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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

CMS Issues Proposed FY2014 Hospice Wage Index Rule - Net Update of 1.1% Projected

Notice Signals CMS Intent on Quality Reporting, Advises on Payment Reform Considerations
April 30, 2013 04:10 PM

Late Monday, April 29, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule “Medicare Program; FY2014 Hospice Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements; and Updates on Payment Reform.”  While the rule includes no proposed changes for payment reforms required by the Affordable Care Act (ACA), it does outline findings from ongoing analysis and provides options for future consideration.  The rule requests comment on proposed changes to the Hospice Quality Reporting Program (HQRP) and a planned Hospice Experience of Care Survey as part of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.  The proposed rule contains numerous comments. The National Association for Home Care & Hospice (NAHC) is in the process of conducting a thorough analysis of the proposed rule and will issue additional reports and findings in future issues of NAHC Report.


For fiscal year (FY) 2014, CMS currently anticipates hospice payments to increase by a net of 1.1 percent on average.  This figure was calculated using the anticipated FY2014 hospital market basket update - currently projected at 2.5 percent - reduced by 0.7 percentage points due to reductions mandated by the Affordable Care Act (ACA).  Changes to the wage index, including the continuing phase-out of the Budget Neutrality Adjustment Factor (BNAF) - FY2014 will be the fifth of the seven year phase out - would further reduce projected payments by 0.7 percentage points.

It should be noted that the hospital market basket and the ACA changes could undergo reestimation. A notice with final payment determinations will be issued this summer.

Hospices that failed to report quality measures required under the Hospice Quality Reporting Program (HQRP) earlier this year would have their market basket values further reduced by 2 percentage points. In the proposed rule CMS notes that in the near future it will issue instructions for hospices that are determined not to have complied with the HQRP requirements to apply for a reconsideration of the reduction.  The notice does not reference the 2 percent sequester required under current law.


CMS included as part of the rule estimated FY2014 payment rates for the four payment categories under hospice. Following is a table that includes the projected payment rates:


Proposed FY2014 Hospice Payment Rates Updated by the Proposed Hospice Payment Update Percentage



FY2013 payment Rates

Multiply by the FY2014 proposed hospice payment update of 1.8 percent

FY2014 Proposed Payment Rate

Labor Share of the proposed payment rate

Non-labor share of the proposed payment rate


Routine Home Care







Continuous Home Care


Full rate=24 hours of care


$=37.99 hourly rate






















Inpatient Respite Care







General Inpatient Care







CMS also provides estimated rates of payment for those providers who failed to comply with the HQRP reporting requirements. They are as follows:


Proposed FY2014 Hospice Payment Rates Updated by the Proposed Hospice Payment Update Percentage for Hospices that DO NOT Submit the Required Quality Data



FY2013 Payment Rates

Multiply by the FY2014 hospice payment update percentage of 1.8 percentage minus 2 percentage points (-0.2)

FY2014 Proposed Payment Rate


Routine Home Care





Continuous Home Care full Rate=24 hours of care $=37.99 hourly rate






Inpatient Respite Care





General Inpatient Care






CMS no longer publishes wage index values in its Federal Register notices. Instead the values are posted online.  The FY2014 hospice wage index values are available here.


As part of the proposed rule, CMS provides insight into its ongoing study aimed at reforming the hospice payment system but DOES NOT propose payment reform changes at this time. 

CMS intends to post the Abt Hospice Study Technical Report on the Hospice Center webpage later this week. 

The proposed rule does include discussion of several options that could be considered for payment reform, including:

  • Use of the initial Medicare Payment Advisory Commission (MedPAC) proposed U-shaped model (first proposed in March 2009) that provides increased payment at the beginning and end of an episode of care, with reduced daily payments in the middle.  CMS comments that concerns with this model include that very short hospice stays have a flatter curve.
  • As an alternative to the U-shaped model, CMS suggests a possible tiered approach to payment with payment tiers based on the length of stay.
  • Use of a possible short-stay add-on to cover the higher costs of patients who are on service for a limited time.
  • CMS does not rule out the possibility of a case-mix based system, however additional data is needed to develop this type of system, including additional diagnoses on claims.

Rebasing of RHC

As part of the notice CMS also discussed rebasing of Routine Home Care (RHC) based on more current data.  CMS indicates that they have found evidence of “potential misalignment” between the current RHC rate and the costs of providing RHC.  They are not proposing rebasing at this time, but indicate one option would be to rebase the three clinical service components - nursing, home health aide, social services/therapy - that comprise 69.7 percent of the RHC rate.  Such rebasing would result in a rebased rate of $140.44 in FY2014. 

If CMS were to include rebasing as part of payment reform, CMS would be required to reprogram the funds to other parts of hospice payment in the first year of payment reform due to the requirement for budget neutrality.

