HealthPartners Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, July 18 -- Seamus Dolan, policy analyst at HealthPartners Inc., Bloomington, Minnesota, has issued a public comment on the Centers for Medicare and Medicaid Services' proposed rule entitled "Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2021 Rates; Quality Reporting and Medicare and Medicaid Promoting Interoperability Programs Requirements for Eligible Hospitals and Critical Access Hospitals". The comment was written on July 10, 2020, and posted on July 14, 2020:

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HealthPartners Inc. appreciates the opportunity to provide comments on the FY 2021 Hospital Inpatient Prospective Payment System proposed rule. Founded in 1957, HealthPartners is the largest consumer governed non-profit health care organization in the nation. Through our care group, we provide medical, dental, behavioral, and mental health care to more than one million patients in Minnesota and western Wisconsin and have a multispecialty group practice of more than 1,700 physicians. We value our partnership with the Centers for Medicare & Medicaid Services (CMS) in continuously improving the quality, experience, and affordability of care for our patients and hope that our input is helpful to you as you prepare the final rule. Our comments provide both feedback on items that we believe work well in addition to our suggestions for possible changes in the proposed rule. We want to thank CMS for the work and effort that has gone into developing these thoughtful proposed rules and appreciate this opportunity to comment.

I. Comment on Improvements to the Worksheet S-10

As mandated by Affordable Care Act, CMS is required to allocate Medicare DSH funds based on an "empirically justified" formula that was originally based on a combination of Medicaid and Medicare supplemental Security Income days as well as uncompensated care cost. Initially, hospitals would receive 25 percent of their Medicare DSH funds under the old formula and 75 percent into a separate uncompensated pool. Over time, CMS transitioned to using the cost report's Worksheet S-10 data on hospital charity care and bad debt to determine the amount of uncompensated care each hospital provides, in place of the pre-ACA formula. However, in past rulemaking the agency has indicated that there are concerns with variations and the completeness of this data, including in its auditing process.

Recommendation

In response to the agency's concerns, we share the following feedback and recommendations:

* Reporting irregularities - An American Hospital Association analysis of FY 2014 data found that a number of hospitals had uncompensated care costs on line 30 of the Worksheet S-10 that totaled more than 50 percent of their total expenses for the facility as a whole. One of these hospitals had uncompensated care costs that were over 800 percent of its total expenses. Another had bad debt expenses that were more than 2000 percent of its total expenses.

- Recommendation - no hospital should receive an add-on payment that exceeds its base reimbursement.

* Review burden - the data request by CMS and implemented by MACs and their subcontractors result in excessively burdensome reporting requirements. In no exaggeration, large DSH hospitals are to report hundreds of thousands of unique charity care claims during the year, with corresponding revenue and transaction codes (contractual allowances, payments, refunds, etc.). This can result in upwards of 10,000,000 lines in an excel spreadsheet, double the previous amount.

- Recommendation - no hospital should receive an add-on payment that exceeds its base reimbursement.

* Equity Issues in Audit Process - For FY 2021, CMS audited 65% of DSH eligible hospitals for determining Factor 3 for UCC. Presumably, the audits are targeted at the highest UCC recipients, which has some merit. However, in a fixed pool scenario, the main problem with lack of 100% audit is that hospitals with erroneous data and relatively small factor 3 ratios benefit at the expense of hospitals which are audited with relatively high factor 3 ratios. There seems to be no oversight for DSH hospitals in the bottom third of UCC distribution.

- Recommendation - CMS should strongly reconsider its use of the Worksheet S-10 until it starts auditing all hospital data. The auditors should pull a random sample of claims and look for anomalies in that fashion.

* Auditor Education - the audit process allows for little time for auditor education. Many of CMS's contractors and subcontractors do not fully understand the expectations for reporting and often MACs follow different interpretations of the rules. For example, cost report instructions state to report the co-insurance and deductibles related to charity care for patients qualifying for patient financial assistance. Some MACs interpret this language as to disallow "co-payments" that are charity care. However, co-payments and co-insurance essentially serve the same purpose, patient liability, and in fact, are both used and allowed for the reporting of bad Medicare debts.

- Recommendation - CMS should adopt a standard template that must be used to complete Worksheet S-10. Additionally, while many auditors have a finance background, they may not be as educated on patient financial services. CMS should help provide general education on how hospitals implement and record transactions on charity care and financial assistance policies that promote a shared understanding.

Moreover, CMS should engage MACs and hospitals prior to the release of substantive revisions to or guidance on cost report instructions to promote an ongoing dialogue on best reporting practices.

II. Comment on changes to the hospital reporting of eCQMs

CMS is proposing to publicly report eCQM performance data for the first time, beginning with data reported for the CY 2021 reporting period, on Hospital Compare and/or data.medicare.gov, or any successor websites. Additionally, CMS proposes progressively increasing the number of quarters hospitals are required to report eCQM data, starting with reporting two quarters in CY 2021, three in CY 2022 and the full year in 2023. They are asking for comment.

Recommendation

Publically reporting eCQM data along with increasing the reporting period to two quarters will burden health care providers during the COVID 19 emergency. Because this data has not been reported in the past, no benchmarking exists to understand how we compare among our peers. To properly prepare for such changes, providers will need capacity to analyze past performance on eCQM measures and then implement improvement initiatives where necessary. The additional quarter in the reporting period would push the deadline for this work up to July 2021.

We encourage CMS to consider CY 2021 a dry-run period to generate benchmark measures for peer comparison followed by publically reporting data from CY 2022. We also ask you to consider delaying the progressive increase in the reporting period by a year, to two quarters in 2022, three quarters in 2023 and a full year in 2024.

Thank you for the opportunity to provide these comments. We hope that they are helpful to you as you develop both the final rule and any additional guidance. We welcome the opportunity to answer any of your questions on our comments and look forward to continuing to be engaged on future regulation development.

Sincerely,

Seamus Dolan

Policy Analyst

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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0052-0002

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