of final episode of hospice care,
caregiver's education, decedent's relationship to caregiver,
caregiver's preferred language and language in which the survey was
completed, and caregiver's age) known to be associated with systematic
difference in survey responses.
i. Patient-Mix Adjustment
Previous research, on both CAHPS[supreg] surveys and other types of
surveys, has identified respondent characteristics that are not under
the control of the entities being assessed but tend to be related to
survey responses. Hence, variations in the proportion of respondents
with such characteristics will be associated with variations in survey
responses that are unrelated to the actual quality of hospice care. To
ensure that comparisons between hospices reflect differences in
performance rather than differences in patient and/or caregiver
characteristics, publicly reported hospice scores will be adjusted for
variations of such characteristics across hospices. This adjustment is
performed using a linear regression model applied to all data within a
quarter, with indicator variables for each hospice and each
characteristic as an independent variable in the model.
ii. Mode Adjustment
We conducted an experiment to determine whether survey mode
adjustments were needed to fairly compare CAHPS[supreg] Hospice Survey
scores. The experiment found that mode adjustments are needed. Publicly
reported CAHPS[supreg] Hospice Survey scores will be adjusted for the
mode of survey administration, which affects scores but is not related
to quality of hospice care (Authorized survey modes are: mail-only,
telephone-only, and mail with telephone follow up, also called mixed
mode.). Mode adjustment is performed prior to patient-mix adjustment; a
mode adjustment value is added/subtracted (depending on the mode) to
each response to the survey by mail-only mode or mixed mode. Responses
obtained using telephone-only mode are not adjusted since this is the
reference mode. As a result of the risk adjustment methodologies
proposed here, the final percentages may vary from the unadjusted
percentage as calculated in the examples provided above.
f. For Further Information About the CAHPS[supreg] Hospice Survey
We encourage hospices and other entities to learn more about the
survey on www.hospicecahpssurvey.org. For direct questions, please
contact the CAHPS[supreg] Hospice Survey Team at
[email protected] or telephone 1-844-472-4621.
The comments and our responses are set forth below.
Comment: One commenter stated that: ``typically anything that is
impacted significantly by patient perception--subjective measures
regarding quality of an end of life process are probably not going to
be meaningful. Combined with low health literacy surrounding dying/end
of life and then tying these measures to the hospice payment structure
is probably damaging. Patients and their families probably receive all
of their knowledge about the dying process from hospices themselves,
and since that topic is quite deep to begin with, and the emotional
state of many families and patients is not one that is prepared to
learn in their circumstances, their responses to their surroundings/the
proceedings of hospice probably do not reflect the actual care they are
receiving.''
Response: We believe that patient experience surveys constitute a
useful element in quality reporting programs. Our Hospice CAHPS[supreg]
survey was designed using interviews with caregivers, providers and
other interested professionals to include questions that address the
domains of interest to the caregiving public. Survey results, combined
with other measures such as the HIS, can provide a more rounded view of
hospice quality. Hospices can, and we believe do, use CAHPS[supreg]
results to help them with quality improvement.
Comment: Several commenters expressed reservations about the
timeframe for reporting CAHPS[supreg] Hospice Survey results publicly
on Hospice Compare. Commenters thought the data would be too outdated
and that it would not reflect adjustments and quality improvement
efforts by the hospices.
Response: We are currently planning on reporting scores using a
rolling average over the most recent eight quarters. We are trying to
balance two competing goals. First, we want to present reliable data.
Second, we want to include as large a proportion of hospices as
possible on the Hospice Compare site. Small sample sizes tend to be
less reliable than larger ones. This means that displaying data for
hospices with only a few completed surveys results in providing less
reliable data. On the other hand, if we only report results with large
numbers of completes, a great many hospices will not appear on the
Compare site at all. We tried to avoid both problems by elongating the
amount of time we are using to report the data. We hoped this would
produce larger numbers of completed surveys for the smaller hospices,
thus allowing them to be reported with more reliable data. We are
willing to consider other options and would welcome more input from
hospices.
Comment: One commenter suggested that CMS look at ways to
ameliorate the age of the publicly reported data by ``appropriately
weighting the current data and separately weight the older data or not
include it at all. Further exploration is needed to include patient/
respondent characteristics that may have an impact on the CAHPS[supreg]
survey responses, including issues that are not currently specified for
use in the risk adjustment of CAHPS[supreg] responses.''
Response: We will explore options, if any, offered by weighting
schemes for the publicly reported data. We assume the commenter would
want the newest data weighted more heavily than older data. We are also
willing to continue to examine patient and respondent characteristics
that may be suitable for case mix adjustment. Remember that case mix
variables must be variables that are beyond the control of the hospice.
Comment: Another commenter suggested that CMS consider using a six
month analysis with the most current data for the reporting of
CAHPS[supreg] results. The commenter was concerned that the eight-
quarter rolling reporting period for CAHPS[supreg] results could be
misleading to the public as organization improvement would not be seen
for an extended period and not reflect current performance.
Response: We will continue to review the decision to use an eight-
quarter average. We are aware that there are several potential pitfalls
with survey data. One of the characteristics of small samples is that
the results may shift greatly month to month because of one or a few
outliers among respondents. As
[[Page 36676]]
a result, including small hospices with small samples sizes on the
Compare site also creates the risk of misleading the public. On the
other hand, we are reluctant to restrict the Hospice Compare site to
large hospices. We welcome more input from hospices on this issue.
Comment: One commenter suggested that CMS consider displaying two
sets of data on Hospice Compare, one for eight quarters of data and one
for four quarters of data, which would address concerns about the age
of the data.
Response: We thank the commenter for this suggestion. We are aware
of the concerns about the age of the data. We believe displaying two
sets of CAHPS[supreg] data would make the CAHPS[supreg] pages on
Hospice Compare more complex and might confuse members of the public.
Comment: One commenter stated that analysis of missing data for the
CAHPS[supreg] Hospice Survey is needed to determine how well the survey
results represent the totality of hospice care quality and assist
hospices with the interpretation of survey results for quality
improvement programs.
Response: Our analysis of CAHPS[supreg] Hospice Survey data suggest
that adjustment for differences in case mix, as is done when
calculating CAHPS[supreg] Hospice Survey measure scores, adequately
addresses nonresponse bias associated with these case mix
characteristics.
Comment: CMS should conduct ongoing analysis of the demographics
and other characteristics (for example, age, gender, diagnosis,
geographic area, care setting, etc.) for those patients whose
caregivers (a) are not included in Hospice CAHPS[supreg]
administration; or (b) do not complete a survey. This information at a
minimum should be shared with hospice providers so it can be used to
inform their quality improvement efforts and development of strategies
to improve survey response rates. CMS should also consider including
these results in Hospice Compare to provide consumers with an idea of
the degree that Hospice CAHPS[supreg] survey respondents may differ
from themselves.
Response: We are conducting ongoing analyses of the characteristics
of decedents for whom CAHPS[supreg] Hospice Surveys are completed, and
is considering a variety of means for sharing this information with
hospices.
