[Federal Register Volume 83, Number 89 (Tuesday, May 8, 2018)]
[Proposed Rules]
[Pages 20934-20970]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-08773]
[[Page 20933]]
Vol. 83
Tuesday,
No. 89
May 8, 2018
Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Part 418
Medicare Program; FY 2019 Hospice Wage Index and Payment Rate Update
and Hospice Quality Reporting Requirements; Proposed Rule
Federal Register / Vol. 83 , No. 89 / Tuesday, May 8, 2018 / Proposed
Rules
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 418
[CMS-1692-P]
RIN 0938-AT26
Medicare Program; FY 2019 Hospice Wage Index and Payment Rate
Update and Hospice Quality Reporting Requirements
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule would update the hospice wage index,
payment rates, and cap amount for fiscal year (FY) 2019. The rule also
proposes to make conforming regulations text changes to recognize
physician assistants as designated hospice attending physicians
effective January 1, 2019. Finally, the rule proposes changes to the
Hospice Quality Reporting Program.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. on June 26, 2018.
ADDRESSES: In commenting, please refer to file code CMS-1692-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-1692-P, P.O. Box 8010,
Baltimore, MD 21244-1850.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1692-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
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[supreg] 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:
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
website as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that website to
view public comments.
Wage index addenda will be available only through the internet on
our website at: (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html.)
I. Executive Summary
A. Purpose
This rule proposes updates to the hospice payment rates for fiscal
year (FY) 2019, as required under section 1814(i) of the Social
Security Act (the Act). This rule also proposes conforming regulations
text changes as a result of section 51006 of the Bipartisan Budget Act
of 2018, which amended section 1861(dd)(3)(B) of the Act such that,
effective January 1, 2019, physician assistants (PAs) will be
recognized as designated hospice attending physicians, in addition to
physicians and nurse practitioners. Finally, this rule proposes changes
to 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, 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 of this proposed rule proposes updates to 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 of this proposed rule, we discuss the FY 2019
hospice payment update percentage of 1.8 percent. Sections III.B.3 and
III.B.4 of this proposed rule update the hospice payment rates and
hospice cap amount for FY 2019 by the hospice payment update percentage
discussed in section III.B.2 of this proposed rule. We also propose
regulations text changes in section III.C and section III.D pertaining
to the definition of ``attending physician'' and ``cap period.''
Finally, in section III.E of this proposed rule, we propose updates
to the HQRP, including: Data review and correction timeframes for data
submitted using the HIS; extension of the Consumer Assessment of
Healthcare Providers and Systems (CAHPS[supreg]) Hospice Survey
participation requirements, exemption criteria and public reporting
policies to future years; procedures to announce quality measure
readiness for public reporting and public reporting timelines; removal
of routine public reporting of the 7 HIS measures; and public display
of public use file data on the Hospice Compare website.
C. Summary of Impacts
The overall economic impact of this proposed rule is estimated to
be $340 million in increased payments to hospices during FY 2019.
D. Improving Patient Outcomes and Reducing Burden Through Meaningful
Measures
Regulatory reform and reducing regulatory burden are high
priorities for CMS. To reduce the regulatory burden on the healthcare
industry, lower health care costs, and enhance patient care, in October
2017, we launched the Meaningful Measures Initiative.\1\ This
initiative is one component of our agency-wide Patients Over Paperwork
Initiative,\2\ which is aimed at evaluating and streamlining
regulations with a goal to reduce unnecessary cost and burden, increase
efficiencies, and improve beneficiary experience. The Meaningful
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Measures Initiative is aimed at identifying the highest priority areas
for quality measurement and quality improvement in order to assess the
core quality of care issues that are most vital to advancing our work
to improve patient outcomes. The Meaningful Measures Initiative
represents a new approach to quality measures that fosters operational
efficiencies, and will reduce the costs including, collection and
reporting burden while producing quality measurement that is more
focused on meaningful outcomes.
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\1\ Meaningful Measures web page: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/MMF/General-info-Sub-Page.html.
\2\ See Remarks by Administrator Seema Verma at the Health Care
Payment Learning and Action Network (LAN) Fall Summit, as prepared
for delivery on October 30, 2017 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-10-30.html.
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The Meaningful Measures Framework has the following objectives:
Address high-impact measure areas that safeguard public
health;
Patient-centered and meaningful to patients;
Outcome-based where possible;
Fulfill each program's statutory requirements;
Minimize the level of burden for health care providers
(for example, through a preference for EHR-based measures where
possible, such as electronic clinical quality measures \3\);
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\3\ See section VIII.A.8.c. of the preamble of this proposed
rule where we seek comment on the potential future development and
adoption of eCQMs.
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Significant opportunity for improvement;
Address measure needs for population based payment through
alternative payment models; and
Align across programs and/or with other payers.
In order to achieve these objectives, we have identified 19
Meaningful Measures areas and mapped them to six overarching quality
priorities as shown in the Table 1 below.
Table 1--Meaningful Measures
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Quality priority Meaningful measure area
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Making Care Safer by Reducing Harm Healthcare-Associated
Caused in the Delivery of Care. Infections.
Preventable Healthcare Harm.
Strengthen Person and Family Engagement Care is Personalized and
as Partners in Their Care. Aligned with Patient's Goals.
End of Life Care according to
Preferences.
Patient's Experience of Care.
Patient Reported Functional
Outcomes.
Promote Effective Communication and Medication Management.
Coordination of Care.
Admissions and Readmissions to
Hospitals.
Transfer of Health Information
and Interoperability.
Promote Effective Prevention and Preventive Care.
Treatment of Chronic Disease.
Management of Chronic
Conditions.
Prevention, Treatment, and
Management of Mental Health.
Prevention and Treatment of
Opioid and Substance Use
Disorders.
Risk Adjusted Mortality.
Work with Communities to Promote Best Equity of Care.
Practices of Healthy Living.
Community Engagement.
Make Care Affordable................... Appropriate Use of Healthcare.
Patient-focused Episode of
Care.
Risk Adjusted Total Cost of
Care.
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By including Meaningful Measures in our programs, we believe that
we can also address the following cross-cutting measure criteria:
Eliminating disparities;
Tracking measurable outcomes and impact;
Safeguarding public health;
Achieving cost savings;
Improving access for rural communities; and
Reducing burden.
We believe that the Meaningful Measures Initiative will improve
outcomes for patients, their families, and health care providers while
reducing burden and costs for clinicians and providers as well as
promoting operational efficiencies.
E. Advancing Health Information Exchange
The Department of Health and Human Services (HHS) has a number of
initiatives designed to encourage and support the adoption of
interoperable health information technology and to promote nationwide
health information exchange to improve health care. The Office of the
National Coordinator for Health Information Technology (ONC) and CMS
work collaboratively to advance interoperability across settings of
care.
The Improving Medicare Post-Acute Care Transformation Act of 2014
(Pub. L. 113 185) (IMPACT Act) requires assessment data to be
standardized and interoperable to allow for exchange of the data among
post-acute providers and other providers. To further progress toward
the goal of interoperability, we are developing a Data Element Library
to serve as a publically available centralized, authoritative resource
for standardized data elements and their associated mappings to health
IT standards. These interoperable data elements can reduce provider
burden by allowing the use and reuse of healthcare data, support
provider exchange of electronic health information for care
coordination, person-centered care, and support real-time, data driven,
clinical decision making. Once available, standards in the Data Element
Library can be referenced on the CMS website and in the ONC
Interoperability Standards Advisory (ISA).
The 2018 Interoperability Standards Advisory (ISA) is available at:
https://www.healthit.gov/standards-advisory.
Most recently, the 21st Century Cures Act (Pub. L. 114-255),
enacted in 2016, requires HHS to take new steps to enable the
electronic sharing of health information ensuring interoperability for
providers and settings across the care continuum. Specifically, the
Congress directed ONC to ``develop or support a trusted exchange
framework, including a common agreement among health information
networks nationally.'' This framework (https://beta.healthit.gov/topic/interoperability/trusted-exchange-framework-and-common-agreement)
outlines a common set of principles for trusted exchange and minimum
terms and conditions for trusted exchange in order to enable
interoperability across disparate health information networks. In
another
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important provision, the Congress established new authority for HHS to
discourage ``information blocking'', defined as practices likely to
interfere with, prevent, or materially discourage access, exchange, or
use of electronic health information. We invite providers to learn more
about these important developments and how they are likely to affect
hospices.
II. Background
A. Hospice Care
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. 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 (42 CFR 418.3). Palliative care is at the core
of hospice philosophy and care practices, and is a critical component
of the Medicare hospice benefit.
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.
As referenced in our regulations at Sec. 418.22(b)(1), to be
eligible for Medicare hospice services, the patient's attending
physician (if any) and the hospice medical director must certify that
the individual is ``terminally ill,'' as defined in section
1861(dd)(3)(A) of the Act and our regulations at Sec. 418.3; that is,
the individual's prognosis is for a life expectancy of 6 months or less
if the terminal illness runs its normal course. The regulations at
Sec. 418.22(b)(3) require that the certification and recertification
forms include a brief narrative explanation of the clinical findings
that support a life expectancy of 6 months or less.
Under the Medicare hospice benefit, the election of hospice care is
one a patient choice and once a terminally ill patient elects to
receive hospice care, a hospice interdisciplinary group is essential in
the seamless provision of services. These hospice services are provided
primarily in the individual's home. The hospice interdisciplinary group
works with the beneficiary, family, and caregivers to develop a
coordinated, comprehensive care plan; reduce unnecessary diagnostics or
ineffective therapies; and maintain ongoing communication with
individuals and their families about changes in their condition. The
beneficiary's care plan will shift over time to meet the changing needs
of the individual, family, and caregiver(s) as the individual
approaches the end of life.
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 Sec. 418.204. A
minimum of 8 hours of nursing care, or nursing and aide care, must be
furnished on a particular day to qualify for the continuous home care
rate (Sec. 418.302(e)(4)).
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. Services Covered by the Medicare Hospice Benefit
Coverage under the Medicare Hospice benefit requires that hospice
services must be reasonable and necessary for the palliation and
management of the terminal illness and related conditions. Section
1861(dd)(1) of the Act establishes the services that are to be rendered
by a Medicare-certified hospice program. These covered services
include: Nursing care; physical therapy; occupational therapy; speech-
language pathology therapy; medical social services; home health aide
services (now called hospice aide services); physician services;
homemaker services; medical supplies (including drugs and biologicals);
medical appliances; counseling services (including dietary counseling);
short-term inpatient care in a hospital, nursing facility, or hospice
inpatient facility (including both respite care and procedures
necessary for pain control and acute or chronic symptom management);
continuous home care during periods of crisis, and only as necessary to
maintain the terminally ill individual at home; and any other item or
service which is specified in the plan of care and for which payment
may otherwise be made under Medicare, in accordance with Title XVIII of
the Act.
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 Medicare
hospice benefit must be available to beneficiaries as needed, 24 hours
a day, 7 days a week (section 1861(dd)(2)(A)(i) of the Act).
Upon the implementation of the hospice benefit, the Congress also
expected hospices to continue to use volunteer services, though these
services are not reimbursed by Medicare (see section 1861(dd)(2)(E) of
the Act). As stated in the FY 1983 Hospice Wage Index and Rate Update
proposed rule (48 FR 38149), the hospice interdisciplinary group should
comprise paid hospice employees as well as hospice volunteers, and that
``the hospice benefit and the resulting Medicare reimbursement is not
intended to diminish the voluntary
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spirit of hospices.'' This expectation supports the hospice philosophy
of community based, holistic, comprehensive, and compassionate end-of-
life care.
C. 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 Medicare program. Part 418, subpart
G, provides for a per diem payment in one of four prospectively-
determined rate categories of hospice care (routine home care (RHC),
CHC, IRC, and general inpatient care (GIP)), based on each day a
qualified Medicare beneficiary is under hospice care (once the
individual has elected). This per diem payment is to include all of the
hospice services and items needed to manage the beneficiary's care, as
required by section 1861(dd)(1) of the Act. There has been little
change in the hospice payment structure since the benefit's inception.
The per diem rate based on level of care was established in 1983, and
this payment structure remains today with some adjustments, as noted
below.
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
changes in the methodology concerning updating the daily payment rates
based on the hospital market basket percentage increase applied to the
payment rates in effect during the previous federal fiscal year.
2. Balanced Budget Act of 1997
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L.
105-33) established that updates to the hospice payment rates beginning
FY 2002 and subsequent FYs be the hospital market basket percentage
increase for the FY.
3. FY 1998 Hospice Wage Index Final Rule
The FY 1998 Hospice Wage Index final rule (62 FR 42860),
implemented a new methodology for calculating the hospice wage index
and instituted an annual Budget Neutrality Adjustment Factor (BNAF) so
aggregate Medicare payments to hospices would remain budget neutral to
payments calculated using the 1983 wage index.
4. FY 2010 Hospice Wage Index Final Rule
The FY 2010 Hospice Wage Index and Rate Update final rule (74 FR
39384) instituted an incremental 7-year phase-out of the BNAF beginning
in FY 2010 through FY 2016. The BNAF phase-out reduced the amount of
the BNAF increase applied to the hospice wage index value, but was not
a reduction in the hospice wage index value itself or in the hospice
payment rates.
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 Department of Health and Human Services (the
Secretary), for FY 2014 and subsequent FYs. Beginning in FY 2014,
hospices that fail to report quality data will have their market basket
percentage increase reduced by 2 percentage points.
Section 1814(a)(7)(D)(i) of the Act, as added by section 3132(b)(2)
of the
Affordable Care Act, requires, effective January 1, 2011, that a
hospice physician or nurse practitioner have a face-to-face encounter
with the beneficiary to determine continued eligibility of the
beneficiary's hospice care prior to the 180th-day recertification and
each subsequent recertification, and to attest that such visit took
place. When implementing this provision, we finalized in the FY 2011
Hospice Wage Index final rule (75 FR 70435) that the 180th-day
recertification and subsequent recertifications would correspond to the
beneficiary's third or subsequent benefit periods. Further, section
1814(i)(6) of the Act, as added by section 3132(a)(1)(B) of the
Affordable Care Act, authorizes the Secretary to collect additional
data and information determined appropriate to revise payments for
hospice care and other purposes. The types of data and information
suggested in the Affordable Care Act could capture accurate resource
utilization, which could be collected on claims, cost reports, and
possibly other mechanisms, as the Secretary determined to be
appropriate. The data collected could be used to revise the methodology
for determining the payment rates for RHC and other services included
in hospice care, no earlier than October 1, 2013, as described in
section 1814(i)(6)(D) of the Act. In addition, we were required to
consult with hospice programs and the Medicare Payment Advisory
Commission (MedPAC) regarding additional data collection and payment
revision options.
