NAHC Details Medicare Hospice Priorities at March on Washington
April 8, 2016 04:42 PM
At the National Association for Home Care & Hospice’s (NAHC) 2016 March on Washington Conference, Theresa M. Forster, Vice President for Hospice Policy & Programs at NAHC, provided an update on priority issues relative to Medicare hospice. Previous NAHC Report coverage summarized the Medicare home health session (available here), and future articles will summarize conference sessions on Medicaid home care and other topics.
Forster said that NAHC had identified three priority issues relative to Medicare hospice for advocates to emphasize during their Capitol Hill visits at the March on Washington. “The three areas that we would recommend that you focus on when you talk about hospice issues are rejection of efforts to include hospice as part of the Medicare Advantage benefit package; second, ensuring the full market basket update for the Medicare hospice benefit; and finally, overseeing the impact of hospice payment reform and steering clear of discussions related to potential rebasing of hospice payments and any site-of-service adjustment for nursing facility residents,” Forster said.
Oversee the Impact of Hospice Payment Reform/Reject Including of “Rebasing” and Site-of-serve Adjustment for Nursing Facility Residents
“We know that the goals of payment reform were to redistribute moneys among hospices and to change the incentives so that there was not as great of a financial incentive for hospices to bring patients onto service and keep them on for long lengths of stay,” Forster said. “But one of the other goals was to ensure that there was more appropriate payment to hospices for care of patients particularly in those beginning days after a patient is referred and in their final days of life. CMS certainly tried to make progress in that direction, but one of the things that we are hearing relative to payment reform is that many hospices that have relatively short lengths of stay for their patients are projecting that they may not do very well. In fact, they will do worse under the new system.”
ISSUE SUMMARY: Under the PPACA, CMS was required to expand collection of hospice data and revise the payment system for, at a minimum, the hospice routine home care (RHC) level of care. CMS expanded collection of data related to visits and costs in 2008, 2010, and 2014. While necessary to ensure reasonable payment reforms, the expanded data collection has significantly increased burdens on providers. During 2015, CMS promulgated and finalized modifications to payments for RHC under hospice that sets out two payment rates -- a higher rate ($186.84 in 2016) for days one through 60 of hospice care and a lower rate ($146.83) for days 61 and over. Unless a patient is off hospice care for more than 60 days, the “count of days” for purposes of determining the appropriate RHC rate includes previous hospice service days. CMS also created a Service Intensity Add-on (SIA) applicable to in-person Registered Nursing and Social Worker visits that are provided during the final seven days of life. The SIA is payable at the hourly rate for Continuous Home Care ($39.37 in FY2016) for up to a total of four hours per day.
RECOMMENDATION:Congress must closely monitor the impact of the payment reform changes implemented by CMS and any future activities to ensure that changes do not reduce access to quality hospice services for Medicare beneficiaries during the final stages of life, and bereavement services to loved ones. Congress must also monitor the impact of payment changes to ensure that CMS has achieved a proper balance between the costs of providing hospice care and payment levels, particularly for short-stay patients. Congress must ensure that CMS does not overstep its charge to refine the hospice payment system by implementing changes like rebasing of RHC or reduced payments for care provided to nursing facility residents that go far beyond the payment refinement needed and sought by the health reform law. Care must be taken to ensure that changes do not disrupt the availability or quality of this most humane service for America’s terminally ill patients and their families, and that hospice remains a benefit available to all at the hour of greatest need – the final stage of life.
Ensure the Full Market Basket Update for the Medicare Hospice Benefit
“As part of the President’s proposed budget, President Obama recommended a reduction in the market basket update for hospices for fiscal years 2018, 2019, and 2020, and also recommended that the hospice market basket be changed,” Forster said. “Right now, we are using the hospital market basket update, and the President has suggested that they create a hospice-specific market basket. Honestly, when this kind of proposal comes through in a budget recommendation, the translation is that it’s a means of reducing outlays under the hospice benefit. So we do have to be very cautious about it at the outset.”
ISSUE SUMMARY:The Patient Protection and Affordable Care Act (PPACA -- Public Law 111-148), requires that the Centers for Medicare & Medicaid Services (CMS) develop Medicare hospice payment system reforms, and contains multiple hospice payment cuts. In addition, CMS has, over seven years, phased out the Budget Neutrality Adjustment Factor (BNAF) to the hospice wage index. As the result of these cuts and imposition of the 2 percent sequester, hospice payments for FY2016 are 12 percent LESS than they would otherwise have been. The PPACA cuts and the sequester will continue into future years, further reducing the ability of hospices to provide comprehensive end-of-life care to patients and their loved ones. Hospices have also been subject to costly new administrative obligations in recent years, and it is expected that CMS will impose additional administrative requirements on hospice programs in the near future that will further increase costs.
