Medicare Program; FY 2018 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements
Proposed rule.
CFR Part: "42 CFR Part 418"
RIN Number: "RIN 0938-AT00"
Citation: "82 FR 20750"
Document Number: "CMS-1675-P"
Page Number: "20750"
"Proposed Rules"
SUMMARY: This proposed rule would update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2018. Additionally, this rule proposes changes to the hospice quality reporting program, including proposing new quality measures, soliciting feedback on an enhanced data collection instrument, and describing plans to publicly display quality measures and other hospice data.
EFFECTIVE DATE: To be assured consideration, comments must be received at one of the addresses provided below, no later than
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For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
Debra Dean-Whittaker, (410) 786-0848 for questions regarding the CAHPS(R) Hospice Survey.
Cindy Massuda, (410) 786-0652 for questions regarding the hospice quality reporting program.
For general questions about hospice payment policy, please send your inquiry via email to: [email protected].
SUPPLEMENTARY INFORMATION: Wage index addenda will be available only through the internet on our Web site at: (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html.)
Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to view public comments.
Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the
Table of Contents
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Impacts
II. Background
A.
B. History of the Medicare Hospice Benefit
C. Services Covered by the Medicare Hospice Benefit
D. Medicare Payment for Hospice Care
1. Omnibus Budget Reconciliation Act of 1989
2. Balanced Budget Act of 1997
3. FY 1998 Hospice Wage Index Final Rule
4. FY 2010 Hospice Wage Index Final Rule
5. The Affordable Care Act
6. FY 2012 Hospice Wage Index Final Rule
7. FY 2015 Hospice Wage Index and Payment Rate Update Final Rule
8. IMPACT Act of 2014
9. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule
10. FY 2017 Hospice Wage Index and Payment Rate Update Final Rule
E. Trends in Medicare Hospice Utilization
III. Provisions of the Proposed Rule
A. Monitoring for Potential Impacts--Affordable Care Act Hospice Reform
1. Hospice Payment Reform: Research and Analyses
a. Length of Stay and Live Discharges
b. Skilled Visits in the Last Days of Life
c. Non-Hospice Spending
2. Initial Analysis of Revised Hospice Cost Report Data
a. Background
b. Methodology
c. Overall Payments and Costs and Costs by Level of Care
B. Proposed FY 2018 Hospice Wage Index and Rate Update
1. Proposed FY 2018 Hospice Wage Index
2. Proposed FY 2018 Hospice Payment Update Percentage
3. Proposed FY 2018 Hospice Payment Rates
4. Hospice Cap Amount for FY 2018
C. Discussion and Solicitation of Comments Regarding Sources of Clinical Information for Certifying Terminal Illness
D. Proposed Updates to the Hospice Quality Reporting Program
1.
2. General Considerations Used for Selection of Quality Measures for the HQRP
3. Policy for Retention of HQRP Measures Adopted for Previous Payment Determination
4. Policy for Adopting Changes to Previously Adopted Measures
5. Previously Adopted Quality Measures for FY 2018 Payment Determination and Future Years
6. Proposed Removal of Previously Adopted Measures
7. Measure Concepts Under Consideration for Future Years
8. Form, Manner, and Timing of Quality Data Submission
9. Previously Adopted APU Determination and Compliance Criteria for the HQRP
10. HQRP Submission Exemption and Extension Requirements for the FY 2019 Payment Determination and Subsequent Years
11. CAHPS(R) Hospice Survey Participation Requirements for the FY 2020 APU and Subsequent Years
12. HQRP Reconsideration and Appeals Procedures for the FY 2018 Payment Determination and Subsequent Years
13. Confidential Feedback Reports
14. Public Display of Quality Measures and Other Hospice Data for the HQRP
IV. Collection of Information Requirements
A. Hospice Item Set
B. Summary of CAHPS(R) Hospice Survey Information Collection Requirements (OMB Control Number 0938-1257)
V. Response to Comments
VI. Request for Information on Medicare Flexibilities and Efficiencies
VII. Regulatory Impact Analysis
A. Statement of Need
B. Overall Impacts
C. Anticipated Effects
D. Detailed Economic Analysis
E. Alternatives Considered
F. Accounting Statement
G. Reducing Regulation and Controlling Regulatory Costs
H. Conclusion
Acronyms
Because of the many terms to which we refer by acronym in this proposed rule, we are listing the acronyms used and their corresponding meanings in alphabetical order:
APU Annual Payment Update
ASPE Assistant Secretary of Planning and Evaluation
BBA Balanced Budget Act of 1997
BIPA Benefits Improvement and Protection Act of 2000
BNAF Budget Neutrality Adjustment Factor
CAHPS(R) Consumer Assessment of Healthcare Providers and Systems
CASPER Certification and Survey Provider Enhanced Reports
CBSA Core-Based Statistical Area
CCN CMS Certification Number
CFR Code of Federal Regulations
CHC Continuous Home Care
CHF Congestive Heart Failure
COPD Chronic Obstructive Pulmonary Disease
CoPs Conditions of Participation
CPI-U Consumer Price Index-Urban Consumers
CVA Cerebral Vascular Accident
CWF Common Working File
CY Calendar Year
DME Durable Medical Equipment
FEHC Family Evaluation of Hospice Care
FY Fiscal Year
GAO Government Accountability Office
GIP General Inpatient Care
HHS
HIS Hospice Item Set
HQRP Hospice Quality Reporting Program
ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modification
ICR Information Collection Requirement
IMPACT Act Improving Medicare Post-Acute Care Transformation Act of 2014
IPPS Inpatient Prospective Payment System
IRC Inpatient Respite Care
LCD Local Coverage Determination
MAC Medicare Administrative Contractor
MACRA Medicare Access and CHIP Reauthorization Act of 2015
MFP Multifactor Productivity
MSA Metropolitan Statistical Area
NF Long Term Care Nursing Facility
NOE Notice of Election
NOTR Notice of Termination/Revocation
NP Nurse Practitioner
NPI National Provider Identifier
PS&R Provider Statistical and Reimbursement Report
Pub. L. Public Law
POC Plan of Care
QAPI Quality Assessment and Performance Improvement
RHC Routine Home Care
RN Registered Nurse
SIA Service Intensity Add-on
SNF Skilled Nursing Facility
TEFRA Tax Equity and Fiscal Responsibility Act of 1982
UHDDS Uniform Hospital Discharge Data Set
U.S.C. United States Code
I. Executive Summary
A. Purpose
This rule proposes updates to the hospice payment rates for fiscal year (FY) 2018, as required under section 1814(i) of the Social Security Act (the Act). This rule also discusses and solicits comments on the source of the clinical information used to certify an individual as terminally ill (that is, having a life expectancy of 6 months or less as defined in section 1861(dd)(3)(A)) as required by section 1814(a)(7)(A) of the Act. Finally, this rule also proposes new quality measures and provides an update on the hospice quality reporting program (HQRP) consistent with the requirements of section 1814(i)(5) of the Act. In accordance with section 1814(i)(5)(A) of the Act, starting in FY 2014, hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to their payments.
B. Summary of the Major Provisions
Section III.A of this proposed rule describes monitoring activities intended to identify potential impacts related to the hospice reform policies finalized in the FY 2016 Hospice Wage Index and Payment Rate Update final rule and analyzes current trends in hospice utilization and expenditures. Section III.B.1 updates the hospice wage index with updated wage data and makes the application of the updated wage data budget neutral for all four levels of hospice care. In section III.B.2, we discuss the FY 2018 hospice payment update percentage of 1.0 percent. Sections III.B.3 and III.B.4 update the hospice payment rates and hospice cap amount for FY 2018 by the hospice payment update percentage discussed in section III.B.2.
In section III.C of this proposed rule, we discuss and solicit comments on the appropriate source(s) of the required clinical information for certification of a medical prognosis of a life expectancy of 6 months or less.
Finally, in section III.D of this proposed rule, we discuss updates to HQRP, including proposed changes to the CAHPS(R) Hospice Survey measures as well as the possibility of utilizing a new assessment instrument to collect quality data. In section III.D, we will also discuss proposed enhancements to the current Hospice Item Set (HIS) data collection instrument to be more in line with other post-acute care settings. The new data collection instrument would be a comprehensive patient assessment instrument, rather than the current chart abstraction tool. Additionally, in this section we discuss our plans for sharing HQRP data publicly later in Calendar Year (CY) 2017, as well as plans to provide public reporting via a Compare Site in CY 2017 and future years.
C. Summary of Impacts
Table 1--Impact Summary Table Provision description Transfers FY 2018 Hospice Wage Index and The overall economic impact of this proposed Payment Rate Update rule is estimated to be an estimated$180 million in increased payments to hospices during FY 2018.
II. Background
A.
Hospice care is a comprehensive, holistic approach to treatment that recognizes that the impending death of an individual, upon his or her choice, warrants a change in the focus from curative care to palliative care for relief of pain and for symptom management. The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. A hospice uses an interdisciplinary approach to deliver medical, nursing, social, psychological, emotional, and spiritual services through a collaboration of professionals and other caregivers, with the goal of making the beneficiary as physically and emotionally comfortable as possible. Hospice is compassionate beneficiary and family/caregiver-centered care for those who are terminally ill.
Medicare regulations define "palliative care" as patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice (
Medicare hospice care is palliative care for individuals with a prognosis of living 6 months or less if the terminal illness runs its normal course. When a beneficiary is terminally ill, many health problems are related to the underlying condition(s), as bodily systems are interdependent. In the 2008 Hospice Conditions of Participation final rule, we stated that "the [hospice] medical director must consider the primary terminal condition, related diagnoses, current subjective and objective medical findings, current medication and treatment orders, and information about unrelated conditions when considering the initial certification of the terminal illness" (73 FR 32176). As referenced in our regulations at
While the goal of hospice care is to allow the beneficiary to remain in his or her home, circumstances during the end-of-life may necessitate short-term inpatient admission to a hospital, skilled nursing facility (SNF), or hospice facility for necessary pain control or acute or chronic symptom management that cannot be managed in any other setting. These acute hospice care services ensure that any new or worsening symptoms are intensively addressed so that the beneficiary can return to his or her home. Limited, short-term, intermittent, inpatient respite care (IRC) is also available because of the absence or need for relief of the family or other caregivers. Additionally, an individual can receive continuous home care (CHC) during a period of crisis in which an individual requires continuous care to achieve palliation or management of acute medical symptoms so that the individual can remain at home. 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 our regulations at
Hospices are expected to comply with all civil rights laws, including the provision of auxiliary aids and services to ensure effective communication with patients and patient care representatives with disabilities consistent with section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act. Additionally, they must provide language access for such persons who are limited in English proficiency, consistent with Title VI of the Civil Rights Act of 1964. Further information about these requirements may be found at http://www.hhs.gov/ocr/civilrights.
B. History of the Medicare Hospice Benefit
Before the creation of the
FOOTNOTE 1 Connor, Stephen. (2007). Development of Hospice and Palliative Care in
FOOTNOTE 2 Paolini, DO, Charlotte. (2001). Symptoms Management at End of Life. JAOA. 101(10). p. 609-615. END FOOTNOTE
As stated in the
The benefit was originally designed to cover hospice care for a finite period of time that roughly corresponded to a life expectancy of 6 months or less. Initially, beneficiaries could receive three election periods: Two 90-day periods and one 30-day period. Currently,
C. Services Covered by the Medicare Hospice Benefit
One requirement for coverage under the
Section 1814(a)(7)(B) of the Act requires that a written plan for providing hospice care to a beneficiary who is a hospice patient be established before care is provided by, or under arrangements made by, that hospice program and that the written plan be periodically reviewed by the beneficiary's attending physician (if any), the hospice medical director, and an interdisciplinary group (described in section 1861(dd)(2)(B) of the Act). The services offered under the
Before the
FOOTNOTE 3 Greer, D., Mor, V., Sherwood, S. (1983) National hospice study analysis plan.
* Patient and family know of the terminal condition.
* Further medical treatment and intervention are indicated only on a supportive basis.
* Pain control should be available to patients as needed to prevent rather than to just ameliorate pain.
* Interdisciplinary teamwork is essential in caring for patient and family.
* Family members and friends should be active in providing support during the death and bereavement process.
* Trained volunteers should provide additional support as needed.
The cost data and the findings on what services hospices provided in the demonstration project were used to design the
D. Medicare Payment for Hospice Care
Sections 1812(d), 1813(a)(4), 1814(a)(7), 1814(i), and 1861(dd) of the Act, and our regulations in part 418, establish eligibility requirements, payment standards and procedures; define covered services; and delineate the conditions a hospice must meet to be approved for participation in the
1. Omnibus Budget Reconciliation Act of 1989
Section 6005(a) of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239) amended section 1814(i)(1)(C) of the Act and provided for the following two changes in the methodology concerning updating the daily payment rates: (1) Effective
2. Balanced Budget Act of 1997
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33) amended section 1814(i)(1)(C)(ii)(VI) of the Act to establish updates to hospice rates for FYs 1998 through 2002. Hospice rates were updated by a factor equal to the hospital market basket percentage increase, minus 1 percentage point. Payment rates for FYs from 2002 have been updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update to the payment rates for subsequent FYs will be the hospital market basket percentage increase for the FY. The Act requires us to use the inpatient hospital market basket to determine hospice payment rates.
3. FY 1998 Hospice Wage Index Final Rule
In the
4. FY 2010 Hospice Wage Index Final Rule
Inpatient hospital pre-floor and pre-reclassified wage index values, as described in the
5. The Affordable Care Act
Starting with FY 2013 (and in subsequent FYs), the market basket percentage update under the hospice payment system referenced in sections 1814(i)(1)(C)(ii)(VII) and 1814(i)(1)(C)(iii) of the Act is subject to annual reductions related to changes in economy-wide productivity, as specified in section 1814(i)(1)(C)(iv) of the Act. In FY 2013 through FY 2019, the market basket percentage update under the hospice payment system will be reduced by an additional 0.3 percentage point (although for FY 2014 to FY 2019, the potential 0.3 percentage point reduction is subject to suspension under conditions specified in section 1814(i)(1)(C)(v) of the Act).
In addition, sections 1814(i)(5)(A) through (C) of the Act, as added by section 3132(a) of the Affordable Care Act, require hospices to begin submitting quality data, based on measures to be specified by the Secretary of the
Section 1814(a)(7)(D)(i) of the Act, as added by section 3132(b)(2) of the Affordable Care Act, requires, effective
6. FY 2012 Hospice Wage Index Final Rule
When the
7. FY 2015 Hospice Wage Index and Payment Rate Update Final Rule
When electing hospice, a beneficiary waives
A hospice "attending physician" is described by the statutory and regulatory definitions as a medical doctor, osteopath, or nurse practitioner whom the beneficiary identifies, at the time of hospice election, as having the most significant role in the determination and delivery of his or her medical care. Over time, we have received reports of problems with the identification of the person's designated attending physician and a third of hospice patients had multiple providers submit Part B claims as the "attending physician," using a claim modifier. The FY 2015 Hospice Wage Index and Payment Rate Update final rule finalized a requirement that the election form include the beneficiary's choice of attending physician and that the beneficiary provide the hospice with a signed document when he or she chooses to change attending physicians (79 FR 50479).
Hospice providers are required to begin using a Hospice Experience of
Finally, the FY 2015 Hospice Wage Index and Payment Rate Update final rule required providers to complete their aggregate cap determination not sooner than 3 months after the end of the cap year, and not later than 5 months after, and remit any overpayments. Those hospices that fail to timely submit their aggregate cap determinations will have their payments suspended until the determination is completed and received by the Medicare Administrative Contractor (MAC) (79 FR 50503).
8. IMPACT Act of 2014
The Improving Medicare Post-Acute Care Transformation Act of 2014 (Pub. L. 113-185) (IMPACT Act) became law on
9. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2016 Hospice Rate Update final rule, we created two different payment rates for RHC that resulted in a higher base payment rate for the first 60 days of hospice care and a reduced base payment rate for subsequent days of hospice care (80 FR 47172). We also created a Service Intensity Add-on (SIA) payment payable for services during the last 7 days of the beneficiary's life, equal to the CHC hourly payment rate multiplied by the amount of direct patient care provided by a registered nurse (RN) or social worker that occurs during the last 7 days (80 FR 47177).