Site of Service Adjustment for Hospice Patients in Nursing Facilities

CMS expresses concern regarding findings of the Office of the Inspector General (OIG) and others relative to delivery of hospice services to patients in nursing facilities.  Study indicates that nursing facility patients receive more services in terms of minutes of care provided than patients at home - particularly in the area of hospice aide services.

CMS indicates that the hospice aide may be providing services that had been provided by the facility aide prior to hospice election.  CMS indicates that they are not proposing a change at this time but may propose a change as part of payment reform.


In July 2012, as part of the FY2013 Hospice Wage Index notice (see NAHC Report, July 25, 2012), CMS expressed concern that data analysis conducted by Abt Associates, the CMS payment reform contractor, revealed that close to 78 percent of hospice claims contained only a single diagnosis, despite the requirement that hospices treat the terminal as well as all related diagnoses under the benefit. 

CMS notes that a more recent analysis indicates that 72 percent of hospices still provide only a single diagnosis on claims.  In this proposed rule, CMS takes great pains to further clarify that hospice providers are required and expected to report multiple diagnoses on claims for several reasons:

  • To comply with Medicare hospice program requirements.
  • To fully describe the patient being treated.
  • To ensure that hospice patients receive holistic, comprehensive care for their terminal and all other related conditions.
  • To fully comply with coding guidelines and conventions.
  • To provide additional information should CMS seek to develop a case-mix based payment system.

Debility and Adult Failure to Thrive

CMS expresses concern about the use of codes under the classification, “Symptoms, Signs, and Ill-defined Conditions” and indicates that they should NOT be used as principal diagnoses when a related definitive diagnosis has been established or confirmed by the provider.  CMS further states that “‘debility’ and ‘adult failure to thrive’ are not appropriate principal diagnoses in the terminally ill population as these diagnoses are incongruous to the comprehensive nature of the hospice assessment, the specific, individualized hospice plan of care, and the hospice services provided.” 

CMS indicates that, as part of the proposed rule, they would clarify that “debility” and “adult failure to thrive” would not be used as principal hospice diagnoses on the hospice claim form.  When reported as a principal diagnosis, these would be considered questionable encounters for hospice care, and the claim would be returned to the provider for a more definitive principal diagnosis. CMS further notes, “We expect hospice providers to code the most definitive, contributory terminal diagnosis in the principal diagnosis field with all other related conditions in the additional diagnoses fields for hospice claims reporting.”

Mental, Behavioral and Neurodevelopmental Disorders

CMS also notes that several diagnoses under “Mental, Behavioral and Neurodevelopmental Disorders” are frequently reported as the principal diagnosis on hospice claims, yet under ICD-9-CM guidelines are not appropriate principal diagnoses.  For such conditions, CMS indicates that the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first, followed by the manifestation.  CMS underscores that it expects hospice providers to follow ICD-9-CM coding guidelines and sequencing rules for all diagnoses and pay particular attention to the specified conventions for dementia codes as depending on the code they may or may not be used as principal diagnoses; they are also variably treated relative to guidelines, and manifestation/etiology or sequencing conventions.

Discrepancies between Inpatient and Hospice Diagnoses

CMS notes that, while ICD-9-CM guidelines indicate that the circumstances of an inpatient admission always govern the selection of principal diagnosis, it frequently is the case that patients electing hospice within three days of a hospital discharge do not always have the inpatient care diagnosis reported on the hospice claim.

Proposed UpdateS to the Hospice Quality Reporting Program (HQRP)

Hospices have just finished with the first mandatory reporting period for the HQRP.  Two measures – the structural measure and the pain measure – are currently part of the program.  Hospices not meeting the Jan, 31, 2013 structural measure reporting deadline and the April 1, 2013 pain measure reporting deadline are scheduled to have their market basket update reduced by 2 percentage points for payments beginning in FY2014.  The market basket update is a component of the hospice payment formula, so depending on other factors, hospices having their market basket update reduced for failure to comply with the HQRP could see a negative payment rate.  A hospice may be eligible to have its reduction reconsidered; CMS announced it plans to use the following process:

Reconsideration process for FY 2014 and subsequent years’ payment determinations:

  • Via letter. CMS would notify hospices found to be non-compliant with the reporting requirements during a given reporting cycle that they are scheduled for a 2 percentage point reduction in their market basket update.
  • The letter would outline a process that hospices would need to follow in order to file a request for reconsideration of the reduction. Details of the process are expected to be released later this spring.
  • CMS could reverse the finding of non-compliance if: (1) the hospice provides proof of full compliance with the all requirements during the reporting period; or (2) the hospice was not able to comply with requirements during the reporting period, and it provides adequate proof of a valid or justifiable excuse for this lack of compliance.

Relative to future HQRP cycles, CMS is proposing that the structural measure related to QAPI indicators and the NQF #0209 pain measure would not be required for the hospice quality reporting program beyond data submission for the FY 2015 payment determination. This is based on the fact that data collections of the structural measure to date - voluntary reporting period in 2012 and first mandatory reporting period - have provided adequate information on hospice’s patient care-related indicators making further reporting on the structural measure unnecessary and the fact that CMS has determined that the NQF # 0209 measure as it is currently collected and reported by hospices is not suitable for long-term use as part of the HQRP. 