6. FY 2012 Hospice Wage Index Final Rule
In the FY 2012 Hospice Wage Index final rule (76 FR 47308 through
47314) we announced that beginning in 2012, the hospice aggregate cap
would be calculated using the patient-by-patient proportional
methodology, within certain limits. We allowed existing hospices the
option of having their cap calculated via the original streamlined
methodology, also within certain limits. As of FY 2012, new hospices
have their cap determinations calculated using the patient-by-patient
proportional methodology. If a hospice's total Medicare payments for
the cap year exceed the hospice aggregate cap, then the hospice must
repay the excess back to Medicare.
7. FY 2015 Hospice Wage Index and Payment Rate Update Final Rule
The FY 2015 Hospice Wage Index and Rate Update final rule (79 FR
50452) finalized a requirement that requires the Notice of Election
(NOE) be filed within 5 calendar days after the effective date of
hospice election. If the NOE is filed beyond this 5-day period, hospice
providers are liable for the services furnished during the days from
the effective date of hospice election to the date of NOE filing (79 FR
50474). Similar to the NOE, the claims processing system must be
notified of a beneficiary's discharge from hospice or hospice benefit
revocation within 5 calendar days after the effective date of the
discharge/revocation (unless the hospice has already filed a final
claim) through the submission of a final claim or a Notice of
Termination or Revocation (NOTR).
The FY 2015 Hospice Wage Index and Rate Update final rule (79 FR
50479) also finalized a requirement that the
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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.
Hospice providers are required to begin using a Hospice Experience
of Care Survey for informal caregivers of hospice patients as of 2015.
The FY 2015 Hospice Wage Index and Rate Update final rule (79 FR 50496)
provided background, eligibility criteria, survey respondents, and
implementation of the Hospice Experience of Care Survey for informal
caregivers, that hospices are required to use as of 2015.
Finally, the FY 2015 Hospice Wage Index and 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 contractor (79 FR 50503).
8. IMPACT Act of 2014
The Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act) (Pub. L. 113-185) became law on October 6, 2014. Section
3(a) of the IMPACT Act mandated that all Medicare certified hospices be
surveyed every 3 years beginning April 6, 2015 and ending September 30,
2025. In addition, section 3(c) of the IMPACT Act requires medical
review of hospice cases involving beneficiaries receiving more than 180
days care in select hospices that show a preponderance of such
patients; section 3(d) of the IMPACT Act contains a new provision
mandating that the cap amount for accounting years that end after
September 30, 2016, and before October 1, 2025 be updated by the
hospice payment update rather than using the consumer price index for
urban consumers (CPI-U) for medical care expenditures.
9. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR
47172), 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. 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 Rate Update final rule (80 FR 47186)
implemented changes mandated by the IMPACT Act, in which the cap amount
for accounting years that end after September 30, 2016 and before
October 1, 2025 is updated by the hospice payment update percentage
rather than using the CPI-U. This was applied to the 2016 cap year,
starting on November 1, 2015 and ending on October 31, 2016. In
addition, we finalized a provision to align the cap accounting year for
both the inpatient cap and the hospice aggregate cap with the fiscal
year for FY 2017 and thereafter. Finally, the FY 2016 Hospice Wage
Index and Rate Update final rule (80 FR 47144) 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.
10. FY 2017 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2017 Hospice Wage Index and Rate Update final rule (81 FR
52160), we finalized several new policies and requirements related to
the HQRP. First, we codified our policy that if the National Quality
Forum (NQF) makes non-substantive changes to specifications for HQRP
measures as part of the NQF's re-endorsement process, we will continue
to utilize the measure in its new endorsed status, without going
through new notice-and-comment rulemaking. We will continue to use
rulemaking to adopt substantive updates made by the NQF to the endorsed
measures we have adopted for the HQRP; determinations about what
constitutes a substantive versus non-substantive change will be made on
a measure-by-measure basis. Second, we finalized two new quality
measures for the HQRP for the FY 2019 payment determination and
subsequent years: Hospice Visits when Death is Imminent Measure Pair
and Hospice and Palliative Care Composite Process Measure-Comprehensive
Assessment at Admission (81 FR 52173). The data collection mechanism
for both of these measures is the HIS, and the measures are effective
April 1, 2017. Regarding the CAHPS[supreg] Hospice Survey, we finalized
a policy that hospices that receive their CMS Certification Number
(CCN) after January 1, 2017 for the FY 2019 Annual Payment Update (APU)
and January 1, 2018 for the FY 2020 APU will be exempted from the
Hospice Consumer Assessment of Healthcare Providers and Systems
(CAHPS[supreg]) requirements due to newness (81 FR 52182). The
exemption is determined by CMS and is for 1 year only.
D. 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 Medicare beneficiaries
receiving hospice services has grown from 513,000 in FY 2000 to nearly
1.5 million in FY 2017. Similarly, Medicare hospice expenditures have
risen from $2.8 billion in FY 2000 to approximately $17.5 billion in FY
2017. Our Office of the Actuary (OACT) projects that hospice
expenditures are expected to continue to increase, by approximately 8
percent annually, reflecting an increase in the number of Medicare
beneficiaries, more beneficiary awareness of the Medicare hospice
benefit for end-of-life care, and a growing preference for care
provided in home and community-based settings.
There have also been changes in the diagnosis patterns among
Medicare hospice enrollees. While in 2002, lung cancer was the top
principal diagnosis, neurologically based diagnoses have topped the
list for the past 5 years. Additionally, in FY 2013, ``debility'' and
``adult failure to thrive'' were the first and sixth most common
hospice claims-reported diagnoses, respectively, accounting for
approximately 14 percent of all diagnoses; however, effective October
1, 2014, these diagnoses are no longer permitted as principal diagnosis
codes on hospice claims. As a result of this, the most common hospice
claims-reported diagnoses have changed from primarily cancer diagnoses
to neurological and organ-based failure diagnoses. The top 20 most
frequently hospice claims-reported diagnoses for FY 2017 are in Table 2
below.
[[Page 20939]]
Table 2--The Top Twenty Principal Hospice Diagnoses, FY 2017
------------------------------------------------------------------------
ICD-10/reported
Rank principal Count Percentage
diagnosis
------------------------------------------------------------------------
1.................... G30.9 Alzheimer's 155,066 10
disease,
unspecified.
2.................... J44.9 Chronic 77,758 5
obstructive
pulmonary
disease.
3.................... I50.9 Heart 69,216 4
failure,
unspecified.
4.................... G31.1 Senile 66,309 4
degeneration of
brain, not
elsewhere
classified.
5.................... C34.90 Malignant 53,137 3
Neoplasm Of Unsp
Part Of Unsp
Bronchus Or Lung.
6.................... G20 Parkinson's 40,186 3
disease.
7.................... G30.1 Alzheimer's 38,710 2
disease with
late onset.
8.................... I25.10 34,761 2
Atherosclerotic
heart disease of
native coronary
art without
angina pectoris.
9.................... J44.1 Chronic 33,547 2
obstructive
pulmonary
disease with
(acute)
exacerbation.
10................... I67.2 Cerebral 30,146 2
atherosclerosis.
11................... C61 Malignant 25,215 2
neoplasm of
prostate.
12................... I63.9 Cerebral 22,825 1
infarction,
unspecified.
13................... N18.6 End stage 21,549 1
renal disease.
14................... C18.9 Malignant 21,543 1
neoplasm of
colon,
unspecified.
15................... C25.9 Malignant 20,851 1
neoplasm of
pancreas,
unspecified.
16................... I51.9 Heart 18,794 1
disease,
unspecified.
17................... I11.0 18,345 1
Hypertensive
heart disease
with heart
failure.
18................... I67.9 18,234 1
Cerebrovascular
disease,
unspecified.
19................... I13.0 15,632 1
Hypertensive
heart and
chronic kidney
disease with
heart failure
and stage 1
through stage 4
chronic kidney
disease, or
unspecified
chronic kidney
disease.
20................... A41.9 Sepsis, 14,012 1
unspecified
organism.
------------------------------------------------------------------------
Note(s): The frequencies shown represent beneficiaries that had a least
one claim with the specific 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 2017 hospice claims data from the CCW, accessed and merged
with ICD-10 codes on January 10, 2018.
In the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR
47201), we clarified that hospices will report all diagnoses identified
in the initial and comprehensive assessments on hospice claims, whether
related or unrelated to the terminal prognosis of the individual,
effective October 1, 2015. Analysis of FY 2017 hospice claims show that
100 percent of hospices reported more than one diagnosis, 89 percent
submitted at least two diagnoses, and 81 percent included at least
three diagnoses.
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 Rate Update
final rule (80 FR 47142), if any. Moreover, in response to Office of
Inspector General (OIG) report ``Hospice Inappropriately Billed
Medicare Over $250 Million for General Inpatient Care'' (OEI-02-10-
00491) released in March 2016, which identified the drugs paid for by
Part D and provided to beneficiaries during GIP stays, we have also
continued to monitor non-hospice spending during a hospice election as
described in this section. Additionally, we have included information
on the costs of hospice care using data from the new hospice Medicare
cost report, effective for cost reporting periods that began on or
after October 1, 2014 (FY 2015). 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,
including such data sources as the Medicare cost reports. These
preliminary analyses may inform future work that could include such
refinements to hospice payment rates.
a. Length of Stay and Live Discharges
Hospice Length of Stay
Eligibility under the Medicare hospice benefit is predicated on the
individual being certified as terminally ill. Medicare regulations at
Sec. 418.3 define ``terminally ill'' to mean that the individual has a
medical prognosis that his or her life expectancy is 6 months or less
if the illness runs its normal course. However, we have recognized in
previous rules that prognostication is not an exact science (79 FR
50470), and thus, a beneficiary may be under a hospice election longer
than 6 months, as long as there remains a reasonable expectation that
the individual has a life expectancy of 6 months or less.
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.
---------------------------------------------------------------------------
\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?'' Journal of General Internal Medicine. 25(10):
1009-19. Doi: 10.1007/s11606-010-1423-9.
---------------------------------------------------------------------------
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,
[[Page 20940]]
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 2017, the average length of stay in hospice was 79.7 days
and the average lifetime length of stay in hospice was 96.2 days. The
average length of stay was 78.1 days in FY 2015, 79.2 days in FY 2016,
and 79.7 days in FY 2017. The average lifetime length of stay similarly
remained virtually the same between FY 2016 and FY 2017, 96.1 and 96.2
days, respectively.
The median (50th percentile) length of stay in FY 2017 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 increased from year to
year.
The Medicare hospice benefit provides four levels of care: Routine
home care, general inpatient care, continuous home care, and inpatient
respite care. 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
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 2017
------------------------------------------------------------------------
Number of % of all
Level of care Site of service hospice days hospice days
------------------------------------------------------------------------
RHC.................. Home + Hospice 66,320,796 55.75
Residential
Facility.
SNF/NF........... 28,656,850 24.09
Assisted Living 20,299,401 17.06
Facility.
Other............ 1,351,575 1.14
-------------------------------
Total......... 116,628,622 98.04
------------------------------------------------------------------------
GIP.................. Inpatient 409,123 0.34
Hospital.
Inpatient Hospice 1,158,985 0.97
Facility.
Skilled Nursing 64,349 0.05
Facility.
Other............ 5,571 0.01
-------------------------------
Total......... 1,638,028 1.38
------------------------------------------------------------------------
CHC.................. Home + Hospice 199,595 0.17
Residential
Facility.
SNF/NF........... 47,098 0.04
Assisted Living 78,927 0.07
Facility.
Other............ 3,758 0.00
-------------------------------
Total......... 329,378 0.28
------------------------------------------------------------------------
IRC.................. Inpatient 32,397 0.03
Hospital.
Inpatient Hospice 121,597 0.10
Facility.
SNF/NF........... 206,983 0.17
Other............ 1,558 0.00
-------------------------------
Total......... 362,535 0.30
-------------------------------
Total............ ................. 118,958,563 100
------------------------------------------------------------------------
Source: Common Working File (CWF) All hospice claims from 2006 to 2017
were included, for beneficiaries whose final claim in FY 2017,
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 2017 (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 177 days in FY 2017. Beneficiaries with Chronic
Kidney Disease and cancer had shorter average lifetime lengths of stay,
56.8 and 63 days, respectively. For all diagnoses, the average lifetime
length of stay was 113.5 days in FY 2017 when level of care at
admission is RHC.
[[Page 20941]]
Table 4--Average Lifetime Length of Stay by Diagnosis and Site of Service on the Day of Admission in FY 2017, When Level of Care at Admission is RHC
--------------------------------------------------------------------------------------------------------------------------------------------------------
Home + hospice Assisted living SNF + LTC or non- Other * All sites of service
residential facility facility skilled nursing -------------------------------------------
-------------------------------------------- facility
---------------------- Average Average
Primary hospice diagnosis at admission Average Average Average Number of lifetime Number of lifetime
Number of lifetime Number of lifetime Number of lifetime benes length of benes length of
benes length of benes length of benes length of stay stay
stay stay stay
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Diagnoses............................. 582,280 110.59 115,742 162.60 219,063 102.87 47,700 79.33 964,785 113.53
Alzheimer's, Dementia, and Parkinson's.... 75,915 191.29 39,288 204.24 60,895 143.63 6,741 173.29 182,839 177.00
CVA/Stroke................................ 18,514 176.77 9,013 200.25 14,364 142.65 1,730 141.33 43,621 169.19
Cancers................................... 223,000 63.21 12,408 97.53 30,219 62.22 17,916 40.23 283,543 62.92
Chronic Kidney Disease.................... 12,319 60.69 1,436 81.71 5,537 45.09 952 38.90 20,244 56.84
Heart (CHF and Other Heart Disease)....... 101,059 130.39 22,138 144.68 36,694 87.61 7,596 94.51 167,487 120.96
Lung (COPD and Pneumonias)................ 57,733 142.60 7,309 152.88 16,286 88.89 3,863 72.27 85,191 131.23
All Other Diagnoses....................... 93,740 110.34 24,150 138.44 55,068 89.83 8,902 67.27 181,860 106.43
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Common Working File (CWF) All hospice claims from 2006 to 2017 were included, for beneficiaries whose final claim in FY 2017, 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: ``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.
As we indicated above, the average lifetime length of stay across
all levels of care at admission was 96.2 days in FY 2017. However, the
average lifetime length of stay was 113.5 days in FY 2017 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 2016-FY 2017
----------------------------------------------------------------------------------------------------------------
FY 2016 FY 2017
---------------------------------------------------------------
Average Average
Number of lifetime Number of lifetime
benes length of stay benes length of stay
----------------------------------------------------------------------------------------------------------------
Any Level of Care at Admission.................. 1,117,643 96.14 1,176,946 96.17
RHC at Admission................................ 909,961 114.02 964,785 113.53
----------------------------------------------------------------------------------------------------------------
Source: Common Working File (CWF) All hospice claims were included, for beneficiaries whose final claim in FY
2017, 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 (Sec. Sec. 418.24(e) and 418.28(c)(3)).