In addition to the hospice payment reform changes discussed, the FY 2016 Hospice Wage Index and Payment Rate Update final rule implemented changes mandated by the IMPACT Act, in which the cap amount for accounting years that end after
Finally, the FY 2016 Hospice Wage Index and Payment Rate Update final rule clarified that hospices must report all diagnoses of the beneficiary on the hospice claim as a part of the ongoing data collection efforts for possible future hospice payment refinements. Reporting of all diagnoses on the hospice claim aligns with current coding guidelines as well as admission requirements for hospice certifications.
10. FY 2017 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2017 Hospice Wage Index and Payment Rate Update final rule, we finalized several new policies and requirements related to the HQRP. First, we codified our policy that if the
E. Trends in Medicare Hospice Utilization
Since the implementation of the hospice benefit in 1983, and especially within the last decade, there has been substantial growth in hospice benefit utilization. The number of
There have also been changes in the diagnosis patterns among
Table 2--The Top Twenty Principal Hospice Diagnoses, FY 2002, FY 2007, FY2013, FY 2016 Rank ICD-9/Reported Principal Diagnosis Count Percentage Year: FY 2002 1 162.9 Lung Cancer 73,769 11 2 428.0 Congestive Heart Failure 45,951 7 3 799.3 Debility Unspecified 36,999 6 4 496 COPD 35,197 5 5 331.0 Alzheimer's Disease 28,787 4 6 436 CVA/Stroke 26,897 4 7 185 Prostate Cancer 20,262 3 8 783.7 Adult Failure To Thrive 18,304 3 9 174.9 Breast Cancer 17,812 3 10 290.0 Senile Dementia, Uncomp. 16,999 3 11153.0 Colon Cancer 16,379 2 12 157.9 Pancreatic Cancer 15,427 2 13 294.8 Organic Brain Synd Nec 10,394 2 14 429.9 Heart Disease Unspecified 10,332 2 15 154.0 Rectosigmoid Colon Cancer 8,956 1 16 332.0 Parkinson's Disease 8,865 1 17 586 Renal Failure Unspecified 8,764 1 18 585 Chronic Renal Failure (End 2005) 8,599 1 19 183.0 Ovarian Cancer 7,432 1 20 188.9 Bladder Cancer 6,916 1 Year: FY 2007 1 799.3 Debility Unspecified 90,150 9 2 162.9 Lung Cancer 86,954 8 3 428.0 Congestive Heart Failure 77,836 7 4 496 COPD 60,815 6 5 783.7 Adult Failure To Thrive 58,303 6 6 331.0 Alzheimer's Disease 58,200 6 7 290.0 Senile Dementia Uncomp. 37,667 4 8 436 CVA/Stroke 31,800 3 9 429.9 Heart Disease Unspecified 22,170 2 10 185 Prostate Cancer 22,086 2 11 174.9 Breast Cancer 20,378 2 12 157.9 Pancreas Unspecified 19,082 2 13153.9 Colon Cancer 19,080 2 14 294.8 Organic Brain Syndrome NEC 17,697 2 15 332.0 Parkinson's Disease 16,524 2 16 294.10 Dementia in Other Diseases w/o Behavior 15,777 2 Dist. 17 586 Renal Failure Unspecified 12,188 1 18 585.6 End Stage Renal Disease 11,196 1 19 188.9 Bladder Cancer 8,806 1 20 183.0 Ovarian Cancer 8,434 1 Year: FY 2013 1 799.3 Debility Unspecified 127,415 9 2 428.0 Congestive Heart Failure 96,171 7 3 162.9 Lung Cancer 91,598 6 4 496 COPD 82,184 6 5 331.0 Alzheimer's Disease 79,626 6 6 783.7 Adult Failure to Thrive 71,122 5 7 290.0 Senile Dementia, Uncomp. 60,579 4 8 429.9 Heart Disease Unspecified 36,914 3 9 436 CVA/Stroke 34,459 2 10 294.10 Dementia in Other Diseases w/o Behavioral 30,963 2 Dist. 11 332.0 Parkinson's Disease 25,396 2 12153.9 Colon Cancer 23,228 2 13 294.20 Dementia Unspecified w/o Behavioral Dist. 23,224 2 14 174.9 Breast Cancer 23,059 2 15 157.9 Pancreatic Cancer 22,341 2 16 185 Prostate Cancer 21,769 2 17 585.6 End-Stage Renal Disease 19,309 1 18 518.81 Acute Respiratory Failure 15,965 1 19 294.8 Other Persistent Mental Dis.--classified 14,372 1 elsewhere 20 294.11 Dementia In Other Diseases w/Behavioral 13,687 1 Dist. Year: FY 2016 1 G30.9 Alzheimer's disease, unspecified 162,845 11 2 I50.9 Heart failure, unspecified 84,088 6 3 J44.9 Chronic obstructive pulmonary disease, 74,131 5 unspecified 4 C34.90 Malignant Neoplasm of Unsp Part of Unsp 57,077 4 Bronchus or Lung 5 G31.1 Senile degeneration of brain, not 55,305 4 elsewhere classified 6 G20 Parkinson's disease 37,245 2 7 I25.10 Atherosclerotic heart disease of native 33,647 2 coronary art without angina pectoris 8 J44.1 Chronic obstructive pulmonary disease with 32,851 2 (acute) exacerbation 9 G30.1 Alzheimer's disease with late onset 29,223 2 10 I67.2 Cerebral atherosclerosis 27,629 2 11 C61 Malignant neoplasm of prostate 24,576 2 12 N18.6 End stage renal disease 22,261 1 13 C18.9 Malignant neoplasm of colon, unspecified 22,203 1 14 I51.9 Heart disease, unspecified 21,868 1 15 C25.9 Malignant neoplasm of pancreas, 20,400 1 unspecified 16 I63.9 Cerebral infarction, unspecified 18,546 1 17 I67.9 Cerebrovascular disease, unspecified 14,879 1 18 C50.919 Malignant neoplasm of unspecified site of 14,022 1 unspecified female breast 19 A41.9 Sepsis, unspecified organism 12,723 1 20 I50.22 Chronic systolic (congestive) heart 12,083 1 failure Note(s): The frequencies shown represent beneficiaries that had at least one claim with the specific ICD-9-CM/ICD-10 code reported as the principal diagnosis. Beneficiaries could be represented multiple times in the results if they have multiple claims during that time period with different principal diagnoses. Source: FY 2002 and 2007 hospice claims data from theChronic Conditions Data Warehouse (CCW), accessed onFebruary 14 andFebruary 20, 2013 . FY 2013 hospice claims data from the CCW, accessed onJune 26, 2014 , and FY 2016 hospice claims data from the CCW, accessed and merged with ICD-10 codes onJanuary 9, 2017 .
While there has been a shift in the reporting of the principal diagnosis as a result of diagnosis clarifications, a significant proportion of hospice claims (49 percent) in FY 2014 only reported a single principal diagnosis, which may not fully explain the characteristics of
III. Provisions of the Proposed Rule
A. Monitoring for Potential Impacts--Affordable Care Act Hospice Reform
1. Hospice Payment Reform: Research and Analyses
This section of the proposed rule describes current trends in hospice utilization and provider behavior, such as lengths of stay, live discharge rates, skilled visits during the last days of life, and non-hospice spending. Utilization data on these metrics were examined to determine the potential impacts related to the hospice reform policies finalized in the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47142), if any. Moreover, in response to
a. Length of Stay and Live Discharges
Hospice Length of Stay
Eligibility under the
The number of days that a hospice beneficiary receives care under a hospice election is referred to as the hospice length of stay. Hospice length of stay can be influenced by a number of factors including disease course, timing of referral, decision to resume curative treatment, and/or stabilization or improvement where the individual is no longer certified as terminally ill. Longer lengths of stay in hospice may reflect admission to hospice earlier in the disease trajectory or miscalculation of prognosis, among other situations. Shorter lengths of stay in hospice may reflect hospice election late in the disease trajectory or a rapidly progressing acute condition. This also may be due to individual reluctance to accept that his or her condition is terminal and choose the hospice benefit; inadequate knowledge regarding the breadth of services available under hospice care; cultural, ethnic, and/or religious backgrounds inhibiting or even precluding the use of hospice services; and other reasons. /4/ As such, hospice lengths of stay are variable.
FOOTNOTE 4 Vig, E., Starks, H., Taylor, J., Hopley, E., Fryer-Edwards, K. (2010). "Why Don't Patients Enroll in Hospice? Can We Do Anything About It?"
We examined length of stay, meaning the number of hospice days during a single hospice election at the date of live discharge or death. We also examined total lifetime length of stay, which would include the sum of all days of hospice care across all hospice elections. This would mean if a beneficiary had one hospice election, was discharged alive, and then re-elected the benefit at a later date, the sum of both elections would count towards their lifetime length of stay. In FY 2016, the average length of stay in hospice was 79 days and the average lifetime length of stay in hospice was 96.1 days. The average length of stay remained virtually the same between FY 2015 and FY 2016, 78 days compared to 79 days, respectively. The average lifetime length of stay similarly remained virtually the same between FY 2015 and FY 2016, 95.2 and 96.1 days, respectively.
The median (50th percentile) length of stay in FY 2016 was 18 days. This means that half of hospice beneficiaries received care for fewer than 18 days and half received care for more than 18 days. While the median length of stay has remained relatively constant over the past several years, the average length of stay has typically increased from year to year.
The Medicare hospice benefit provides four levels of care: Routine home care (RHC), general inpatient care (GIP), continuous home care (CHC), and inpatient respite care (IRC). The majority of hospice patient care is provided at the RHC level of care and can be provided wherever the patient calls "home," including nursing homes and assisted living facilities. As indicated in Table 3 below, most hospice care (98 percent) provided is routine home care (RHC). Approximately 56 percent of all hospice days are provided at the RHC level of care in the patient's residence whereas 41 percent is provided at the RHC level of care to patients that reside in a nursing home or assisted living facility.
Table 3--Share of Hospice Days by Level of Care and Site of Service, for Beneficiaries Discharged Alive or Deceased in FY 2016 Level of care Site of service Number of % of all hospice hospice days days RHC Home + Hospice Residential 59,818,337 55.75 Facility SNF/NF 25,953,198 24.19 Assisted Living Facility 18,182,931 16.95 Other 1,224,979 1.14 Total 105,179,44598.02 GIP Inpatient Hospital 378,792 0.35 Inpatient Hospice Facility 1,060,487 0.99 Skilled Nursing Facility 59,158 0.06 Other 5,571 0.01 Total 1,504,008 1.40 CHC Home + Hospice Residential 180,206 0.17 Facility SNF/NF 42,224 0.04 Assisted Living Facility 69,849 0.07 Other 484 0.00 Total 292,763 0.27 IRC Inpatient Hospital 29,895 0.03 Inpatient Hospice Facility 111,004 0.10 SNF/NF 185,351 0.17 Other 1,490 0.00 Total 327,740 0.31 Total 107,303,956 100 Source: Common Working File (CWF). All hospice claims from 2006 to 2016 were included, for beneficiaries whose final claim in FY 2016, according to through date, for a hospice discharge (excluded status code "30", indicating a continuing patient). Hospice days with invalid or missing site of service HCPCS code are excluded.
In addition to analyzing the hospice average and average lifetime lengths of stay, we examined the average lifetime lengths of stay associated with hospice principal diagnoses by site of service at admission in FY 2015 (see Table 4 below). We limited our analysis to those beneficiaries that were receiving RHC at admission. As noted in Table 3 above, RHC was the level of care for 98 percent of all hospice days. We found that beneficiaries with chronic, progressive neurological diseases such as Alzheimer's disease and related dementias, and Parkinson's disease had the longest average lifetime lengths of stay at 165.3 days in FY 2015. Beneficiaries with Chronic Kidney Disease and cancer had shorter average lifetime lengths of stay, 57 and 63.7 days, respectively. For all diagnoses, the average lifetime length of stay was 113.5 days in FY 2015 when level of care at admission is RHC.
Table 4--Average Lifetime Length of Stay by Diagnosis and Site of Service on the Day of Admission in FY 2015, When Level of Care at Admission Is RHC Home + hospice resi- Assisted living SNF + LTC or non- dential facility facility skilled nursing facility Primary hospice Number of Average Number of Average Number of Average diagnosis at benes lifetime benes lifetime benes lifetime admission length of length of length of stay stay stay All Diagnoses 576,657 106.75 101,085 159.77 208,747 106.21 Alzheimer's, 83,527 172.45 39,019 186.89 67,438 140.34 Dementia, and Parkinson's CVA/Stroke 32,329 95.82 9,359 98.97 23,927 77.17 Cancers 233,771 62.04 11,773 93.90 30,437 63.23 Chronic Kidney 14,328 58.41 1,655 82.34 6,644 47.60 Disease Heart (CHF and 101,243 121.77 19,784 131.11 35,052 83.54 Other Heart Disease) Lung (COPD and 58,183 131.97 6,866 127.83 16,631 82.42 Pneumonias) All Other 53,276 163.47 12,629 254.83 28,618 150.98 Diagnoses
Table 4--Average Lifetime Length of Stay by Diagnosis and Site of Service on the Day of Admission in FY 2015, When Level of Care at Admission Is RHC Other All sites of service Primary hospice Number of Average Number of Average diagnosis at benes lifetime benes lifetime admission length of length of stay stay All Diagnoses 9,530 90.90 897,298 113.51 Alzheimer's, 2,314 143.33 192,593 165.32 Dementia, and Parkinson's CVA/Stroke 971 53.56 66,668 90.06 Cancers 1,964 46.41 278,047 63.69 Chronic Kidney 273 48.84 22,907 57.01 Disease Heart (CHF and 1,771 84.69 158,167 115.14 Other Heart Disease) Lung (COPD and 870 65.42 82,656 122.11 Pneumonias) All Other 1,367 125.28 96,260 173.36 Diagnoses Source: Common Working File (CWF). All hospice claims from 2006 to 2015 were included, for beneficiaries whose final claim in FY 2015, according to through date, for a hospice discharge (excluded status code "30", indicating a continuing patient). Diagnosis code and site of service were determined by the first hospice claim for a beneficiary. Diagnosis categories are consistent with those outlined in Abt's 2015 technical report (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/December-2015-Technical-Report.pdf). Note 1: "Other" category includes inpatient hospital, inpatient hospice facility, LTCH, IPF, and places not otherwise specified. Although dementia was no longer a valid primary diagnosis for the hospice benefit, our study time period examines primary diagnoses dating back to 2006. Note 2: The data used for this table spans multiple years (2006 and forward). We were not able to convert ICD-9-CM diagnosis codes to ICD-10-CM codes, given the inherent complexities with appropriately mapping ICD-9-CM codes to ICD-10-CM codes, in time for this proposed rule. Therefore, we limited this analysis to those hospice patients that were discharged (alive or deceased) in FY 2015.
As we indicated above, the average lifetime length of stay across all levels of care at admission was 96.1 days in FY 2016. However, the average lifetime length of stay was 114 days in FY 2016 when the level of care was RHC at admission (see Table 5 below). This suggests that beneficiaries not receiving RHC level of care at admission had shorter lifetime lengths of stay compared to the beneficiaries whose level of care was RHC at admission. In particular, those beneficiaries who are admitted to hospice at the GIP level of care typically are more acute and often die without transitioning to RHC and thus, have overall shorter lengths of stay. Therefore, the shorter lengths of stay for those admitted at the GIP level of care affect the overall average lifetime length of stay across all levels of care.
