The commenter was also concerned that it's not likely that most payroll applications used by hospice providers can correctly allocate costs by level of care, so due to different methods applied by hospice providers to estimate this, the labor costs will also be impacted. on Section 418.312(b)(3) would include the eight measure removal factors as follows: CMS may remove a quality measure from the Hospice QRP based on one or more of the following factors: (1) Measure performance among hospices is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made. We will apply the principles of this Memorandum to new claims-based measures for hospice. The Hospice Quality Reporting Program (HQRP) specifies reporting requirements for both the Hospice Item Set (HIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey. 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. Then, for each level of care separately, we further trimmed the sample of cost reports. In the proposed rule, the denominator description is discussed accurately, as the number of beneficiaries with at least one day of hospice during the last three days of life within a reporting period. Beneficiary's name and hospice medical record identifier; 4. In particular, a single-concept claims-based measure may not adequately account for all relevant circumstances that might influence a hospice's performance. Additionally, we believe that both the requirements at 418.76(h) are exempt from the PRA. 38. Readers who want more information about the development of the survey, originally called the Hospice Experience of Care Survey, may refer to 79 FR 50452 and 78 FR 48261. For example, see: Teno J.M., Bowman, J., Plotzke, M., Gozalo, P.L., Christian, T., Miller, S.C., Williams, C., & Mor, V. (2015). 5. More information and documentation can be found in our hereafter referred to as the March 27, 2020 CMS Guidance Memorandum. Public Health Emergency. We believe that the 1-year 5 percent cap transitional policy provided for FY 2021 was an adequate safeguard against any significant payment reductions, allowed for sufficient time to make operational changes for future fiscal years, and provided a reasonable balance between mitigating some short-term instability in hospice payments and improving the accuracy of the payment adjustment for differences in area wage levels. Azar, A. M. (2020 March 15). This website allows consumers, providers, and other stakeholders to search for all Medicare-certified hospice providers and view their information and quality measure scores. February 26, 2020. https://www.medscape.com/viewarticle/925769#vp_1. Due to aggressive automated scraping of FederalRegister.gov and eCFR.gov, programmatic access to these sites is limited to access to our extensive developer APIs. We stated that hospices can develop processes (including how to document such requests from non-hospice providers and Medicare contractors) to address circumstances in which the non-hospice provider or Medicare contractor requests the addendum, and the beneficiary or representative does not (86 FR 19725). This original public reporting schedule included the exempted quarters of Q4 2019 and Q1 and Q2 2020 in six refreshes for HIS and 11 refreshes for CAHPS. The sub-regulatory Quality Measure Users' Manual will be posted on the HQRP Current Measures web page to provide measure specifications. Response: We appreciate the opportunity to provide clarification. Beginning with CY 2017 data, hospice PUF data are public as part of the Post-Acute Care and Hospice Provider Utilization and Payment PUF (hereafter PAC PUF). This proposed methodology assumes the ratio of total overhead benefit costs to total noncapital overhead costs is consistent among all four levels of care. We performed analyses using Stata/MP Version 16.1. Collection or public reporting of a measure leads to negative unintended consequences; or. (viii) The costs associated with a measure outweigh the benefit of its continued use in the program. We calculated claims-based measures using HH QRP CY 2017 to 2019 data, to simulate using the most recent data while excluding the same quarters (Q1 and Q2) that are relevant from the COVID-19 PHE exception. In the FY 2012 Hospice Wage Index final rule (76 FR 47308 through 47314) it was announced that beginning in 2012, the hospice aggregate cap would be calculated using the patient-by-patient proportional methodology, within certain limits. For questions regarding the hospice conditions of participation, contact Mary Rossi-Coajou at (410) 786-6051 and CAPT James Cowher at (410) 786-1948. 