Immediately upon hospice revocation, Medicare coverage resumes for
those Medicare benefits previously waived with the hospice election. A
revocation can only be made by the beneficiary, in writing, and must
specify the effective date of the revocation. A hospice cannot
``revoke'' a beneficiary's hospice election, nor is it appropriate for
hospices to encourage, request, or demand that the beneficiary or his
or her representative revoke his or her hospice election. Like the
hospice election, a hospice revocation is to be an informed choice
based on the beneficiary's goals, values and preferences for the
services the person wishes to receive through Medicare.
Federal regulations limit the circumstances in which a Medicare
hospice provider may discharge a patient from its care. In accordance
with Sec. 418.26, discharge from hospice care is permissible when the
patient moves out of the provider's service area, is determined to be
no longer terminally ill, or for cause. Hospices may not discharge the
patient at their discretion, even if the care may be costly or
inconvenient for the hospice program. As we indicated in the FY 2015
Hospice Wage Index and Payment Rate Update proposed and final rules, we
understand that the rate of live discharges should not be zero, given
the uncertainties of prognostication and the ability of beneficiaries
and their families to revoke the hospice election at any time (79 FR
26549 and 79 FR 50463). On July 1, 2012, we began collecting discharge
information on the claim to capture the reason for all types of
discharges which includes, death, revocation, transfer to another
hospice, moving out of the hospice's service area, discharge for cause,
or due to the beneficiary no longer being considered terminally ill
(that is, no longer qualifying for hospice services). In FY 2017,
approximately 16.7 percent of hospice beneficiaries were discharged
alive (see Figure 1 below). Beneficiary revocations represented 44
percent of all live discharges whereas 45 percent of live discharges
were instances where the beneficiary was discharged because the
beneficiary was considered no longer terminally ill, and 9 percent of
live discharges were instances where beneficiaries transferred to other
hospices. In analyzing hospice live discharge rates over time, Figure 1
demonstrates an incremental decrease in average annual rates of live
discharge rates from FY 2007 to FY 2015, but an increase in the live
discharge rate
[[Page 20942]]
between FY 2015 and FY 2016, and a slight decrease between FY 2016 and
FY 2017. Between FY 2007 and FY 2017, there has been a reduction in the
live discharge rate of 23.7 percent over this time period.
[GRAPHIC] [TIFF OMITTED] TP08MY18.000
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 47.6 percent of their patients alive in FY 2017.
Table 6--Distribution of Live Discharge Rates for Hospices With 50 or More Live Discharges, FY 2015 to FY 2017
----------------------------------------------------------------------------------------------------------------
Live discharge rate (%)
Statistics -----------------------------------------------
FY 2015 FY 2016 FY 2017
----------------------------------------------------------------------------------------------------------------
5th Percentile.................................................. 6.9% 7.0% 6.9%
10th Percentile................................................. 8.5% 8.5% 8.4%
25th Percentile................................................. 11.6% 11.8% 11.7%
Median.......................................................... 16.8% 17.1% 17.3%
75th Percentile................................................. 24.7% 25.6% 25.4%
90th Percentile................................................. 35.9% 37.8% 37.3%
95th Percentile................................................. 45.6% 49.2% 47.6%
# Providers..................................................... 3,215 3,268 3,312
----------------------------------------------------------------------------------------------------------------
Source: FY 2015, FY 2016, and FY 2017 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, 22
percent of the live discharges occurred within 30 days of the start of
hospice care, 10 percent between 31 to 60 days, 14 percent between 61
to 90 days, 20 percent between 91 to 180 days, and 35 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 2017. However, we will continue to monitor the data
available so as to identify any concerning behavior in response to
recent payment policy reforms.
[[Page 20943]]
[GRAPHIC] [TIFF OMITTED] TP08MY18.001
b. Skilled Visits in the Last Days of Life
As we noted in both the FY 2016 and FY 2017 Hospice Wage Index and
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 Rate
Update final rule (80 FR 47164 through 47177), the SIA payment policy
was finalized with an implementation date of January 1, 2016. This
payment was developed in part with the objective of encouraging visits
during the last days of life. Additionally, in the FY 2017 Hospice Wage
Index and Rate Update final rule (81 FR 52143), we finalized two new
hospice HQRP measures effective April 1, 2017: (1) Hospice Visits When
Death is Imminent, assessing hospice staff visits to patients and
caregivers in the last week of life; and (2) Hospice and Palliative
Care Composite Process Measure, assessing the percentage of hospice
patients who received care processes consistent with existing
guidelines. These efforts represent meaningful advances in encouraging
visits to hospice beneficiaries during the time period preceding death.
In the FY 2016 Hospice Wage Index and 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 beneficiary discharges, 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 Medicare beneficiaries.
As part of our monitoring efforts, we assessed the delivery of
hospice care during the period of time preceding death. Analysis of FY
2017 claims data, which encompasses hospice claims from October 1, 2016
through September 30, 2017, shows that on any given day during the last
7 days of a hospice election, nearly 42 percent of the time the patient
has not received a skilled visit (skilled nursing or social worker
visit) (see Table 7 below). This figure represents an incremental
improvement when compared to the figures presented in our FY 2018
Hospice Wage Index and Rate Update proposed rule (82 FR 20762), where
FY 2016 claims showed approximately 44 percent for this metric.
Additionally, Table 7 shows that approximately 20 percent of
beneficiaries did not receive a skilled visit (skilled nursing or
social work visit) on the day of death in FY 2017. This value also
indicates an improvement compared to the FY 2016 claims data, in which
nearly 21 percent of hospice beneficiaries did not receive a skilled
visit on the day of death (82 FR 20762).
[[Page 20944]]
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 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
Days before death
-------------------------------------------------------------------------------------------
Visit length 0 Days All 7 days
(day of 1 Day (%) 2 Days (%) 3 Days (%) 4 Days (%) 5 Days (%) 6 Days (%) combined
death) (%)
--------------------------------------------------------------------------------------------------------------------------------------------------------
No Visit........................................ 19.9 34.6 42.3 47.7 51.7 55.0 57.4 42.3
15 Minutes to 1 Hour............................ 26.3 31.1 29.0 27.4 26.0 25.0 24.2 27.2
1 Hour, 15 Minutes to 2 Hours................... 27.3 20.7 18.3 16.4 15.0 13.6 12.8 18.4
2 Hours, 15 Minutes to 3 Hours.................. 13.9 7.4 6.0 5.1 4.4 3.9 3.5 6.8
3 Hours, 15 Minutes to 3 Hours, 45 Minutes...... 4.9 2.3 1.8 1.4 1.2 1.0 0.9 2.1
4 or More Hours................................. 7.7 3.9 2.6 2.0 1.6 1.3 1.2 3.2
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: FY 2017 hospice claims data from Common Working File (CWF) (as of January 1, 2018).
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 2017, Tables 8 and 9 below show the frequency
and length of visits for skilled nursing and social work separately.
Analysis of FY 2017 claims data shows that on any given day during the
last 7 days of a hospice election, almost 45 percent of the time the
patient had not received a visit by a skilled nurse, and 89 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 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
Days before death
-------------------------------------------------------------------------------------------
Visit length 0 Days (day All 7 days
of death) 1 Day (%) 2 Days (%) 3 Days (%) 4 Days (%) 5 Days (%) 6 Days (%) combined
(%)
--------------------------------------------------------------------------------------------------------------------------------------------------------
No Visit........................................ 21.3 37.3 45.3 50.9 55.0 58.3 60.8 45.1
15 Minutes to 1 Hour............................ 27.3 33.3 30.3 28.1 26.2 24.9 23.9 28.1
1 Hour, 15 Minutes to 2 Hours................... 27.9 19.6 17.1 15.2 13.8 12.5 11.6 17.6
2 Hours, 15 Minutes to 3 Hours.................. 13.3 5.5 4.3 3.6 3.1 2.7 2.4 5.4
3 Hours, 15 Minutes to 3 Hours, 45 Minutes...... 4.2 1.6 1.1 0.9 0.8 0.6 0.6 1.5
4 or More Hours................................. 6.1 2.8 1.8 1.4 1.1 0.9 0.8 2.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: FY 2017 hospice claims data from Common Working File (CWF) (as of January 1, 2018).
Table 9--Frequency and Length of Social Work Visits During the Last 7 Days of a Hospice Election Ending in Death, FY 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
Days before death
-------------------------------------------------------------------------------------------
Visit length 0 Days (day All 7 days
of death) 1 Day (%) 2 Days (%) 3 Days (%) 4 Days (%) 5 Days (%) 6 Days (%) combined
(%)
--------------------------------------------------------------------------------------------------------------------------------------------------------
No Visit........................................ 89.5 86.5 88.2 89.5 90.2 90.9 91.3 89.3
15 Minutes to 1 Hour............................ 6.6 9.3 8.2 7.4 7.0 6.5 6.2 7.4
1 Hour, 15 Minutes to 2 Hours................... 2.8 3.5 3.0 2.7 2.5 2.2 2.1 2.8
2 Hours, 15 Minutes to 3 Hours.................. 0.7 0.5 0.4 0.3 0.3 0.3 0.2 0.4
3 Hours, 15 Minutes to 3 Hours, 45 Minutes...... 0.2 0.1 0.1 0.0 0.0 0.0 0.0 0.1
4 or More Hours................................. 0.2 0.1 0.1 0.0 0.0 0.0 0.0 0.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: FY 2017 hospice claims data from Common Working File (CWF) (as of January 1, 2018).
[[Page 20945]]
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 Medicare
hospice beneficiaries in the RHC level of care in the 7 days preceding
death was approximately 1.6 hours per day. As depicted in Figure 3
below, from our analysis of FY 2016 and 2017 hospice claims data that
begins January 1, 2016 and spans through September 30, 2017, a
relatively consistent level of nursing and medical social services
visits are being provided among RHC days in the 7 days prior to death,
averaging around 1.6 hours per day. For the period spanning January 1,
2016 through September 30, 2017, our analysis shows that approximately
1.24 hours of services were provided by RNs, 0.18 hours were provided
by Licensed Practical Nurses (LPNs), and 0.18 hours were provided by
social workers per day. We note that for purposes of the SIA payment,
only those hours of service provided by an RN, which became separately
categorized as G0299 beginning January 1, 2016, and medical social
worker count toward the calculation of the SIA payment. Additionally,
we note that G0154 was retired as of January 1, 2016; however, this
code was still reported by some providers in the months of January and
February 2016, and thus was included in Figure 3.
[GRAPHIC] [TIFF OMITTED] TP08MY18.002
Given this evaluation of this more comprehensive dataset, which
encompasses the payment policy changes that began on January 1, 2016,
we are concerned at the lack of increase in visits to hospice patients
at the end of life. Beneficiaries appear to be receiving similar levels
of care when compared to time periods prior to the implementation of
the payment policy reforms, which may indicate that hospices are not
providing additional resources to patients during a time of increased
need. We expect that hospices would be increasing visit frequency at
the end of life, as the SIA payment serves to compensate providers for
the cost of providing additional, more intensive care at the end of
life, in addition to the payment already made for those RHC level of
care days that qualify for the SIA.
Moreover, as described in the FY 2017 Hospice Wage Index and Rate
Update final rule (81 FR 52173), our quality reporting program started
data collection effective April 1, 2017 for the quality measure pair,
Hospice Visits When Death is Imminent, via the implementation of the
new Hospice Item Set (HIS) V2.00. This measure pair assesses hospice
staff visits to patients at the end of life. Measure 1 assesses the
percentage of patients receiving at least one visit from registered
nurses, physicians, nurse practitioners, or physician assistants in the
last 3 days of life while Measure 2 measures the percentage of patients
receiving at least two visits from medical social workers, chaplains or
spiritual counselors, LPNs, or hospice aides in the last 7 days of
life. Data collected on these measures for the time period of 2017 will
be applied to the Hospice Quality Reporting Program's Annual Payment
Update (APU) in FY 2019, impacting provider payment based on quality of
hospice care provided to Medicare beneficiaries. We will continue to
monitor the provision of hospice services at end-of-life and impacts of
the SIA payment and other policies.
c. Non-Hospice Spending
When a beneficiary elects the Medicare hospice benefit, he or she
waives the right to Medicare payment for services related to the
treatment of the individual's condition with respect to which a
diagnosis of terminal illness has been made, except for services
[[Page 20946]]
provided by the designated hospice and the attending physician. Hospice
services are comprehensive and we have reiterated since 1983 that
``virtually all'' care needed by the terminally ill individual would be
provided by hospice. We believe that it would be unusual and
exceptional to see services provided outside of hospice for those
individuals who are approaching the end of life. However, we continue
to conduct ongoing analysis of non-hospice spending during a hospice
election and the results of our analysis seems to suggest the
unbundling of items and services that perhaps should have been provided
and covered under the Medicare hospice benefit.
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
2017 data. We found that in FY 2017, Medicare paid over $900 million
for items and services under Parts A, B, and D for beneficiaries during
a hospice election. Medicare payments for non-hospice Part A and Part B
items and services received by hospice beneficiaries during hospice
election were $730 million in FY 2011, $745 million in FY 2012, $709
million in FY 2013, $621 million in FY 2014, $591 million in FY 2015,
$586 million in FY 2016, and $566 million in FY 2017 (see Figure 4
below). The beneficiary cost sharing amount in FY 2017 was $138
million. Non-hospice spending for Part A and Part B items and services
has decreased each year since we began reporting these findings.
Overall, from FY 2011 to FY 2017 non-hospice Medicare spending for
Parts A and B during hospice election declined 23 percent. However,
there continues to be a non-trivial amount of non-hospice Parts A and B
spending on beneficiaries under a hospice election, and we will
continue to monitor data regarding this issue.
[GRAPHIC] [TIFF OMITTED] TP08MY18.003
We also examined Part D spending from FY 2011 to FY 2017 for those
beneficiaries under a hospice election. The data shows Medicare
payments for non-hospice Part D drugs received by hospice beneficiaries
during a hospice election were $325 million in FY 2011, $331 million in
FY 2012, $348 million in FY 2013, $294 million in FY 2014, $314 million
in FY 2015, $351 million in FY 2016, and $380 million in FY 2017 (see
Figure 5). In contrast to non-hospice spending during a hospice
election for Medicare Parts A and B items and services, non-hospice
spending for Part D drugs increased in FY 2017 compared to FY 2011.
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 Medicare
Part D there has been an increase in hospice beneficiaries filling
prescriptions for a separate category of drugs we refer to as
maintenance drugs, as recently analyzed by CMS (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/2016-11-15-Part-D-Hospice-Guidance.pdf). Currently, maintenance drugs for
beneficiaries under a hospice election are not subject to the Part D PA
process. After a hospice election, many maintenance drugs as well as
drugs used to treat or cure a condition are typically discontinued as
the focus of care shifts to palliation and comfort measures. However,
there are maintenance drugs that are appropriate to continue as they
may offer symptom relief for the palliation and management of the
terminal illness and related conditions, and therefore should be
covered under the hospice benefit, not Part D. Examples of maintenance
drugs are those used to treat high blood pressure, heart disease,
asthma and diabetes. These categories include beta blockers, calcium
channel blockers, corticosteroids, and insulin.