Table 5--Average Lifetime Length of Stay Level of Care to RHC at Admission, FY 2015-FY 2016 FY 2015 FY 2016 Number of Average Number of Average benes lifetime benes lifetime length of length of stay stay Any Level of Care at Admission 1,111,967 95.16 1,117,643 96.14 RHC at Admission 897,298 113.51 909,961 114.02 Source: Common Working File (CWF). All hospice claims from 2006 to 2016 were included, for beneficiaries whose final claim in FY 2016, according to through date, for a hospice discharge (excluded status code "30", indicating a continuing patient).
Live Discharges
A beneficiary who has elected hospice may revoke his or her hospice election at any time and for any reason. The regulations state that if the hospice beneficiary (or his or her representative) revokes the hospice election, the beneficiary may, at any time, re-elect to receive hospice coverage for any other hospice election period that he or she is eligible to receive (
Federal regulations limit the circumstances in which a
See Illustration in Original Document.
As part of our ongoing monitoring efforts, we analyzed the distribution of live discharge rates among hospices with 50 or more discharges (discharged alive or deceased). Table 6 shows that there is significant variation in the rate of live discharge between the 10th and 90th percentiles. Most notably, hospices at the 95th percentile discharged 49.1 percent of their patients alive in FY 2016. While the live discharge rate in FY 2016 for every percentile has decreased compared to FY 2014, the median live discharge rate remains around 17 percent.
Table 6--Distribution of Live Discharge Rates for Hospices With 50 or More Live Discharges, FY 2014 to FY 2016 Live discharge rate Statistics FY 2014 FY 2015 FY 2016 5th Percentile 7.5% 6.9% 6.8% 10th Percentile 9.0% 8.5% 8.4% 25th Percentile 12.4% 11.6% 11.6% Median 17.6% 16.8% 16.9% 75th Percentile 26.5% 24.6% 25.4% 90th Percentile 39.4% 35.9% 37.2% 95th Percentile 50.0% 45.6% 49.1% # Providers 3,160 3,215 3,232 Source: FY 2014, FY 2015, and FY 2016 hospice claims data from Common Working File (CWF) that list a discharge status code (meaning claims were excluded if they listed status code 30, indicating a continuing patient). Live discharges were defined as hospice claims with a status code of "01".
Finally, we looked at the distribution of live discharges by length of stay intervals. In looking at the length of stay intervals, 26 percent of the live discharges occurred within 30 days of the start of hospice care, 13 percent between 31 to 60 days, 14 percent between 61 to 90 days, 19 percent between 91 to 180 days, and 28 percent of live discharges occurred after a length of stay over 180 days of hospice care (see Figure 2 below). The proportion of live discharges occurring between the length of stay intervals was relatively constant from FY 2013 to FY 2016. Overall, our analyses do not reveal any anomalies in trends in lengths of stay and rates of live discharge at this time. However, we will continue to monitor the data available so as to identify any concerning behavior in response to recent payment policy reforms.
See Illustration in Original Document.
b. Skilled Visits in the Last Days of Life
As we noted in both the FY 2016 and FY 2017 Hospice Wage Index and Payment Rate Update final rules (80 FR 47164 and 81 FR 52143, respectively), we are concerned that many hospice beneficiaries may not be receiving skilled visits during the last days of life. In the period of time immediately preceding death, patient needs typically surge and more intensive services are warranted, so we expect that the provision of care would proportionately escalate in order to meet the increased clinical, emotional, and other needs of the hospice beneficiary and his or her family and caregiver(s). The last week of life is typically the period within the terminal illness trajectory that is associated with the highest symptom burden, typically marked by impactful physical and emotional symptoms, necessitating attentive care and engagement from the integrated hospice team.
In the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47164 through 47177), the Service Intensity Add-on (SIA) payment policy was finalized with an implementation date of
In the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47164), commenters expressed concern regarding potential impacts of the new payment policies. Some noted that the new payment structures could potentially impact patient access to hospice care and articulated concerns around provider jettisoning of hospice beneficiaries, specifically around the 60-day mark of a hospice stay. In response to these concerns, we pledged to monitor real-time hospice data, evaluating for any shifts in utilization or provision of services to
As part of our monitoring efforts, we assessed the delivery of hospice care during the period of time preceding death. Analysis of FY 2016 claims data, which encompasses hospice claims from
Table 7--Frequency and Length of Skilled Nursing and Social Work Visits (Combined) During the Last 7 Days of a Hospice Election Ending in Death, FY 2016 Days Before Death Visit length 0 days 1 day 2 days 3 days 4 days 5 days 6 days All 7 (day of (%) (%) (%) (%) (%) (%) days death) com- (%) bined (%) No Visit 21.2 36.7 43.7 48.9 53.1 55.8 58.0 43.6 15 Minutes to 25.6 30.0 28.2 26.7 25.2 24.4 23.7 26.5 1 Hour 1 Hour, 15 26.8 20.0 17.8 15.9 14.5 13.5 12.6 17.9 Minutes to 2 Hours 2 Hours, 15 13.8 7.1 5.8 4.9 4.3 3.9 3.5 6.6 Minutes to 3 Hours 3 Hours, 15 4.8 2.3 1.8 1.5 1.2 1.1 1.0 2.1 Minutes to 3 Hours, 45 Minutes 4 or More 7.8 3.9 2.7 2.1 1.7 1.4 1.2 3.3 Hours Source: FY 2016 hospice claims data from Common Working File (CWF) (as ofDecember 9, 2016 ).
While Table 7 above shows the frequency and length of skilled nursing and social work visits combined during the last 7 days of a hospice election in FY 2016, Tables 8 and 9 below show the frequency and length of visits for skilled nursing and social work separately. Analysis of FY 2016 claims data shows that on any given day during the last 7 days of a hospice election, almost 47 percent of the time the patient had not received a visit by a skilled nurse, and 90 percent of the time the patient had not received a visit by a social worker (see Tables 8 and 9, respectively). We believe it is important to ensure that beneficiaries and their families and caregivers are, in fact, receiving the level of care necessary during critical periods such as the very end of life.
Table 8--Frequency and Length of Skilled Nursing Visits During the Last 7 Days of a Hospice Election Ending in Death, FY 2016 Days Before Death Visit length 0 days 1 day 2 days 3 days 4 days 5 days 6 days All 7 (day of (%) (%) (%) (%) (%) (%) days death) com- (%) bined (%) No Visit 22.7 39.6 46.9 52.2 56.5 59.2 61.5 46.5 15 Minutes to 26.4 31.5 29.1 27.0 25.2 24.1 23.2 27.0 1 Hour 1 Hour, 15 27.3 19.0 16.8 14.9 13.4 12.5 11.5 17.2 Minutes to 2 Hours 2 Hours, 15 13.2 5.4 4.2 3.5 3.0 2.7 2.4 5.4 Minutes to 3 Hours 3 Hours, 15 4.1 1.6 1.2 0.9 0.7 0.7 0.6 1.5 Minutes to 3 Hours, 45 Minutes 4 or More 6.2 2.9 1.9 1.4 1.2 1.0 0.8 2.4 Hours Source: FY 2016 hospice claims data from Common Working File (CWF) (as ofDecember 9, 2016 ).
Table 9--Frequency and Length of Social Work Visits During the Last 7 Days of a Hospice Election Ending in Death, FY 2016 Days Before Death Visit length 0 days 1 day 2 days 3 days 4 days 5 days 6 days All 7 (day of (%) (%) (%) (%) (%) (%) days death) com- (%) bined No Visit 89.9 87.1 88.6 89.7 90.5 91.1 91.4 89.6 15 Minutes to 6.3 8.8 7.8 7.1 6.6 6.3 6.1 7.1 1 Hour 1 Hour, 15 2.7 3.4 3.0 2.7 2.5 2.3 2.2 2.7 Minutes to 2 Hours 2 Hours, 15 0.7 0.5 0.4 0.4 0.3 0.3 0.3 0.4 Minutes to 3 Hours 3 Hours, 15 0.2 0.1 0.1 0.0 0.0 0.0 0.0 0.1 Minutes to 3 Hours, 45 Minutes 4 or More 0.2 0.1 0.1 0.0 0.0 0.0 0.0 0.1 Hours Source: FY 2016 hospice claims data from Common Working File (CWF) (as ofDecember 9, 2016 ).
Additionally, we have analyzed the overall levels of nursing and medical social services provided during the 7 days prior to death. In an assessment of FY 2015 claims, we estimate that the total number of hours of skilled services, including skilled nursing (as reported with code G0154) and medical social services visits, provided to
See Illustration in Original Document.
Given this evaluation of the initial wave of data, which now encompasses the payment policy changes that began on
c. Non-Hospice Spending
When a beneficiary elects the
We first reported findings on 2012 non-hospice spending during a hospice election in the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79 FR 50452). This proposed rule updates our analysis of non-hospice spending during a hospice election using FY 2016 data. We found that in FY 2016,
See Illustration in Original Document.
We also examined Part D spending from FY 2012 to FY 2016 for those beneficiaries under a hospice election. The data shows
Recent analyses of Part D prescription drug event (PDE) data suggest that the current prior authorization (PA) has reduced Part D program payments for drugs in four targeted categories (analgesics, anti-nauseants, anti-anxiety, and laxatives). However, under
FOOTNOTE 5 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/2016-11-15-Part-D-Hospice-Guidance.pdf. END FOOTNOTE
See Illustration in Original Document.
Table 10 below details the various components of Part D spending for patients receiving hospice care for FY 2016. The portion of the
Table 10--Drug Cost Sources for Hospice Beneficiaries' FY 2016 Drugs Received Through Part D Component FY 2016 expenditures Patient Pay Amount$47,289,374 Low Income Cost-Sharing Subsidy 103,715,821 Other True Out-of-Pocket Amount 1,749,182 Patient Liability Reduction due to 15,868,623 Other Payer Amount Covered Drug Plan Paid Amount 243,791,919 Non-Covered Plan Paid Amount 7,878,966 Six Payment Amount Totals 420,293,884 Unknown/Unreconciled 15,836,435 Gross Total Drug Costs, Reported 436,130,318 Source: Analysis of 100% FY 2016 Medicare Claim Files. For more information on the components above and on Part D data, go to theResearch Data Assistance Center's (ResDAC's) Web site at: http://www.resdac.org/.
Hospices are responsible for covering drugs and biologicals related to the palliation and management of the terminal illness and while the patient is under hospice care. For a prescription drug to be covered under Part D for an individual enrolled in hospice, the drug must be for treatment unrelated to the terminal illness or related conditions. After a hospice election, many maintenance drugs or drugs used to treat or cure a condition are typically discontinued as the focus of care shifts to palliation and comfort measures. However, those same drugs may be appropriate to continue as they may offer symptom relief for the palliation and management of the terminal prognosis. /5/ In our ongoing analysis of non-hospice spending, we remain concerned that common palliative and other disease-specific drugs for hospice beneficiaries that should be covered under the Part A
FOOTNOTE 5 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/2016-11-15-Part-D-Hospice-Guidance.pdf. END FOOTNOTE
FOOTNOTE 6 https://oig.hhs.gov/oas/reports/region6/61000059.asp, "Medicare Could Be Paying Twice for Prescriptions for Beneficiaries in Hospice." END FOOTNOTE
We continue to expect that hospices should be providing virtually all of the care needed by terminally ill individuals, including related prescription drugs. The comprehensive nature of the services covered under the
To the extent that individuals receive services outside of the
2. Initial Analysis of Revised Hospice Cost Report Data
a. Background
As mentioned in section II.B of this proposed rule, the
As described in the FY 2016 Hospice Wage Index and Payment Rate Update final rule, we finalized changes to the hospice cost report form in order to broaden the scope and detail of data we collect regarding the costs of providing hospice care (80 FR 47150). /7/ We believed that changes were needed to the hospice cost report in order to collect data on the costs of services provided at each level of care, rather than by costs per day, regardless of the level of care. The revisions to the cost report form for freestanding hospices became effective for cost reporting periods beginning on or after
FOOTNOTE 7 CMS Transmittal 2864. "Additional Data Reporting Requirements for Hospice Claims", Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2864CP.pdf. END FOOTNOTE
FOOTNOTE 8 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1P243.pdf. END FOOTNOTE
b. Methodology
Section 1814(i)(6) of the Act, as amended by section 3132(a)(1)(B) of the Affordable Care Act, authorized the Secretary to collect additional data and information determined appropriate to revise payments for hospice care and other purposes. The data collected may be used to revise the methodology for determining the payment rates for RHC and other services included in hospice care. Effective
c. Overall Payments and Costs and Costs by Level of Care
For the purposes of evaluating calculated costs per day by level of care compared to
*
*
*
*
Table 11 shows the distribution of the calculated Average Cost Per Day by Level of Care, using data from Worksheet C--Rows 3, 8, 13, 18--Column 3.
Table 11--Summary Statistics: Medicare Costs Per Day By Level of Care, FY 2015 Level of Number of Mean Weighted Minimum 25th care cost mean value Percentile reports CHC cost per 1,088$91 $49 $4 $18 day, per hour RHC cost per 2,578 133 123 50 105 day IRC cost per 1,930 632 467 38 221 day GIP cost per 1,782 1,079 792 64 564 day
Table 11--Summary Statistics: Medicare Costs Per Day By Level of Care, FY 2015 Level of Median 75th Maximum FY2015 care Percentile value per diem payment amounts CHC cost per$51 $95 $1,853 $929.91 for day, per 24 hours (
|%hour 38.75 hourly
rate). RHC cost per 125 150 399 159.34. day IRC cost per 343 549 17,813 164.81. day GIP cost per 879 1,251 10,858 708.77. day Source:
As mentioned above, the data analyzed were trimmed to minimize the effect of statistical anomalies. Nevertheless, there is substantial variation in the reported cost per day by hospices. Total cost per day values in the four levels of care span from a minimum of
Conversely, for CHC the estimated median and weighted mean costs per day, per hour are
We recognize that this is the first period in which hospices have supplied cost information on the revised cost report that became effective for cost reporting periods beginning on or after
B. Proposed FY 2018 Hospice Wage Index and Rate Update
1. Proposed FY 2018 Hospice Wage Index
The hospice wage index is used to adjust payment rates for hospice agencies under the
We use the previous FY's hospital wage index data to calculate the hospice wage index values. For FY 2018, the hospice wage index will be based on the FY 2017 hospital pre-floor, pre-reclassified wage index. This means that the hospital wage data used for the hospice wage index is not adjusted to take into account any geographic reclassification of hospitals including those in accordance with section 1886(d)(8)(B) or 1886(d)(10) of the Act. The appropriate wage index value is applied to the labor portion of the payment rate based on the geographic area in which the beneficiary resides when receiving routine home care (RHC) or continuous home care (CHC). The appropriate wage index value is applied to the labor portion of the payment rate based on the geographic location of the facility for beneficiaries receiving general inpatient care (GIP) or Inpatient Respite Care (IRC).
There exist some geographic areas where there were no hospitals, and thus, no hospital wage index data on which to base the calculation of the hospice wage index. In the FY 2008 Hospice Wage Index final rule (72 FR 50214), we implemented a methodology to update the hospice wage index for such areas. In cases where there was a rural area without rural hospital wage data, we use the average pre-floor, pre-reclassified hospital wage index data from all contiguous Core-Based Statistical Areas (CBSAs), to represent a reasonable proxy for the rural area. The term "contiguous" means sharing a border (72 FR 50217). Currently, the only rural area without a hospital from which hospital wage data could be derived is
In the FY 2010 Hospice Wage Index final rule (74 FR 39386), we adopted the policy that for urban labor markets without a hospital from which hospital wage index data could be derived, all of the CBSAs within the state would be used to calculate a statewide urban average pre-floor, pre-reclassified hospital wage index value to use as a reasonable proxy for these areas. For FY 2018, the only CBSA without a hospital from which hospital wage data can be derived is 25980,
As described in the
On
The proposed hospice wage index applicable for FY 2018 (
2. Proposed Hospice Payment Update Percentage
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33) amended section 1814(i)(1)(C)(ii)(VI) of the Act to establish updates to hospice rates for FYs 1998 through 2002. Hospice rates were to be updated by a factor equal to the inpatient hospital market basket percentage increase set out under section 1886(b)(3)(B)(iii) of the Act, minus 1 percentage point. Payment rates for FYs since 2002 have been updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update to the payment rates for subsequent FYs must be the inpatient market basket percentage increase for that FY. The Act historically required us to use the inpatient hospital market basket as the basis for the hospice payment rate update.