200 Independence Avenue, S.W. We encourage providers to report their cost report data accurately and timely. In the FY 2014 Hospice Wage Index and Payment Rate Update final rule (78 FR 48234), and in compliance with section 1814(i)(5)(C) of the Act, we finalized the specific collection of data items that support the seven NQF-endorsed hospice measures described in Table 6. While we received comments, this update is statutorily required and self-implementing. We intend to submit additional claims-based measures for future consideration and solicit public comment. We estimate that aggregate payments to hospices in FY 2022 will increase by $480 million as a result of the market basket update, compared to payments in FY 2021. Section 1814(a)(7)(D)(i) of the Act, as added by section 3132(b)(2) of the. Response: We appreciate commenters' concerns regarding the administrative burden in quality reporting. 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 $8.0 million to $41.5 million in any 1 year), or being nonprofit organizations. We then sum the CHC compensation costs and total CHC costs of the remaining providers, yielding a proposed compensation cost weight for CHC. (2) Administrative data, such as Medicare claims data, used for hospice quality measures to capture services throughout the hospice stay, are required and fulfill the HQRP requirements for 418.306(b). Prior to finalizing a timeline, CMS will provide multiple opportunities to share information and receive comments from stakeholders. We are also finalizing regulatory changes that are not directly related to PHE waivers that will clarify or align some policies that have been raised as concerns by stakeholders. (2019). While external circumstances could justify a hospice's poor performance on a single claims-based indicator, it would be unlikely for external circumstances to impact Start Printed Page 42558multiple claims-based indicators considered simultaneously. CMS expects hospices to honor patient wishes on a case-by-case basis. We stated in the final rule that the addendum is intended to complement the Hospice Conditions of Participation (CoPs) at 418.52(c)(7) and (8), which require hospices to verbally inform beneficiaries, at the time of hospice election, of the services covered under the Medicare hospice benefit, as well as the limitations of such services (84 FR 38509). The ten indicators, aggregated into a single HCI score, convey a broad overview of the quality of the provision of hospice care services and validates well with CAHPS Willingness to Recommend and Rating of this Hospice. Additional claim-based measure concepts we are considering for development include hospice services on weekends, transitions after hospice live discharge, Medicare expenditures per beneficiary (including the share of non-hospice spending during hospice election, and the share for hospice care prior to the last year of life), and post-mortem visits as measures of hospice quality. For complete information about, and access to, our official publications The OFR/GPO partnership is committed to presenting accurate and reliable Response: If a non-hospice provider requests the addendum, the hospice must furnish the addendum, however, the non-hospice provider is not required to sign the addendum. (d) Timeframes for the hospice election statement addendum. This indicator identifies whether a hospice is at or above the 10th percentile in terms of the percentage of beneficiaries with a RN, LPN, and/or medical social services visit in the last 3 days of life. In a 2016 report, the OIG has expressed concern at the potentially inappropriate billing of GIP care. 804(2). Our proposal to use the 2018 MCR data recognizes that providers have had 4 years to familiarize themselves with the form and, thereby, improve the accuracy of the data. Many waivers and modifications were made effective as of March 1, 2020[4647] in accordance with the president's declaration. However, we will remain open to reconsidering the frequency of reporting claims across all PAC settings in the future, should data after implementation indicate that such change is warranted. In this way, it is different from an average-based composite measure and sets a higher bar for performance. The individual measures show performance for only one process and do not demonstrate whether the hospice provides high-quality care overall, as an organization. The 'Hospice Rates' links contain the standardized Medicare payment amount for each hospice level of care. However, if there is reason to believe continued collection of a measure raises potential safety concerns, we will take immediate action to remove the measure from the HQRP and will not wait for the annual Start Printed Page 42554rulemaking cycle. For HIS, the quarters are defined based on submission of HIS admission or discharge assessments. In addition, this rule rebases the labor shares of the hospice payment rates and finalizes clarifying regulations text changes to the election statement addendum requirements finalized in the FY 2020 Hospice Wage Index