Comment: One commenter said that caregiver involvement in care
should be included in case mix adjustment of the CAHPS[supreg] Hospice
Survey measures.
Response: Case-mix adjustment addresses factors that are
systematically associated with differences in how caregivers respond to
the CAHPS[supreg] Hospice Survey, and that are not in the control of
the hospice. Hospice activities may influence the degree of caregiver
involvement.
Comment: One commenter noted that the 47 CAHPS[supreg] hospice
survey questions do not address the care planning and/or patient and
family/family caregiver shared decision making. The commenter also
noted that the CAHPS[supreg] survey does ask related questions, but
only after the death of the patient.
Response: We chose to make Hospice CAHPS[supreg] a survey of
caregivers that occurs after the death of the patient, in order to
obtain information about the entire trajectory of hospice care, not
just the care upon which the patient was themselves able to respond. As
the commenter noted, the survey does ask questions related to care
planning and shared-decision making. When developing the questions for
the survey we focused on domains that caregivers told us were important
to them. We are willing to consider other questions for inclusion in
the survey and will think further about care planning and shared
decision making in the future.
Comment: One commenter mentioned that there are no questions about
the ``extent to which the family was able to satisfactorily or
confidently engage in the care or support of their terminally ill
family member.''
Response: We are willing to consider items for inclusion in the
survey. We think the subject raised by the comment would be related to
how often hospice training resulted in the caregiver being confident in
caring for or support of a terminally ill patient.
Comment: One commenter supported ``that CAHPS[supreg] Hospice
Survey scores for a given hospice be displayed as ``top-box'' scores,
with the national average top-box score for participating hospices
provided for comparison. This will allow hospice providers to
understand their measures and identify areas for improvement.''
Response: We are planning to include national average top box
scores for CAHPS[supreg] on Hospice Compare.
Comment: One commenter suggested that CMS incorporate additional
information into the Hospice Compare Web site. Specifically, they
recommended helping the users understand what the hospice benefit
entails. They also suggested that the site provide advice on how to use
quality reports to choose hospices.
Response: We are designing the Hospice Compare site to provide
users with information about the hospice benefit. We are also testing
the site to make sure it is understandable to the public. We will
provide information about how the data are calculated and what it
includes when the hospice data is published on Hospice Compare. We
anticipate this occurring in the Winter of 2018.
Comment: One commenter said, ``It would be wonderful if there were
comments and explanations that tell the story of what the HIS and data
elements were saying. A summary of sorts?''
Response: We appreciate the commenter's suggestion and will
consider for the future, including a guide or legend that describes the
measures. We agree that stakeholders would find this useful.
Comment: One commenter raised a concern about some of the national
benchmarking scores for CAHPS[supreg], asking if it is a valid measure
when the national benchmark scores are all low in one area. The
commenter also asked if anyone is evaluating these survey items.
Response: We are not certain what the commenter means by
``benchmark scores are all low in one area.'' It is unclear if the
commenter means a geographic area or a topic area. Hospice usage and
quality can and does vary by geographic region. The questions included
in the Hospice CAHPS[supreg] survey are thoroughly reviewed by the
Agency for Healthcare Research and Quality (AHRQ) and other healthcare
and research professionals. The CAHPS Hospice Survey was awarded use of
the CAHPS trademark after extensive review by AHRQ's CAHPS[supreg]
Consortium. Measures from the survey were reviewed and endorsed by the
National Quality Forum (NQF #2651). The questions were also reviewed by
the multi-stakeholder MAP, which guides the selection of measures for
HHS.
Comment: One commenter raised the issue of fairness regarding
hospices that are not included in Hospice Compare due to their small
volume of patients served and their length of service.
Response: We are aware of the issue as it impacts inclusion in
Hospice Compare. This is the major rationale for showing eight quarters
of data--it allows us to display more reliable data for more hospices.
We welcome further advice on how best to handle the fairness issue
while at the same time providing accurate information to the public. We
also welcome alternative suggestions for a solution to this issue.
Comment: One commenter noted, ``Families often tell hospice
providers they do not understand why they were sent a second
CAHPS[supreg] survey. They state that they either complete the second
survey or assume we sent it by mistake. Many question the program's
[[Page 36677]]
organizational skills. The instructions/process sent with the surveys
needs to be clearer for bereaved family members.''
Response: We will work with vendors to make sure that caregivers
know why they received a second survey. Much of the time the reason is
that the caregiver's completed survey is sent late enough that we are
into a second wave of mailings to ``non-respondents.'' The
questionnaires cross in the mail.
12. HQRP Reconsideration and Appeals Procedures for the FY 2018 Payment
Determination and Subsequent Years
In the FY 2015 Hospice final rule (79 FR 50496), we notified
hospice providers on how to seek reconsideration if they received a
noncompliance decision for the FY 2016 payment determination and
subsequent years. A hospice may request reconsideration of a decision
by CMS that the hospice has not met the requirements of the HQRP for a
particular period.
We clarified that any hospice that wishes to submit a
reconsideration request must do so by submitting an email to CMS
containing all of the requirements listed on the HQRP Web site at:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Reconsideration-Requests.html.
Electronic email sent to [email protected] is the
only form of submission that will be accepted. Any reconsideration
requests received through any other channel including the United States
Postal Service (USPS) or phone will not be considered as a valid
reconsideration request. In the FY 2017 final rule (81 FR 52143) we
further clarified that providers should submit reconsideration requests
of decision by CMS that the hospice has not met the CAHPS[supreg]
Hospice Survey requirements using the same process (81 FR 52181).
(Details about the reports and emails received after data submission
are in the CAHPS[supreg] Hospice Quality Assurance Guidelines, which is
available on the official CAHPS[supreg] Hospice Survey Web site,
www.hospicecahpssurvey.org). We codified this process at Sec.
418.312(h). In addition, we codified at Sec. 418.306(b)(2) that
beginning with FY 2014 and each subsequent FY, the Secretary shall
reduce the market basket update by 2 percentage points for any hospice
that does not comply with the quality data submission requirements for
that FY and solicited comments on all of the proposals and the
associated regulations text at Sec. 418.312 and in Sec. 418.306 in
section VI of this final rule. Official instructions regarding the
payment reduction reconsideration process can be located under the
Regulations and Guidance, Transmittals, 2015 Transmittals Web site at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals.html.
In the past, only hospices found to be non-compliant with the
reporting requirements set forth for a given payment determination
received a notification from CMS of this finding along with
instructions for requesting reconsideration in the form of a USPS
letter. In the FY 2016 Hospice Wage Index final rule (80 FR 47198), we
stated that we would use the QIES CASPER reporting system as an
additional mechanism to communicate to hospices regarding their
compliance with the reporting requirements for the given reporting
cycle. We have implemented this additional communication mechanism via
the CASPER Hospice Timeliness Compliance Threshold Report previously
discussed in the FY 2017 Hospice Wage Index proposed rule at 81 FR
25527 and 25528. We will continue to send notification of noncompliance
via delivery of a letter via the USPS. We previously finalized our
proposal (80 FR 47198) to publish a list of hospices who successfully
meet the reporting requirements for the applicable payment
determination on the CMS HQRP Web site. The list of providers found to
be compliant with the FY 2017 APU requirements can be found on the CMS
HQRP Web site here: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices.html.
