NAHC Submits Comments on FY2017 Proposed Hospice Payment, Quality Regulations
June 24, 2016 08:28 AM
On April 21, 2016, the Centers for Medicare & Medicaid Services (CMS) issued Medicare Program; FY2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements (CMS-1652-P), the proposed Medicare hospice payment and policy rule for fiscal year (FY) 2017. Since that time, the National Association for Home Care & Hospice (NAHC) sought input and conducted numerous discussions with hospice stakeholders on aspects of the proposed rule, and submitted comments on June 20, 2016. Given that the FY2016 rule made significant payment and policy changes for hospice, it came as no surprise that the FY2017 proposed hospice payment rule placed most of its emphasis on next steps for the Hospice Quality Reporting Program (HQRP). In keeping with the content of the proposed rule, NAHC’s comments also place predominant emphasis on planned changes to the HQRP but also provide general comments related to hospice utilization and other trends discussed in the rule. Following is a summary of comments submitted by NAHC to CMS.
Hospice Utilization, Research and Analyses, Monitoring Payment Reform
NAHC notes in its comments that growth in utilization of hospice services has slowed dramatically and requests that CMS provide additional detail that helps to identify the cause(s) of this slowdown so as to determine whether access to care is being impaired. NAHC also requests information on outcomes related to CMS’ previously announced referrals of hospices to Program Integrity and other oversight bodies (these referrals were the result of data analyses conducted related to payment reform). NAHC also notes the significant increase in hospice claims submitted with multiple diagnoses and posits that this will likely continue to improve since the Hospice PEPPER now provides hospices agency-specific data on the percent of claims that they have submitted that include only one diagnosis.
CMS includes as part of the proposed rule discussion of hospice’s role in Medicare end-of-life spending (including pre-hospice spending) and spending outside of hospice while patients are on a hospice election. CMS found that patients with the longest lengths of stay have lower pre-hospice Medicare spending than those on hospice service for shorter lengths of time, but that overall Medicare spending for these longer stay patients tends to be higher than spending for those on hospice care for a shorter period of time. NAHC points out in its comments that it is oftentimes more difficult to predict life expectancy for longer-stay hospice patients due to their terminal diagnosis (Alzheimer’s, neurological disorders), and prior to hospice service they likely receive a mix of services weighted heavily toward personal and supportive services, which are frequently financed privately or under Medicaid. With election of hospice care the patient is then eligible for coverage of some of these services as part of the bundle of covered services. NAHC also cautions against movement toward a case-mix based hospice payment system and expresses support for payment refinements that help to incentivize appropriate timing on enrollment for hospice. Further, NAHC expresses support for monitoring of the impact of payment reform on hospices with a high proportion of short-stay patients. If the most recent payment refinements are affecting these providers negatively, CMS should work toward addressing this. NAHC also underscores the need for advancements related to processing of Notices of Election and Notices of Termination/Revocation so that patient status on hospice care is recorded in the Common Working File (CWF) on a more timely basis.
Updates to the HQRP
NAHC expresses support CMS’ recognition of the importance of the variety of hospice disciplines as part of its measures pair “Hospice Visits When Death is Imminent”, but relative to the measure cautions against creation of an environment that drives unnecessary visits. NAHC recommends that bereavement coordinators and volunteers be included as part of the measures when it undergoes revisions and urges that CMS develop a definition of a visit (for purposes of these measures) that is somewhat different from the definition used for claims submission. This would mean that post mortem visits, social worker phone calls, and other services would be included as part of that definition. CMS would be required to make changes to the measure numerator but NAHC believes that it is warranted. NAHC advises that any calculations made from these measures be risk-adjusted to reflect a patient and/or family’s right to decline visits in order to maintain privacy.
NAHC raises several issues related to the Hospice Item Set (HIS) Composite measure, including advising that the scores should be risk-adjusted to reflect patients that are on service for short periods of time. In such cases, hospices must have the freedom to prioritize response to immediate needs, and may not be able to deliver all seven care processes in instances where a very short length of stay ends in death. Further, NAHC is concerned that public reporting of the Composite measures without sufficient explanation of the difference between process and outcome measures could mislead consumers, and indicates it might be appropriate to wait to publicly report the Composite measures until such time as the Hospice CAHPS findings can be reported. NAHC also expresses support for the Medicare Payment Advisory Commission’s recommendations that CMS pursue hospice outcome measures and actively eliminate measures that are no longer considered good measures of quality of care.
In its comments NAHC generally supports plans to create a hospice comprehensive patient assessment instrument but asks that CMS seek stakeholder input on the instrument throughout its development. NAHC also encourages CMS to consider options for development of measures that reflect quality of care at different points across the length of stay rather than just looking at patient admission and discharge as is currently the plan. NAHC also expresses concern that the new instrument will likely be completed by skilled staff at the time of care delivery so cost estimates must take that into account.
NAHC also provides some comment on star ratings for hospice, urging that CMS not utilize a bell curve for ranking of hospice programs as this type of ranking is not generally understood by the public.
The full text of NAHC’s comments to CMS on the FY2017 proposed hospice payment rule is available here.