and Payment Rate Update final rule (84 FR 38484). A federal government website managed by the The publicly-reported version of HCI on Care Compare will only include the final HCI score, and not the component indicators. As we prepare to update Care Compare for their removal, we will consider ways to revise the measure description for the HIS Comprehensive Measure on Care Compare so that it adequately explains the elements contained in the measure. Others noted that the delay could allow time for additional analysis of the measure, and for more transparency about the rationale for it. The HCI will complement the existing HIS Comprehensive Measure and does not replace any existing reported measures. Twenty unique stakeholders submitted their comments on the proposal to rebase the hospice labor shares. Response: As described in the FY 2022 hospice proposed rule (86 FR 19717 through 19719), our proposed calculation to derive the hospice labor shares uses the sum of five categories of compensation costs. This revision is subject to the PRA; however, the information collection burden associated with the existing requirements at 418.76(c)(1) are accounted for under the information collection request currently approved OMB control number 0938-1067 (Expiration date: March 31, 2024). At the same time, we want to report measures scores to the public for as many hospices as possible, including small hospices. The commenters stated that many of these hospices providers have some of the best accounting records in the industry and the proposed methodology for calculating the labor components eliminates the costs of these facilities from consideration. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. We exclude all claims for a beneficiary if a beneficiary ever had two overlapping hospice days on separate claims. #2158 Payment-Standardized Medicare Spending Per Beneficiary (MSPB). It is necessary for the hospice to document that the addendum was discussed and whether or not it was requested, in order to prevent potential claims denials related to any absence of an addendum (or addendum updates) in the medical record. 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 the regulations at 418.204. The finalized reasons for removing quality measures are: 1. 13. 2019: Vulnerabilities in Hospice Care (Office of the Inspector General). We will take the recommendation of a single star rating into consideration for the future. Form, Manner, and Timing of Quality Data Submission, a. Statutory Penalty for Failure To Report, 10. The FY 2022 rates for hospices that do not submit the required quality data would be updated by the FY 2022 hospice payment update percentage of 2.0 percent minus 2 percentage points. If, in the judgment of the hospice interdisciplinary team, which includes the hospice physician, the patient's symptoms cannot be effectively managed at home, then the patient is eligible for general inpatient care (GIP), a more medically intense level of care. At this point, we are still assessing the impact of all waivers and flexibilities on beneficiaries and the delivery of healthcare services under the PHE. In chapter 6 of the June 2007 Report to Congress, MedPAC recommended the new wage index should: Use wage data from all employers and industry-specific occupational weights, adjust for geographic differences in the ratio of benefits to wages, adjust at the county level and smooth large differences between counties, and be implemented so that large changes in wage index values are phased in over a transition period. The FY 2020 Hospice Wage Index and Payment Rate Update final rule (84 FR 38484) finalized the proposal to migrate to a new internet Quality Improvement and Evaluation System (iQIES) that will enable us to make real-time upgrades. We believe that a signed addendum indicates the hospice discussed the addendum and its contents with the beneficiary (or representative). Several commenters suggested that CMS adjust the thresholds for specific services, such as gaps in skilled nursing visits, and phase in the thresholds over time. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. The attachments to OMB Bulletin No. documents in the last year, 37 Commenters also encouraged CMS to provide early testing and education for providers on HIT and to provide a structured FHIR transition framework for key stakeholders. (2010). 