13. Confidential Feedback Reports
As part of our effort to promote use of standardized quality data
to improve quality of care, in December 2016, we made available two new
provider feedback reports: The Hospice-Level Quality Measure Report and
the Patient Stay-Level Quality Measure Report. These confidential
feedback reports are available to each hospice using the CASPER system,
and are part of the class of CASPER reports known as Quality Measure
(QM) Reports. These reports are separate from public reporting and are
for provider viewing only (to the extent permissible under federal
law), for the purposes of internal provider quality improvement. These
reports are on-demand and thus enable hospice providers to view and
compare their performance to the national average for a reporting
period of their choice.
Hospices are able to view their data and information at both the
hospice and patient stay levels for their HIS-based quality measures.
The CASPER hospice-level QM Reports contain information such as the
numerator, denominator, hospice-level QM score, and national average.
The CASPER patient stay-level QM Reports show whether each patient stay
is counted toward each quality measure. The HIS based QMs reported in
both reports include:
NQF #1641 Treatment Preferences
NQF #1647 Beliefs/Values
NQF #1634 Pain Screening
NQF #1637 Pain Assessment
NQF #1639 Dyspnea Screening
NQF #1638 Dyspnea Treatment
NQF #1617 Bowel Regimen
For more information on the CASPER QM Reports, we refer readers to
the CASPER QM Factsheet on the HQRP Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices.html. This fact
sheet contains detailed information about each CASPER QM report
currently available, the data included in the reports, and how
providers can use the reports as part of their Quality Assessment and
Performance Improvement (QAPI) efforts. For technical information on
the reports and how to access the CASPER QM Reports, we refer readers
to: https://www.qtso.com/hospicetrain.html.
As new HIS measures are implemented in the HQRP, we will continue
to expand the functionality of the QM reports to allow providers to
view data on additional HIS measures. We will announce refinements and
additions to the QM reports through sub-regulatory communication
channels and in future rulemaking cycles.
We also proposed to provide hospices with preview reports of their
data prior to the quarterly publication of CAHPS[supreg] Hospice Survey
data on the Compare site. The reports will be provided through the
CASPER reporting system. Each hospice will receive only its own,
individual reports.
14. Public Display of Quality Measures and Other Hospice Data for the
HQRP
Under section 1814(i)(5)(E) of the Act, the Secretary is required
to establish procedures for making any quality data submitted by
hospices available to the public. These procedures shall ensure that a
hospice has the opportunity to review the data that is to be made
public for the hospice prior to such data being made public. The
Secretary shall report quality measures that relate to hospice
[[Page 36678]]
care provided by hospice programs on a publicly available CMS Web site.
In the FY 2017 Hospice final rule, we discussed our analysis of HIS
data to inform which measures were eligible for public reporting and
reportability analysis to determine data selection period and minimum
denominator size for measures to be publicly reported. Based on
analysis results, we determined that all 7 HIS quality measures adopted
for the FY 2016 and beyond (NQF #1634, NQF #1637, NQF #1639, NQF #1638,
NQF #1641, NQF #1647, NQF #1617), calculated based on a rolling 12-
month data selection period, to be eligible for public reporting with a
minimum denominator size of 20 patient stays. For additional details on
these analyses, we refer readers to the FY 2017 Hospice final rule (81
FR 52183 through 52184).
In the FY 2017 Hospice final rule, we also clarified policies for
reportability analyses for new measures. As stated in the FY 2017
Hospice final rule, new measures will undergo reportability analysis to
determine (1) appropriateness for public reporting and (2) appropriate
data selection period. In accordance with discussion in the prior
year's rule, we will use the same analytic approach used in previous
reportability analyses to determine data selection period and minimum
denominator size for the Hospice and Palliative Care Composite Process
Measure--Comprehensive Assessment at Admission. We will begin
reportability analyses for the Hospice Visits When Death is Imminent
Measure Pair once data for the measure are available. Results of
reportability analyses conducted for these new measures will be
communicated through future rulemaking.
To meet the Affordable Care Act's requirement for making quality
measure data public, we are developing a CMS Hospice Compare Web site,
which will allow consumers, providers and stakeholders to search for
all Medicare-certified hospice providers and view their information and
quality measure scores. We anticipate that public reporting of HQRP
data on the CMS Compare Web site will begin August 2017. To help
providers prepare for public reporting, we will offer opportunities for
stakeholder engagement and education prior to the rollout of a CMS
Hospice Compare site. We will offer outreach opportunities for
providers through CMS HQRP Public reporting Web page: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Public-Reporting.html, listserv messages via the Post-Acute Care QRP listserv,
MLN Connects[supreg] National Provider Calls & Events, MLN
Connects[supreg] Provider eNews and announcements on Open Door Forums
and Special Open Door Forums. Finally, we will offer educational
support and outreach to all hospice providers on the systems and
processes for reviewing their data prior to public reporting;
availability of educational support and outreach opportunities will be
communicated through the listed channels above.
We will provide hospices an opportunity to preview their quality
measure data prior to publicly reporting information. These quality
measure data reports or ``preview reports'' will be made available in
the CASPER system prior to public reporting and will offer providers
the opportunity to preview their quality measure data prior to public
reporting on the CMS Hospice Compare Web site. We will provide hospices
30 days to review the preview report beginning from the date on which
they can access the report. Hospices will have an opportunity to
request review of their data by CMS during the 30 day preview period if
they believe that errors in data submitted to CMS may have resulted in
incorrect measure scores and can submit proof along with a plan
describing how the errors will be corrected. We will review these
requests and if we confirm that the errors have affected the measures
and agree to correct the measure, we will suppress the measure on the
Hospice Compare Web site for one time only and display the corrected
measure during the subsequent quarterly refresh of the Compare Web
site. When the preview reports are ready for providers to access,
anticipated August 2017 prior to the release of Hospice Compare, we
will post the policies and procedures for providers to submit requests
for reviewing of their data by CMS on the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Public-Reporting.html. CMS encourages hospices to use CASPER QM Reports (see
section III.D.14 of the FY 2018 proposed rule) to review their HIS
quality measures after they submit the HIS data to CMS. If hospices
determine that erroneous data have been submitted, they should submit
either of these two types of HIS records: Modify existing record or
inactivate existing record to correct their data. HIS data corrected
before the data are frozen for the creation of the preview reports will
be reflected in the preview reports.
We proposed to begin public reporting of CAHPS[supreg] Hospice
Survey measures in 2018. Specifically, we proposed to publicly report
data in winter CY 2018 on all eight CAHPS[supreg] Hospice Survey
measures. Scores would be displayed based on eight rolling quarters of
data and would initially use CAHPS[supreg] Hospice Survey data
collected from caregivers of patients who died while receiving hospice
care between April 1, 2015 and March 31, 2017. We proposed that the
display of these scores be updated quarterly, and that scores be
displayed only for those hospices for which there are 30 or more
completed questionnaires during the reporting period. Scores will not
be displayed for hospices with fewer than 30 completed questionnaires
during the reporting period.