[[Page 20947]]
[GRAPHIC] [TIFF OMITTED] TP08MY18.004
Table 10 below details the various components of Part D spending
for patients receiving hospice care for FY 2017. The portion of the
$474.2 million total Part D spending that was paid by Medicare is the
sum of the Low Income Cost-Sharing Subsidy (row 2 in Table 10) and the
Covered Drug Plan Paid Amount (row 5), or approximately $380.5 million.
The beneficiary cost sharing amount was approximately $68.6 million,
including patient pay amount (row 1), other true out-of-pocket amount
(row 3), and patient liability reduction due to other payer amount (row
4).
Table 10--Drug Cost Sources for Hospice Beneficiaries' FY 2017 Drugs
Received Through Part D
------------------------------------------------------------------------
FY 2017
Component expenditures
------------------------------------------------------------------------
Patient Pay Amount...................................... $50,903,365
Low Income Cost-Sharing Subsidy......................... 111,159,483
Other True Out-of-Pocket Amount......................... 1,555,456
Patient Liability Reduction due to Other Payer Amount... 16,153,569
Covered Drug Plan Paid Amount........................... 269,308,517
Non-Covered Plan Paid Amount............................ 8,664,146
Six Payment Amount Totals............................... 457,744,535
Unknown/Unreconciled.................................... 16,425,792
---------------
Gross Total Drug Costs, Reported...................... 474,170,328
------------------------------------------------------------------------
Source: Analysis of 100% FY 2017 Medicare Claim Files. For more
information on the components above and on Part D data, go to the
Research Data Assistance Center's (ResDAC's) website at: http://www.resdac.org/.
Hospices are responsible for covering drugs and biologicals related
to the palliation and management of the terminal illness and related
conditions 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. As noted above, 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 are covered
under the Part A Medicare hospice benefit are instead being covered and
paid for through Part D. Based on our own analysis as demonstrated in
the data provided above and similar analyses conducted by the OIG
regarding Part D drug expenditures for Medicare hospice beneficiaries,
we believe that Medicare could be paying twice for drugs that are
already covered under the hospice per diem payment by also paying for
them under Part D.\6\
---------------------------------------------------------------------------
\5\ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/2016-11-15-Part-D-Hospice-Guidance.pdf.
\6\ https://oig.hhs.gov/oas/reports/region6/61000059.asp,
``Medicare Could Be Paying Twice for Prescriptions for Beneficiaries
in Hospice.''
---------------------------------------------------------------------------
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 Medicare hospice benefit is structured such that hospice
beneficiaries should not have to routinely seek items, services, and/or
medications beyond those provided by hospice. The hospice medical
director, the attending physician (if any), and the hospice
interdisciplinary group (IDG) determine, on a case-by-case basis, what
items and services are related and unrelated to the palliation and
management of the terminal illness and related conditions during the
admission process, the initial and comprehensive assessments, and in
[[Page 20948]]
the development of the hospice plan of care (Sec. Sec. 418.25, 418.54,
and 418.56).
To the extent that individuals receive services outside of the
Medicare hospice benefit, Medicare coverage is determined by whether or
not the services are for the treatment of a condition completely
unrelated to the individual's terminal illness and related conditions
(48 FR 38148). However, we have presented hospice monitoring data from
the past several years, as seen above, that continue to show a non-
trivial amount of items, services, and medications being furnished
outside of the Medicare hospice benefit to beneficiaries under a
hospice election. We encourage hospices to educate beneficiaries
regarding the comprehensive nature of the hospice benefit. Although it
should be rare, if any conditions are identified by the hospice as
unrelated to the terminal illness and related conditions, we further
encourage hospices to inform the beneficiary (or representative) at or
near the time of election and provide the clinical rationale for such
determinations. The regulations at Sec. 476.78 state that providers
must inform Medicare beneficiaries at the time of admission, in
writing, that the care for which Medicare payment is sought will be
subject to Quality Improvement Organization (QIO) review. If a
beneficiary disagrees with the hospice determination of what conditions
are unrelated to the terminal illness and related conditions (and thus
arguably not provided as part of the hospice benefit), we strongly
encourage hospices to work to resolve the disagreement with the
beneficiary (or representative), taking into consideration his or her
wishes, treatment preferences and goals. If a resolution cannot be
reached, the beneficiary and the hospice can agree to participate in a
flexible, dialogue-based resolution process, called immediate advocacy,
which is coordinated by the QIO. We will continue to monitor non-
hospice spending during a hospice election and consider ways to address
this issue through future regulatory and/or program integrity efforts,
if needed.
2. Initial Analysis of Revised Hospice Cost Report Data
a. Background
As mentioned in section II.B of this proposed rule, the Medicare
hospice per diem payment amounts were developed to cover all services
needed for the palliation and management of the terminal illness and
related conditions, as described in section 1861(dd)(1) of the Act.
Services provided under a written plan of care could include: Nursing
care provided by or under the supervision of a registered professional
nurse; physical therapy, occupational therapy, speech-language
pathology services; counseling (including dietary counseling); medical
social services under the direction of a physician; services of a home
health aide; homemaker services; medical supplies (including drugs and
biologicals) and the use of durable medical equipment; physician
services; short-term inpatient care (including both respite care and
care necessary for pain control and acute and chronic symptom
management) in a qualified inpatient facility; or any other item or
service which has been specified in the plan of care for which payment
may be made under Medicare. Under the current payment system, hospices
are paid for each day that a beneficiary is enrolled in hospice care,
regardless of whether services are rendered on any given day.
As described in the FY 2016 Hospice Wage Index and 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 October 1, 2014. The
instructions for completing the revised freestanding hospice cost
report form are found in the Medicare Provider Reimbursement Manual-
Part 2, chapter 43.\8\ Medicare-certified institutional providers are
required to submit an annual cost report to a Medicare contractor. The
cost report contains provider information such as facility
characteristics, utilization data, costs by cost center (for all payers
as well as Medicare), Medicare settlement data, and financial statement
data.
---------------------------------------------------------------------------
\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.
\8\ https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1P243.pdf.
---------------------------------------------------------------------------
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 October 1,
2014, we finalized changes to the hospice cost report to improve data
collection on the costs of providing hospice care. We conducted an
updated analysis of the revised cost report data (CMS Form 1984-14) for
freestanding hospices with cost reporting periods in FY 2016, which
totaled 2,867 reports. Using this data we calculated preliminary
estimates of total costs per day by level of care. It is important to
note that the values we computed for cost per day include all payer
sources, both Medicare and non-Medicare; however, we believe that the
total cost figures represent a reasonable proxy for estimating costs
related to the provision of care for Medicare beneficiaries. In order
to compute total Medicare-related costs by level of care, we multiplied
the computed cost per day by level of care (as reported on Worksheet C)
for each hospice by the number of Medicare days by level of care. We
then calculated total payments by level of care for each hospice by
multiplying the FY 2016 Medicare hospice payments by level of care by
the number of Medicare days by level of care. Total costs, payments,
and days by level of care were summed for each unique hospice. In order
to more accurately account for the hourly CHC cost per day, we used
data from Medicare claims in order to quantify the hours of CHC
provided by summing the values reported in revenue center 0652, which
tallies the units of CHC care. We then divided the CHC costs by the
number of CHC hours as reported in revenue center 0652 to calculate a
CHC per-hour value. Additionally, we obtained hospice provider
characteristics from the Provider of Services (POS) file from December
2016; from that dataset, 4,367 unique providers were identified.
In order to evaluate the cost report data for implausible cost
reports or cost reports that included unexpected data values, we
applied three distinct trimming methodologies. The first trim applied a
simple truncation at the statistical ends of the data. For each
calculated outcome (for example, total RHC costs per day), we excluded
those values that are above the 99th percentile and those values that
are below the 1st percentile. For the purposes of this discussion, we
refer to this trim as the ``1% Trim.''
The second trim is a more robust trim meant to remove unexpected
results from the cost report data. For the
[[Page 20949]]
purposes of this discussion, we refer to this trim as the ``CMS Trim.''
The following list shows the exclusion criteria used for this trimming
approach. For each element we have listed the number of hospices
impacted by each exclusion criteria with the notation ``n=XX''.
Additionally, we note that an individual hospice's cost report may have
been impacted by multiple exclusion criteria.
1. We exclude cost reports less than 10 months or more than 14
months in length (n=130).
2. We excluded hospices with missing payment (n=2) or cost
information (n=0).
3. We excluded hospices with negative payment (n=0) or cost
information (n=21).
4. We exclude hospices that are in the 1st or 99th percentile of
cost per day (n=60). Cost is determined from Worksheet F-2--Row 41--
Colum 2 (Total operating expenses). Days are determined from Worksheet
S-1--Row 34--Column 4 (Total unduplicated days). Note that these values
compute cost per day including all payer sources.
5. We exclude hospices that are in the top and bottom 5 percent of
hospices in terms of margins (n=290). Margins were computed including
all payer sources. Cost is determined from Worksheet F-2--Row 41--Colum
2 (Total operating expenses). Payments come from worksheet F-2--Row
26--Column 4 (Total Revenues).
6. We exclude hospices that have extreme payment or cost values
(n=108). This trimming criterion included agencies where the log of the
ratio of payment to cost exceeded the 90th percentile of its
distribution plus 1.5 times the interdecile range or if it was less
than the 10th percentile minus 1.5 times its interdecile range.
In order to improve the quality of data submitted on the cost
report, industry representatives suggested various edits, which, for
the purposes of this discussion will be labeled ``Level 1 Edits'' as
they would cause the hospice cost report to be revised before being
accepted by the Medicare Administrative Contractors (MACs). These types
of edits could force adherence to certain cost reporting principles and
could lead to the reporting of higher-quality hospice cost data. The
suggested edits would cause Worksheet A to generate a Level 1 Edit and
reject a cost report if no costs were included in the following
recommended Cost Centers:
Line 3--Employee Benefits
Line 4--Administrative and General
Line 5--Plant Operations and Maintenance
Line 13--Volunteer Services Coordination
Line 14--Pharmacy
Line 28--Registered Nurse
Line 37--Hospice Aide and Homemaker Services
Line 38--Durable Medical Equipment/Oxygen
Line 41--Labs and Diagnostics
Line 1--Capital Related Costs--Building and Fixtures and
Line 33--Medical Social Services
In order to estimate the potential impact of the application of
these possible edits, we analyzed the 2016 hospice cost report data and
applied the edits to the cost centers highlighted by industry
representatives and removed cost reports where data was not submitted
for the lines of interest. For each of the cost centers identified, we
excluded those cost reports that provided no cost data on the line
items. In total, almost 66 percent of the cost reports submitted by
hospices for 2016 were missing data on one of the reporting lines
identified as essential.
Table 11--Number and Percentage of Freestanding Hospice Cost Reports With Missing Information in Worksheet A--
Column 7--``Level 1 Edits''
----------------------------------------------------------------------------------------------------------------
N that are
Part of the cost report Line % missing missing
----------------------------------------------------------------------------------------------------------------
Employee Benefits............................................... 3 13.80 385
Administrative & General........................................ 4 0.29 8
Plant Operations and Maintenance................................ 5 45.16 1,260
Volunteer Services Coordination................................. 13 37.71 1,052
Pharmacy........................................................ 14 12.47 348
Registered Nurse................................................ 28 1.22 34
Hospice Aide and Homemaker Services............................. 37 2.69 75
Durable Medical Equipment/Oxygen................................ 38 11.65 325
Labs Diagnostics................................................ 41 22.83 637
Capital Related Costs--Building and Fixtures.................... 1 17.13 478
Medical Social Services......................................... 33 4.37 122
Missing Any of the Above........................................ .............. 65.59 1,830
----------------------------------------------------------------------------------------------------------------
Source: Medicare hospice cost report data for FY 2016.
Given the high volume of cost reports that show zero costs on lines
that are expected to be populated, it is evident that hospices may not
be providing thorough and representative cost data currently. If we
were to implement the industry-requested Level 1 edits to the 2016 cost
reports, nearly two thirds of the reports would be rejected based on
missing cost data. Given that these edits are for consideration only
and have not yet been proposed, we plan to continue collaborating with
the provider community to identify ways in which we may foster the
submission of high quality hospice cost data. We reiterate that this
``Potential Level 1 Edit'' approach is for discussion purposes only and
may be considered for potential future use.
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 Medicare payment amounts, we compared the reported
costs on the Medicare cost report to the FY 2016 per diem payment rates
by level of care. In order to estimate the potential impact of the
application of the three different trim methodologies mentioned above,
we analyzed the 2016 hospice cost report data and applied the three
sets of edits. Table 12 below 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.
[[Page 20950]]
Table 12--Total Cost per Diem by Level of Care Applying Three Trim Methodologies
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2016
Number of Weighted Minimum 25th 75th Maximum per diem
Level of care cost Mean mean value percentile Median percentile value payment
reports amounts
--------------------------------------------------------------------------------------------------------------------------------------------------------
CHC:
1% Trim................................. 1,171 78 51 2 19 51 90 1,576 * $944.79
CMS Trim................................ 1,111 135 52 0 18 51 91 19,864
Level 1 Edits........................... 425 129 53 0 23 52 86 19,864
RHC:
1% Trim................................. 2,715 133 125 64 107 127 151 315 161.89
CMS Trim................................ 2,465 148 124 6 106 126 149 19,372
Level 1 Edits........................... 967 139 123 1 105 125 145 3,487
IRC:
1% Trim................................. 1,987 498 397 52 215 313 483 6,678 167.45
CMS Trim................................ 1,828 629 448 2 214 311 489 67,766
Level 1 Edits........................... 800 602 415 2 215 299 492 25,817
GIP:
1% Trim................................. 1,794 1,040 841 75 586 856 1,187 10,370 720.11
CMS Trim................................ 1,664 1,353 834 2 590 858 1,192 149,422
Level 1 Edits........................... 737 1,287 880 19 596 835 1,094 60,779
--------------------------------------------------------------------------------------------------------------------------------------------------------
* $39.37/hr.
Source: Medicare hospice cost report & claims data for FY 2016.
Note: Weighted means are computed based on the number of days by level of care.
