[1617] However, a 2013 OIG report[18] Index Earned Point Criterion: Hospices earn a point towards the HCI if they provided at least one CHC or GIP service day within a reporting period. For more information about HQRP Requirements, please visit the frequently-updated HQRP website and especially the Best Practice, Education and Training Library, and Help Desk web pages at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Start Printed Page 42577Quality-Reporting. We understand the possibility of conflating the differences between the ABN and the hospice election statement addendum. Star ratings benefit the public in that they can be easier for some to understand than absolute measure scores, and they make comparisons between hospices more straightforward. documents in the last year, 887 We also excluded those providers whose IRC compensation costs were greater than total IRC costs. For example, see: Teno J.M., Bowman, J., Plotzke, M., Gozalo, P.L., Christian, T., Miller, S.C., Williams, C., & Mor, V. (2015). The re-endorsement can be found on the NQF website at: https://www.qualityforum.org/Measures_Reports_Tools.aspx. 47. One commenter stated during the pandemic more time has been needed to train and retrain on infection control standards, as well as changes in communication due to practice changes. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. The commenters requested that CMS provide the final number of hospices with inpatient units that were used in the calculation of the labor components for both levels of care, and the total universe of IRC and GIP providers. Third, we estimated reliability scores. Some stakeholders raised concerns that claims data may not adequately express the quality of care provided, and may be better suited as an indicator for program integrity or compliance issues. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. This will allow existing aides to be re-trained more quickly in order to return to the workforce to provide high quality patient care. 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. On August 31, 2020, we added correcting language to the FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements; Correcting Amendment (85 FR 53679) hereafter referred to as the FY 2021 HQRP Correcting Amendment. Depending on whether hospices that meet this minimum sample size have different score patterns than smaller hospices, the initial cut-points may be too high or too low. Comment: Many commenters stated that focusing the competency training on specific deficient skills provided greater efficiency for hospices. Testing results showed that using the CAR scenario would achieve scientifically acceptable quality measure scores for the HH QRP. The reclassification provision found in section 1886(d)(10) of the Act is specific to hospitals. Comment: A commenter asked CMS to define whether or not a mailed copy of the form would be acceptable. Given the timing of the COVID-19 PHE onset, we determined that we would not use HH QRP OASIS, claims, or HH CAHPS data from Q1 and Q2 of 2020 for public reporting, and that we would assess the impact of the COVID-19 PHE on HH QRP data from Q4 2019. 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. The analysis included data on the number of beneficiaries using the hospice benefit, live discharges, reported diagnoses on hospice claims, Medicare hospice spending, and Parts A, B and D non-hospice spending during a hospice election. 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. 36. On July 29, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1754-F) that updates Medicare hospice payments and the aggregate cap amount for FY 2022 in accordance with existing statutory and regulatory requirements. One commenter urged CMS to give special consideration to challenges faced by rural health care providers with specific attention given to the impact workforce shortages have in setting reimbursement rates related to the labor shares. While we stated that we would not be responding to specific comments submitted in response to this Request for Information in the FY 2022 Hospice Wage Index final rule, we will actively consider all input as we develop future regulatory proposals or future sub-regulatory policy guidance. on We found a stronger correlation coefficient with CAHPS would recommend scores for HVLDL than for HVWDII. As discussed previously, we are finalizing our proposal to remove the seven HIS Measures from public reporting on Care Compare no earlier than May 2022. While the standardized patient assessment data elements for certain post-acute care providers required under the IMPACT Act of 2014 is not applicable to hospices, it makes reasonable sense to include some of those standardized elements that appropriately and feasibly apply to hospice. For each level of care, we proposed to calculate noncapital overhead costs for each level of care to be equal to Worksheet B, column 18, less the sum of Worksheet B, columns 0 through 2, for line 50 (CHC), or line 51 (RHC) or line 52 (IRC) or line 53 (GIP). Furthermore, we expect that hospices will have processes in place when they are obtaining a signed addendum from a beneficiary or representative. of the issuing agency. Each indicator equally affects the single HCI score, reflecting the equal importance of each aspect of care delivered from admission to discharge. These proportions were based on skilled nursing facility wage and nonwage cost limits and Start Printed Page 42533skilled nursing facility costs per day (48 FR 38155 through 38156; 56 FR 26917). Finally, as proposed, to derive the compensation cost weights for each level of care for each provider, we divide compensation costs for each level of care by total costs for each level of care. Section 1814(i)(5)(A)(i) of the Act was amended by section 407(b) of Division CC, Title IV of the CAA 2021 (Pub. The proposed CAHPS Hospice Survey stars will adopt a similar overall approach, although using top-box scores rather than linear means, based on our analyses of existing data. Until the ACFR grants it official status, the XML Results for both HCI and HVLDL indicate that using 2 years of data increases reportability. 