Section 3401(g) of the Affordable Care Act mandated that, starting with FY 2013 (and in subsequent FYs), the hospice payment update percentage would be annually reduced by changes in economy-wide productivity as specified in section 1886(b)(3)(B)(xi)(II) of the Act. The statute defines the productivity adjustment to be equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multifactor productivity (MFP). In addition to the MFP adjustment, section 3401(g) of the Affordable Care Act also mandated that in FY 2013 through FY 2019, the hospice payment update percentage would be reduced by an additional 0.3 percentage point (although for FY 2014 to FY 2019, the potential 0.3 percentage point reduction is subject to suspension under conditions specified in section 1814(i)(1)(C)(v) of the Act).
Normally, the proposed hospice payment update percentage for FY 2018 would have been based on the estimated inpatient hospital market basket update of 2.9 percent (based on
Currently, the labor portion of the hospice payment rates is as follows: For RHC, 68.71 percent; for CHC, 68.71 percent; for General Inpatient Care, 64.01 percent; and for Respite Care, 54.13 percent. The non-labor portion is equal to 100 percent minus the labor portion for each level of care. Therefore, the non-labor portion of the payment rates is as follows: For RHC, 31.29 percent; for CHC, 31.29 percent; for General Inpatient Care, 35.99 percent; and for Respite Care, 45.87 percent. Beginning with cost reporting periods starting on or after
3. Proposed FY 2018 Hospice Payment Rates
There are four payment categories that are distinguished by the location and intensity of the services provided. The base payments are adjusted for geographic differences in wages by multiplying the labor share, which varies by category, of each base rate by the applicable hospice wage index. A hospice is paid the RHC rate for each day the beneficiary is enrolled in hospice, unless the hospice provides CHC, IRC, or GIP. CHC is provided during a period of patient crisis to maintain the patient at home; IRC is short-term care to allow the usual caregiver to rest and be relieved from caregiving; and GIP is to treat symptoms that cannot be managed in another setting.
As discussed in the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47172), we implemented two different RHC payment rates, one RHC rate for the first 60 days and a second RHC rate for days 61 and beyond. In addition, in the final rule, we adopted a Service Intensity Add-on (SIA) payment for RHC for when direct patient care is provided by a RN or social worker during the last 7 days of the beneficiary's life. The SIA payment is equal to the CHC hourly rate multiplied by the hours of nursing or social work provided (up to 4 hours total) that occurred on the day of service, if certain criteria are met. In order to maintain budget neutrality, as required under section 1814(i)(6)(D)(ii) of the Act, the new RHC rates were adjusted by a SIA budget neutrality factor.
As discussed in the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47177), we will continue to make the SIA payments budget neutral through an annual determination of the SIA budget neutrality factor (SBNF), which will then be applied to the RHC payment rates. The SBNF will be calculated for each FY using the most current and complete FY utilization data available at the time of rulemaking. For FY 2018, we calculated the SBNF using FY 2016 utilization data. We examined skilled nursing and social work visit data for the last 7 days of life where RHC was billed and found that, from
In the FY 2017 Hospice Wage Index and Payment Rate Update final rule (82 FR 52156), we initiated a policy of applying a wage index standardization factor to hospice payments in order to eliminate the aggregate effect of annual variations in hospital wage data. In order to calculate the wage index standardization factor, we simulate total payments using the proposed FY 2018 hospice wage index and compare it to our simulation of total payments using the FY 2017 hospice wage index. By dividing payments for each level of care using the proposed FY 2018 wage index by payments for each level of care using the FY 2017 wage index, we obtain a wage index standardization factor for each level of care (RHC days 1-60, RHC days 61+, CHC, IRC, and GIP). The wage index standardization factors for each level of care are shown in the tables below.
Lastly, the hospice payment rates for hospices that submit the required quality data would be increased by the proposed FY 2018 hospice payment update percentage of 1.0 percent as discussed in section III.B.2. The proposed FY 2018 RHC rates are shown in Table 12. The proposed FY 2018 payment rates for CHC, IRC, and GIP are shown in Table 13.
Table 12--Proposed FY 2018 Hospice RHC Payment Rates Code Description FY 2017 SBNF Wage index FY 2018 FY 2018 payment standardiz proposed Proposed rates ation hospice payment factor payment rates update 651 Routine Home$190.55 x 1.0018 x 1.0000 x 1.01$192.80 Care (days 1-60) 651 Routine Home$149.82 x 1.0005 x 1.0001 x 1.01$151.41 Care (days 61+)
Table 13--Proposed FY 2018 Hospice CHC, IRC, and GIP Payment Rates Code Description FY 2017 Wage index FY 2018 FY 2018 payment standardization proposed proposed rates factor hospice payment payment rates update 652 Continuous Home$964.63 x 1.0022 x 1.01$976.42 Care Full Rate = 24 hours of care$40.68 = FY 2018 hourly rate 655 Inpatient Respite 170.97 x 1.0006 x 1.01 172.78 Care 656 General Inpatient 734.94 x 1.0017 x 1.01 743.55 Care
Sections 1814(i)(5)(A) through (C) of the Act require that hospices submit quality data, based on measures to be specified by the Secretary. In the FY 2012 Hospice Wage Index final rule (76 FR 47320 through 47324), we implemented a Hospice Quality Reporting Program (HQRP) as required by section 3004 of the Affordable Care Act. Hospices were required to begin collecting quality data in
Table 14--Proposed FY 2018 Hospice RHC Payment Rates for Hospices That DO NOT Submit the Required Quality Data Code Description FY 2017 SBNF Wage index FY 2018 FY 2018 payment standardiz proposed proposed rates ation hospice payment factor payment rates update of 1% minus 2 percentage points = - 0.1% 651 Routine Home$190.55 x 1.0018 x 1.0000 x 0.99$188.98 Care (days 1-60) 651 Routine Home$149.82 x 1.0005 x 1.0001 x 0.99 148.41 Care (days 61+)
Table 15--Proposed FY 2018 Hospice CHC, IRC, and GIP Payment Rates for Hospices That DO NOT Submit the Required Quality Data Code Description FY 2017 Wage index FY 2018 FY 2018 payment standardization proposed Proposed rates factor hospice payment payment rates update 652 Continuous Home$964.63 x 1.0022 x 0.99$957.08 Care Full Rate = 24 hours of care$39.88 = FY 2018 hourly rate 655 Inpatient Respite$170.97 x 1.0006 x 0.99$169.36 Care 656 General Inpatient 734.94 x 1.0017 x 0.99 728.83 Care
4. Hospice Cap Amount for FY 2018
As discussed in the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47183), we implemented changes mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). Specifically, for accounting years that end after
C. Discussion and Solicitation of Comments Regarding Sources of Clinical Information for Certifying Terminal Illness
Hospice provides relief from pain and symptoms, provides psychosocial and spiritual comfort, and allows an individual to die with dignity and surrounded by family and friends. Despite the invaluable support hospices offer, it is not an easy decision and not one individuals generally arrive at on their own. Election of hospice is a significant decision and one which patients and their physicians do not take lightly, as it involves a shift in traditional health care philosophy from curative to palliative care. In general, the majority of hospice referrals do come from family physicians who have often cared for patients with chronic illnesses for long periods of time. /9/ These providers are in the unique position of understanding and identifying the individualized progression of the patient's illness and recognizing when the condition becomes terminal. To be eligible to elect the
FOOTNOTE 9 Michelle T. Weckmann, MD, MS,
1. Diagnosis of the terminal condition of the patient.
2. Other health conditions, whether related or unrelated to the terminal condition.
3. Current clinically relevant information supporting all diagnoses.
The admission requirements at
Multiple clinical tools and guidelines, and more specifically the Medicare Administrative Contractor (MAC) Local Coverage Determinations (LCDs), exist to assist the patient-designated attending physician and hospice medical director/hospice physician designee in determining the patient's terminal prognosis. These guidelines provide indicators that support a decline in clinical status, including, but not limited to: History of recurrent infections, worsening symptoms that are non- responsive to treatment, increasing emergency department and clinician visits, laboratory results supporting progression of disease, and change in functional status. /10/ However, documentation of these indicators would likely not exist without some degree of long-term monitoring and evaluation by a physician separate from the hospice medical director/hospice physician designee. As such, this information would typically be found in the referring physician's and/or acute/post- acute care facility's medical records.
FOOTNOTE 10 https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx. END FOOTNOTE
Understandably, many family physicians typically take on the role of the attending physician once the patient chooses to elect hospice. They have played an invaluable role in coordinating care throughout the spectrum of the patient's life, and as such, have in depth "knowledge of the patient's values, family issues, and communication style." /11/ However, in accordance with our regulation at
FOOTNOTE 11 Michelle T. Weckmann, MD, MS,
No visits to the patient are covered under the
There are ongoing concerns that some hospice patients may be inappropriately certified as terminally ill.
FOOTNOTE 12
In response to those concerns, the "Medicare Program; Hospice Care Amendments" proposed rule (67 FR 70363,
Additionally, the
FOOTNOTE 13
In the "Medicare Program; Hospice Wage Index and Payment Rate Update FY 2015" final rule (79 FR 50470), we again provided guidance on determining beneficiaries' eligibility for hospice, reiterating that the hospice "is required to make certain that the physician's clinical judgment can be supported by clinical information and other documentation that provide a basis for the certification of a life expectancy of 6 months or less if the illness runs its normal course." This discussion reinforced the importance of ensuring that hospices are thorough in their eligibility determinations so that hospice beneficiaries are able to access all of their
Accordingly, we are soliciting comments for possible future rulemaking, on amending the regulations at
D. Proposed Updates to the Hospice Quality Reporting Program (HQRP)
1.
Section 3004(c) of the Affordable Care Act amended section 1814(i)(5) of the Act to authorize a quality reporting program for hospices. Section 1814(i)(5)(A)(i) of the Act requires that beginning with FY 2014 and each subsequent FY, the Secretary shall reduce the market basket update by 2 percentage points for any hospice that does not comply with the quality data submission requirements for that FY. Depending on the amount of the annual update for a particular year, a reduction of 2 percentage points could result in the annual market basket update being less than 0 percent for a FY and may result in payment rates that are less than payment rates for the preceding FY. Any reduction based on failure to comply with the reporting requirements, as required by section 1814(i)(5)(B) of the Act, would apply only for the particular year involved. Any such reduction would not be cumulative or be taken into account in computing the payment amount for subsequent FYs. Section 1814(i)(5)(C) of the Act requires that each hospice submit data to the Secretary on quality measures specified by the Secretary. The data must be submitted in a form, manner, and at a time specified by the Secretary.
2. General Considerations Used for Selection of Quality Measures for the HQRP
Any measures selected by the Secretary must be endorsed by the consensus-based entity, which holds a contract regarding performance measurement, including the endorsement of quality measures, with the Secretary under section 1890(a) of the Act. This contract is currently held by the
We consider related factors that may affect measures in the HQRP. We understand that social risk factors such as income, education, race and ethnicity, employment, disability, community resources, and social support (certain factors of which are also sometimes referred to as socioeconomic status (SES) factors or socio-demographic status (SDS) factors) play a major role in health. One of our core objectives is to improve beneficiary outcomes including reducing health disparities, and we want to ensure that all beneficiaries, including those with social risk factors, receive high quality care. In addition, we seek to ensure that the quality of care furnished by providers and suppliers is assessed as fairly as possible under our programs while ensuring that beneficiaries have adequate access to excellent care.
We have been reviewing reports prepared by the
FOOTNOTE 14 https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs. END FOOTNOTE
FOOTNOTE 15 https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs. END FOOTNOTE
FOOTNOTE 16
In addition, the NQF has undertaken a 2-year trial period in which new measures, measures undergoing maintenance review, and measures endorsed with the condition that they enter the trial period can be assessed to determine whether risk adjustment for selected social risk factors is appropriate for these measures. This trial entails temporarily allowing inclusion of social risk factors in the risk-adjustment approach for these measures. At the conclusion of the trial, NQF will issue recommendations on the future inclusion of social risk factors in risk adjustment for quality measures.
As we continue to consider the analyses and recommendations from these reports and await the results of the NQF trial on risk adjustment for quality measures, we are continuing to work with stakeholders in this process. As we have previously communicated, we are concerned about holding providers to different standards for the outcomes of their patients with social risk factors because we do not want to mask potential disparities or minimize incentives to improve the outcomes for disadvantaged populations. Keeping this concern in mind, while we sought input on this topic previously, we continue to seek public comment on whether we should account for social risk factors in measures in the HQRP, and if so, what method or combination of methods would be most appropriate for accounting for social risk factors. Examples of methods include: Confidential reporting to providers of measure rates stratified by social risk factors, public reporting of stratified measure rates, and potential risk adjustment of a particular measure as appropriate based on data and evidence.
In addition, we are also seeking public comment on which social risk factors might be most appropriate for reporting stratified measure scores and/or potential risk adjustment of a particular measure. Examples of social risk factors include, but are not limited to, dual eligibility/low-income subsidy, race and ethnicity, and geographic area of residence. We are seeking comments on which of these factors, including current data sources where this information would be available, could be used alone or in combination, and whether other data should be collected to better capture the effects of social risk. We will take commenters' input into consideration as we continue to assess the appropriateness and feasibility of accounting for social risk factors in the HQRP. We note that any such changes would be proposed through future notice and comment rulemaking.
We look forward to working with stakeholders as we consider the issue of accounting for social risk factors and reducing health disparities in our programs. Of note, implementing any of the above methods would be taken into consideration in the context of how this and our other programs operate (for example, data submission methods, availability of data, statistical considerations relating to reliability of data calculations, among others), so we also welcome comment on operational considerations. We are committed to ensuring that its beneficiaries have access to and receive excellent care, and that the quality of care furnished by providers and suppliers is assessed fairly in our programs.
3. Policy for Retention of HQRP Measures Adopted for Previous Payment Determinations
For the purpose of streamlining the rulemaking process, we finalized our policy in the FY 2016 Hospice Wage Index final rule (80 FR 47187) that when we adopt measures for the HQRP beginning with a payment determination year, these measures would automatically be adopted for all subsequent years' payment determinations, unless we proposed to remove, suspend, or replace the measures. Quality measures would be considered for removal by us for reasons including, but not limited to:
* Measure performance among hospices was so high and unvarying that meaningful distinction in improvements in performance could no longer be made;
* Performance or improvement on a measure did not result in better patient outcomes;
* A measure did not align with current clinical guidelines or practice;
* A more broadly applicable measure (across settings, populations, or conditions) for the particular topic was available;
* A measure that was more proximal in time to desired patient outcomes for the particular topic was available;
* A measure that was more strongly associated with desired patient outcomes for the particular topic was available; or
* Collection or public reporting of a measure led to negative unintended consequences.
For any such removal, the public would be given an opportunity to comment through the annual rulemaking process. However, if there was reason to believe continued inclusion of a measure in the HQRP would encourage delivery of care that raised potential safety concerns, we would take immediate action to remove the measure from the HQRP and not wait for the annual rulemaking cycle. The measures would be promptly removed and we would immediately notify hospices and the public of such a decision through the CMS HQRP Web site, listserv messages via the Post-Acute Care QRP listserv, /17/ MLN Connects(R) National Provider Calls & Events, MLN Connects(R) Provider eNews. Following immediate removal of the measures, we would also notify the public of any such removal in the next annual rulemaking cycle. CMS expects immediate removal of a measure due to safety concerns to be an unlikely event, given the rigorous testing and analysis all measures undergo prior to adoption in the HQRP.