As described above, the cost report data analyzed were trimmed to
minimize the effect of statistical anomalies. Nevertheless, there is
substantial variation in the reported cost per day by hospices under
each of the three trimming methodologies. The results displayed in
Table 12 indicate that applying the 1% Trim leads to the exclusion of
the least number of cost reports, while applying Level 1 Edits leads to
the exclusion of the largest number of cost reports. For instance, when
total RHC costs per day are trimmed based on the 1% Trim, 2,715 cost
reports are retained. Applying the CMS Trim slightly reduces the number
of cost reports to 2,465, while applying Level 1 Edits reduces the
sample to 967 reports. However, we note that reductions in sample size
do not necessarily lead to the exclusion of the largest outliers. For
instance, the maximum value for total RHC costs per day is $315 after
the 1% Trim, the analogous value after the CMS Trim is $19,372, and the
analogous value after Level 1 Edits is $3,487. For mean values, we
calculated both unweighted means as well as the means that are weighted
by the number of days by level of care. Weighted means are closer to
the medians than unweighted means, suggesting that extreme values come
from smaller hospices with fewer hospices days. The estimated median
cost values are lower than the base payment rate for RHC, but not for
CHC, IRC, or GIP.
Total cost per day values in the four levels of care span from a
minimum of $1 to maximum values in the tens of thousands. Because of
this wide range of values in the distribution, we used the median as
well as the mean values weighted by the number of days by level of care
as reference points in these preliminary analyses. When compared with
the FY 2016 per diem payment rates, the calculated median and weighted
mean costs associated with providing RHC are lower than the base
payment rates. As noted in section III.A of this proposed rule, the RHC
level of care accounts for over 98 percent of all hospice days based on
our analysis of claims for FY 2017. The median and weighted mean costs
for the provision of RHC under all three trim methodologies cluster
around an estimated $126 and $124 respectively, with both figures
presenting lower values than the single RHC FY 2016 per diem payment
rate of $161.89, a difference of approximately $38 and $38
respectively.
Conversely, for CHC the estimated median and weighted mean costs
per day under each of the three trim methodologies hover around $51 and
52 per hour, respectively. The FY 2016 payment rate for CHC was $39.37
per hour. The CHC level of care accounts for approximately 0.28 percent
of all hospice days in FY 2017, as noted in section III.A of this
proposed rule. Similarly, the median and weighted mean costs per day
associated with the provision of GIP care under all three trim
methodologies is estimated in the mid-$800 range, while the FY 2016 per
diem payment amount for GIP was $720.11. As noted in section III.A of
this proposed rule, the GIP level of care accounts for approximately
1.38 percent of all hospice days based on our analysis of FY 2017
claims. Likewise, costs per day associated with the IRC level of care
are estimated at around $300 for median values and in a range of $397
to nearly $450 under the three trimming methodologies for weighted mean
values. We note that the per diem payment amount for the IRC level of
care for FY 2015 was $167.45, showing a gap between the estimated costs
and current payment rate. We estimate that IRC days represent
approximately 0.30 percent of all hospice days in FY 2017 claims as
described in section III.A of this proposed rule.
As we continue to gather more cost report data, we plan to conduct
more thorough analyses of the cost report data and fully assess
Medicare-related hospice costs as compared with Medicare hospice
payments by level of care. We encourage hospices to continue to submit
the most accurate data possible on Medicare cost reports and invite
feedback regarding potential edits and other strategies for improving
the data for hospice providers.
B. Proposed FY 2019 Hospice Wage Index and Rate Update
1. Proposed FY 2019 Hospice Wage Index
The hospice wage index is used to adjust payment rates for hospice
agencies under the Medicare program to reflect local differences in
area wage levels, based on the location where services are furnished.
The hospice wage index utilizes the wage adjustment factors used by the
Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital
wage adjustments. Our regulations at Sec. 418.306(c) require each
[[Page 20951]]
labor market to be established using the most current hospital wage
data available, including any changes made by Office of Management and
Budget (OMB) to the Metropolitan Statistical Areas (MSAs) definitions.
We use the previous FY's hospital wage index data to calculate the
hospice wage index values. For FY 2019, the hospice wage index will be
based on the FY 2018 hospital pre-floor, pre-reclassified wage index.
This means that the hospital wage data used for the hospice wage index
are 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 RHC or 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 GIP or IRC.
In the FY 2006 Hospice Wage Index final rule (70 FR 45135), we
adopted the policy that, for urban labor markets without a hospital
from which hospital wage index data could be derived, all of the Core-
Based Statistical Areas (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 2019, the only CBSA without a hospital from which hospital wage
data can be derived is 25980, Hinesville-Fort Stewart, Georgia.
There exist some geographic areas where there were no hospitals,
and thus, no hospital wage data on which to base the calculation of the
hospice wage index. In the FY 2008 Hospice Wage Index final rule (72 FR
50217 through 50218), we implemented a methodology to update the
hospice wage index for rural areas without hospital wage data. 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 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 Puerto Rico. However, for rural Puerto
Rico, we would not apply this methodology due to the distinct economic
circumstances that exist there (for example, due to the close proximity
to one another of almost all of Puerto Rico's various urban and non-
urban areas, this methodology would produce a wage index for rural
Puerto Rico that is higher than that in half of its urban areas);
instead, we would continue to use the most recent wage index previously
available for that area. For FY 2019, we propose to continue to use the
most recent pre-floor, pre-reclassified hospital wage index value
available for Puerto Rico, which is 0.4047, subsequently adjusted by
the hospice floor.
As described in the August 8, 1997 Hospice Wage Index final rule
(62 FR 42860), the pre-floor and pre-reclassified hospital wage index
is used as the raw wage index for the hospice benefit. These raw wage
index values are subject to application of the hospice floor to compute
the hospice wage index used to determine payments to hospices. Pre-
floor, pre-reclassified hospital wage index values below 0.8 are
adjusted by a 15 percent increase subject to a maximum wage index value
of 0.8. For example, if County A has a pre-floor, pre-reclassified
hospital wage index value of 0.3994, we would multiply 0.3994 by 1.15,
which equals 0.4593. Since 0.4593 is not greater than 0.8, then County
A's hospice wage index would be 0.4593. In another example, if County B
has a pre-floor, pre-reclassified hospital wage index value of 0.7440,
we would multiply 0.7440 by 1.15 which equals 0.8556. Because 0.8556 is
greater than 0.8, County B's hospice wage index would be 0.8.
On February 28, 2013, OMB issued OMB Bulletin No. 13-01, announcing
revisions to the delineation of MSAs, Micropolitan Statistical Areas,
and Combined Statistical Areas, and guidance on uses of the delineation
in these areas. In the FY 2016 Hospice Wage Index and Rate Update final
rule (80 FR 47178), we adopted the OMB's new area delineations using a
1-year transition. In that final rule, we also stated that beginning
October 1, 2016, the wage index for all hospice payments would be fully
based on the new OMB delineations.
On August 15, 2017, OMB issued bulletin No. 17-01, which is
available at https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/bulletins/2017/b-17-01.pdf. In this bulletin, OMB announced that one
Micropolitan Statistical Area, Twin Falls, Idaho, now qualifies as a
Metropolitan Statistical Area. The new CBSA (46300) comprises the
principal city of Twin Falls, Idaho in Jerome County, Idaho and Twin
Falls County, Idaho. The FY 2019 hospice wage index value for CBSA
46300, Twin Falls, Idaho, will be 0.8000.
The proposed hospice wage index applicable for FY 2019 (October 1,
2018 through September 30, 2019) is available on our website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html.
2. Proposed FY 2019 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).
The proposed hospice payment update percentage for FY 2019 is based
on the estimated inpatient hospital market basket update of 2.9 percent
(based on IHS Global Inc.'s first quarter 2018 forecast with historical
data through the fourth quarter 2017). Due to the requirements at
sections 1886(b)(3)(B)(xi)(II) and 1814(i)(1)(C)(v) of the Act, the
estimated inpatient hospital market basket update for FY 2019 of 2.9
percent must be reduced by a MFP adjustment as mandated by Affordable
Care Act (currently estimated to be 0.8 percentage point for FY 2019).
The estimated inpatient hospital market basket update for FY 2019 is
reduced
[[Page 20952]]
further by 0.3 percentage point, as mandated by the Affordable Care
Act. In effect, the proposed hospice payment update percentage for FY
2019 is 1.8 percent.
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
October 1, 2014, freestanding hospice providers are required to submit
cost data using CMS Form 1984-14 (https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports/Hospice-2014.html). We are currently analyzing this data for possible
use in updating the labor portion of the hospice payment rates. Any
changes to the labor portions would be proposed in future rulemaking
and would be subject to public comments.
3. Proposed FY 2019 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 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 that final rule, we implemented a
Service Intensity Add-on (SIA) payment for RHC 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 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 utilization data available at the time of rulemaking. For
FY 2018, we calculated the SBNF using FY 2017 utilization data. For FY
2019, the SBNF that would apply to days 1 through 60 is calculated to
be 0.9991. The SBNF that would apply to days 61 and beyond is
calculated to be 0.9998.
In the FY 2017 Hospice Wage Index and Rate Update final rule (81 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
FY 2019 hospice wage index and compare it to our simulation of total
payments using the FY 2018 hospice wage index. By dividing payments for
each level of care using the FY 2019 wage index by payments for each
level of care using the FY 2018 wage index, we obtain a wage index
standardization factor for each level of care (RHC days 1 through 60,
RHC days 61+, CHC, IRC, and GIP). The wage index standardization
factors for each level of care are shown in the tables below.
The proposed FY 2019 RHC rates are shown in Table 13. The proposed
FY 2019 payment rates for CHC, IRC, and GIP are shown in Table 14.
Table 13--Proposed FY 2019 Hospice RHC Payment Rates
--------------------------------------------------------------------------------------------------------------------------------------------------------
Proposed FY
FY 2018 SIA budget Wage index 2019 hospice Proposed FY
Code Description payment rates neutrality standardization payment 2019 payment
factor factor update rates
--------------------------------------------------------------------------------------------------------------------------------------------------------
651................................. Routine Home Care (days 1-60).... $192.78 x 0.9991 x 1.0009 x 1.018 $196.25
651................................. Routine Home Care (days 61+)..... 151.41 x 0.9998 x 1.0007 x 1.018 154.21
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 14--Proposed FY 2019 Hospice CHC, IRC, and GIP Payment Rates
----------------------------------------------------------------------------------------------------------------
Proposed FY
FY 2018 Wage index 2019 hospice Proposed FY
Code Description payment rates standardization payment 2019 payment
factor update rates
----------------------------------------------------------------------------------------------------------------
652..................... Continuous Home Care. $976.42 x 1.0048 x 1.018 $998.77
Full Rate = 24 hours
of care.
$41.62 = hourly rate.
655..................... Inpatient Respite 172.78 x 1.0007 x 1.018 176.01
Care.
656..................... General Inpatient 743.55 x 1.0015 x 1.018 758.07
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
[[Page 20953]]
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 October 2012, and submit that quality
data in 2013. 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 with
respect to that FY. The proposed FY 2019 rates for hospices that do not
submit the required quality data would be updated by the proposed FY
2019 hospice payment update percentage of 1.8 percent minus 2
percentage points. These rates are shown in Tables 15 and 16.
Table 15--Proposed FY 2019 Hospice RHC Payment Rates for Hospices That Do Not Submit the Required Quality Data
--------------------------------------------------------------------------------------------------------------------------------------------------------
Proposed FY
2019 hospice
SIA budget Wage index payment Proposed FY
Code Description FY 2018 neutrality standardization update of 2019 payment
payment rates factor factor 1.8% minus 2 rates
percentage
points = -0.2%
--------------------------------------------------------------------------------------------------------------------------------------------------------
651................................. Routine Home Care (days 1-60).... $192.78 x 0.9991 x 1.0009 x 0.998 $192.39
651................................. Routine Home Care (days 61+)..... 151.41 x 0.9998 x 1.0007 x 0.998 151.18
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 16--Proposed FY 2019 Hospice CHC, IRC, and GIP Payment Rates for Hospices That Do Not Submit the Required
Quality Data
----------------------------------------------------------------------------------------------------------------
Proposed FY
2019 hospice
Wage index payment Proposed FY
Code Description FY 2018 standardization update of 2019 payment
payment rates factor 1.8% minus 2 rates
percentage
points = -0.2%
----------------------------------------------------------------------------------------------------------------
652..................... Continuous Home Care. $976.42 x 1.0048 x 0.998 $979.14
Full Rate= 24 hours
of care.
$40.80 = hourly rate.
655..................... Inpatient Respite 172.78 x 1.0007 x 0.998 172.56
Care.
656..................... General Inpatient 743.55 x 1.0015 x 0.998 743.18
Care.
----------------------------------------------------------------------------------------------------------------
4. Proposed Hospice Cap Amount for FY 2019
As discussed in the FY 2016 Hospice Wage Index and Rate Update
final rule (80 FR 47183), we implemented changes mandated by the IMPACT
Act of 2014 (P. L. 113-185). Specifically, for accounting years that
end after September 30, 2016 and before October 1, 2025, the hospice
cap is updated by the hospice payment update percentage rather than
using the CPI-U. The proposed hospice cap amount for the 2019 cap year
will be $29,205.44, which is equal to the 2018 cap amount ($28,689.04)
updated by the proposed FY 2019 hospice payment update percentage of
1.8 percent.
C. Request for Information Update--Comments Related to Hospice Claims
Processing
In the FY 2018 Hospice Wage Index and Rate Update proposed rule (82
FR 20789), we invited public comments to start a national conversation
about improvements that can be made to the health care delivery system
that reduce unnecessary burdens for clinicians, other providers, and
patients and their families. We specifically stated that we would not
respond to the comment submissions in the final rule. Instead, we would
review the submitted request for information comments and actively
consider them as we develop future regulatory proposals or future sub-
regulatory policy guidance.
After reviewing all submitted requests for information, we believe
one recommendation in particular warranted a revision to our current
policy. Commenters suggested that CMS remove the requirement to report
detailed drug data on the hospice claim as a way to reduce burden for
hospices. We initially began asking for this information via Hospice
Change Request 8358 in support of hospice payment reform [https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Transmittals-Items/Hospice-CR8358-R2747CP.html]. After determining that
this information is not currently used for quality, payment, or program
integrity purposes, we are removing this requirement effective October
1, 2018. We also believe this could result in a significant reduction
of burden to Medicare hospices, potentially reducing the number of line
items on hospice claims by approximately 21.5 million, in aggregate. We
will allow hospices two options for reporting hospice drug information.
Providers will have the option to continue to report infusion pumps and
drugs, with corresponding NDC information, on the hospice claim as
separate line items. This submission option will no longer be
mandatory. Alternatively, hospices can submit total, aggregate DME and
drug charges on the claim. We believe that removing the requirement for
the separate submission of detailed drug information on hospice claim
lines and offering the alternative option to submit aggregate, total
charge amounts provides flexibility for hospices as well as potentially
reducing burden. In order to effectuate this change, we will issue a
detailed sub-
[[Page 20954]]
regulatory change request, effective October 1, 2018.