Like other CMS Compare Web sites, the Hospice Compare Web site
will, in time, feature a quality rating system that gives each hospice
a rating of between 1 and 5 stars. Hospices will have prepublication
access to their own agency's quality data, which enables each agency to
know how it is performing before public posting of data on the Hospice
Compare Web site. Public comments regarding how the rating system would
determine a hospice's star rating and the methods used for
calculations, as well as a proposed timeline for implementation will be
announced via the CMS HQRP Web page, listserv messages via the Post-
Acute Care QRP listserv, MLN Connects[supreg] National Provider Calls &
Events, MLN Connects[supreg] Provider eNews and announcements on Open
Door Forums and Special Open Door Forums. We will announce the timeline
for development and implementation of the star rating system in future
rulemaking. Lastly, as part of our ongoing efforts to make healthcare
more transparent, affordable, and accountable for all hospice
stakeholders, we have posted a hospice directory and quality data on a
public data set located at https://data.medicare.gov. This data will
serve as a helpful resource regarding information on Medicare-certified
hospice agencies throughout the nation. In an effort to move toward
public reporting of hospice data, we have initially posted demographic
data of hospice agencies that have been registered with Medicare. This
list includes high-level demographic data for each agency, including
provider name, address, phone numbers, ownership type, CCN, profit
status, and date of original CMS certification. The posting of this
hospice data directory
[[Page 36679]]
occurred on June 14, 2016, and will be refreshed quarterly. Information
can be located at https://data.medicare.gov/data/hospice-directory.
Additionally, we have posted two hospice data files containing national
level aggregate quality data regarding seven HIS quality measures and
CAHPS[supreg] Hospice Survey measures in December 2016. These data
files are a one-time release with a goal to make quality data available
prior to the release of the Hospice Compare in August 2017. Additional
details regarding hospice datasets will be announced via the CMS HQRP
Web page, listserv messages via the Post-Acute Care QRP listserv, MLN
Connects[supreg] National Provider Calls & Events, MLN Connects[supreg]
Provider eNews and announcements on Open Door Forums and Special Open
Door Forums. In addition, we have provided the list of CASPER/ASPEN
contacts, Regional Office and State coordinators in the event that a
Medicare-certified agency is either not listed in the database or the
characteristics/administrative data (name, address, phone number,
services, or type of ownership) are incorrect or have changed. To
continue to meet Medicare enrollment requirements, all Medicare
providers are required to report changes to their information in their
enrollment application as outlined in the Provider-Supplier Enrollment
Fact Sheet Series located at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_InstProv_FactSheet_ICN903783.pdf. Once the Hospice Compare
Web site is released in August 2017, https://data.medicare.gov will
post the official datasets used on the Medicare.gov Compare Web sites
provided by CM.
The comments and our responses are set forth below.
Comment: CMS received several comments that were supportive of
public reporting of hospice quality measures. Commenters noted that
they were in favor of CMS' efforts to publicly report hospice quality
data to support the timely and transparent reporting of HQRP data to
hospice beneficiaries, their families and caregivers, providers, and
other stakeholders. One commenter shared that the public reporting of
hospice quality data was essential to achieving industry goals of
delivering the right care, to the right patient, at the right time.
Several commenters had suggestions, recommendations, and concerns about
specific aspects of the public display of HIS quality measure data.
These specific comments are summarized below.
Response: We appreciate the commenters' support of public reporting
of hospice quality measures. We address commenters' specific concerns
with respect to the public display of quality measures in our responses
below.
Comment: One commenter expressed concern that hospices not included
in public reporting due to not meeting the minimum denominator size for
public reporting, may be disadvantaged. This commenter believed that
the lack of data on the Hospice Compare Web site may disadvantage these
smaller providers as consumers may unfairly assume that the lack of
publicly displayed data indicates lower quality providers. The
commenter believed that this may raise an issue of fairness, whereby
those hospices without publicly displayed quality data may be
negatively impacted by consumers who misinterpret missing data as an
indicator of quality in and of itself and choose not to receive
services from these providers. To mitigate this issue, the commenter
suggested that CMS develop a means to counterbalance the potential
negative consequences for these hospices for which quality information
is not publicly displayed.
Response: We appreciate the commenter sharing concerns regarding
the possible negative impact of the minimum denominator size on small
hospices. The minimum denominator size of 20 patient stays for HIS data
was established through extensive data analysis to ensure that QM
scores were statistically meaningful and reliable. The determination of
the minimum denominator size balanced the necessity of yielding
statistically meaningful QM scores and the goal of allowing as many
hospices as possible to have their QM scores publicly displayed.
Analysis conducted by RTI International shows that only about 10
percent of hospices would not have accumulated enough patient stays to
have their HIS quality measures publicly displayed. The results of this
data analysis are summarized in the Measure Testing Executive Summary
document posted on the ``Current Measures'' portion of the CMS HQRP Web
site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html.
In order to counterbalance any potential negative impact of some
hospices not having their measure data publicly displayed, we plan to
clearly indicate on the Hospice Compare Web site instances where data
is not displayed due to a small denominator size. We believe that this
will signal to consumers that, in such instances, the lack of data is
not an indication of poor quality but rather a result of the hospice
having too few admissions to allow for reporting of a reliable QM. This
approach is consistent with other quality reporting programs. We will
also consider future education and outreach activities to educate
consumers about the minimum denominator size for public reporting to
inform the public that a lack of publicly displayed data does not
necessarily indicate of poor quality.
Comment: One commenter noted that many providers have high scores
on the current HIS-based QMs and that the limited range of scores could
make it difficult for consumers to differentiate between high and low
quality providers. The commenter suggested that publicly displayed data
be presented as a rating or in another similar format.
Response: We agree that many hospice providers are performing well
on the HIS-based QMs. The overall distribution and variability of the
scores of the seven HIS QMs that will be publicly displayed initially
indicate that most hospices are completing the important care processes
for most hospice patients around hospice admission. However, there is
still noticeable room for improvement. Analysis completed by RTI
International shows that a low percentage of hospices have perfect
scores for most measures and a small percentage of hospices have very
low scores. To view the results of these analyses please see the
Measure Testing Executive Summary document posted on the ``Current
Measures'' portion of the CMS HQRP Web site at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html. In preparation for public
reporting, CMS's measure development contractor, RTI International,
interviewed hospice caregivers. Interviews with these caregivers found
that public display of these measures would be useful in avoiding low-
performing providers. Additionally, publicly reporting these measures
inform consumers the important care processes that they should expect
upon hospice admission.
Finally, the Hospice Compare Web site will likely feature a quality
rating system that gives each hospice a rating such as between 1 and 5
stars. This will help supplement the measure scores by presenting the
data as a rating. We will announce the timeline for the development and
implementation of the star rating system in future rulemaking.