20-01 consistent with our longstanding policy of adopting OMB delineation updates, we note that specific wage index updates would not be necessary for FY 2022 as a result of adopting these OMB updates. One commenter stated that their hospice revisited the way relatedness is defined, and realized that many diagnoses that were previously thought to be unrelated were related. Any future revisions to the hospice labor shares will be proposed and subject to public comments in future rulemaking. A gap of at least 1 day without hospice ends the sequence. (iii) A measure does not align with current clinical guidelines or practice. The first column shows the breakdown of all hospices by provider type and control (non-profit, for-profit, government, other), facility location, facility size. For more information about Care Compare, please see the Update on the Hospice Quality Reporting Requirements for FY 2022 in section D. Since 2017, we have increased and improved available information about the care hospices provide for consumers. Fewer observed hospice Start Printed Page 42562services on weekends (relative to that provided on weekdays) is not itself an indication of a lack of access. We will continue to monitor the HIS Comprehensive Assessment Measure performance and consider if removal or refinements would be appropriate in the future. The CoPs are not relevant to payment questions regarding the use of technology, such as telehealth, in the provision of hospice services. Several commenters stated that the determination of relatedness, as applied to coverage decisions connected to terminal prognosis, is a clinical decision specific to the unique clinical circumstances of each patient. 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. Instead, progress on HCI will occur over longer time frames, and annual updates are sufficient to support hospices' efforts to improve. Some beneficiaries or representatives may have time constraints that prevent them from signing and returning the addendum by a certain deadline, in which case, the date that the hospice furnishes the addendum to the beneficiary may differ from the date that the beneficiary (or representative) signs the addendum. 202-690-6145. Assuming an average reading speed of 250 words per minute, it would take approximately 2.4 hours for the staff to review half of it. Results of this experiment will Start Printed Page 42575help to inform changes to the survey in the future. As part of developing the HCI, we conducted reportability, variability, and validity testing using claims data from FY 2019. This could lead to unintended negative consequences for those providers fulfilling the true spirit and intent of the benefit. 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. Numerator: Total skilled nursing minutes provided by a hospice on all RHC service days within a reporting period. As such, the implementation of these clarifications on October 1, 2021 would not cause a burden for software updates. In addition, we will monitor the compensation cost weights reported by hospices over time to determine if changes to the labor share are appropriate. 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. Comment: Several commenters requested that CMS communicate widely and display prominently notices and information about the increase in the penalty for failure to comply with HQRP requirements. Furthermore, we believe 3 calendar days, rather than 3 business days continues to be appropriate, as hospice care is provided around the clock rather than only during business days and hours. Indicator Seven: Per-Beneficiary Medicare Spending, (8). 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. Response: The proposed hospice labor shares for the IRC level of care and GIC level of care (after trimming for outliers) is based on costs for 416 and 295 providers, respectively. Other comments also suggested that data already provided in PEPPER reports should not be included in HCI or that CMS should share the indicators in the PEPPER reports rather than implement the HCI quality measure to provide hospices the opportunity to implement continuous quality improvement activities. http://www.qualityforum.org/Publications/2020/02/MAP_2020_Considerations_for_Implementing_Measures_Final_Report_-_PAC_LTC.aspx. Section 418.312 is amended by revising paragraph (b) to read as follows: (b) Submission of Hospice Quality Reporting Program data. on We began public reporting of the results of the CAHPS Hospice Survey on Hospice Compare as of February 2018. This also entailed using 4 quarters of HH QRP data from CY 2019 for the all-cause hospitalization and emergency department use claims-based measures, 8 quarters of HH QRP data from CY2018 and CY2019 for Medicare spending per beneficiary (MSPB) and discharge to community (DTC) claims-based measures; and or 12 quarters from January 2017 to December 2019 for the potentially preventable readmission claims-based measure. As with the NOE, the claims processing system must be notified of a beneficiary's discharge