Another suggestion which we would like to highlight was for CMS to
remove the sequential billing requirement, which requires that claims
are submitted in chronological order. While we are always evaluating
ways to make operational improvements, sequential billing for hospice
claims is required because of how hospice benefit periods are
constructed in statute. Specifically, section 1812(a)(4) of the Social
Security Act creates a sequence of benefit periods, defining coverage
for periods of ``hospice care with respect to the individual during up
to two benefit periods of 90 days each and an unlimited number of
subsequent periods of 60 days each . . .'' Sequential billing ensures
that Medicare systems create and exhaust each period before creating a
later period, maintaining the statutorily-required sequence. In
addition, as finalized in the FY 2016 Hospice Wage Index and Payment
Rate Update final rule (80 FR 47142), payment for routine home care now
varies depending on length of stay (a higher rate for days 1-60 and a
lower rate for days 61+) making the sequential billing of hospice
claims necessary to accurately pay claims and ensure the system applies
benefit periods. Sequential billing ensures correct payments are made
and to providers, minimizes the need to resubmit claims or face claims
denials, and ultimately reduces burden. As a result, we are not able to
eliminate the sequential billing requirement for hospice claims.
While we are not proposing changes to either the hospice billing
procedures or payment regulations in this proposed rule, we will
consider whether future regulatory or sub-regulatory changes are
warranted to reduce unnecessary burden. We thank the commenters for
taking the time to convey their thoughts and suggestions on this
initiative.
D. Proposed Regulations Text Changes in Recognition of Physician
Assistants as Designated Attending Physicians
When electing the Medicare hospice benefit, the beneficiary agrees
to forgo the right to have Medicare payment made for services related
to the beneficiary's terminal illness and related conditions, except
when such services are provided by the designated hospice and the
beneficiary's designed attending physician as outlined in section
1812(d)(2)(A) of the Act. The designated attending physician plays an
important role in the care of a Medicare hospice beneficiary. If a
beneficiary designates an attending physician, the beneficiary or his
or her representative acknowledges that the identified attending
physician was his or her choice and that the attending physician
identified by the beneficiary, at the time he or she elects to receive
hospice care, has the most significant role in the determination and
delivery of the individual's medical care. The designated attending
physician is required to certify that the beneficiary is terminally ill
and participates as a member of the hospice IDG that establishes and/or
or updates the individual's plan of care, ensuring that the Medicare
beneficiary receives high quality hospice care.
Under the current hospice regulations at 42 CFR 418.3, the
attending physician is defined as a doctor of medicine or osteopathy
who is legally authorized to practice medicine or surgery by the state
in which he or she performs that function, or a nurse practitioner, and
is identified by the individual, at the time he or she elects to
receive hospice care, as having the most significant role in the
determination and delivery of the individual's medical care. A nurse
practitioner is defined as a registered nurse who performs such
services as legally authorized to perform (in the state in which the
services are performed) in accordance with state law (or state
regulatory mechanism provided by state law) and who meets training,
education, and experience requirements described in 42 CFR 410.75.
Section 51006 of the Bipartisan Budget Act of 2018 (Pub. L. 115-
123) amended section 1861(dd)(3)(B) of the Social Security Act such
that, effective January 1, 2019, physician assistants (PAs) will be
recognized as designated hospice attending physicians, in addition to
physicians and nurse practitioners. We define the PA as a professional
who has graduated from an accredited physician assistant educational
program who performs such services as he or she is legally authorized
to perform (in the state in which the services are performed) in
accordance with state law (or state regulatory mechanism provided by
state law) and who meets the training, education, and experience
requirements as the Secretary may prescribe. The PA qualifications for
eligibility for furnishing services under the Medicare program can be
found in the regulations at 42 CFR 410.74(c). We note section
1861(s)(2)(K)(i) of the Act states that PAs are authorized to furnish
physician services under their State scope of practice, under the
general supervision of a physician; therefore the regulations at 42 CFR
410.150(a)(15) require that payment for PA services may be made to the
employer or contractor of a PA.
Effective January 1, 2019, Medicare will pay for medically
reasonable and necessary services provided by PAs to Medicare
beneficiaries who have elected the hospice benefit and who have
selected a PA as their attending physician. PAs are paid 85 percent of
the fee schedule amount for their services as designated attending
physicians. Attending physician services provided by PAs may be
separately billed to Medicare only if the PA is the beneficiary's
designated attending physician, services are medically reasonable and
necessary, services would normally be performed by a physician in the
absence of the PA, whether or not the PA is directly employed by the
hospice, and services are not related to the certification of terminal
illness.
Since PAs are not physicians, as defined in 1861(r)(1) of the Act,
they may not act as medical directors or physicians of the hospice or
certify the beneficiary's terminal illness and hospices may not
contract with a PA for their attending physician services as described
in section 1861(dd)(2)(B)(i)(III) of the Act, which outlines the
requirements of the interdisciplinary group as including at least one
physician, employed by or under contract with the agency or
organization. All of these provisions apply to PAs without regard to
whether they are hospice employees.
Finally, we note that the Bipartisan Budget Act of 2018 did not
make changes to which practitioners can certify terminal illness for a
Medicare beneficiary nor who may perform the face-to-face encounter.
Section 1814(a)(7)(A)(i)(I) of the Act was amended by section 51006 of
the Bipartisan Budget Act of 2018 to specify that certification of
terminal illness for hospice benefits shall be based on the clinical
judgment of the hospice medical director or physician member of the IDG
and the individual's attending physician, if he or she has one (except
for the purposes of certifying terminal illness the individual's
attending physician does not include a nurse practitioner or a
physician assistant [emphasis added]), regarding the normal course of
the individual's illness. No one other than a medical doctor or doctor
of osteopathy can certify or re-certify terminal illness. PAs were not
authorized by section 51006 of the Bipartisan Budget Act of 2018 (Pub.
L. 115-123) to perform the required hospice face-to-face encounter for
recertifications. The hospice face-to-face encounter is required per
section 1814(a)(7)(D)(i) of the Act, which continues to state that only
a hospice
[[Page 20955]]
physician or a hospice nurse practitioner can perform the encounter.
The regulations at 42 CFR 418.22 will continue to state that the
hospice face-to-face encounter must be performed by a hospice physician
or hospice nurse practitioner.
In summary, we propose to make statutorily-required updates to
Sec. 418.3 in the Hospice Care regulations to expand the definition of
attending physician to include physician assistants (PA). We also
propose to amend 42 CFR 418.304 (Payment for physician and nurse
practitioner services) in the Hospice Care regulations to include the
details outlined above regarding Medicare payment for designated
hospice attending physician services provided by physician assistants.
We are soliciting comments on these proposed changed to the regulations
at Sec. Sec. 418.3 and 418.304.
E. Proposed Technical Correction Regarding Hospice Cap Period
Definition
In the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR
47142), we finalized aligning the cap period, for both the inpatient
cap and the hospice aggregate cap, with the federal FY for FY 2017 and
later. Therefore, the cap year now begins October 1 and ends on
September 30 (80 FR 47186). We propose to make a technical correction
in Sec. 418.3 to reflect the revised timeframes for hospice cap
periods. Specifically, we propose that 42 CFR 418.3 would specify that
the cap period means the twelve-month period ending September 30 used
in the application of the cap on overall hospice reimbursement
specified in Sec. 418.309. We are soliciting comments on this
technical change to our regulations at Sec. 418.3.
F. Updates to the Hospice Quality Reporting Program (HQRP)
1. Background and Statutory Authority
The Hospice Quality Reporting Program includes HIS and CAHPS.
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 nor 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 Hospice QRP
a. Background
The ``Meaningful Measures'' initiative is intended to provide a
framework for quality measurement and improvement work at CMS. While
this framework serves to focus on those core issues that are most vital
to providing high-quality care and improving patient outcomes, it also
takes into account opportunities to reduce paperwork and reporting
burden on providers associated with quality measurement. To that end,
we have begun assessing our programs' quality measures in accordance
with the Meaningful Measures framework. We refer readers to the
Executive Summary, for more information on the ``Meaningful Measures''
initiative.
b. Accounting for Social Risk Factors in the Hospice QRP
In the FY 2018 Hospice Wage Index final rule (82 FR 36652 through
36654), we discussed the importance of improving beneficiary outcomes
including reducing health disparities. We also discussed our commitment
to ensuring that medically complex patients, as well as those with
social risk factors, receive excellent care. We discussed how studies
show that social risk factors, such as being near or below the poverty
level, as set out annually in HHS guidelines, https://www.federalregister.gov/documents/2018/01/18/2018-00814/annual-update-of-the-hhs-poverty-guidelines, belonging to a racial or ethnic minority
group, or living with a disability, can be associated with poor health
outcomes and how some of this disparity is related to the quality of
health care.\9\ Among our core objectives, we aim to improve health
outcomes, attain health equity for all beneficiaries, and ensure that
complex patients as well as those with social risk factors receive
excellent care. Within this context, reports by the Office of the
Assistant Secretary for Planning and Evaluation (ASPE) and the National
Academy of Medicine have examined the influence of social risk factors
in CMS value-based purchasing programs.\10\ As we noted in the FY 2018
Hospice Wage Index final rule (82 FR 36652 through 36654), ASPE's
report to Congress, which was required by section 2(d) of the IMPACT
Act, found that, in the context of value-based purchasing programs,
dual eligibility was the most powerful predictor of poor health care
outcomes among those social risk factors that they examined and tested.
ASPE is continuing to examine this issue in its second report required
by the IMPACT Act, which is due to Congress in the fall of 2019. In
addition, as we noted in the FY 2018 IPPS/LTCH PPS final rule (82 FR
38428), the National Quality Forum (NQF) undertook a 2-year trial
period in which certain new measures and measures undergoing
maintenance review have been assessed to determine if risk adjustment
for social risk factors is appropriate for these measures.\11\ The
trial period ended in April 2017 and a final report is available at:
http://www.qualityforum.org/SES_Trial_Period.aspx. The trial concluded
that ``measures with a conceptual basis for adjustment generally did
not demonstrate an empirical relationship'' between social risk factors
and the outcomes measured. This discrepancy may be explained in part by
the ``methods used for adjustment and the limited availability of
robust data on social risk factors''. NQF has extended the
socioeconomic status (SES) trial,\12\ allowing further examination of
social risk factors in outcome measures.
---------------------------------------------------------------------------
\9\ See, for example United States Department of Health and
Human Services. ``Healthy People 2020: Disparities. 2014.''
Available at: http://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities; or National Academies of Sciences,
Engineering, and Medicine. Accounting for Social Risk Factors in
Medicare Payment: Identifying Social Risk Factors. Washington, DC:
National Academies of Sciences, Engineering, and Medicine 2016.
\10\ Department of Health and Human Services Office of the
Assistant Secretary for Planning and Evaluation (ASPE), ``Report to
Congress: Social Risk Factors and Performance Under Medicare's
Value-Based Purchasing Programs.'' December 2016. Available at:
https://aspe.hhs.gov/pdf-report/report-congress-social-risk-factors-and-performance-under-medicares-value-based-purchasing-programs.
\11\ Available at: http://www.qualityforum.org/SES_Trial_Period.aspx.
\12\ Available at: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=86357.
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In the FY 2018/CY 2018 proposed rules for our quality reporting and
[[Page 20956]]
value-based purchasing programs, we solicited feedback on which social
risk factors provide the most valuable information to stakeholders and
the methodology for illuminating differences in outcomes rates among
patient groups within provider that would also allow for a comparison
of those differences, or disparities, across providers. Feedback we
received across our quality reporting programs included encouraging CMS
to explore whether factors that could be used to stratify or risk
adjust the measures (beyond dual eligibility); considering the full
range of differences in patient backgrounds that might affect outcomes;
exploring risk adjustment approaches; and offering careful
consideration of what type of information display would be most useful
to the public.
We also sought public comment on confidential reporting and future
public reporting of some of our measures stratified by patient dual-
eligibility. In general, commenters noted that stratified measures
could serve as tools for hospitals to identify gaps in outcomes for
different groups of patients, improve the quality of health care for
all patients, and empower consumers to make informed decisions about
health care. Commenters encouraged us to stratify measures by other
social risk factors such as age, income, and educational attainment.
With regard to value-based purchasing programs, commenters also
cautioned CMS to balance fair and equitable payment while avoiding
payment penalties that mask health disparities or discouraging the
provision of care to more medically complex patients. Commenters also
noted that value-based payment program measure selection, domain
weighting, performance scoring, and payment methodology must account
for social risk.
As a next step, we are considering options to improve health
disparities among patient groups within and across hospitals by
increasing the transparency of disparities as shown by quality
measures. We also are considering how this work applies to other CMS
quality programs in the future. We refer readers to the FY 2018 IPPS/
LTCH PPS final rule (82 FR 38403 through 38409) for more details, where
we discuss the potential stratification of certain Hospital Inpatient
Quality Reporting Program outcome measures. Furthermore, we continue to
consider options to address equity and disparities in our value-based
purchasing programs.
We plan to continue working with ASPE, the public, and other key
stakeholders on this important issue to identify policy solutions that
achieve the goals of attaining health equity for all beneficiaries and
minimizing unintended consequences.
c. New Measure Removal Factor
In the FY 2016 Hospice Final Rule (80 FR 47186), we adopted seven
factors for measure removal. We are adopting an eighth factor to
consider when evaluating measures for removal from the HQRP measure
set: The costs associated with a measure outweighs the benefit of its
continued use in the program.
As we discussed in the Executive Summary, we are engaging in
efforts to ensure that the HQRP measure set continues to promote
improved health outcomes for beneficiaries while minimizing the overall
costs associated with the program. We believe these costs are multi-
faceted and includes not only the burden associated with reporting, but
also the costs associated with complying with the program. We have
identified several different types of costs, including, but not limited
to: (1) Provider and clinician information collection burden and burden
associated with the submitting/reporting of quality measures to CMS;
(2) the provider and clinician cost associated with complying with
other Hospital IQR programmatic requirements; (3) the provider and
clinician cost associated with participating in multiple quality
programs, and tracking multiple similar or duplicative measures within
or across those programs; (4) the cost to CMS associated with the
program oversight of the measure including measure maintenance and
public display; and/or (5) the provider and clinician cost associated
with compliance to other federal and/or state regulations (depending
upon the measure). For example, it may be needlessly costly and/or of
limited benefit to retain or maintain a measure for which our analyses
show no longer meaningfully supports program objectives (for example,
informing beneficiary choice or payment scoring). It may also be costly
for health care providers to track the confidential feedback and
preview reports, as well as publicly reported information on a measure
we use in more than one program. We may also have to expend unnecessary
resources to maintain the specifications for the measure, including the
tools we need to collect, validate, analyze, and publicly report the
measure data. Furthermore, beneficiaries may find it confusing to see
public reporting on the same measure in different programs. There also
may be other burdens associated with a measure that arise on a case-by-
case basis.
When these costs outweigh the evidence supporting the continued use
of a measure in the HQRP, we believe it may be appropriate to remove
the measure from the program. Although we recognize that one of the
main goals of the HQRP is to improve beneficiary outcomes by
incentivizing health care providers to focus on specific care issues
and making public data related to those issues, we also recognize that
those goals can have limited utility where, for example, the publicly
reported data is of limited use because it cannot be easily interpreted
by beneficiaries and used to influence their choice of providers. In
these cases, removing the measure from the HQRP may better accommodate
the costs of program administration and compliance without sacrificing
improved health outcomes and beneficiary choice.