Comment: CMS received a few comments raising concerns about
consumers' understanding of quality measure data reported on the
Hospice Compare Web site. They recommended that CMS ensure that all
information posted to the Web site is meaningful
[[Page 36680]]
and easily understandable to the general public. Commenters suggested
that supplemental information, including general descriptions of the
Medicare hospice benefit and consumer-friendly explanations of the HIS
data be included on the Hospice Compare Web site to provide context for
interpretation of publicly reported quality data. Furthermore, one
commenter suggested CMS engage patients, caregivers, providers, and
other stakeholders in the development process for the Hospice Compare
Web site to ensure that the data presented are meaningful and
actionable.
Response: We appreciate commenters' suggestions on information to
include on the Hospice Compare Web site. We will take these into
consideration as we continue to develop the Web site. We are committed
to ensuring that all publicly reported data is presented in an
appropriate and meaningful manner to the public. As such, we are
working with our Web site development contractor to ensure that the
Hospice Compare Web site will be tested for usability, readability, and
navigation before its launch in August 2017. Consumers and stakeholders
are continuously involved and are having opportunities for input
throughout the development process. Text on the Hospice Compare Web
site will comply with the Plain Writing Act of 2010. In addition to
complying with the Plain Language Act, we are also taking into account
variations in health and general literacy, and are soliciting input
from key stakeholders and technical experts in the development and
presentation of publicly available data.
Comment: A commenter raised concerns that public reporting of
quality measures could lead to negative unintended consequences for
hospice providers, such as reduced referrals.
Response: We appreciate the commenter's concerns about potential
negative implications of public reporting of quality data. It is our
hope that the public display of hospice-level data will provide an
incentive to providers to identify areas of improvement and develop
performance improvement plans to improve the quality of care delivered
to their patients and their performance on quality measures. By
developing performance improvement plans around areas for improvement,
hospices can help minimize negative impacts on referrals. We will
continue to carefully consider any potential unintended consequences of
public reporting as we develop and report future HIS-based measures.
Comment: A few commenters expressed concerns that data reported in
the inaugural release of the Hospice Compare Web site would be
incorrect, and cited two main reasons for potential inaccuracies in
data. One commenter believed that provider knowledge gaps about measure
specifications could lead to errors in coding of HIS items and,
subsequently, errors in measure scores and the display of incorrect
measure data. The commenter encouraged CMS to identify knowledge gaps
and quickly provide education to correct these misunderstandings so
that inaccurate data (that is, data that is not reflective of actual
care processes taking place but rather of inaccurate coding of HIS
items) is not reported on Hospice Compare. A second reason that
commenters provided was that there was insufficient time to preview HIS
data submissions prior to public reporting. These commenters believed
that hospices did not have sufficient time to correct data during the
30-day preview period.
Response: We appreciate commenters taking time to express their
concerns about the accuracy of publicly reported data. We agree that it
is of the upmost importance that data presented on the Web site is
accurate and that providers have all the information and training
necessary to accurately report HIS-based quality measure scores. We
encourage providers to submit questions about measure specifications,
coding guidance for HIS items, public reporting, and the preview period
to the Hospice Quality Help Desk at
[email protected]. We monitor common types of
questions submitted to the Help Desk and use this information to
determine potential knowledge gaps that should be the focus of regular
outreach and education efforts. Such regular education efforts and
clarifications in coding guidance for the HIS are communicated to
providers on a regular basis through quarterly Question & Answer
documents, Help Desk guidance, spotlights and announcements, and MLN
eNews Listservs. We encourage providers to regularly check the CMS HQRP
Web page for these educational materials. We routinely communicate
updates about measure specifications and/or HIS items through these
educational and communication outlets.
To prevent the public display of incorrect HIS measure data, we
encourage hospices to use their CASPER QM reports (see section III.D.13
of the FY 2018 Hospice proposed rule) to regularly review their HIS
quality measure scores. If hospices determine that erroneous data have
been submitted, providers should use the HIS record modification and
inactivation processes, as outlined in the HIS Manual available on the
``Hospice Item Set (HIS)'' portion of the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html.
Hospice providers can submit modification and inactivation requests up
to 36 months from the target date of any given HIS record. Regular
monitoring of CASPER QM reports will help ensure that erroneous data
are identified early and errors can be corrected in a timely manner. In
addition to using QM reports as a mechanism for identifying errors, we
also encourages hospices to proactively prevent errors in submitted
data by ensuring that staff and clinicians are trained on the latest
coding guidance, and that quality assurance and monitoring processes
are in place to prevent the submission of incorrect data. We would like
to note that HIS data corrected after the data are frozen for the
creation of the Provider Preview Reports will not be reflected in the
upcoming Hospice Compare Web site update, but will be displayed in the
subsequent quarterly update. Because of this, we encourage providers to
implement quality assurance and monitoring processes and check CASPER
QM reports frequently.
Once the preview reports are generated, the underlying data cannot
be corrected. If a hospice disagrees with the QM scores presented in
their preview report, the hospice will have the opportunity to request
review of their data by CMS during the 30-calendar day preview period.
We will review these requests and if CMS agrees that the data is
incorrect, the data will be suppressed for one quarter and the
corrected data will be posted during the subsequent quarterly refresh
of the Compare site. The process for CMS review of data is posted on
the ``Hospice Quality Public Reporting'' portion of the CMS HQRP Web
site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Public-Reporting.html. The 30-calendar day preview period for Hospice
Compare is consistent with preview periods in other quality reporting
programs and has been sufficient in other settings. We encourage
providers to sign up for the Post-Acute Care QRP listserv for more
information about preview report roll-out and the preview period. We
will take concerns about the length of the preview period into
consideration for
[[Page 36681]]
future updates to public reporting of quality data.
Comment: CMS received several comments in support of the future
development of a star rating system for the Hospice Compare Web site.
Commenters provided several suggestions on creating a star rating
system that would be useful to consumers and providers. A majority of
commenters were opposed to a normative approach to calculating star
ratings where ratings are placed on a bell curve. They believed that
this approach would be confusing to consumers and not truly indicative
of hospice performance. Commenters preferred a criterion approach for
star ratings where CMS would establish benchmarks and calculate ratings
based on hospice performance in relation to the established quality
benchmark. Other commenters suggested that the star ratings include
criteria beyond measure scores, such as patient/family satisfaction,
financial performance, geographic indicators, and specialized services
provided by the hospice.
Response: We appreciate commenters' detailed input on the
development of a star rating methodology for hospice. While we have not
set a date for implementing such a system, it is of paramount concern
to us to develop a star rating methodology that is valid, reliable, and
meaningful to consumers. We will alert our stakeholders once we are
closer to entering that phase. We will provide continued opportunities
for the provider community and other stakeholders to comment on and
provide input to development of a star a proposed rating system. In
addition to regular HQRP communication channels, we expect to solicit
input from the public regarding star rating methodology through
communication channels which may include special listening sessions,
Open Door Forums, a TEP, and other opportunities. Additionally, we will
benefit from lessons learned from the development and implementation of
the star ratings in other quality reporting programs to help guide
development of star ratings for hospice. Finally, we will announce the
timeline for development and implementation of Hospice star ratings in
future rulemaking, which will provide additional opportunity for
stakeholders to provide public feedback on any proposed star rating
methodology.