from hospice or hospice benefit revocation within 5 calendar days after the effective date of the discharge/revocation (unless the hospice has already filed a final claim) through the submission of a final claim or a Notice of Termination or Revocation (NOTR). Section 418.306 is amended by revising paragraph (b)(2) to read as follows: (2) For fiscal years 2014 and through 2023, in accordance with section 1814(i)(5)(A)(i) of the Act, in the case of a Medicare-certified hospice that does not submit hospice quality data, as specified by the Secretary, the payment rates are equal to the rates for the previous fiscal year increased by the applicable hospice payment update percentage increase, minus 2 percentage points. CMS issued a final rule, CMS-1629-F, which created two routine home care daily payment rates. Denominator: The total number of all live discharge from the hospice within a reporting year. Other indicators, such as nurse visits (RN and LPN) on weekends or near death, have a criterion of higher than the 10th percentile, identifying hospice care delivery during the most vulnerable periods during a hospice stay. We propose to continue to report the most recent 8 quarters of available data after the freeze, but not to include the data from the exempted quarters of Q1 and Q2 of 2020 as issued in the March 27, 2020 Guidance Memorandum with the effected quarters. Second, for each scenario, we conducted a split-half reliability analysis and estimated intra-class correlation (ICC) scores, where higher scores imply better internal reliability. This was a concern for many commenters because it would mean that star ratings would be available only for large hospices. Fast Healthcare Interoperability Resources (FHIR) in Support of the Hospice Quality Reporting Program RFI. PDF Texas Health and Human Services Commission Provider Finance Department Some commenters were concerned about the comparative nature of CAHPS star ratings and a few called for an alternative methodology that would rate hospices against a benchmark. The standard of practice for hospice is that care and services are provided on an in-person basis based on needs identified in the comprehensive assessment and services ordered by the IDG and outlined in the plan of care. However, in light of the COVID-19 PHE, we plan to monitor the upcoming MCR Start Printed Page 42534data to see if a more frequent revision to the hospice labor shares is necessary in order to reflect the most recent cost structures of hospice providers. This addressed five of the six COVID-19 PHE-affected quarters for HIS-based measures, and five of the 11 COVID-19 PHE-affected quarters of CAHPS-based measures. Numerator: Total sum of minutes provided by the hospice during skilled nursing visits during RHC services days occurring on Saturdays or Sunday within a reporting period. In the FY 2021 Hospice Wage Index final rule (85 FR 47070) we stated that if appropriate, we would propose any updates from OMB Bulletin No. Services Covered by the Medicare Hospice Benefit, 1. An official website of the United States government. Numerator: The number of decedent beneficiaries receiving a visit by a skilled nurse or social worker for the hospice in the last 3 days of the beneficiary's life within a reporting period. Section 418.24(c) sets forth the elements that must be included on the addendum: 1. One commenter requested that CMS work with stakeholders and the hospice community to identify the best approaches, and separate worksheets, for GIP and inpatient respite costs, including both hospices that operate a freestanding facility and hospices that have contracted beds. Response: The exclusion criteria used for HVWDII and now HVLDL criteria remain the same. They ask us to consider a more gradual transition to new quality initiatives, staggered and prioritized. National Quality Forum. An official website of the United States government. This will allow us to maximize the number of hospices that will have CAHPS scores displayed on Care Compare, protect the reliability of the data, and report as much of the most recent data as possible. For FY 2022, we proposed to continue to use the most recent pre-floor, pre-reclassified hospital wage index value available for Puerto Rico, which is 0.4047, subsequently adjusted by the hospice floor. Response: We acknowledge the commenters' concern that the proposed rule did not explicitly state when we plan to propose any revisions to the hospice labor shares beyond FY 2022. One commenter stated that the service intensity add-on (SIA) payment has been one of the greatest improvements in the hospice benefit in recent years. The specifications for Indicator Ten, Visits Near Death, are as follows: As discussed during the NQF's January 2021 MAP meeting, the HCI summarizes information from ten indicators with each indicator representing key components of the hospice care received, recognizing care delivery and processes. This final regulation is subject to the Congressional Review Act provisions of the Small Business Regulatory Enforcement Fairness Act of 1996 (5 U.S.C. In section III.F of this rule, we finalize proposals to the HQRP including the addition of claims-based Hospice Care Index (HCI) measure, and Hospice Visits in the Last Days of Life (HVLDL) measure for public reporting; removal of the seven Hospice Item Set (HIS) measures because a more broadly applicable measure, the NQF #3235 HIS Comprehensive Assessment Measure for the particular topic is available and already publicly reported; and further development of the Hospice Outcome and Patient Evaluation (HOPE) assessment instrument. Applications are available at the, Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. 