FOOTNOTE 17 CMS, Post-Acute Care QRP listerv, available at: https://public-dc2.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12265. END FOOTNOTE
4. Policy for Adopting Changes to Previously Adopted Measures
To further streamline the rulemaking process, we finalized in the FY 2017 Hospice Wage Index final rule that if measures in the HQRP undergo non-substantive changes in specifications as part of their NQF re-endorsement process, we would subsequently utilize the measure with their new endorsed status in the HQRP without going through new notice-and-comment rulemaking (81 FR 52159). As mentioned previously, quality measures selected for the HQRP must be endorsed by the NQF unless they meet the statutory criteria for exception under section 1814(i)(5)(D)(ii) of the Act. The NQF is a voluntary consensus standard-setting organization with a diverse representation of consumer, purchaser, provider, academic, clinical, and other healthcare stakeholder organizations. The NQF was established to standardize healthcare quality measurement and reporting through its consensus measure development process (http://www.qualityforum.org/About_NQF/Mission_and_Vision.aspx). The NQF undertakes review of: (a) New quality measures and national consensus standards for measuring and publicly reporting on performance, (b) regular maintenance processes for endorsed quality measures, (c) measures with time-limited endorsement for consideration of full endorsement, and (d) ad hoc review of endorsed quality measures, practices, consensus standards, or events with adequate justification to substantiate the review. Through NQF's or the measure steward's measure maintenance process, measures are sometimes updated to incorporate changes that we believe do not substantively change the intent of the measure. Examples of such changes may include updated diagnosis or procedure codes or changes to exclusions to the patient population or definitions. While we address such changes on a case-by case basis, we generally believe these types of maintenance changes are distinct from substantive changes to measures that result in what are considered new or different measures. Additionally, since the NQF endorsement and measure maintenance process is one that ensures transparency, public input, and discussion among representatives across the healthcare enterprise, /18/ we believe that the NQF measure endorsement and maintenance process itself is transparent, scientifically rigorous, and provides opportunity for public input. Thus, we finalized our proposal to codify at
FOOTNOTE 18 "NQF: How Endorsement Happens--
Finally, we will continue to use rulemaking to adopt substantive updates made by the NQF to the endorsed measures we have adopted for the HQRP. We continue to make these determinations about what constitutes a substantive versus non-substantive change on a measure-by-measure basis. A change would be deemed substantive if the intent of the measure changes, the facility/setting changes, the data sources changes, the level of analysis changes, and/or the measure is removed. We will continue to provide updates about changes to measure specifications as a result of NQF endorsement or maintenance processes through the CMS HQRP Web site, listserv messages on the Post-Acute Care QRP listserv, MLN Connects(R) National Provider Calls & Events, MLN Connects(R) Provider eNews and announcements on Open Door Forums and Special Open Door Forums.
5. Previously Adopted Quality Measures for FY 2018 Payment Determination and Future Years
In the FY 2014 Hospice Wage Index final rule (78 FR 48257), and in compliance with section 1814(i)(5)(C) of the Act, we finalized the specific collection of data items that support the following 7 NQF-endorsed measures for hospice:
* NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen,
* NQF #1634 Pain Screening,
* NQF #1637 Pain Assessment,
* NQF #1638 Dyspnea Treatment,
* NQF #1639 Dyspnea Screening,
* NQF #1641 Treatment Preferences,
* NQF #1647 Beliefs/Values Addressed (if desired by the patient). /19/
FOOTNOTE 19 Previously finalized as a "modified measure" in the FY17 and prior rules (81 FR 52160). Following NQF maintenance endorsement, NQF #1647 measure specifications where updated and now aligns with the measure data lookback period for this program. END FOOTNOTE
We finalized the following two additional measures in the FY 2017 Hospice Wage Index final rule effective
* Hospice Visits when Death is Imminent
* Hospice and Palliative Care Composite Process Measure--Comprehensive Assessment at Admission
We finalized the HIS effective
Hospices are required to complete and submit a HIS-Admission and a HIS-Discharge record for each patient admission. Hospices failing to report quality data via the HIS for patient admissions occurring in 2017 will have their market basket update reduced by 2 percentage points in FY 2019 (beginning in
The 7 NQF endorsed HIS measures adopted in FY 2014 Hospice Wage Index final rule successfully underwent NQF Endorsement Maintenance in 2016. /20/ We recognize that the NQF endorsement process is an important part of measure development and plan to submit the two measures finalized in the FY 2017 Hospice Wage Index final rule for NQF endorsement once sufficient measure data are available and we conduct the analyses necessary to support NQF submission for endorsement (for example, reliability and validity analyses). Typically, we need at least 4 quarters worth of data to conduct the necessary analyses and establish measure reliability and validity. Because the Hospice and Palliative Care Composite Process Measure--Comprehensive Assessment at Admission did not require any new data collection and can be calculated using existing data, CMS's measure development contractor,
FOOTNOTE 20
Table 16--Previously Finalized Quality Measures Affecting the FY 2019 Payment Determination and Subsequent Years NQF No. Measure name Payment Data Data submission determination collection deadline (APU) year for mechanism which the quality measure was first adopted 1641 Treatment FY 2016 Hospice Item Set Rolling--within Preferences 30 days of patient admission or discharge (event date). 1647 Beliefs/Values FY 2016 Addressed (if desired by the patient) 1634 Pain Screening FY 2016 1637 Pain Assessment FY 2016 1639 Dyspnea FY 2016 Screening 1638 Dyspnea FY 2016 Treatment 1617 Patients Treated FY 2016 with an Opioid Who Are Given a Bowel Regimen N/A Hospice and FY 2019 Rolling--within Palliative Care 30 days of Composite patient Process admission or Measure-- discharge (event Comprehensive date) for Assessment at patient Admission admissions to hospice on 04/01/2017 and onward. N/A Hospice Visits FY 2019 When Death is Imminent Measure Pair
6. Proposed Removal of Previously Adopted Measures
We are not proposing to remove any of the current HQRP measures at this time. Any future proposals regarding removal, suspension, or replacement of measures will be proposed in this section of future rules. As stated in section III.D.3, a quality measure that is adopted and implemented in the HQRP will be retained for all subsequent years, unless the measure is proposed for removal, suspension, or replacement by CMS. Policies and criteria for removing a measure include those identified in section III.D.3 of this proposed rule.
7. Measure Concepts Under Consideration for Future Years
Although we are not proposing any HIS-based measures in this proposed rule, we have measure concepts under consideration for future years.
Our paramount concern is to develop quality measures that promote care that is person-centered, high quality, and safe. We continue to work with our measure development contractor,
* Priority Area 1: Potentially Avoidable Hospice Care Transitions
The concept of a claims-based measure focusing on transitions of care was first introduced in the FY 2016 Hospice Wage Index final rule (80 FR 47188 through 47189). Comments received during this rule were overall supportive of our efforts to develop more robust quality measures that capture hospice performance and show links to patient and family outcomes. We refer readers to the FY 2016 Hospice Wage Index final rule (80 FR 47188 through 47189) for additional detail: https://www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-19033.pdf.
Potentially avoidable hospice care transitions at end of life are burdensome to patients, families, and the health care system at large, because they are associated with adverse health outcomes, lower patient and family satisfaction, higher health care costs, and fragmentation of care delivery.21 22 23 24 25 By encouraging hospice providers to assess and manage patients' risk of care transitions, this measure concept has the potential to improve quality care at the end of life by reducing potentially avoidable hospice care transitions.
FOOTNOTE 21 Aldridge MDP, MBA; Epstein, Andrew J. Ph.D.; Brody, Abraham A. RN, Ph.D.; Lee, Eric J. MPH; Cherlin, Emily Ph.D., MSW; Bradley, Elizabeth H. Ph.D. The Impact of Reported Hospice Preferred Practices on Hospital Utilization at the End of Life Medical Care. 2016;54(7):657-663. END FOOTNOTE
FOOTNOTE 22 Wang S-Y, Aldridge MD, Gross CP, et al. Transitions Between Healthcare Settings of Hospice Enrollees at the End of Life.
FOOTNOTE 23 Carlson MDA, Herrin J, Du Q, et al. Impact of Hospice Disenrollment on Health Care Use and Medicare Expenditures for Patients With Cancer.
FOOTNOTE 24 Teno JM, Bowman J, Plotzke M, et al. Characteristics of Hospice Programs With Problematic Live Discharges.
FOOTNOTE 25 Prsic E, Plotzke M, Christian TJ, Gozalo P, Teno JM. A National Study of Live Hospice Discharges between 2000 and 2012.
* Priority Area 2: Access to Levels of Hospice Care
The Medicare Hospice Benefit covers four levels of care to meet patients' and families' clinical needs: Routine home care (RHC), continuous home care (CHC), general inpatient care (GIP), and inpatient respite care. The goal of this measure concept is to assess the rates at which hospices provide different levels of hospice care. The measure has the potential to improve access to various levels of care for patients and caregivers. Appropriate use of CHC and GIP increases the likelihood of a hospice patient dying in his or her location of choice, decreases health resource utilization resulting in potential cost savings, and increases patient and caregiver satisfaction.26 27 Measuring use of levels of care will incentivize hospice providers to continuously assess patient and caregiver needs and provide the appropriate level of care to meet these needs.
FOOTNOTE 26 Barclay, J., et al., Association of hospice patients' income and care level with place of death. JAMA Internal Medicine, 2013. 173(6): p. 450-456. END FOOTNOTE
FOOTNOTE 27 Casarett, D., et al., Does Continuous Hospice Care Help Patients Remain at Home?
These two measure concepts are under development, and details regarding measure definitions, specifications and timeline for implementation will be communicated in future rulemaking. We are soliciting comments regarding high priority concept areas for future measure development.
8. Form, Manner, and Timing of Quality Data Submission
a. Background
Section 1814(i)(5)(C) of the Act requires that each hospice submit data to the Secretary on quality measures specified by the Secretary. Such data must be submitted in a form and manner, and at a time specified by the Secretary. Section 1814(i)(5)(A)(i) of the Act requires that beginning with the FY 2014 and for each subsequent FY, the Secretary shall reduce the market basket update by 2 percentage points for any hospice that does not comply with the quality data submission requirements for that FY.
b. Policy for New Facilities To Begin Submitting Quality Data
In the FY 2015 Hospice Wage Index final rule (79 FR 50488), we finalized a policy stating that any hospice that receives its CMS Certification Number (CCN) (also known as the Medicare Provider Number) notification letter dated on or after
In the FY 2016 Hospice Wage Index final rule (80 FR 47189), we further clarified and finalized our policy for the timing of new providers to begin reporting data to CMS. The clarified policy finalized in the FY 2016 Hospice Wage Index final rule (80 FR 47189) distinguished between when new hospice providers are required to begin submitting HIS data and when providers will be subject to the potential 2 percentage point annual payment update (APU) reduction for failure to comply with HQRP requirements. In summary, the policy finalized in the FY 2016 Hospice Wage Index final rule (80 FR 47189 through 47190) clarified that providers must begin submitting HIS data on the date listed in the letterhead of the CCN Notification letter received from CMS but will be subject to the APU reduction based on whether the CCN Notification letter was dated before or after
This policy allows us to receive HIS data on all patient admissions on or after the date a hospice receives their CCN notification letter, while at the same time allowing hospices flexibility and time to establish the necessary accounts for data submission before they are subject to the potential APU reduction for a given reporting year. Currently, new hospices may experience a lag between
c. Previously Finalized Data Submission Mechanisms, Timelines, and Deadlines
In the FY 2015 Hospice Wage Index final rule (79 FR 50486), we finalized our policy requiring that hospices complete and submit HIS records for all patient admissions to hospice after
The QIES ASAP system provides reports upon successful submission and processing of the HIS records. The final validation report may serve as evidence of submission. This is the same data submission system used by nursing homes, inpatient rehabilitation facilities, home health agencies, and long-term care hospitals for the submission of Minimum Data Set Version 3.0 (MDS 3.0), Inpatient Rehabilitation Facility-patient assessment instrument (IRF-PAI), Outcome Assessment Information Set (OASIS), and Long-Term Care Hospital Continuity Assessment Record & Evaluation Data Set (LTCH CARE), respectively. We have provided hospices with information and details about use of the HIS through postings on the HQRP Web site, Open Door Forums, announcements in the CMS MLN Connects(R) Provider e-News (
Hospices are evaluated for purposes of the quality reporting program based on whether or not they submit data, not on their substantive performance level for the required quality measures. In order for us to appropriately evaluate the quality reporting data received by hospice providers, it is essential HIS data be received in a timely manner.
The submission date is the date on which the completed record is submitted and accepted by the QIES ASAP system. In the FY 2016 Hospice Wage Index final rule (80 FR 47191), we finalized our policy that beginning with the FY 2018 payment determination, hospices must submit all HIS records within 30 days of the event date, which is the patient's admission date for HIS-Admission records or discharge date for HIS-Discharge records.
For HIS-Admission records, the submission date must be no later than the admission date plus 30 calendar days. The submission date can be equal to the admission date, or no greater than 30 days later. The QIES ASAP system will issue a warning on the Final Validation Report if the submission date is more than 30 days after the patient's admission date.
For HIS-Discharge records, the submission date must be no later than the discharge date plus 30 calendar days. The submission date can be equal to the discharge date, or no greater than 30 days later. The QIES ASAP system will issue a warning on the Final Validation Report if the submission date is more than 30 days after the patient's discharge date.
The QIES ASAP system validation edits are designed to monitor the timeliness of submission and ensure that providers' submitted records conform to the HIS data submission specifications. Providers are notified when timing criteria have not been met by warnings that appear on their Final Validation Reports. A standardized data collection approach that coincides with timely submission of data is essential to establish a robust quality reporting program and ensure the scientific reliability of the data received. In the FY 2016 Hospice Wage Index final rule (80 FR 47191), we also clarified the difference between the completion deadlines and the submission deadlines. Current sub-regulatory guidance produced by CMS (for example, HIS Manual, HIS trainings) states that the completion deadlines for HIS records are 14 days after the Event Date for HIS-Admission records and 7 days after the Event Date for HIS-Discharge records. Completion deadlines continue to reflect CMS guidance only; these guidelines are not statutorily specified and are not designated through regulation. These guidelines are intended to offer clear direction to hospice agencies in regards to the timely completion of HIS-Admission and HIS-Discharge records. The completion deadlines define only the latest possible date on which a hospice should complete each HIS record. This guidance is meant to better align HIS completion processes with clinical workflow processes; however, hospices may develop alternative internal policies to complete HIS records. Although it is at the discretion of the hospice to develop internal policies for completing HIS records, we will continue to recommend that providers complete and attempt to submit HIS records early, prior to the previously finalized submission deadline of 30 days, beginning in FY 2018. Completing and attempting to submit records early allows providers ample time to address any technical issues encountered in the QIES ASAP submission process, such as correcting fatal error messages. Completing and attempting to submit records early will ensure that providers are able to comply with the 30 day submission deadline. HQRP guidance documents, including the CMS HQRP Web site, HIS Manual, HIS trainings, Frequently Asked Questions, and Fact Sheets, continue to offer the most up-to-date CMS guidance to assist providers in the successful completion and submission of HIS records. Availability of updated guidance will be communicated to providers through the CMS HQRP Web site, listserv messages via the Post-Acute Care QRP listserv, MLN Connects(R) National Provider Calls & Events, MLN Connects(R) Provider eNews and announcements on Open Door Forums and Special Open Door Forums.
d. New Data Collection and Submission Mechanisms Under Consideration: Hospice Evaluation & Assessment Reporting Tool (HEART)
We have made great progress in implementing the objectives set forth in the quality reporting and data collection activities required by sections 3004 of the Affordable Care Act. To date, we have established the HQRP, which includes clinical quality measures from the HIS and patient experience of care measures from the CAHPS(R) Hospice Survey. We have also finalized payment reform measures, including changes to the RHC payment rate and the implementation of a Service Intensity Add-On (SIA) payment, effective
As discussed in the FY 2017 final rule (81 FR 52177), to facilitate continued progress towards the requirements set forth in section 3004 of the Affordable Care Act, we are in the early stages of the development of a new data collection mechanism for use by hospices. This new data collection mechanism would be a hospice patient assessment tool, which would serve two primary objectives concordant with the Affordable Care Act legislation: (1) To provide the quality data necessary for HQRP requirements and the current function of the HIS; and (2) provide additional clinical data that could inform future payment refinements. In the FY 2017 final rule (81 FR 52176 through 52179), we solicited input from the public on the development of a hospice patient assessment tool that would collect quality, clinical, and other data with the ability to be used to inform future payment refinement efforts. Overall, feedback from the public was supportive of the move towards a standardized patient assessment instrument, and commenters offered some guiding principles for CMS to keep in mind in the development of a patient assessment tool, given the unique nature of hospice care. For a detailed discussion of the public comments and responses, as well as CMS's guiding principles and motivation behind the development of a hospice patient assessment tool, we refer readers to the FY 2017 final rule (81 FR 52177 through 52179).