As part of the proposed budget for FY 2017, the President recommended reducing the hospice market basket update by an additional 1.7 percentage points in each of FY2018, 2019, and 2020. Further, the proposed FY2017 budget includes plans to create a hospice-specific market basket (as opposed to the hospital market basket currently in use for hospice services). These changes are estimated to reduce hospice outlays by nearly $10 billion over nine years (FY2018 - 2026). The proposed budget also references additional unspecified, “budget-neutral” hospice policy changes.
RECOMMENDATION:Congress should reject the President’s FY2017 proposed market basket changes and closely examine the President’s unspecified “budget neutral” proposals, giving serious consideration to their potential impact on access to high quality hospice services. Imposition of across-the-board cuts like those recommended by the President run counter to the intent of hospice payment reform, which was to ensure that payments over the course of care better reflect actual costs incurred and to reapportion payments within the system. Congress should oppose any major hospice policy changes until such time as the impact of hospice payment reforms and other changes are fully known. Until such time as any proposed policy can be fully analyzed for its impact on delivery of care and in the context of all other recent hospice policy changes, Congress should reject proposals that would further diminish hospices’ ability to provide high-quality, comprehensive services to patients in their final days of life and support to those patients’ loved ones.
Reject Efforts to Include Hospice as Part of Medicare Advantage Benefit Package
“This is definitely an issue that has come into vogue in terms of discussions on Capitol Hill,” Forster said. “On its face it seems like a very logical thing to do: create that symmetry for hospice and Medicare Advantage that we have got for other Medicare benefits. However, for those of you who are engaged in home health delivery, you know what kinds of issues have come up relative to trying to work with the Medicare Advantage programs and delivery and episodic based benefit that you have. Hospice is even more unique (in my opinion) than home health relative to Medicare Advantage.”
ISSUE SUMMARY: Historically hospice care has been excluded from Medicare Advantage (MA), but the Medicare Payment Advisory Commission (MedPAC) has recommended that Congress enact legislation to make hospice part of the MA benefit package. Further, in late 2015 the Bipartisan Chronic Care Working Group of the Senate Finance Committee issued a Policy Options Document that indicates the group is considering requiring MA plans to offer hospice as part of their benefit package. These efforts have raised significant concerns among hospice providers and patient advocates, including:
Medicare beneficiaries enrolled in MA that elect hospice will no longer have a choice of the hospice provider that will care for them in their final days of life and may be subject to substantial coinsurances;
MA plans will contract with hospices at payments below the cost of providing the full Medicare hospice benefit, and on different terms than those under which hospice care is provided under fee-for-service (FFS). As a result, beneficiaries may not receive a hospice benefit equivalent to that which they would receive under FFS;
Many hospices provide additional services beyond the scope of the benefit (such as massage, music, and other therapies) because they have proven therapeutic value for terminally ill individuals. Continuing availability of these services may be at risk if hospice services are provided by way of MA plans;
Medicare eligibility for hospice requires that a patient be deemed terminally ill with a prognosis of six months or less if the disease follows its normal course. Tensions could arise between a MA plan and its contracted hospice relative to whether a patient does or does not meet Medicare’s hospice eligibility requirements; conflicts also may arise over what conditions are related or not related to the terminal condition and whether responsibility for care rests with the MA plan or the hospice;
The Medicare hospice benefit is currently undergoing significant change, including imposition of a new payment system for RHC starting January 1, 2016 and there are uncertainties about what impact these changes may have on the delivery of hospice care, as well as about potential additional changes in the hospice program. These uncertainties will impact hospices’ willingness to enter into contracts with MA plans, particularly if the contracts do not, at a minimum, cover costs; and
The terms under which MA plans enter into contracts with hospice organizations could run counter to Congress’ goal for hospice payment reform, which is to ensure that hospice payments better reflect actual costs of care over the course of a patient’s stay on hospice.
Recommendation: Beneficiaries entering MA are, as a general rule, anticipating their needs for curative care rather than end-of-life care. Decisions about end-of-life care are deeply personal and of great significance to patients and their families. Congress should, therefore, reject current efforts to incorporate hospice as part of the MA benefit package. If inclusion of hospice under MA is to be considered, it should first be studied through a demonstration program that examines inclusion of hospice services under different types of MA plans, and thoroughly analyzes the impact of the model on hospice patients and their families.
Stay tuned to NAHC Report for further coverage of the March on Washington.