The measure results show too much variance in what hospices collect, aggregate, and report, and there is a high rate of patient exclusion due to patient ineligibility for the measure and patients’ denying pain at the initial assessment.  CMS proposes to collect data on two other measures related to pain (see below) Pain Screening and Pain Assessment.  Information about patient comfort related to pain is not currently proposed but CMS indicated they plan to include this in the HQRP at a later time.

Hospice Item Set (HIS)

CMS has developed a hospice-specific data item set that contains seven quality measures endorsed by the National Quality Forum (NQF) for hospice.  Hospices would complete and submit an HIS upon a patient’s admission and at discharge.  The following are the seven proposed quality measures.  All are endorsed by the NQF:

  1. NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen
  2. NQF #1634 Pain Screening
  3. NQF #1637 Pain Assessment           
  4. NQF #1638  Dyspnea Treatment          
  5. NQF #1639  Dyspnea Screening
  6. NQF #1641  Treatment Preferences           
  7. NQF #1647  Beliefs/Values Addressed (if desired by the patient)

CMS proposes implementation of the HIS in July 2014 - which would affect payments beginning in FY2016 - with reporting continuing regularly for each patient admitted to hospice on or after July 1, 2014, regardless of payer source

CMS would provide details on data collection and submission timing prior to implementation of the HIS.  Hospice programs would be evaluated for purposes of the quality reporting program based on whether or not they submit data, instead of their performance level on required measures. There would be a 2-percentage point reduction in a hospice’s market basket update if it does not submit data.  CMS would provide reports to individual hospices on their performance on the measures calculated from data submitted via the HIS. The specifics of the reporting system and precisely when specific measures would be made available have not yet been determined.

Electronic data submission would be required for the FY 2015 payment determination and beyond. There would be no other data submission method available.  CMS would make submission software available for the HIS to hospices at no cost.

Public reporting would not be implemented in FY 2016.  It may occur during the FY 2018 APU year, allowing ample time for data analysis, review of measures’ appropriateness for use for public reporting, and allowing hospices the required time to review their own data prior to public reporting.  As with all publicly reported data, CMS will need to assess the validity and reliability of the quality measures to be used in public reporting. 

Data collected by hospices during CY 2015 would be analyzed starting in CY 2015. Decisions about whether to report some or all of the quality measures publicly would be based on the findings of an analysis of the CY 2015 data.  CMS will develop the infrastructure for public reporting, and provide hospices an opportunity to review their data as required by the ACA.

CMS is currently developing a Hospice Experience of Care Survey as reported in the April 9 issue of NAHC Report.   The survey captures such topics as hospice provider communications with patients and family members, hospice provider care, and patient and family member characteristics. The survey would allow the informal caregiver, i.e. a family member or friend, to provide an overall rating of the hospice care their patient received, and would ask if they would recommend “this hospice” to others.  The Hospice Experience of Care Survey would allow for comparisons across hospices.  Part of the survey includes demographic characteristics of the patients and their caregivers that can be used to feed into case-mix adjustments of the publicly-reported data.  During national implementation of this survey, hospices would be required to offer the survey, but individual caregivers would respond only if they voluntarily chose to do so.  Hospices would be required to contract with an approved survey vendor and to provide the sampling frame to the approved vendor on a monthly basis

The following are proposed key dates for the national implementation of the Hospice Experience of Care Survey:

  • Hospices would contract with a CMS-approved survey vendor to conduct a “dry run” of the survey for at least one month in the first quarter of CY 2015 (January 2015 through March 2015)
  • Vendors would submit data on the hospice’s behalf to the CMS hospice patient experience data center. The deadline for data submission has not yet been finalized
  • “Dry run” data would not be publicly reported
  • Hospices would contract with CMS-approved vendors to begin continuous monthly data collection starting April 1, 2015.
  • The FY 2017 Annual Payment Update (APU) determination, based in part on the Hospice Experience of Care Survey, would include a dry run for at least 1 month in the first quarter of CY 2015 (January 2015, February 2015, and/or March 2015) plus 3 quarters of continuous monthly participation (April 1, 2015 through December 31, 2015).
  • Subsequent APU determinations would be based upon 4 quarters of continuous monthly participation from January 1 through December 31 of the relevant CY.
  • Hospices that had fewer than 50 unduplicated or unique deceased patients in the period from January 1, 2014 through December 31, 2014 would be exempt from the Hospice Experience of Care Survey data collection and reporting requirements for the FY 2017 payment determination.

In summary, CMS proposes to implement the HQRP requirements with a test run for at least one month in the first quarter of CY2015, with continuous monthly data collection beginning April 1, 2015, to meet the annual payment update requirements for FY2017. The Hospice Experience of Care Survey would be added to the HQRP requirements for the FY2017 annual payment update.




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