22. We anticipate that star ratings will be released prior to a new version of the survey. Therefore, we are not seeking OMB approval for any information collection or recordkeeping activities that may be conducted in connection with the revisions to 418.76(h). 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. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. Response: We agree that hospice care is interdisciplinary care delivered by clinical and non-clinical staff supporting the patient's plan of care. For this indicator, we identified hospice stays that included 30 or more consecutive days of hospice. Stakeholders also suggested several valuable exploratory analyses, improvements for the indicators presented, and ideas for eventual public display for CMS to consider. We received a total of 32 comments pertaining to the proposed revision to the CoPs. In Paperwork Reduction Act package (PRA), CMS-10390 (OMB control number: 0938-1153), we provided the HVLDL specifications and also proposed to replace the HVWDII measure pair with the HVLDL. However, providers with substantially higher percent of live discharge than their peers could signal a potential concern with quality of care or program integrity. The SBNF is used to reduce the overall RHC rate to ensure that SIA payments are budget-neutral. 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. A summary of these comments and our responses appear below: Comments: Several commenters encouraged CMS to thoughtfully consider the implementation timeline for HOPE and the collection demographic and social risk factor data. These commenters stated that the impact of COVID-19 on the labor component of the rates cannot be captured in cost report data that is at least 2 years old. PDFHospice The specifications for Indicator Seven, Per-Beneficiary Medicare Spending, are as follows: Medicare Hospice CoPs require a member of the interdisciplinary team to ensure ongoing assessment of patient and caregiver needs. Section 1814(i)(5)(C) of the Act requires that each hospice submit data to the Secretary on quality measures specified by the Secretary. publication in the future. They were concerned that this number is nearly double the number of survey responses required from home health agencies (40 completes) and more than double the number of responses a hospice must currently have for CAHPS Hospice Survey measures to be reported (30 completes). Similarly, section 1871(b)(1) of the Act requires the Secretary to provide for notice of the proposed rule in the Federal Register and a period of not less than 60 days for public comment for rulemaking carrying out the administration of the insurance programs under title XVIII of the Act. The commenter stated that they believe their patients and their representatives would welcome this option; however, it is unclear whether mailing the form is acceptable for CMS. Having only the most recent data can also help incentivize hospices with lower scores to make changes and have the results of their effort be reflected in better scores. National Quality Forum. Comment: Several comments recommended that CMS not implement HCI because the indicators seem to emphasize medical services, focused heavily on services provided by RNs/LPNs, or do not account for the full interdisciplinary group (for example, claims do not account for spiritual care). As a claims-based measure, the HCI measure will not impose any requirements for collection of new information. In the FY 2022 Hospice Wage Index and Payment Rate Update proposed rule (86 FR 19720), we proposed the market basket percentage increase of 2.5 percent for FY 2022 using the most current estimate of the inpatient hospital market basket (based on IHS Global Inc.'s fourth-quarter 2020 forecast with historical data through the third quarter 2020). By dividing total payments for each level of care (RHC days 1 through 60, RHC days 61+, CHC, IRC, and GIP) using the FY 2022 wage index, current labor shares and payment rates for each level of care by the total payments for each level of care using the final revised labor shares and FY 2022 wage index and payment. Consumers have generally welcomed star ratings. Other commenters recommended that CMS change the requirement from 3 calendar days to 3 business days. Comment: Many commenters offered suggestions regarding additional aspects of the election statement addendum for which we did not propose clarifying changes. The hospice cap amount for the FY 2022 cap year will be $31,297.61, which is equal to the FY 2021 cap amount ($30,683.93) updated by the FY 2022 hospice payment update percentage of 2.0 percent. We believe that updating the data in February 2022 by more than a year relative to the November 2020 freeze data would assist consumers by providing more relevant quality data and allow hospices to demonstrate more recent performance. Comment: Another specific concern raised by commenters was that the cost reports should be amended to allow for a greater breakdown of costs for contracted vs. hospice-administered inpatient services. [32] As stated above, we believe that our current method for calculating the IRC and GIP compensation cost weights provides an accurate measure of the labor shares for these levels of care. Therefore, the HCI composite yields a more reliable provider ranking. 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. Such data must be submitted in a form and manner, and at a time specified by the Secretary.
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