We are proposing that we would remove measures based on this factor
on a case-by-case basis. We might, for example, decide to retain a
measure that is burdensome for health care providers to report if we
conclude that the benefit to beneficiaries justifies the reporting
burden. Our goal is to move the program forward in the least burdensome
manner possible, while maintaining a parsimonious set of meaningful
quality measures and continuing to incentivize improvement in the
quality of care provided to patients.
We are inviting public comment on our proposal to adopt an
additional measure removal factor, ``the costs associated with a
measure outweighs the benefit of its continued use in the program,''
beginning with the FY 2019 Hospice Wage Index final rule.
3. Previously Adopted Quality Measures for FY 2019 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 National
Quality Forum (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 2 additional measures in the FY 2017
Hospice Wage Index final rule, effective
[[Page 20957]]
April 1, 2017. Data collected will, if not reported, affect payments
for FY 2019 and subsequent years. (81 FR 52163 through 52173):
Hospice Visits when Death is Imminent
Hospice and Palliative Care Composite Process Measure--
Comprehensive Assessment at Admission
The Hospice and Palliative Care Composite Process Measure--
Comprehensive Assessment at Admission measure (hereafter referred to as
``the Hospice Comprehensive Assessment Measure'') underwent an off-
cycle review by the NQF Palliative and End-of-Life Standing Committee
and successfully received NQF endorsement in July 2017.
Data for the Hospice Visits when Death is Imminent measure pair is
being collected using new items added to the HIS V2.00.0, effective
April 1, 2017. We will need at least 4 quarters of reliable data to
conduct the necessary analyses to support submission to NQF. We will
also need to assess the quality of data submitted in the first quarter
of item implementation to determine whether they can be used in the
analyses. We have begun analysis of the data, and, pending analysis, we
will submit the Hospice Visits when Death is Imminent measure pair to
NQF for endorsement review in accordance with NQF project timelines and
call for measures. We will use a similar process to analyze and submit
new quality measures to NQF for endorsement in future years. Providers
will be notified of measure endorsement and the public reporting
through sub-regulatory channels.
In the FY 2015 Hospice Wage Index final rule (79 FR 50491 through
50496), we also finalized the Consumer Assessment of Healthcare
Providers and Systems (CAHPS[supreg]) Hospice Survey to support quality
measures based on patient and family experience of care. We refer
readers to section III.D.5 of the FY 2019 Proposed Rule for details
regarding the CAHPS[supreg] Hospice Survey, including public reporting
of selected survey measures.
Table 17--Previously Finalized Quality Measures Affecting the FY 2019
Payment Determination and Subsequent Years
------------------------------------------------------------------------
Year the measure
was first
NQF No. Hospice item set adopted for use
quality measure in APU
determination
------------------------------------------------------------------------
1641.......................... Treatment Preferences. FY 2016.
1647.......................... Beliefs/Values FY 2016.
Addressed (if desired
by the patient).
1634.......................... Pain Screening........ FY 2016.
1637.......................... Pain Assessment....... FY 2016.
1639.......................... Dyspnea Screening..... FY 2016.
1638.......................... Dyspnea Treatment..... FY 2016.
1617.......................... Patients Treated with FY 2016.
an Opioid Who are
Given a Bowel Regimen.
3235.......................... The Hospice and FY 2019.
Palliative Care
Composite Process
Measure--Comprehensiv
e Assessment at
Admission.
TBD........................... Hospice Visits when FY 2019.
Death is Imminent.
------------------------------------------------------------------------
4. 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. Revised Data Review and Correction Timeframes for Data Submitted
Using the HIS
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 on or after July 1, 2014.
For each HQRP reporting year, we require that hospices submit data in
accordance with the reporting requirements specified in the FY 2015
Hospice final rule (79 FR 50486) for the designated reporting period.
Electronic submission is required for all HIS records. For more
information about HIS data collection and submission policies and
procedures, we refer readers to the FY 2018 Hospice Wage Index final
rule (82 FR 36663) and the CMS HQRP website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html. For more information about
CAHPS[supreg] Hospice Survey data submission policies and timelines, we
refer readers to section III.D.5 of the FY 2019 proposed rule.
Hospices currently have 36 months to modify HIS records. However,
only data modified before the public reporting ``freeze date'' are
reflected in the corresponding CMS Hospice Compare website refresh. For
more information about the HIS ``freeze date'', please see the Public
Reporting: Key Dates for Providers page on the CMS HQRP website:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Public-Reporting-Key-Dates-for-Providers.html.
To ensure that the data reported on Hospice Compare is accurate, we
propose that hospices be provided a distinct period of time to review
and correct the data that is to be publically reported. This approach
would allow hospices a time frame in which they may analyze their data
and make corrections (up until 11:59:59 p.m. PST of the quarterly
deadline) prior to receiving their preview reports. Once the preview
reports are received, it is infeasible to make corrections to the data
underlying the quality measure scores that are to be made public.
Therefore, we are proposing that for data reported using the HIS that
there be a specified time period for data review and a correlating data
correction deadline for public reporting at which point the data is
frozen for the associated quarter. Similar to the policies outlined in
the FY 2016 SNF final rule (81 FR 24271) and the FY 2016 IPPS/LTCH
final rule (80 FR 49754), at this deadline for public reporting, we
propose that data from HIS records with target dates within the
correlating quarter become a frozen ``snapshot'' of data for public
reporting purposes. Any record-level data correction after the date on
which the data are frozen will not be incorporated into measure
calculation for the
[[Page 20958]]
purposes of public reporting on the CMS Hospice Compare website. For
each calendar quarter of data submitted using the HIS, approximately
4.5 months after the end of each CY quarter we are proposing a
deadline, or freeze date for the submissions of corrections to records.
We note that this newly proposed data correction deadline for HIS
records is separate and apart from the established 30-day data
submission deadline. More information about the data submission
deadline can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/.
Specifically, each deadline would occur on the 15th of the CY month
that is approximately 4.5 months after the end of each CY quarter, and
that hospices would have up until 11:59:59 p.m. PST on that date to
submit corrections or requests for inactivation of their data for the
quarter involved. For example, for data reported in CY Q1, the freeze
date would be August 15th, for CY Q2 the freeze date would be November
15th and so on. Under this policy, any modification to or inactivation
of records that occur after the proposed correction deadline would not
be reflected in publicly reported data on the CMS Hospice Compare
website. For example, for the data collected during the 1st quarter,
that is January 1st through March 31st of a given year, the hospice
will have until 11:59:59 p.m. PST on August 15th of that year to ensure
all of their data is correct. Any modifications to first quarter data
that are submitted to us after August 15th would not be reflected
during any subsequent Hospice Compare refresh. We believe that this is
a reasonable amount of time to allow providers to make any necessary
corrections to submitted data prior to public reporting. This revised
policy aligns HQRP with the policies and procedures that exist in our
other quality reporting programs including the post-acute care
programs, which also enables providers to review their data and make
necessary corrections within the specified time frame of approximately
4.5 months following the end of a given CY quarter and prior to the
public reporting of such data.
We propose that beginning January 1, 2019, HIS records with target
dates on or after January 1, 2019 will have a data correction deadline
for public reporting of approximately 4.5 months after the end of each
CY quarter in which the target date falls, and that hospices will have
until 11:59:59 p.m. PST on the deadline to submit corrections.
We also propose that for the purposes of public reporting, the
first quarterly freeze date for CY 2019 data corrections will be August
15, 2019. To accommodate those HIS records with target dates prior to
January 1, 2019 and still within a target period for public reporting,
we also propose to extend to hospices the opportunity to review their
data and submit corrections up until the CY 19 Q1 deadline of 11:59:59
p.m. PST on August 15, 2019. Table 18 presents the proposed data
correction deadlines for public reporting beginning in CY 2019.
Table 18--Data Correction Deadlines for Public Reporting Beginning CY
2019
------------------------------------------------------------------------
Data correction deadline
Data reporting period * for public reporting *
------------------------------------------------------------------------
Prior to January 1, 2019.................. August 15, 2019.
January 1, 2019-March 31, 2019............ August 15, 2019.
April 1, 2019-June 30, 2019............... November 15, 2019.
July 1, 2019-September 30, 2019........... February 15, 2020.
October 1, 2019-December 31, 2019......... May 15, 2020.
------------------------------------------------------------------------
* This CY time period involved is intended to inform both CY 2019 data
and to serve as an illustration for the review and correction
deadlines that are associated with each calendar year of data
reporting quarter.
We are soliciting public comments on these proposals.
5. CAHPS[supreg] Hospice Survey Participation Requirements for the FY
2023 APU and Subsequent Years
The CAHPS[supreg] Hospice Survey of CMS' HQRP 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 may refer to
79 FR 50452 and 78 FR 48261.
a. Background and Description of the CAHPS[supreg] Hospice Survey
The CAHPS[supreg] Hospice Survey is the first standardized national
survey available to collect information on patients' and informal
caregivers' 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.
In addition, the survey introduces standard survey administration
protocols that allow for fair comparisons across hospices.
Although the development of the CAHPS[supreg] Hospice Survey
predates the Meaningful Measures initiative, it used many of the
Meaningful Measure principles in its development. The overarching
quality priority of ``Strengthen Person and Family Engagement as
Partners in Their Care'' includes Meaningful Measure areas such as
``Care is personalized and Aligned with Patient's Goals,'' ``End of
Life Care According to Preferences'' and ``Patients Experience of
Care.'' The survey questions were developed with input from caregivers
of patients who died under hospice care. The survey focuses on topics
that are meaningful to caregivers/patients and supports CMS's efforts
to put the patient and their family members first.
Details regarding CAHPS[supreg] 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[supreg] Hospice
Survey website: https://www.HospiceCAHPSsurvey.org, and in the
CAHPS[supreg] Hospice Survey Quality Assurance Guidelines (QAG), which
are posted on the website.
b. Overview of the CAHPS[supreg] Hospice Survey Measures
The CAHPS[supreg] Hospice Survey is administered after the patient
is deceased and queries the decedent's primary, informal caregiver
(usually a family member) regarding the patient and family experience
of care, unlike the Hospital CAHPS[supreg] Survey deployed in 2006 (71
FR 48037 through 48039) and other subsequent CAHPS[supreg] surveys.
National implementation of the CAHPS[supreg] Hospice Survey commenced
January 1, 2015 as stated in the FY 2015 Hospice Wage Index and Payment
Rate Update final rule (79 FR 50452).
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, getting help for symptoms, and interactions with
hospice staff. The survey also contains 2 global rating questions and
asks for self-reported demographic information (race/ethnicity,
educational attainment level, languages spoken at home, among others).
The CAHPS[supreg] Hospice Survey
[[Page 20959]]
measures received NQF endorsement on October 26th, 2016 (NQF #2651).
Measures derived from the CAHPS[supreg] Hospice Survey include 6 multi-
item (composite) measures and 2 global ratings measures. They received
NQF endorsement on October 26, 2016 (NQF #2651). We adopted these 8
survey-based measures for the CY 2018 data collection period and for
subsequent years. These 8 measures are reported on Hospice Compare.
c. Data Sources
As discussed in the CAHPS[supreg] Hospice Survey QAG V4.0 (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 2020, FY
2021, and FY 2022 APUs (82 FR 36673). We propose to extend the same
participation requirements to all future years, for example, the FY
2023, FY 2024 and FY 2025 Annual Payment and subsequent updates. To
summarize, to meet the CAHPS[supreg] Hospice Survey requirements for
the HQRP, we propose 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[supreg] 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[supreg] 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. We invite public comment on this
proposal.
d. Public Reporting of CAHPS[supreg] Hospice Survey Results
We began public reporting of the results of the CAHPS[supreg]
Hospice Survey on Hospice Compare as of February 2018. The first report
of CAHPS[supreg] data covered survey results from deaths occurring
between Quarter 2, 2015 and Quarter 1, 2017. We report the most recent
8 quarters of data on the basis of a rolling average with the most
recent quarter of data being added and the oldest quarter of data
removed from the averages for each data refresh. We detailed the
calculation of these measures in 82 FR 36674. We refresh the data 4
times a year in the months of February, May, August, and November. We
will not publish CAHPS[supreg] data for any hospice that has fewer than
30 completed surveys due to concerns about statistical reliability. We
propose to use the same public reporting policies in future years. We
are soliciting comments on this proposal.
e. Volume-Based Exemption for CAHPS[supreg] Hospice Survey Data
Collection and Reporting Requirements
We previously finalized a volume-based exemption for CAHPS[supreg]
Hospice Survey Data Collection and Reporting requirements in the FY
2017 final rule (82 FR 36671). We propose to continue our policy for a
volume-based exemption for CAHPS[supreg] Hospice Survey Data Collection
for FY 2023 and every year thereafter. For example, for the FY 2023
APU, hospices that have fewer than 50 survey eligible decedents/
caregivers in the period from January 1, 2020 through December 31, 2020
(reference year) are eligible to apply for an exemption from
CAHPS[supreg] Hospice Survey data collection and reporting requirements
(corresponds to the CY 2021 data collection period). To qualify,
hospices must submit an exemption request form for the FY 2023 APU. The
exemption request form is available on the official CAHPS[supreg]
Hospice Survey website: http://www.hospiceCAHPSsurvey.org.
Hospices that intend to claim the size exemption are required to
submit to CMS their total unique patient count for the period of
January 1, 2020 through December 31, 2020 (reference year). The due
date for submitting the exemption request form for the FY 2023 APU is
December 31, 2021. Exemptions for size are active for 1 year only. If a
hospice continues to meet the eligibility requirements for this
exemption in future FY APU periods, the organization needs to request
the exemption annually for every applicable FY APU period.
For FY 2024 APU, hospices that have fewer than 50 survey eligible
decedents/caregivers in the period from January 1, 2021 through
December 31, 2021 (reference year) are eligible to apply for an
exemption from CAHPS[supreg] Hospice Survey data collection and
reporting requirements. Hospices that intend to claim the size
exemption are required to submit to CMS their total unique patient
count for the period of January 1, 2021 through December 31, 2021. The
due date for submitting the exemption request form for the FY 2024 APU
is December 31, 2022. Exemptions for size are active for 1 year only.
If a hospice continues to meet the eligibility requirements for this
exemption in future FY APU periods, the organization must request the
exemption annually for every applicable FY APU period.
For the FY 2025 APU, hospices that have fewer than 50 survey
eligible decedents/caregivers in the period from January 1, 2022
through December 31, 2022 (reference year) are eligible to apply for an
exemption from CAHPS[supreg] Hospice Survey data collection and
reporting requirements for the FY 2025 payment determination. Hospices
that intend to claim the size exemption are required to submit to CMS
their total unique patient count for the period of January 1, 2022
through December 31, 2022. The due date for submitting the exemption
request form for the FY 2025 APU is December 31, 2023. If a hospice
continues to meet the eligibility requirements for this exemption in
future FY APU periods, the organization must request the exemption
annually for every applicable FY APU period.