As noted in the FY 2017 final rule, we envision the hospice patient assessment tool itself as an expanded HIS. The hospice patient assessment tool would include current HIS items, as well as additional clinical items that could also be used for payment refinement purposes or to develop new quality measures. The hospice patient assessment tool would not replace existing requirements set forth in the Medicare Hospice CoPs (such as the initial and comprehensive assessment), but would be designed to complement data that are collected as part of high-quality clinical care. The new data collection effort would replace the current HIS, but would not replace other HQRP data collection efforts (that is, the CAHPS(R) Hospice Survey), nor would it replace regular submission of claims data. We envision that patient assessment data would be collected upon a patient's admission to and discharge from any
We are not proposing a hospice patient assessment tool at this time; we are still in the early stages of development of an assessment tool to determine the appropriate content and feasibility of such a tool. As such, we have made progress over the past year in the development of a hospice patient assessment tool, preliminarily called the Hospice Evaluation & Assessment Reporting Tool (HEART). CMS's measure development contractor,
As mentioned in the FY 2017 final rule, it is important for CMS to develop a hospice patient assessment tool that is scientifically rigorous and clinically appropriate for the hospice population, thus we believe that continued and transparent involvement of stakeholders is critical. We will continue to receive stakeholder input from MedPAC and ongoing input from the provider community,
9. Previously Adopted APU Determination and Compliance Criteria for the HQRP
a. Background
The HQRP is currently designed as a "pay-for-reporting" system, meaning that it is the act of submitting data that determines compliance with HQRP requirements. Performance level is not a consideration when determining market basket updates/APU. Reporting compliance is determined by successfully fulfilling both the Hospice CAHPS(R) Survey requirements and the HIS data submission requirements.
b. Previously Finalized HIS Data Submission Timelines and Compliance Thresholds for FY 2018 Payment Determination and Subsequent Years
To accurately analyze quality reporting data received by hospice providers, it is imperative we receive ongoing and timely submission of all HIS-Admission and HIS-Discharge records. In the FY 2016 Hospice Wage Index final rule (80 FR 47192), we finalized the timeliness criteria for submission of HIS-Admission and HIS-Discharge records. The finalized timeliness criteria were in response to input from our stakeholders seeking additional specificity related to HQRP compliance affecting FY payment determinations and, due to the importance of ensuring the integrity of quality data submitted.
As stated in that rule, beginning with the FY 2018 payment determination and subsequent FY payment determinations, all HIS records would have to be submitted within 30 days of the event date, which is the patient's admission date or discharge date.
In conjunction with the timeliness criteria for submission of HIS-Admission and HIS-Discharge records, in the FY 2016 Hospice Wage Index final rule (80 FR 47192) we also finalized a policy to establish an incremental threshold for compliance over a 3-year period. To be compliant for the FY 2018 APU determination, hospices must submit no less than 70 percent of their total number of HIS-Admission and HIS-Discharge records by no later than 30 days from the event date. The timeliness threshold is set at 80 percent for the FY 2019 APU determination and at 90 percent for the FY 2020 APU determination and subsequent years. The threshold corresponds with the overall amount of HIS records received from each provider that fall within the established 30 day submission timeframes. Our ultimate goal is to require all hospices to achieve a compliance rate of 90 percent or more.
To summarize, in the FY 2016 Hospice Wage Index final rule (80 FR 47193), we finalized our policy to implement the timeliness threshold requirement beginning with all HIS-Admission and HIS-Discharge records that occur after
* Beginning
* Beginning
* Beginning
In July of 2016, we released the Hospice Timeliness Compliance Threshold Report in the Certification and Survey Provider Enhanced Reports (CASPER) system. This report allows providers with a QIES ASAP User ID to check their preliminary compliance with the 70/80/90 timeliness compliance threshold described above. For more information on the Hospice Timeliness Compliance Threshold Report, we refer readers to the Timeliness Compliance Threshold Fact Sheet, available on the HIS portion of the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html and Chapter 3 of the CASPER User's Manual, available on the QTSO Web site: https://www.qtso.com/hospicetrain.html.
In the FY 2016 Hospice Wage Index final rule (80 FR 47192 through 47193), we provided clarification regarding the methodology used in calculating the 70 percent/80 percent/90 percent compliance thresholds. In general, HIS records submitted for patient admissions and discharges occurring during the reporting period (
c. CAHPS(R) Participation Requirements for FY 2018 APU Determination and Determinations for Subsequent Years
In the FY 2015 Hospice Wage Index final rule, we added the CAHPS(R) Hospice Survey to the Hospice Quality Reporting Program requirements for the FY 2017 payment determination and determinations for subsequent FY APU years (79 FR 50491).
In the FY 2017 Hospice Wage Index final rule, we finalized that to meet the HQRP requirements for the FY 2018, FY 2019 and FY 2020 APU payment determinations, hospices would collect survey data on a monthly basis for the months of
10. HQRP Submission Exemption and Extension Requirements for the FY 2019 Payment Determination and Subsequent Years
a. Extraordinary Circumstances Exemption and Extension
In the FY 2015 Hospice Wage Index final rule (79 FR 50488), we finalized our proposal to allow hospices to request, and for CMS to grant, exemptions/extensions for the reporting of required HIS quality data when there are extraordinary circumstances beyond the control of the provider. Such extraordinary circumstances may include, but are not limited to, acts of nature or other systemic issues with our data systems. We further finalized that hospices must request such an exemption or extension within 30 days of the date that the extraordinary circumstances occurred.
In certain instances, however, it may be difficult for hospices to timely evaluate the impact of extraordinary circumstances within 30 calendar days. For other quality reporting programs such as the Hospital Inpatient Quality Reporting (81 FR 57182), Inpatient Rehabilitation Facility Quality Reporting Program (81 FR 52125) and the Long-term Care Hospital Quality Reporting Program (81 FR 25205), we have reevaluated our policy and subsequently finalized through rulemaking an extension of that period of time to 90 calendar days. We are therefore proposing to extend the deadline for submitting an exemption or extension request to 90 calendar days from the qualifying event which is preventing a hospice from submitting their quality data for the HQRP. We believe that extending the deadline to 90 calendar days would allow hospices more time to determine whether it is necessary and appropriate to submit an exemption or extension request and to provide a more comprehensive account of the qualifying event in their request form to CMS. For example, if a hospice has suffered damage due to a hurricane on
Further, while we finalized our policy in the past for exception/extension for the submission of the HIS data, we propose to extend this policy beyond the submission of the HIS date to submission of the CAHPS(R) Hospice Survey data, given that multiple data submission processes could be impacted by the same qualifying event.
Therefore, we are proposing for FY 2019 payment determination and subsequent payment determinations to extend the period of time a hospice may have to submit a request for an extension or exception for quality reporting purposes from 30 calendar days to 90 calendar days after the date that the extraordinary circumstances occurred, by submitting a request to CMS via email to the HQRP mailbox at [email protected]. Exemption or extension requests sent to us through any other channel will not be considered valid. The request for an exemption or extension must contain all of the finalized requirements as outlined on our Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Extensions-and-Exemption-Requests.html.
If a hospice is granted an exemption or extension, timeframes for which an exemption or extension is granted will be applied to the new timeliness requirement so such hospices are not penalized. If a hospice is granted an exemption, we will not require that the hospice submit HIS and/or CAHPS(R) Hospice Survey data for a given period of time. By contrast, if we grant an extension to a hospice, the hospice will still remain responsible for submitting data collected during the timeframe in question, although we will specify a revised deadline by which the hospice must submit these quality data.
This process does not preclude us from granting extensions/exemptions to hospices that have not requested them when we determine that an extraordinary circumstance, such as an act of nature, affects an entire region or locale. We may grant an extension/exemption to a hospice if we determine that a systemic problem with our data collection systems directly affected the ability of the hospice to submit data. If we make the determination to grant an extension/exemption to hospices in a region or locale, we will communicate this decision through the various means, including the CMS HQRP Web site, listserv messages via the Post-Acute Care QRP listserv, MLN Connects(R) National Provider Calls & Events, MLN Connects(R) Provider eNews and announcements on Open Door Forums and Special Open Door Forums. We are soliciting comments on these proposals.
b. Volume-Based Exemption for CAHPS(R) Hospice Survey Data Collection and Reporting Requirements
We previously finalized a volume-based exemption for CAHPS(R) Hospice Survey Data Collection and Reporting requirements in the FY 2017 Final Rule (81 FR 52181). Hospices that have fewer than 50 survey-eligible decedents/caregivers in the period from
Hospices that have fewer than 50 survey-eligible decedents/caregivers in the period from
Hospices that have fewer than 50 survey-eligible decedents/caregivers in the period from
c. Newness Exemption for CAHPS(R) Hospice Survey Data Collection and Reporting Requirements
CMS previously finalized a one-time newness exemption for hospices that meet the criteria (81 FR 52181). Accordingly, hospices that are notified about their Medicare CCN after
11. CAHPS(R) Hospice Survey Participation Requirements for the FY 2020 APU and Subsequent Years
The CAHPS(R) Hospice Survey of CMS' Hospice Quality Reporting Program is used to collect data on the experiences of hospice patients and the primary caregivers listed in their hospice records. Readers who want more information are referred to our extensive discussion of the Hospice Experience of Care prior to our proposal for the public reporting of measures should refer to 79 FR 50452 and 78 FR 48261.
a. Background and Description of the CAHPS(R) Hospice Survey
The CAHPS(R) Hospice Survey is the first standardized national survey available to collect information on patient's and informal caregiver's experience of hospice care. Patient-centered experience measures are a key component of the CMS Quality Strategy, emphasizing patient-centered care by rating experience as a means to empower patients and their caregivers and improving the quality of their care. /28/ In addition, the survey introduces standard survey administration protocols that allow for fair comparisons across hospices.
FOOTNOTE 28 CMS National Quality Strategy 2016. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/cms-quality-strategy.pdf. END FOOTNOTE
Details regarding CAHPS(R) Hospice Survey national implementation, survey administration, participation requirements, exemptions from the survey's requirements, hospice patient and caregiver eligibility criteria, fielding schedules, sampling requirements, survey instruments, and the languages that are available for the survey, are all available on the official CAHPS(R) Hospice Survey Web site, www.HospiceCAHPSsurvey.org and in the CAHPS(R) Hospice Survey Quality Assurance Guidelines (QAG), which is posted on the Web site.
b. Overview of Proposed Measures
The CAHPS Hospice Survey was developed in line with the
The survey consists of 47 questions and is available (using the mailed version) in English, Spanish, Chinese, Russian, Portuguese, Vietnamese, Polish, and Korean. It covers topics such as access to care, communications, experience at hospice facilities, and interactions with hospice staff. The survey also contains two global rating questions and asks for self-reported demographic information (race/ethnicity, educational attainment level, languages spoken at home, among others).
The CAHPS(R) Hospice Survey measures received NQF endorsement on
* Hospice Team Communication;
* Getting Timely Care;
* Treating Family Member with Respect;
* Getting Emotional and Religious Support;
* Getting Help for Symptoms; and
* Getting Hospice Care Training.
Each of the six composite survey-based measures consists of two or more questions. The two global survey-based measures are:
* Rating of Hospice; and
* Willingness to
The two global survey-based measures are comprised of a single question each and ask the primary caregiver of the decedent to rate the care provided by the hospice facility and his or her willingness to recommend the hospice to family and friends. More information about these measures can be found on the official CAHPS(R) Hospice Survey Web site, www.HospiceCAHPSsurvey.org and in the CAHPS(R) Hospice Survey Quality Assurance Guidelines (QAG), which is posted on the Web site.
The eight survey-based measures we are proposing were included on the CY 2016 MUC /29/ list, and reviewed by the MAP. /30/
FOOTNOTE 29 CMS, List of Measures Under Consideration for
FOOTNOTE 30
* CAHPS(R) Hospice Survey: Rating of Hospice (MUC ID: MUC16-31)
* CAHPS(R) Hospice Survey:
* CAHPS(R) Hospice Survey: Willingness to Recommend (MUC16-33)
* CAHPS(R) Hospice Survey: Getting Hospice Care Training (MUC16-35)
* CAHPS(R) Hospice Survey: Getting Timely Care (MUC16-36)
* CAHPS(R) Hospice Survey: Getting Emotional and Religious Support (MUC16-37)
* CAHPS(R) Hospice Survey: Getting Help for Symptoms (MUC16-39)
* CAHPS(R) Hospice Survey: Treating Family Member with Respect (MUC16-40)
The MAP supported rulemaking for all eight "patient-reported" measures derived from the CAHPS(R) Hospice Survey. The MAP noted that the CAHPS(R) Hospice Survey measures may offer an indication of global quality of care by including the perspective of both patients and their caregivers.
c. Data Sources
As discussed in the CAHPS (R) Hospice Survey Quality Assurance Guidelines V3.0 (QAG V3.0) (http://www.hospicecahpssurvey.org/en/quality-assurance-guidelines/), the survey has three administration methods: Mail-only, telephone only, and mixed mode (mail with telephone follow-up of non-respondents). We previously finalized the participation requirements for the FY 2018 and FY 2019 Annual Payment Updates (80 FR 47194). To summarize, to meet the CAHPS(R) Hospice Survey requirements for the HQRP, we are proposing that hospice facilities must contract with a CMS-approved vendor to collect survey data for eligible patients on a monthly basis and report that data to CMS on the hospice's behalf by the quarterly deadlines established for each data collection period. The list of approved vendors is available at: http://www.hospicecahpssurvey.org/en/approved-vendor-list.
Hospices are required to provide lists of the patients who died under their care, along with the associated primary caregiver information, to their respective survey vendors to form the samples for the CAHPS(R) Hospice Survey. We emphasize the importance of hospices providing complete and accurate information to their respective survey vendors in a timely manner. Hospices must contract with an approved CAHPS(R) Hospice Survey vendor to conduct the survey on their behalf. Hospices are responsible for making sure their respective survey vendors meet all data submission deadlines. Vendor failures to submit data on time are the responsibility of the hospices.
i. Requirements for the FY 2020 Annual Payment Update
To meet participation requirements for the FY 2020 annual payment update (APU),
Table 17--CAHPS(R) Hospice Survey Data Submission Dates for the APU in FY 2020, FY 2021, and FY 2022 Sample months Quarterly data submission deadlines (that is, month of death) *1 *2 FY 2020 APU January-March 2018 (Q1)August 8, 2018 . April-June 2018 (Q2)November 14, 2018 . July-September 2018 (Q3)February 13, 2019 . October-December 2018 (Q4)May 8, 2019 . FY 2021 APU January-March 2019 (Q1)August 14, 2019 . April-June 2019 (Q2)November 13, 2019 . July-September 2019 (Q3)February 12, 2020 . October-December 2019 (Q4)May 13, 2020 . FY 2022 APU January-March 2020 (Q1)August 12, 2020 . April-June 2020 (Q2)November 12, 2020 . *3 July-September 2020 (Q3)February 10, 2021 . October-December 2020 (Q4)May 12, 2021 . *1 Data collection for each sample month initiates 2 months following the month of patient death (for example, in April for deaths occurring in January). *2 Data submission deadlines are the second Wednesday of the submission months, which are the months August, November, February, and May. *3 Second Wednesday isVeterans Day Holiday.
ii. Requirements for the FY 2021 Annual Payment Update
To meet participation requirements for the FY 2021 APU,
iii. Requirements for the FY 2022 Annual Payment Update
To meet participation requirements for the FY 2022 APU,
d. Measure Calculations
As noted above, we are proposing to adopt six composite CAHPS(R) Hospice Survey-based measures and two global survey-based measures. As with other measures adopted for HQRP, a hospice's performance for a given payment determination year will be based upon the successful submission of data required in accordance with the administrative, form, manner and timing requirements established for the program. Therefore, hospices' scores on the CAHPS(R) Hospice Survey-based measures will not affect whether they are subject to the 2.0 percentage point payment reduction for hospices that fail to report data required to be submitted.