IV. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
Unless noted otherwise, all salary information is from the Bureau
of Labor Statistics (BLS) Web site at http://www.bls.gov/oes and
includes a fringe benefits package worth 100 percent of the base
salary. The mean hourly wage rates are based on May, 2015 BLS data for
each discipline.
Section 1814(i)(5)(C) of the Act requires that each hospice submit
data to the Secretary on quality measures specified by the Secretary.
This data must be submitted in a form and manner, and at a time
specified by the Secretary.
We solicited public comment and received no comments on each of
these issues for the following sections of this document that contain
information collection requirements (ICRs) and are finalizing them.
A. Hospice Item Set (OMB Control Number 0938-1153)
In the FY 2014 Hospice Wage Index final rule (78 FR 48257), and in
compliance with section 1814(i)(5)(C) of the Act, we finalized the
specific collection of data items that support the following 7 NQF
endorsed measures for hospice:
NQF #1617 Patients Treated with an Opioid who are Given a
Bowel Regimen,
NQF #1634 Pain Screening,
NQF #1637 Pain Assessment,
NQF #1638 Dyspnea Treatment,
NQF #1639 Dyspnea Screening,
NQF #1641 Treatment Preferences,
NQF #1647 Beliefs/Values Addressed (if desired by the
patient).
We finalized the following two additional measures in the FY 2017
Hospice Wage Index final rule affecting FY 2019 payment determinations
(81 FR 52163 through 52173):
Hospice Visits when Death is Imminent
Hospice and Palliative Care Composite Process Measure--
Comprehensive Assessment at Admission
Data for the aforementioned 9 measures is collected via the HIS as
discussed in the FY 2017 Hospice Wage Index final rule (81 FR 52189)
and covered under OMB control number 0938-1153. The HIS V2.00.0 was
approved by the Office of Management and Budget on April 17, 2017 under
control number 0938-1153. We are not making any new updates or
additional collections of information in this rule in regards to the
Hospice Item Set or its constituent quality measures.
B. Summary of CAHPS[supreg] Hospice Survey Information Collection
Requirements (OMB Control Number 0938-1257)
National Implementation of the Hospice Experience of Care Survey
(CAHPs Hospice Survey) data measures are covered under OMB control
number 0938-1257 and is summarized here for convenience. We have
implemented patient experience surveys in a number of settings
including Medicare, Medicare Advantage, and Part D Prescription Drug
Plans, hospitals, and home health agencies. Other CAHPS[supreg] surveys
exist for hemodialysis facilities, nursing homes, and physician
practices. The hospice survey differs from most other CMS patient
experience surveys because its target population is bereaved family
members or close friends of patients who died in hospice care. Family
members and friends are the best source of information regarding the
entire trajectory of hospice care. In addition, many hospice patients
are very ill and unable to answer survey questions.
Surveys are administered by CMS-approved survey vendors hired by
hospice providers to conduct the survey on their behalf. The survey
vendor may collect data in one of three modes: Mail-only, telephone-
only, or mixed mode (mail with telephone follow-up). The sample
consists of bereaved family members or close friends of patients who
died while receiving hospice care (1) at home, (2) in a nursing home,
or (3) an inpatient setting (that is, freestanding inpatient unit or
acute care hospital). The questionnaire is composed of 47 items.
The estimated annualized burden hours and costs to respondents for
the national implementation of the CAHPS[supreg] Hospice Survey are
shown in Tables 18 and 19. Based on participation in national
implementation in the CAHPS[supreg] Hospice Survey from Quarter 2 2015
through Quarter 1 2016, we assume that
[[Page 36682]]
3,414 hospices will administer the survey to an average of 278.7 cases.
Thus, we estimate that the CAHPS[supreg] Hospice Survey will be
administered to a maximum of 951,482 individuals each year for the
duration of the collection period covered by this application for the
purposes of national implementation. As not all sampled cases will
complete the survey, this estimate reflects the maximum burden
possible. The estimated number of responses is based on actual hospice
participation in national implementation of the CAHPS[supreg] Hospice
Survey. Table 18 shows the estimated annualized burden for the
respondents' time to participate in the national implementation data
collection. The survey contains 47 items and is estimated to require an
average administration time of 10.4 minutes in English (at a pace of
4.5 items per minute) and 12.5 minutes in Spanish (assuming 20 percent
more words in the Spanish translation), for an average response time of
10.47 minutes or 0.174 hours (assuming that 1 percent of survey
respondents complete the survey in Spanish). These burden and pace
estimates are based on CMS' experience with the CAHPS[supreg] Hospice
Survey and surveys of similar length that were fielded with Medicare
beneficiaries. As indicated below, the annual total burden hours for
survey participants are estimated to be 165,959.57 for the continued
national implementation of the survey.
Table 18--Estimated Annualized Burden Hours for Respondents: National Implementation of the CAHPS[supreg]
Hospice Survey
----------------------------------------------------------------------------------------------------------------
Number of
Survey version Number of responses per Hours per Total burden
respondents respondent response hours
----------------------------------------------------------------------------------------------------------------
CAHPS[supreg] Hospice Survey.................... 951,482 1 0.174 165,959.57
---------------------------------------------------------------
Total....................................... 951,482 1 0.174 165,959.57
----------------------------------------------------------------------------------------------------------------
Table 19 shows the cost burden to respondents associated with their
time to complete a survey as part of national implementation. The
annual total cost burden is estimated to be $7,710,481.60. This
estimate is higher than the $3,034,789.70 estimated in the prior OMB
filing, due to the increased number of hospices participating (and
correspondingly, the increased number of respondents), as well as an
increase in the average hourly rate.
Table 19--Estimated Annualized Cost Burden for Respondents: National Implementation
----------------------------------------------------------------------------------------------------------------
Number of Total burden Average hourly Total cost
Form name respondents hours wage rate * burden
----------------------------------------------------------------------------------------------------------------
CAHPS[supreg] Hospice Survey.................... 951,482 165,959.57 * $46.46 $7,710,481.60
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Total....................................... 951,482 165,959.57 * 46.46 7,710,481.60
----------------------------------------------------------------------------------------------------------------
* Source: Data from the U.S. Bureau of Labor Statistics' May 2015 National Occupational Employment and Wage
Estimates for all salary estimates (http://www.bls.gov/oes). This figure includes a 100% fringe benefit on an
average wage of $23.23. Retrieved April 10, 2017.
V. Regulatory Impact Analysis
A. Statement of Need
This final rule meets the requirements of our regulations at Sec.
418.306(c), which requires annual issuance, in the Federal Register, of
the hospice wage index based on the most current available CMS hospital
wage data, including any changes to the definitions of Core-Based
Statistical Areas (CBSAs), or previously used Metropolitan Statistical
Areas (MSAs). This final rule will also update payment rates for each
of the categories of hospice care, described in Sec. 418.302(b), for
FY 2018 as required under section 1814(i)(1)(C)(ii)(VII) of the Act.