2021-16311 Filed 7-29-21; 4:15 pm], updated on 4:15 PM on Friday, April 28, 2023, updated on 8:45 AM on Friday, April 28, 2023, 126 documents These covered services include: Nursing care; physical therapy; occupational therapy; speech-language pathology therapy; medical social services; home health aide services (called hospice aide services); physician services; homemaker services; medical supplies (including drugs and biologicals); medical appliances; counseling services (including dietary counseling); short-term inpatient care in a hospital, nursing facility, or hospice inpatient facility (including both respite care and procedures necessary for pain control and acute or chronic symptom management); continuous home care during periods of crisis, and only as necessary to maintain the terminally ill individual at home; and any other item or service which is specified in the plan of care and for which payment may otherwise be made under Medicare, in accordance with Title XVIII of the Act. Our simulations indicate that the hospices that only meet the reporting threshold when using 2 years of data have performance scores substantially lower than average. L. 116-260) to change the payment reduction for failing to meet hospice quality reporting requirements from 2 to 4 percentage points. Items, Services, and Drugs Related and Unrelated to the Terminal Illness and Related Conditions, 2. documents in the last year, 422 A summary of these comments and our responses to those comments appear below: Comment: A few commenters requested more information regarding the labor share standardization factor; specifically, its purpose, and any anticipated future use of the factor. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. Drawing on lessons learned through research and stakeholder feedback, Care Compare includes features and functionalities that appeal to Hospice Compare consumers. We also Start Printed Page 42604recognize that different types of entities are in many cases affected by mutually exclusive sections of the final rule, and therefore, for the purposes of our estimate we assume that each reviewer reads approximately 50 percent of the rule. Final Decision: We are finalizing our proposal to use the FY 2022 pre-floor, pre-reclassified hospital wage index data as the basis for the FY 2022 hospice wage index. They stated that more nurses are retiring, competition for available nurses is fierce, and many hospices are paying premium salaries and bonuses to recruit and retain qualified nursing staff. This policy will apply beginning with FY 2024 annual payment update (APU). We will continue to apply ideas shared by the Caregiver Workgroup participants as we refine plans for the measure's public display to minimize the risk of misinterpretation. Comment: A few commenters stated that the survey is too long. This interdisciplinary, holistic scope of the HIS Comprehensive Assessment Measure better aligns with the public's expectations for hospice care. For HVLDL, one commenter suggested that CMS notify consumers that the measure does not capture visits from chaplains, volunteers, hospice aides, and complementary therapies, among others. The final FY 2022 labor shares are 66.0 percent for routine home care, 75.2 percent for continuous home care, 61.0 percent for inpatient respite care, and 63.5 percent for general inpatient care. Response: We appreciate commenters' concerns that HQRP measures will not be able to adequately differentiate hospices if they become topped out. We also understand why commenters might expect process measures to be prone to topping out. CMS has taken this into consideration in designing the HCI measure. As MedPAC noted,[22] (2) For accounting years that end after September 30, 2016, and before October 1, 2030, the cap amount is the cap amount for the preceding accounting year updated by the percentage update to payment rates for hospice care for services furnished during the fiscal year beginning on the October 1 preceding the beginning of the accounting year as determined pursuant to section 1814(i)(1)(C) of the Act (including the application of any productivity or other adjustments to the hospice percentage update). This feature is not available for this document. Response: We appreciate the support by comments recognizing the value HCI brings to consumers by providing more information not previously available about hospices. The CR also updates the FY 2023 hospice aggregate cap amount. One commenter recommended that CMS explore ways to educate hospice providers about how they can inform their beneficiaries (or representative) when items, services, or drugs are considered related, but non-covered due to reasons such as not reasonable or necessary for the palliation and management of the terminal illness and related conditions. They commented that these data could be skewed by the public health emergency. IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN. For the OASIS, the exempted quarters are based upon admission and discharge assessments. To support new measure development, our contractor convened TEP meetings in 2020 to provide feedback on several measure concepts. These providers reflected approximately 53,000 IRP days of which about 47,000 were Medicare and approximately 