We propose that
For additional information on the specifications of these measures, including details regarding top-box scoring methodology and mode and case-mix adjustment, please refer to the CAHPS(R) Hospice Survey Web page at http://www.hospicecahpssurvey.org/en/.
i. Composite Survey-Based Measures
Unadjusted hospice scores on each composite CAHPS(R) Hospice Survey-based measure would be calculated by determining the proportion of "top-box" responses for each question within the composite and averaging these proportions over all the questions in the composite measure. For example, to assess hospice performance on the composite measure CAHPS(R) Hospice Survey--Hospice Team Communication, we would calculate the proportion of top-box responses for each of the measure's six questions, add those proportions together, and divide by the number of questions in the composite measure (in this case, six).
As a specific example, we take a theoretical hospice facility that had 50 surveys completed and received the proportions of "top-box" responses through sample calculations:
* 25 "top-box" responses out of 50 total responses on Question One
* 40 "top-box" responses out of 50 total responses on Question Two
* 50 "top-box" responses out of 50 total responses on Question Three
* 35 "top-box" responses out of 50 total responses on Question Four
* 45 "top-box" responses out of 50 total responses on Question Five
* 40 "top-box" responses out of 50 total responses on Question Six
Based on the above responses, we would calculate that hospice's unadjusted measure score for public reporting as follows:
See Illustration in Original Document.
This calculation would give this example hospice an unadjusted score of 0.78 or 78 percent for the Hospice Team Communication measure for purposes of public reporting. We note that an adjusted hospice score would be calculated by adjusting the score for each question for differences in the characteristics of decedents and caregivers across hospices and for mode as described in section 11.e, and then averaging across questions within the measure as described here. Further detailed information regarding scoring and risk adjustment can be found at the CAHPS(R) Hospice Survey Web site (http://www.hospicecahpssurvey.org/en/technical-specifications/).
ii. Global Survey-Based Measures
We are proposing to adopt two global CAHPS(R) Hospice Survey measures. CAHPS(R) Hospice Survey--Rating of Hospice asks the primary caregiver of the decedent to rate the care provided by the hospice on a scale of 0 to 10, and CAHPS(R) Hospice Survey--Willingness to Recommend asks about the caregiver's willingness to recommend the hospice to family and friends on a scale of "Definitely No" to "Definitely Yes". Unadjusted hospice performance on each of the two global CAHPS(R) Hospice Survey-based measures would be calculated by the proportion of respondents providing high-value responses (that is, a 9 to 10 rating or "Definitely Yes") to the survey questions over the total number of respondents. For example, if a hospice received 45 9- and 10-point ratings out of 50 responses, this hospital would receive a 0.9 or 90 percent unadjusted score, which would then be adjusted for differences in the characteristics of decedents and caregivers across hospices and modes, as described in section 12.E.
iii. Cohort
The CAHPS(R) Hospice Survey is administered to all eligible patients/caregivers--or a random sample thereof--who meet the eligibility criteria. Eligible patients, regardless of insurance or payment, can participate.
For purposes of each survey-based measure captured in the CAHPS(R) Hospice Survey, an "eligible patient" is a decedent 18 years or older:
* With death at least 48 hours following last admission to hospice care
* for whom there is a caregiver of record
* whose caregiver is someone other than a non-familial legal guardian
* for whom the caregiver has a
Patients who are still alive or whose admission to the hospice resulted in a live discharge, are not eligible to participate in the survey. In addition, decedents/caregivers who initiate or voluntarily request that the hospice not reveal the patient's identity; and/or not survey the patient/caregiver ("no publicity patients/caregivers") are excluded from the sample.
e. Risk Adjustment
The CAHPS(R) Hospice Survey measures assess activities that are fully under the control of hospice care professionals and/or hospice organizations. In order to ensure fair comparisons in public reporting, we believe it is necessary and appropriate to adjust for factors that are not directly related to hospice performance, such as patient mix, for these CAHPS(R) Hospice Survey measures. The survey based measures are adjusted for decedent and caregiver characteristics (including the lag time between patient death and survey response; decedent's age, payer for hospice care, decedent's primary diagnosis, decedent's length of final episode of hospice care, caregiver's education, decedent's relationship to caregiver, caregiver's preferred language and language in which the survey was completed, and caregiver's age) known to be associated with systematic difference in survey responses.
i. Patient Mix Adjustment
Previous research, on both CAHPS(R) surveys and other types of surveys, has identified respondent characteristics that are not under the control of the entities being assessed but tend to be related to survey responses. Hence, variations in the proportion of respondents with such characteristics will be associated with variations in survey responses that are unrelated to the actual quality of hospice care. To ensure that comparisons between hospices reflect differences in performance rather than differences in patient and/or caregiver characteristics, publicly reported hospice scores will be adjusted for variations of such characteristics across hospices. This adjustment is performed using a linear regression model applied to all data within a quarter, with indicator variables for each hospice and each characteristic as an independent variable in the model.
ii. Mode Adjustment
We conducted an experiment to determine whether survey mode adjustments were needed to fairly compare CAHPS(R) Hospice Survey scores. The experiment found that mode adjustments are needed. Publicly reported CAHPS(R) Hospice Survey scores will be adjusted for the mode of survey administration, which affects scores but is not related to quality of hospice care. (Authorized survey modes are: Mail-only, telephone-only, and mail with telephone follow up, also called mixed mode.) Mode adjustment is performed prior to patient-mix adjustment; a mode adjustment value is added/subtracted (depending on the mode) to each response to the survey by mail-only mode or mixed mode. Responses obtained using telephone-only mode are not adjusted since this is the reference mode.
As a result of the risk adjustment methodologies proposed here, the final percentages may vary from the unadjusted percentage as calculated in the examples provided above.
f. For Further Information About the CAHPS(R) Hospice Survey
We encourage hospices and other entities to learn more about the survey on www.hospicecahpssurvey.org. For direct questions, please contact the CAHPS(R) Hospice Survey Team at [email protected] or telephone 1-844-472-4621.
12. HQRP Reconsideration and Appeals Procedures for the FY 2018 Payment Determination and Subsequent Years
In the FY 2015 Hospice Wage Index final rule (79 FR 50496), we notified hospice providers on how to seek reconsideration if they received a noncompliance decision for the FY 2016 payment determination and subsequent years. A hospice may request reconsideration of a decision by CMS that the hospice has not met the requirements of the HQRP for a particular period.
We clarified that any hospice that wishes to submit a reconsideration request must do so by submitting an email to CMS containing all of the requirements listed on the HQRP Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Reconsideration-Requests.html. Electronic email sent to [email protected] is the only form of submission that will be accepted. Any reconsideration requests received through any other channel including the
In the past, only hospices found to be non-compliant with the reporting requirements set forth for a given payment determination received a notification from CMS of this finding along with instructions for requesting reconsideration in the form of a
13. Confidential Feedback Reports
As part of our effort to promote use of standardized quality data to improve quality of care, in
Providers are able to view their data and information at both the hospice and patient stay levels for it's HIS based quality measures. The CASPER hospice-level QM Reports contain information such as the numerator, denominator, hospice-level QM score, and national average. The CASPER patient stay-level QM Reports show whether each patient stay is counted toward each quality measure. The HIS based QMs reported in both reports include:
* NQF #1641 Treatment Preferences
* NQF #1647 Beliefs/Values
* NQF #1634 Pain Screening
* NQF #1637 Pain Assessment
* NQF #1639 Dyspnea Screening
* NQF #1638 Dyspnea Treatment
* NQF #1617 Bowel Regimen
For more information on the CASPER QM Reports, we refer readers to the CASPER QM Factsheet on the HQRP Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices.html. This fact sheet contains detailed information about each CASPER QM report currently available, the data included in the reports, and how providers can use the reports as part of their Quality Assessment and Performance Improvement (QAPI) efforts. For technical information on the reports and how to access the CASPER QM Reports, we refer readers to: https://www.qtso.com/hospicetrain.html.
As new HIS measures are implemented in the HQRP, we will continue to expand the functionality of the QM reports to allow providers to view data on additional HIS measures. We will announce refinements and additions to the QM reports through sub-regulatory communication channels and in future rulemaking cycles.
We also propose to provide hospices with preview reports of their data prior to the quarterly publication of CAHPS(R) Hospice Survey data on the Compare site. The reports will be provided through the CASPER reporting system. Each hospice will receive only its own, individual reports.
14. Public Display of Quality Measures and Other Hospice Data for the HQRP
Under section 1814(i)(5)(E) of the Act, the Secretary is required to establish procedures for making any quality data submitted by hospices available to the public. These procedures shall ensure that a hospice has the opportunity to review the data that is to be made public for the hospice prior to such data being made public. The Secretary shall report quality measures that relate to hospice care provided by hospice programs on a publicly available CMS Web site.
In the FY 2017 rule, we discussed our analysis of HIS data to inform which measures were eligible for public reporting and reportability analysis to determine data selection period and minimum denominator size for measures to be publicly reported. Based on analysis results, we determined that all 7 HIS quality measures adopted for the FY 2016 and beyond (NQF #1634, NQF #1637, NQF #1639, NQF #1638, NQF #1641, NQF #1647, NQF #1617), calculated based on a rolling 12 month data selection period, to be eligible for public reporting with a minimum denominator size of 20 patient stays. For additional details on these analyses, we refer readers to the FY 2017 final rule (81 FR 52183 through 52184).
In the FY 2017 final rule we also clarified policies for reportability analyses for new measures. As stated in the FY 2017 final rule, new measures will undergo reportability analysis to determine (1) appropriateness for public reporting and (2) appropriate data selection period. In accordance with discussion in the prior year's rule, we will use the same analytic approach used in previous reportability analyses to determine data selection period and minimum denominator size for the Hospice and Palliative Care Composite Process Measure--Comprehensive Assessment at Admission. We will begin reportability analyses for the Hospice Visits When Death is Imminent Measure Pair once data for the measure are available. Results of reportability analyses conducted for these new measures will be communicated through future rulemaking.
To meet the Affordable Care Act's requirement for making quality measure data public, we are developing a CMS Hospice Compare Web site, which will allow consumers, providers and stakeholders to search for all
We will provide hospices an opportunity to preview their quality measure data prior to publicly reporting information. These quality measure data reports or "preview reports" will be made available in the CASPER system prior to public reporting and will offer providers the opportunity to preview their quality measure data prior to public reporting on the CMS Hospice Compare Web site. We will provide hospices 30 days to review the preview report beginning from the date on which they can access the report. Hospices will have an opportunity to request review of their data by CMS during the 30-day preview period if they believe that errors in data submitted to CMS may have resulted in incorrect measure scores and can submit proof along with a plan describing how the errors will be corrected. We will review these requests and if we confirm that the errors have affected the measures and agree to correct the measure, we will suppress the measure on the Hospice Compare Web site for one time only and display the corrected measure during the subsequent quarterly refresh of the Compare Web site. When the preview reports are ready for providers to access, anticipated summer of CY 2017 prior to the release of Hospice Compare, we will post the policies and procedures for providers to submit requests for reviewing of their data by CMS on the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/Hospice-Quality-Reporting/Hospice-Quality-Public-Reporting.html.
CMS encourages hospices to use CASPER QM Reports (see section III.D.14 of this proposed rule) to review their HIS quality measures after they submit the HIS data to CMS. If hospices determine that erroneous data have been submitted, they should submit either of these two types of HIS records: Modify existing record or inactivate existing record to correct their data. HIS data corrected before the data are frozen for the creation of the preview reports will be reflected in the preview reports.
We propose to begin public reporting of CAHPS(R) Hospice Survey measures in 2018. Specifically, we are proposing to publicly report data in winter CY 2018 on all eight CAHPS(R) Hospice Survey measures. Scores would be displayed based on eight rolling quarters of data and would initially use CAHPS(R) Hospice Survey data collected from caregivers of patients who died while receiving hospice care between
Like other CMS Compare Web sites, the Hospice Compare Web site will, in time, feature a quality rating system that gives each hospice a rating of between 1 and 5 stars. Hospices will have prepublication access to their own agency's quality data, which enables each agency to know how it is performing before public posting of data on the Hospice Compare Web site. Public comments regarding how the rating system would determine a hospice's star rating and the methods used for calculations, as well as a proposed timeline for implementation will be announced via the CMS HQRP Web page, listserv messages via the Post-Acute Care QRP listserv, MLN Connects(R) National Provider Calls & Events, MLN Connects(R) Provider eNews and announcements on Open Door Forums and Special Open Door Forums. We will announce the timeline for development and implementation of the star rating system in future rulemaking.
Lastly, as part of our ongoing efforts to make healthcare more transparent, affordable, and accountable for all hospice stakeholders, we have posted a hospice directory and quality data on a public data set located at https://data.medicare.gov. This data will serve as a helpful resource regarding information on
IV. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to provide 60-day notice in the
* The need for the information collection and its usefulness in carrying out the proper functions of our agency.
* The accuracy of our estimate of the information collection burden.
* The quality, utility, and clarity of the information to be collected.
* Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.
Unless noted otherwise, all salary information is from the
Section 1814(i)(5)(C) of the Act requires that each hospice submit data to the Secretary on quality measures specified by the Secretary. This data must be submitted in a form and manner, and at a time specified by the Secretary.
We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements (ICRs):
A. Hospice Item Set
In the FY 2014 Hospice Wage Index final rule (78 FR 48257), and in compliance with section 1814(i)(5)(C) of the Act, we finalized the specific collection of data items that support the following 7 NQF endorsed measures for hospice:
* NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen,
* NQF #1634 Pain Screening,
* NQF #1637 Pain Assessment,
* NQF #1638 Dyspnea Treatment,
* NQF #1639 Dyspnea Screening,
* NQF #1641 Treatment Preferences,
* NQF #1647 Beliefs/Values Addressed (if desired by the patient).
We finalized the following two additional measures in the FY 2017 Hospice Wage Index final rule affecting FY 2019 payment determinations (81 FR 52163 through 52173):
* Hospice Visits when Death is Imminent
* Hospice and Palliative Care Composite Process Measure--Comprehensive Assessment at Admission
Data for the aforementioned 9 measures is collected via the HIS as discussed in the FY 2017 Hospice Wage Index final rule (81 FR 52189) and covered under OMB control number 0938-1153. The HIS V2.00.0 was approved by the
B. Summary of CAHPS(R) Hospice Survey Information Collection Requirements (OMB Control Number 0938-1257)
National Implementation of the Hospice Experience of
Surveys are administered by CMS-approved survey vendors hired by hospice providers to conduct the survey on their behalf. The survey vendor may collect data in one of three modes: Mail-only, telephone-only, or mixed mode (mail with telephone follow-up). The sample consists of bereaved family members or close friends of patients who died while receiving hospice care (1) at home, (2) in a nursing home, or (3) an inpatient setting (that is, freestanding inpatient unit or acute care hospital). The questionnaire is composed of 47 items.