Section 411(d) of the Medicare Access and CHIP Reauthorization Act of
2015 (MACRA) amended section 1814(i)(1)(C) of the Act such that for
hospice payments for FY 2018, the market basket percentage increase
shall be 1 percent. Finally, section 3004 of the Affordable Care Act
amended the Act to authorize a quality reporting program for hospices
and this rule discusses changes in the requirements for the hospice
quality reporting program in accordance with section 1814(i)(5) of the
Act.
B. Overall Impacts
We estimate that the aggregate impact of the payment provisions in
this final rule will result in an increase of $180 million in payments
to hospices, resulting from the hospice payment update percentage of
1.0 percent. The impact analysis of this final rule represents the
projected effects of the changes in hospice payments from FY 2017 to FY
2018. Using the most recent data available at the time of rulemaking,
in this case FY 2016 hospice claims data, we apply the current FY 2017
wage index and labor-related share values to the level of care per diem
payments and SIA payments for each day of hospice care to simulate FY
2017 payments. Then, using the same FY 2016 data, we apply the FY 2018
wage index and labor-related share values to simulate FY 2018 payments.
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. The nature of the
Medicare program is such that the changes may interact, and the
complexity of the interaction of these changes could make it difficult
to predict accurately the full scope of the impact upon hospices.
We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(January 18, 2011), the Regulatory Flexibility Act (September 19, 1980,
Pub. 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.
L. 104-4), Executive Order 13132 on Federalism (August 4,
[[Page 36683]]
1999), the Congressional Review Act (5 U.S.C. 804(2) and Executive
Order 13771 on Reducing Regulation and Controlling Regulatory Costs
(January 30, 2017).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). Section
3(f) of Executive Order 12866 defines a ``significant regulatory
action'' as an action that is likely to result in a rule: (1) Having an
annual effect on the economy of $100 million or more in any 1 year, or
adversely and materially affecting a sector of the economy,
productivity, competition, jobs, the environment, public health or
safety, or state, local or tribal governments or communities (also
referred to as ``economically significant''); (2) creating a serious
inconsistency or otherwise interfering with an action taken or planned
by another agency; (3) materially altering the budgetary impacts of
entitlement grants, user fees, or loan programs or the rights and
obligations of recipients thereof; or (4) raising novel legal or policy
issues arising out of legal mandates, the President's priorities, or
the principles set forth in the Executive Order.
A regulatory impact analysis (RIA) must be prepared for major rules
with economically significant effects ($100 million or more in any 1
year). We estimate that this rulemaking is ``economically significant''
as measured by the $100 million threshold, and hence also a major rule
under the Congressional Review Act. Accordingly, we have prepared a RIA
that, to the best of our ability presents the costs and benefits of the
rulemaking.
C. Anticipated Effects
The Regulatory Flexibility Act (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. The great
majority of hospitals and most other health care providers and
suppliers are small entities by meeting the Small Business
Administration (SBA) definition of a small business (in the service
sector, having revenues of less than $7.5 million to $38.5 million in
any 1 year), or being nonprofit organizations. For purposes of the RFA,
we consider all hospices as small entities as that term is used in the
RFA. HHS's practice in interpreting the RFA is to consider effects
economically ``significant'' only if greater than 5 percent of
providers reach a threshold of 3 to 5 percent or more of total revenue
or total costs. The effect of the FY 2018 hospice payment update
percentage results in an overall increase in estimated hospice payments
of 1.0 percent, or $180 million. Therefore, the Secretary has
determined that this final rule will not create a significant economic
impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a metropolitan
statistical area and has fewer than 100 beds. This final rule only
affects hospices. Therefore, the Secretary has determined that this
final rule will not have a significant impact on the operations of a
substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2017, that
threshold is approximately $148 million. This final rule is not
anticipated to have an effect on state, local, or tribal governments,
in the aggregate, or on the private sector of $148 million or more.
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. We have reviewed this final rule under these criteria of
Executive Order 13132, and have determined that it will not impose
substantial direct costs on state or local governments.
If regulations impose administrative costs on private entities,
such as the time needed to read and interpret this final rule, we
should estimate the cost associated with regulatory review. Due to the
uncertainty involved with accurately quantifying the number of entities
that will review the rule, we assume that the total number of unique
commenters on the published proposed rule will be the number of
reviewers of this final rule. We acknowledge that this assumption may
understate or overstate the costs of reviewing this final rule. It is
possible that not all commenters reviewed the proposed rule in detail,
and it is also possible that some reviewers chose not to comment on the
proposed rule. For these reasons we thought that the number of comments
received on the proposed rule would be a fair estimate of the number of
reviewers of this final rule. We also recognize that different types of
entities are in many cases affected by mutually exclusive sections of
this final rule, and therefore for the purposes of our estimate we
assume that each reviewer reads approximately 50 percent of the rule.
Using the wage information from the BLS for medical and health service
managers (Code 11-9111), we estimate that the cost of reviewing this
rule is $105.16 per hour, including overhead and fringe benefits
(https://www.bls.gov/oes/current/oes_nat.htm). Assuming an average
reading speed, we estimate that it would take approximately 1.6 hours
for the staff to review half of this rule. For each hospice that
reviews the rule, the estimated cost is $168.26 (1.6 hours x $105.16).
Therefore, we estimate that the total cost of reviewing this regulation
is $15,143.40 ($168.26 x 90 reviewers).
A summary of the comments we received on the RIA and our responses
to those comments are set forth below.
Comment: A commenter disagreed with CMS' assertion the proposed
rule will not create a significant economic impact on a substantial
number of small entities. The commenter believes that the impact of the
overall increase will not be felt proportionally across hospices. Small
hospices will face significant financial hardships, especially those
with fewer data collection resources, who would be subject to the 2
percent penalty for inadequate quality data submission. The commenter
encouraged CMS to provide a more detailed analysis of the impact on
hospices, especially small and rural hospices.
Response: Hospices are estimated to receive a 1 percent increase in
payments in FY 2018. Based on our analysis, we concluded that the
policies in the proposed rule would not result in an estimated total
adverse impact of 3 to 5 percent or more on Medicare revenue for
greater than 5 percent of hospices. The 1 percent payment update is
statutorily-mandated by MACRA (Pub. L. 114-10, enacted April 16, 2015).
Furthermore, we believe that Table 20 sufficiently describes the impact
on rural hospices as well as small hospices (as measured by the number
of RHC days).
[[Page 36684]]
Comment: A commenter agreed that if regulations impose
administrative costs on private entities, such as the time needed to
read and interpret the proposed rule, CMS should estimate the cost
associated with regulatory review. The commenter stated that CMS should
not assume that the number of commenters equates to the number of
reviewers. Many individual hospices, especially smaller hospices, may
not submit an individual comment but instead will collaborate with
their professional associations to provide comments. However, each
hospice still thoroughly reviews, engages in background research,
interprets and assesses the impact of proposals on current practice, as
well as how practices may need to shift if proposals are finalized, in
order to engage in those collective processes to prepare a comment
letter.