136,000 GIC days of which about 108,000 were Medicare. Response: We will not include data from Q1 and Q2 2020 in Star Rating calculations, as hospices were exempted from submitting these quarters of data to CMS due to the COVID-19 PHE. Simulation means a training and assessment technique that mimics the reality of the homecare environment, including environmental distractions and constraints that evoke or replicate substantial aspects of the real world in a fully interactive fashion, in order to teach and assess proficiency in performing skills, and to promote decision making and critical thinking. (1) Standardized set of admission and discharge items Hospices are required to complete and submit an admission Hospice Item Set (HIS) and a discharge HIS for each patient to capture patient-level data, regardless of payer or patient age. Numerator: The total number of live discharges from the hospice occurring on or after 180 days of enrollment in hospice within a reporting period. This means the hospice may furnish the addendum within the required timeframe; however, the signature date may be beyond the required timeframe. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Prior to enactment of this provision, the hospice cap update was set to revert to the original methodology of updating the annual cap amount by the CPI-U beginning on October 1, 2025. Learn more here. FY 2022 Hospice Payment Update Percentage, D. Clarifying Regulation Text Changes for the Hospice Election Statement Addendum, E. Hospice Waivers Made Permanent Conditions of Participation, 2. For GIP, we proposed to multiply this ratio by total other patient care costs for GIP (Worksheet A-4, column 7, lines 38 through 46). In order to be counted, the from date of the hospitalization had to occur no more than 2 days after the date of hospice live discharge. We are also proposing in this rule to adopt the HCI into the HQRP for FY2022. This approach parallels the one used by CMS for calculating star ratings for hospitals. Because the reclassification provision and the hospital rural floor applies only to hospitals, and not to hospices, we continue to believe the use of the pre-floor and pre-reclassified hospital wage index results in the most appropriate adjustment to the labor portion of the hospice payment rates. The provision of care would proportionately escalate to meet the increased clinical, emotional, and other needs of the patient and family. Indicator Nine: Skilled Nursing Minutes on Weekends, c. Measure Reportability, Variability, and Validity, e. Form, Manner and Timing of Data Collection and Submission, 4. We encourage all key stakeholders to continue to stay informed and engaged through the HQRP Forums, Open Door Forums, Quarterly Updates, and listserv notifications.Start Printed Page 42571. The commenters suggest a delay in publicly reporting or no earlier than May 2022, which would to allow time for internal analysis. For each hospice, we sum together all skilled nursing minutes provided on RHC days that occur on a Saturday or Sunday and divide by the sum of all skilled nursing minutes provided on all RHC days. This indicator identifies whether a hospice is below the 90th percentile in terms of the percentage of live Start Printed Page 42561discharges that are followed by a hospitalization (within two days of hospice discharge) and then the patient dies in the hospital. Therefore, we proposed to exclude providers that reported costs greater than zero on Worksheet A-3, column 7, line 25 (Inpatient CareContracted) for IRC and Worksheet A-4, column 7, line 25 (Inpatient CareContracted) for GIP. (1) If the addendum is requested within the first 5 days of a hospice election (that is, in the first 5 days of the hospice election date), the hospice must provide this information, in writing, to the individual (or representative), non-hospice provider, or Medicare contractor within 5 days from the date of the request. In the March 27, 2020 CMS Guidance Memo, we granted an exception to the HH QRP reporting requirements under the HH QRP exceptions and extension requirements for Quarter 4 (Q4) 2019 (October 1, 2019 through December 31, 2019), Q1 2020 (January 1, 2020 through March 30, 2020), and Q2 2020 (April 1, 2020 through June 30, 2020). This measure helps to ensure all hospice patients receive a holistic comprehensive assessment. We use four rolling quarters of data to publicly display Home Health Care Consumer Assessment of Healthcare Providers and Systems (HH CAHPS) Survey measures on Care Compare. We also received several comments responding to how CMS should incentivize the use of HIT. documents in the last year, 84 States choosing to implement this cap must specify its use in the Medicaid state plan. of the issuing agency. CMS froze CAHPS data starting with the November 2020 refresh and concluding with the November 2021 refresh. The FY 2019 Hospice Wage Index and Payment Rate Update final rule (83 FR 38622) introduced the Meaningful Measure Initiative to hospice providers to identify high priority areas for quality measurement and improvement. Thus, these exemptions or extensions can occur when a hospice encounters certain extraordinary circumstances. A service intensity add-on payment will be made for the social worker visits and nursing visits provided by a registered nurse (RN), when provided during routine home care in the last 7 days of life. Comment: Many commenters stated that focusing the competency training on specific deficient skills provided greater efficiency for hospices. 