The estimated annualized burden hours and costs to respondents for the national implementation of the CAHPS(R) Hospice Survey are shown in Tables 18 and 19. Based on participation in national implementation in the CAHPS(R) Hospice Survey from Quarter 2 2015 through Quarter 1 2016, we assume that 3,414 hospices will administer the survey to an average of 278.7 cases. Thus, we estimate that the CAHPS(R) Hospice Survey will be administered to a maximum of 951,482 individuals each year for the duration of the collection period covered by this application for the purposes of national implementation. As not all sampled cases will complete the survey, this estimate reflects the maximum burden possible. The estimated number of responses is based on actual hospice participation in national implementation of the CAHPS(R) Hospice Survey.
Table 18 shows the estimated annualized burden for the respondents' time to participate in the national implementation data collection. The survey contains 47 items and is estimated to require an average administration time of 10.4 minutes in English (at a pace of 4.5 items per minute) and 12.5 minutes in Spanish (assuming 20 percent more words in the Spanish translation), for an average response time of 10.47 minutes or 0.174 hours (assuming that 1 percent of survey respondents complete the survey in Spanish). These burden and pace estimates are based on CMS' experience with the CAHPS(R) Hospice Survey and surveys of similar length that were fielded with
Table 18--Estimated Annualized Burden Hours for Respondents: National Implementation of the CAHPS(R) Hospice Survey Survey version Number of Number of Hours per Total respondents responses response burden per hours respondent CAHPS(R) Hospice Survey 951,482 1 0.174 165,959.57 Total 951,482 1 0.174 165,959.57
Table 19 shows the cost burden to respondents associated with their time to complete a survey as part of national implementation. The annual total cost burden is estimated to be $7,710,481.60. This estimate is higher than the $3,034,789.70 estimated in the prior OMB filing, due to the increased number of hospices participating (and correspondingly, the increased number of respondents), as well as an increase in the average hourly rate.
Table 19--Estimated Annualized Cost Burden for Respondents: National Implementation Form name Number of Total burden Average Total cost respondents hours hourly wage burden rate* CAHPS(R) 951,482 165,959.57 * $46.46 $7,710,481.60 Hospice Survey Total 951,482 165,959.57 * $46.46 $7,710,481.60 * Source: Data from theU.S. Bureau of Labor Statistics' May 2015 National Occupational Employment and Wage Estimates for all salary estimates (http://www.bls.gov/oes). This figure includes a 100% fringe benefit on an average wage of $23.23. Retrieved April 10, 2017.
If you comment on these information collection, that is, reporting, recordkeeping or third-party disclosure requirements, please submit your comments electronically as specified in the ADDRESSES section of this proposed rule.
Comments must be received by 5 p.m. June 26, 2017.
V. Response to Comments
Because of the large number of public comments we normally receive on Federal Register documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the DATES section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document.
VI. Request for Information on CMS Flexibilities and Efficiencies
CMS is committed to transforming the health care delivery system--and the
As we work to maintain flexibility and efficiency throughout the
We would like to take this opportunity to invite the public to submit their ideas for regulatory, subregulatory, policy, practice, and procedural changes to better accomplish these goals. Ideas could include payment system redesign, elimination or streamlining of reporting, monitoring and documentation requirements, aligning
We note that this is a Request for Information only. Respondents are encouraged to provide complete but concise responses. This Request for Information is issued solely for information and planning purposes; it does not constitute a Request for Proposal (RFP), applications, proposal abstracts, or quotations. This Request for Information does not commit the
VII. Regulatory Impact Analyses
A. Statement of Need
This proposed rule meets the requirements of our regulations at
B. Overall Impacts
We estimate that the aggregate impact of the payment provisions in this proposed rule would result in an increase of $180 million in payments to hospices, resulting from the hospice payment update percentage of 1.0 percent. The impact analysis of this proposed rule represents the projected effects of the changes in hospice payments from FY 2017 to FY 2018. Using the most recent data available at the time of rulemaking, in this case FY 2016 hospice claims data, we apply the current FY 2017 wage index and labor-related share values to the level of care per diem payments and SIA payments for each day of hospice care to simulate FY 2017 payments. Then, using the same FY 2016 data, we apply the proposed FY 2018 wage index and labor-related share values to simulate FY 2018 payments. Certain events may limit the scope or accuracy of our impact analysis, because such an analysis is susceptible to forecasting errors due to other changes in the forecasted impact time period. The nature of the
We have examined the impacts of this rule as required by Executive Order 12866 on Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. 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. L. 104-4), Executive Order 13132 on Federalism (August 4, 1999), the Congressional Review Act (5 U.S.C. 804(2) and Executive Order 13771 on Reducing Regulation and Controlling Regulatory Costs (January 30, 2017).
Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). Section 3(f) of Executive Order 12866 defines a "significant regulatory action" as an action that is likely to result in a rule: (1) Having an annual effect on the economy of $100 million or more in any 1 year, or adversely and materially affecting a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or state, local or tribal governments or communities (also referred to as "economically significant"); (2) creating a serious inconsistency or otherwise interfering with an action taken or planned by another agency; (3) materially altering the budgetary impacts of entitlement grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raising novel legal or policy issues arising out of legal mandates, the President's priorities, or the principles set forth in the Executive Order.
A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). We estimate that this rulemaking is "economically significant" as measured by the $100 million threshold, and hence also a major rule under the Congressional Review Act. Accordingly, we have prepared a RIA that, to the best of our ability presents the costs and benefits of the rulemaking.
C. Anticipated Effects
The RFA requires agencies to analyze options for regulatory relief of small businesses if a rule has a significant impact on a substantial number of small entities. 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 $7.5 million to $38.5 million in any 1 year), or being nonprofit organizations. For purposes of the RFA, we consider all hospices as small entities as that term is used in the RFA. HHS's practice in interpreting the RFA is to consider effects economically "significant" only if they reach a threshold of 3 to 5 percent or more of total revenue or total costs. The effect of the proposed FY 2018 hospice payment update percentage results in an overall increase in estimated hospice payments of 1.0 percent, or $180 million. Therefore, the Secretary has determined that this proposed rule will not create a significant economic impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan statistical area and has fewer than 100 beds. This proposed rule only affects hospices. Therefore, the Secretary has determined that this proposed rule would not have a significant impact on the operations of a substantial number of small rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. In 2017, that threshold is approximately $148 million. This proposed rule is not anticipated to have an effect on state, local, or tribal governments, in the aggregate, or on the private sector of $148 million or more.
Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on state and local governments, preempts State law, or otherwise has Federalism implications. We have reviewed this proposed rule under these criteria of Executive Order 13132, and have determined that it will not impose substantial direct costs on state or local governments.
If regulations impose administrative costs on private entities, such as the time needed to read and interpret this proposed rule, we should estimate the cost associated with regulatory review. Due to the uncertainty involved with accurately quantifying the number of entities that will review the rule, we assume that the total number of unique commenters on last year's proposed rule will be the number of reviewers of this proposed rule. We acknowledge that this assumption may understate or overstate the costs of reviewing this rule. It is possible that not all commenters reviewed last year's rule in detail, and it is also possible that some reviewers chose not to comment on the proposed rule. For these reasons we thought that the number of past commenters would be a fair estimate of the number of reviewers of this rule. We welcome any comments on the approach in estimating the number of entities which will review this proposed rule.
We also recognize that different types of entities are in many cases affected by mutually exclusive sections of this proposed rule, and therefore for the purposes of our estimate we assume that each reviewer reads approximately 50 percent of the rule. We seek comments on this assumption.
Using the wage information from the BLS for medical and health service managers (Code 11-9111), we estimate that the cost of reviewing this rule is $90.16 per hour, including overhead and fringe benefits (https://www.bls.gov/oes/2015/may/naics4_621100.htm). Assuming an average reading speed, we estimate that it would take approximately 1.3 hours for the staff to review half of this proposed rule. For each hospice that reviews the rule, the estimated cost is $117.21 (1.3 hours x $90.16). Therefore, we estimate that the total cost of reviewing this regulation is $7, 032.60 ($117.21 x 60 reviewers).
D. Detailed Economic Analysis
The proposed FY 2018 hospice payment impacts appear in Table 20. We tabulate the resulting payments according to the classifications in Table 20 (for example, facility type, geographic region, facility ownership), and compare the difference between current and proposed payments to determine the overall impact.
The first column shows the breakdown of all hospices by urban or rural status, census region, hospital-based or freestanding status, size, and type of ownership, and hospice base. The second column shows the number of hospices in each of the categories in the first column.
The third column shows the effect of the annual update to the wage index. This represents the effect of using the proposed FY 2018 hospice wage index. The aggregate impact of this change is zero percent, due to the proposed hospice wage index standardization factor. However, there are distributional effects of the proposed FY 2018 hospice wage index.
The fourth column shows the effect of the proposed hospice payment update percentage for FY 2018. The proposed FY 2018 hospice payment update percentage of 1 percent is mandated by section 1814(i)(1)(C) of the Act, as amended by section 411(d) of the MACRA.
The fifth column shows the effect of all the proposed changes on FY 2018 hospice payments. It is projected that aggregate payments will increase by 1.0 percent, assuming hospices do not change their service and billing practices in response.
As illustrated in Table 20, the combined effects of all the proposals vary by specific types of providers and by location. For example, due to the changes proposed in this rule, the estimated impacts on FY 2018 payments range from a 0.9 percent decrease for hospices providing care in the rural outlying region to a 1.7 percent increase for hospices providing care in the urban Pacific region.
Table 20--Projected Impact to Hospices for FY 2018 Number of Updated Proposed FY 2018 providers wage data FY total (%) 2018 change hospice (%) payment update (%) (1) (2) (3) (4) (5) All Hospices 4,295 0.0 1.0 1.0 Urban Hospices 3,323 0.0 1.0 1.0 Rural Hospices 972 0.1 1.0 1.1 Urban Hospices--New England 134 -0.7 1.0 0.3 Urban Hospices--Middle Atlantic 249 0.1 1.0 1.1 Urban Hospices--South Atlantic 429 -0.3 1.0 0.7 Urban Hospices--East North Central 405 -0.1 1.0 0.9 Urban Hospices--East South Central 159 0.0 1.0 1.0 Urban Hospices--West North Central 229 -0.2 1.0 0.8 Urban Hospices--West South Central 648 0.0 1.0 1.0 Urban Hospices--Mountain 315 -0.1 1.0 0.9 Urban Hospices--Pacific 716 0.7 1.0 1.7 Urban Hospices--Outlying 39 -0.6 1.0 0.4 Rural Hospices--New England 23 0.0 1.0 1.0 Rural Hospices--Middle Atlantic 40 0.6 1.0 1.6 Rural Hospices--South Atlantic 134 0.1 1.0 1.1 Rural Hospices--East North Central 140 0.2 1.0 1.2 Rural Hospices--East South Central 124 -0.1 1.0 0.9 Rural Hospices--West North Central 181 0.2 1.0 1.2 Rural Hospices--West South Central 180 0.1 1.0 1.1 Rural Hospices--Mountain 101 0.2 1.0 1.2 Rural Hospices--Pacific 46 0.3 1.0 1.3 Rural Hospices--Outlying 3 -1.9 1.0 -0.9 0--3,499 RHC Days (Small) 960 0.2 1.0 1.2 3,500-19,999 RHC Days (Medium) 2,001 0.1 1.0 1.1 20,000+ RHC Days (Large) 1,334 0.0 1.0 1.0 Non-Profit Ownership 1,058 0.0 1.0 1.0 For Profit Ownership 2,682 0.1 1.0 1.1 Government Ownership 155 -0.3 1.0 0.7 Other Ownership 400 -0.2 1.0 0.8 Freestanding Facility Type 3,323 0.0 1.0 1.0 HHA/Facility-Based Facility Type 972 0.0 1.0 1.0 Source: FY 2016 hospice claims from the Chronic Condition Data Warehouse (CCW) Research Identifiable File (RIF) in January 2017. Region Key:New England =Connecticut ,Maine ,Massachusetts ,New Hampshire ,Rhode Island ,Vermont ; Middle Atlantic=Pennsylvania ,New Jersey ,New York ; South Atlantic=Delaware ,District of Columbia , Florida,Georgia ,Maryland ,North Carolina ,South Carolina ,Virginia ,West Virginia ; East North Central=Illinois ,Indiana ,Michigan ,Ohio ,Wisconsin ; East South Central=Alabama ,Kentucky ,Mississippi ,Tennessee ; West North Central=Iowa ,Kansas ,Minnesota ,Missouri ,Nebraska ,North Dakota ,South Dakota ; West South Central=Arkansas ,Louisiana ,Oklahoma ,Texas ; Mountain=Arizona ,Colorado ,Idaho ,Montana ,Nevada ,New Mexico ,Utah ,Wyoming ; Pacific=Alaska ,California ,Hawaii ,Oregon ,Washington ; Outlying=Guam ,Puerto Rico ,Virgin Islands
E. Alternatives Considered
Since the hospice payment update percentage is determined based on statutory requirements, we did not consider not updating hospice payment rates by the payment update percentage. Payment rates since FY 2002 have been updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update to the payment rates for subsequent years must be the market basket percentage for that FY. Section 3401(g) of the Affordable Care Act also mandates that, starting with FY 2013 (and in subsequent years), the hospice payment update percentage will be annually reduced by changes in economy-wide productivity as specified in section 1886(b)(3)(B)(xi)(II) of the Act. In addition, section 3401(g) of the Affordable Care Act mandates that in FY 2013 through FY 2019, the hospice payment update percentage will be reduced by an additional 0.3 percentage point (although for FY 2014 to FY 2019, the potential 0.3 percentage point reduction is subject to suspension under conditions specified in section 1814(i)(1)(C)(v) of the Act). For FY 2018, since the hospice payment update percentage is determined based on statutory requirements at section 1814(i)(1)(C) of the Act, as amended by section 411(d) of the MACRA, we cannot consider not updating the hospice payment rates by the hospice payment update percentage, nor can we consider updating the hospice payment rates by the hospice payment update percentage absent the change to section 1814(i)(1)(C) as amended by MACRA.
F. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 21, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. Table 21 provides our best estimate of the possible changes in
Table 21--Accounting Statement: Classification of Estimated Transfers and Costs, From FY 2017 to FY 2018 Category Transfers Annualized Monetized Transfers $180 million. * From Whom to Whom? Federal Government toMedicare Hospices. * The net increase of $180 million in transfer payments is a result of the 1.0 percent hospice payment update compared to payments in FY 2017.
G. Reducing Regulation and Controlling Regulatory Costs
Executive Order 13771, titled "Reducing Regulation and Controlling Regulatory Costs," was issued on January 30, 2017 (82 FR 9339, February 3, 2017). Section 2(a) of Executive Order 13771 requires an agency, unless prohibited by law, to identify at least two existing regulations to be repealed when the agency publicly proposes for notice and comment, or otherwise promulgates, a new regulation. In furtherance of this requirement, section 2(c) of Executive Order 13771 requires that the new incremental costs associated with new regulations shall, to the extent permitted by law, be offset by the elimination of existing costs associated with at least two prior regulations. OMB's implementation guidance, issued on April 5, 2017, explains that "Federal spending regulatory actions that cause only income transfers between taxpayers and program beneficiaries (for example, regulations associated with . . .
H. Conclusion
We estimate that aggregate payments to hospices in FY 2018 would increase by $180 million, or 1.0 percent, compared to payments in FY 2017. We estimate that in FY 2018, hospices in urban and rural areas would experience, on average, 1.0 percent and 1.1 percent increases, respectively, in estimated payments compared to FY 2017. Hospices providing services in the urban Pacific and rural Middle Atlantic regions would experience the largest estimated increases in payments of 1.7 percent and 1.6 percent, respectively. Hospices serving patients in urban areas in the
In accordance with the provisions of Executive Order 12866, this regulation was reviewed by the Office of Management and Budget.
Dated: April 12, 2017.
Administrator,
Dated: April 17, 2017.
Secretary, Department of
[FR Doc. 2017-08563 Filed 4-27-17; 4:15 pm]
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