Response: We thank the commenter for proving feedback on the
methodology used to determine the costs associated with regulatory
review. We will take the comment under consideration for any future
refinements to the methodology used to determine the costs of
regulatory review. As noted previously, we already take many of these
costs into account.
D. Detailed Economic Analysis
The FY 2018 hospice payment impacts appear in Table 20. We tabulate
the resulting payments according to the classifications in Table 20
(for example, facility type, geographic region, facility ownership),
and compare the difference between current and future payments to
determine the overall impact.
The first column shows the breakdown of all hospices by urban or
rural status, census region, hospital-based or freestanding status,
size, and type of ownership, and hospice base. The second column shows
the number of hospices in each of the categories in the first column.
The third column shows the effect of the annual update to the wage
index. This represents the effect of using the FY 2018 hospice wage
index. The aggregate impact of this change is zero percent, due to the
hospice wage index standardization factor. However, there are
distributional effects of the FY 2018 hospice wage index.
The fourth column shows the effect of the hospice payment update
percentage for FY 2018. The FY 2018 hospice payment update percentage
of 1 percent is mandated by section 1814(i)(1)(C) of the Act, as
amended by section 411(d) of the MACRA.
The fifth column shows the effect of all the changes on FY 2018
hospice payments. It is projected that aggregate payments will increase
by 1.0 percent, assuming hospices do not change their service and
billing practices.
As illustrated in Table 20, the combined effects of all the
proposals vary by specific types of providers and by location. For
example, due to the changes in this rule, the estimated impacts on FY
2018 payments range from a 0.9 percent decrease for hospices providing
care in the rural outlying region to a 1.7 percent increase for
hospices providing care in the urban Pacific region.
Table 20--Projected Impact to Hospices for FY 2018
----------------------------------------------------------------------------------------------------------------
FY 2018
Number of Updated wage hospice FY 2018 total
providers data (%) payment update change (%)
(%)
(1) (2) (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
All Hospices.................................... 4,355 0.0 1.0 1.0
Urban Hospices.................................. 3,381 0.0 1.0 1.0
Rural Hospices.................................. 974 0.1 1.0 1.1
Urban Hospices--New England..................... 134 -0.7 1.0 0.3
Urban Hospices--Middle Atlantic................. 252 0.1 1.0 1.1
Urban Hospices--South Atlantic.................. 430 -0.3 1.0 0.7
Urban Hospices--East North Central.............. 407 -0.1 1.0 0.9
Urban Hospices--East South Central.............. 159 0.0 1.0 1.0
Urban Hospices--West North Central.............. 233 -0.2 1.0 0.8
Urban Hospices--West South Central.............. 662 0.0 1.0 1.0
Urban Hospices--Mountain........................ 327 -0.1 1.0 0.9
Urban Hospices--Pacific......................... 736 0.7 1.0 1.7
Urban Hospices--Outlying........................ 41 -0.6 1.0 0.4
Rural Hospices--New England..................... 23 0.0 1.0 1.0
Rural Hospices--Middle Atlantic................. 40 0.6 1.0 1.6
Rural Hospices--South Atlantic.................. 135 0.1 1.0 1.1
Rural Hospices--East North Central.............. 141 0.2 1.0 1.2
Rural Hospices--East South Central.............. 124 -0.1 1.0 0.9
Rural Hospices--West North Central.............. 181 0.2 1.0 1.2
Rural Hospices--West South Central.............. 180 0.1 1.0 1.1
Rural Hospices--Mountain........................ 101 0.2 1.0 1.2
Rural Hospices--Pacific......................... 46 0.3 1.0 1.3
Rural Hospices--Outlying........................ 3 -1.9 1.0 -0.9
0-3,499 RHC Days (Small)........................ 1,004 0.2 1.0 1.2
3,500-19,999 RHC Days (Medium).................. 2,017 0.1 1.0 1.1
20,000+ RHC Days (Large)........................ 1,334 0.0 1.0 1.0
Non-Profit Ownership............................ 1,059 0.0 1.0 1.0
For Profit Ownership............................ 2,735 0.1 1.0 1.1
Government Ownership............................ 155 -0.3 1.0 0.7
Other Ownership................................. 406 -0.2 1.0 0.8
Freestanding Facility Type...................... 3,379 0.0 1.0 1.0
HHA/Facility-Based Facility Type................ 976 0.0 1.0 1.0
----------------------------------------------------------------------------------------------------------------
Source: FY 2016 hospice claims from the Chronic Condition Data Warehouse (CCW) Research Identifiable File (RIF)
in June 2017.
Region Key:
[[Page 36685]]
New England=Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont; Middle
Atlantic=Pennsylvania, New Jersey, New York; South Atlantic=Delaware, District of Columbia, Florida, Georgia,
Maryland, North Carolina, South Carolina, Virginia, West Virginia; East North Central=Illinois, Indiana,
Michigan, Ohio, Wisconsin; East South Central=Alabama, Kentucky, Mississippi, Tennessee; West North
Central=Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota; West South Central=Arkansas,
Louisiana, Oklahoma, Texas; Mountain=Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming;
Pacific=Alaska, California, Hawaii, Oregon, Washington; Outlying=Guam, Puerto Rico, Virgin Islands.
E. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 21, we have
prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this final rule. Table
21 provides our best estimate of the possible changes in Medicare
payments under the hospice benefit as a result of the policies in this
final rule. This estimate is based on the data for 4,355 hospices in
our impact analysis file, which was constructed using FY 2016 claims
available in June 2017. All expenditures are classified as transfers to
hospices.
Table 21--Accounting Statement: Classification of Estimated Transfers
and Costs, From FY 2017 to FY 2018
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $180 million *
From Whom to Whom?........................ Federal Government to
Medicare Hospices.
------------------------------------------------------------------------
* The net increase of $180 million in transfer payments is a result of
the 1.0 percent hospice payment update compared to payments in FY
2017.
F. Reducing Regulation and Controlling Regulatory Costs
Executive Order 13771, entitled ``Reducing Regulation and
Controlling Regulatory Costs,'' was issued on January 30, 2017 (82 FR
9339, February 3, 2017). It has been determined that this final rule is
a transfer rule that does not impose more than de minimis costs as
described above and thus is not a regulatory or deregulatory action for
the purposes of Executive Order 13771.
G. Conclusion
We estimate that aggregate payments to hospices in FY 2018 will
increase by $180 million, or 1.0 percent, compared to payments in FY
2017. We estimate that in FY 2018, hospices in urban and rural areas
will experience, on average, 1.0 percent and 1.1 percent increases,
respectively, in estimated payments compared to FY 2017. Hospices
providing services in the urban Pacific and rural Middle Atlantic
regions will experience the largest estimated increases in payments of
1.7 percent and 1.6 percent, respectively. Hospices serving patients in
urban areas in the New England region will experience, on average, the
lowest estimated increase of 0.3 percent in FY 2018 payments.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
Dated: July 25, 2017.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
Dated: July 27, 2017
Thomas E. Price,
Secretary, Department of Health and Human Services.
[FR Doc. 2017-16294 Filed 8-1-17; 4:15 pm]
BILLING CODE 4120-01-P