1. CBSA Code CBSA Name CBSA Type; 10100: Aberdeen, SD: Micropolitan: 10140: Aberdeen, WA: Micropolitan: 10180: Abilene, TX: Metropolitan: 10220: Ada, OK: Micropolitan: 10260 For the public display of HCI, our measure development contractor convened two small caregiver workgroups to gather impressions and input on the value of HCI for consumers. In addition, section 407(a)(2) of the CAA 2021 removes the prohibition on public disclosure of hospice surveys performed be a national accreditation agency in section 1865(b) of the Act, thus allowing the Secretary to disclose such accreditation surveys. In the FY 2022 Hospice Wage Index and Rate Update final rule ( 86 FR 42532 through 42539 ), we finalized a policy to rebase and revise the labor shares for CHC, RHC, IRC and GIP using Medicare cost report (MCR) data for freestanding hospices (collected via CMS Form 1984-14, OMB NO. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. A summary of the comments we received on this proposal and our responses to those comments appear below: Comment: We received many comments supporting HH QRP reporting to resume beginning January 2022. In the original schedule (Table 20), the October 2020 refresh included Q4 2019 measure based on OASIS and HH CAHPS data and is the last refresh before Q1 2020 data are included. Centers for Medicare & Medicaid Services. Claims data are the best available data source for measuring care during the hospice stay and present an opportunity to bridge the quality measurement gap that currently exists between the HIS and CAHPS Hospice Survey. This two-stage approach allows for calculation of stable cut-points that reflect the full range of hospice performance. We encourage commenters to provide us input and comments on these provisions in response to that rule. The Medicare Hospice CoPs require that hospice comprehensive assessments identify patients' physical, psychosocial, emotional, and spiritual needs and address them to promote the hospice patient's comfort throughout the end-of-life process. The HIS Comprehensive Assessment Measure is a composite measure that serves to ensure all hospice patients receive a comprehensive assessment for both physical and psychosocial needs at admission. Patients electing to receive hospice services should expect quality care and a comprehensive assessment of their needs at admission, which the HIS Comprehensive Assessment Measure reflects. Use the PDF linked in the document sidebar for the official electronic format. As we are able to obtain more recent cost report data, we will monitor the labor shares by ownership-type over time. A few commenters stated that if data from the hospice cost report is to be used for calculating the labor component by level of care, revisions to the cost report should be proposed to address current inconsistent, but acceptable, reporting practices. Specifically, the updates consisted of changes to NECTA delineations and the redesignation of a single rural county into a newly created Micropolitan Statistical Area. For direct questions, contact the CAHPS Hospice Survey Team at hospiceCAHPSsurvey@HCQIS.org or call 1-(844) 472-4621. Final Decision: In this final rule, we are not making any revisions to the HIS Comprehensive Assessment Measure. Chapter 12: Hospice Services. Comment: Several commenters raised issues about the eight quarters of data included in public reporting. As we determine the most appropriate way to display the measure, we will ensure that the scope of the HIS Comprehensive Measure is clear for consumers, who can use the information with other information on the website to make their decisions. They called for customer research on how the public would interpret the absence of star ratings as well as research on the extent to which the public understands how star ratings are calculated. The presence of revenue code 0656 (GIP) on the hospice claim. Therefore, in the FY 2022 proposed rule (86 FR 19724) we provided clarification on, and proposed modifications to, certain signature and timing requirements and proposed corresponding clarifying regulations text changes.