Table 19--Size Exemption Key Dates FY 2023, FY 2024 and FY 2025
----------------------------------------------------------------------------------------------------------------
Reference year
(count total
Fiscal year Data collection number of unique Size exemption form
year patients in submission deadline
this year)
----------------------------------------------------------------------------------------------------------------
FY 2023..................................... 2021 2020 December 31, 2021.
FY 2024..................................... 2022 2021 December 31, 2022.
FY 2025..................................... 2023 2022 December 31, 2023.
----------------------------------------------------------------------------------------------------------------
[[Page 20960]]
f. Newness Exemption for CAHPS[supreg] Hospice Survey Data Collection
and Reporting Requirements
We previously finalized a one-time newness exemption for hospices
that meet the criteria (81 FR 52181). We propose to continue the
newness exemption for FY 2023, FY 2024, FY 2025, and all future years.
Specifically, hospices that are notified about their Medicare CCN
after January 1, 2021 are exempted from the FY 2023 APU CAHPS[supreg]
Hospice Survey requirements due to newness. Likewise, hospices notified
about their Medicare CCN after January 1, 2022 are exempted from the FY
2024 APU CAHPS[supreg] Hospice Survey requirements due to newness.
Hospices notified about their Medicare CCN after January 1, 2023 are
exempted from the FY 2025 APU CAHPS[supreg] Hospice Survey requirements
due to newness. No action is required on the part of the hospice to
receive this exemption. The newness exemption is a one-time exemption
from the survey. We encourage hospices to keep the letter they receive
providing them with their CCN. The letter can be used to show when you
received your number.
We propose that this newness exemption to the CAHPS[supreg] Hospice
Survey will apply to all future years. We invite public comment on this
proposal.
g. Requirements for the FY 2023 APU
To meet participation requirements for the FY 2023 APU, Medicare-
certified hospices must collect CAHPS[supreg] Hospice Survey data on an
ongoing monthly basis from January 2021 through December 2021 (all 12
months) to receive their full payment for the FY 2023 APU. All data
submission deadlines for the FY 2023 APU are in Table 20. CAHPS[supreg]
Hospice Survey vendors must submit data by the deadlines listed in
Table 20 for all APU periods listed in the table and moving forward.
There are no late submissions permitted after the deadlines, except for
extraordinary circumstances beyond the control of the provider as
discussed above.
Table 20--CAHPS[supreg] Hospice Survey Data Submission Dates for the APU
in FY 2023, FY 2024, and FY 2025
------------------------------------------------------------------------
CAHPS Quarterly data
Sample months \1\ (month of death) submission deadlines \2\
------------------------------------------------------------------------
FY 2023 APU
------------------------------------------------------------------------
CY January-March 2021 (Quarter 1)......... August 11, 2021.
CY April-June 2021 (Q2)................... November 10, 2021.
CY July-September 2021 (Q3)............... February 9, 2022.
CY October-December 2021 (Q4)............. May 11, 2022.
------------------------------------------------------------------------
FY 2024 APU
------------------------------------------------------------------------
CY January-March 2022 (Q1)................ August 10, 2022.
CY April-June 2022 (Q2)................... November 9, 2022.
CY July-September 2022 (Q3)............... February 8, 2023.
CY October-December 2022 (Q4)............. May 10, 2023.
------------------------------------------------------------------------
FY 2025 APU
------------------------------------------------------------------------
CY January-March 2023 (Q1)................ August 9, 2023.
CY April-June 2023 (Q2)................... November 8, 2023.
CY July-September 2023 (Q3)............... February 14, 2024.
CY October-December 2023 (Q4)............. May 8, 2024.
------------------------------------------------------------------------
\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.
h. Requirements for the FY 2024 APU
To meet participation requirements for the FY 2024 APU, Medicare-
certified hospices must collect CAHPS[supreg] Hospice Survey data on an
ongoing monthly basis from January 2022 through December 2022 (all 12
months) to receive their full payment for the FY 2024 APU. All data
submission deadlines for the FY 2024 APU are in Table 20. CAHPS[supreg]
Hospice Survey vendors must submit data by the deadlines listed in
Table 20 for all APU periods listed in the table and moving forward.
There are no late submissions permitted after the deadlines, except for
extraordinary circumstances beyond the control of the provider as
discussed above.
i. Requirements for the FY 2025 APU
To meet participation requirements for the FY 2025 APU, Medicare-
certified hospices must collect CAHPS[supreg] Hospice Survey data on an
ongoing monthly basis from January 2023 through December 2023 (all 12
months) to receive their full payment for the FY 2025 APU. All data
submission deadlines for the FY 2025 APU are in Table 20. CAHPS[supreg]
Hospice Survey vendors must submit data by the deadlines listed in
Table 20 for all APU periods listed in the table and moving forward.
There are no late submissions permitted after the deadlines, except for
extraordinary circumstances beyond the control of the provider as
discussed above.
j. For Further Information About the CAHPS[supreg] Hospice Survey
We encourage hospices and other entities to learn more about the
survey on: https://www.hospiceCAHPSsurvey.org. For direct questions,
please contact the CAHPS[supreg] Hospice Survey Team at
[email protected] or telephone 1-844-472-4621.
6. 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 prior to such data being made public; the data will be available
on our public website.
To meet the Affordable Care Act's requirement for making quality
measure data public, we launched the Hospice Compare website in August
2017. This website allows consumers, providers, and other stakeholders
to search for all Medicare-certified hospice providers and view their
information and quality measure scores. Since its release, the CMS
Hospice Compare website has reported 7 HIS Measures (NQF #1641, NQF
#1647, NQF #1634, NQF #1637, NQF #1639, NQF #1638, and NQF #1617). In
February 2018, CAHPS[supreg] Hospice Survey measures (NQF #2651) were
added to the website.
a. Adding Quality Measures to Publically Available Websites--Procedures
To Determine Quality Measure Readiness for Public Reporting
Quality measures are added to Hospice Compare once they meet
readiness standards for public reporting, which is determined through
the following processes.
First, we assess the reliability and validity of each quality
measure to determine the scientific acceptability of each measure. This
acceptability analysis is the first step in determining a measure's
readiness for public reporting. We evaluate the quality
[[Page 20961]]
measures using the NQF Measure Evaluation Criteria found on the NQF
website here: http://www.qualityforum.org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria.aspx#scientific.
Analyses to assess scientific acceptability of new measures are
important to determine if the measure produces reliable and credible
results when implemented. Reliability testing demonstrates that a
measure is correctly specified by ensuring that ``measure data elements
are repeatable, producing the same results a high proportion of time
when assessed in the same population in the same time period and/or
that the measure score is precise.'' Validity testing demonstrates that
measure specifications are consistent with the focus of the measure and
that the measure score can accurately distinguish between quality of
care provided by providers. Reliability and validity are tested at both
the data item and quality measure levels. For example, at the item-
level, we examine the missing data rate and cross validate the data
elements between the assessment data and Medicare claims to ensure
validity of the data elements. At the quality measure level, we conduct
split-half analysis, consistency analysis across time, stability
analysis, and signal-to-noise analysis to demonstrate the reliability
of the measures. We examine the relationships between different quality
measures assessing similar quality areas to demonstrate the validity of
the quality measures.
To establish reliability and validity of the quality measures, at
least 4 quarters of data are analyzed. The first quarter of data after
new adoption of, or changes to, standardized data collection tools may
reflect the learning curve of the hospices; we first analyze these data
separately to determine the appropriateness to use them to establish
reliability and validity of quality measures.
To further inform which of the measures are eligible for public
reporting, we then examine the distribution of hospice-level
denominator size for each quality measure to assess whether the
denominator size is large enough to generate the statistically reliable
scores necessary for public reporting. This goal of this analysis is to
establish the minimum denominator size for public reporting, which is
referred to as reportability analysis. Reportability analysis is
necessary because, if a hospice QM score is generated from a
denominator that is too small, the observed measure score may be a
biased assessment of the provider's performance, yielding scores that
are statistically unreliable. Thus, we have set a minimum denominator
size for public reporting, as well as the data selection period
necessary to generate the minimum denominator size for the CMS Hospice
Compare website.
This approach to testing reliability, validity, and reportability
of quality measures (QMs) is consistent with the approach taken in
other CMS quality reporting programs. Further, CMS provides hospices
the opportunity to review their measures through their Certification
and Survey Provider Enhanced Reports (CASPER) and additionally
publishes the methodology related to the calculation of each quality
measure in the Hospice Quality Measure User's Manual, which is updated
with the addition of each quality measure to the Hospice QRP. Since
December 2016, two provider feedback reports have been available to
providers: The Hospice-Level Quality Measure Report and the Patient
Stay-Level Quality Measure Report. These confidential feedback reports
are available to each hospice using the CASPER system, and are part of
the class of CASPER reports known as QM Reports. These reports are for
the purposes of internal provider quality improvement and are available
to hospices on-demand. We encourage providers to use the CASPER QM
Reports to review their HIS quality measures regularly to ensure
submitted quality measure data is correct. For more information on the
CASPER QM Reports, we refer readers to the CASPER QM Factsheet on the
HQRP website at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices.html.
Because we follow the above outlined processes in determining the
readiness for a quality measure to be publicly reported, and perform
the necessary analysis to determine and demonstrate that our measures
meet the NQF standards for reliability, validity, and reportability,
prior to publicly reporting provider performance on these quality
metrics, we are proposing to announce to providers, any future intent
to publicly report a quality measure on Hospice Compare, including
timing, through sub-regulatory means.
Conducting these analyses and announcing measures timeline and
readiness for public reporting through sub-regulatory channels will
allow us to implement measures for public reporting in a more
expeditious, yet still transparent manner, benefitting the public by
providing QM data as soon as it is determined to meet the minimum
standards for public reporting. We will continue to provide updates
about public reporting of QMs through the normal CMS HQRP communication
channels, including postings and announcements on the CMS HQRP website,
MLN eNews communications, national provider association calls, and
announcements on Open Door Forums. We are soliciting comments on this
proposal.
b. Quality Measures To Be Displayed on Hospice Compare in FY 2019
We anticipate that we will begin public reporting of the HIS-based
Hospice Comprehensive Assessment Measure (NQF #3235), a composite
measure of the 7 original HIS Measures (NQF #1641, NQF #1647, NQF
#1634, NQF #1637, NQF #1639, NQF #1638, and NQF #1617), on the CMS
Hospice Compare website in Fall 2019. For more information on how this
measure is calculated, please see the HQRP QM User's Manual v2.00 in
the ``Downloads'' section of the Current Measures page on the CMS HQRP
website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html.
The reporting period for which the measure will be displayed on the CMS
Hospice Compare website will align with the currently established
procedures for the 7 HIS measures. For more information about reporting
periods, please see the Public Reporting: Key Dates for Providers page
on the CMS HQRP website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Public-Reporting-Key-Dates-for-Providers.html. We used the analytic
approach described above to determine reliability, validity, and
reportability of the HIS-based Hospice Comprehensive Assessment Measure
(NQF #3235). Reliability and validity testing found that the Hospice
Comprehensive Assessment Measure had high reliability and validity. For
more information about the reliability and validity of this measure,
please see the NQF Palliative and End-of-Life Care Off-Cycle Measure
Review 2017 Publication available for download here: https://www.qualityforum.org/Publications/2017/09/Palliative_and_End-of-Life_Care_Off-Cycle_Measure_Review_2017.aspx. Per the approach
described above, we then conducted reportability analysis. Based on
reportability analysis results, we determined this measure, calculated
based on a 12-rolling month data selection period, to be eligible for
[[Page 20962]]
public reporting with a minimum denominator size of 20 patient stays. A
majority of hospices, using rolling 4 quarters of data, have at least
20 patient stays eligible for the calculation and public reporting of
the Hospice Comprehensive Assessment Measure. We plan to begin public
reporting of the Hospice Comprehensive Assessment Measure with a
minimum denominator size of 20.
We also anticipate that we will begin public reporting of the HIS-
based Hospice Visits when Death is Imminent Measure Pair in FY 2019.
This same analytic approach described above will be applied to
determine the reliability, validity, and reportability of the Hospice
Visits when Death is Imminent Measure Pair. This measure pair assesses
hospice staff visits to patients at the end of life. Specifications for
the Hospice Visits when Death is Imminent measure pair were finalized
in the FY 2017 Hospice Final Rule (81 FR 52162). Pending the
finalization of our proposal to announce future intentions to publicly
display hospice quality measures via sub-regulatory means, the exact
timeline for public reporting of this measure pair will be announced
through regular sub-regulatory channels once necessary analyses and
measure specifications are finalized.
c. Updates to the Public Display of HIS Measures
As discussed previously, we strive to put patients first, ensuring
they are empowered to make decisions about their own healthcare, along
with their clinicians, using data-driven information that are
increasingly aligned with a parsimonious set of meaningful quality
measures that drive quality improvement. We recognize that the HQRP
represents a key component in bringing quality measurement,
transparency, and improvement to the hospice care setting. To that end,
we have begun analyzing our programs' measures in accordance with the
Meaningful Measures framework to ensure high quality care and that
empowers patients to make decisions about their own healthcare, using
consumable, data-driven information.
With this framework in mind, we evaluated our measure set and
specifically the measure Hospice and Palliative Care Composite Process
Measure--Comprehensive Assessment at Admission (NQF #3235) which we
intend to publicly display on the Hospice Compare website in FY 2019.
Through feedback received, we have learned that while the 7 original
HIS measures (NQF #1641, NQF #1647, NQF #1634, NQF #1637, NQF #1639,
NQF #1638, and NQF #1617) that represent the individual care processes
captured in this composite measure are important, the composite measure
provides for consumers a more accessible measure for evaluating the
quality of a hospice.
The composite measure is more illustrative than the individual,
high performing measures based on analyses. The hospice performance
scores on the 7 component measures that comprise the composite measure
are high (a score of 90 percent or higher on most component measures);
however, analyses also show that, on average, a much lower percentage
of patient stays received all seven desirable care processes at
admission. Thus, by assessing hospices' performance of a comprehensive
assessment via an all-or-none calculation methodology, the composite
measure sets a higher standard of care for hospices and reveals a
larger performance gap. Meaning, the composite measure holds hospices
to a higher standard by requiring them to perform all seven care
processes for a given patient admission. The performance gap identified
by the composite measure creates opportunities for quality improvement
and may motivate providers to conduct a greater number of high priority
care processes for as many patients as possible upon admission to
hospice.
The table below shows the mean measure score across all hospices
for Hospice and Palliative Care Composite Process Measure--
Comprehensive Assessment Measure at Admission and the 7 component
measures that would no longer be routinely individually displayed on
Hospice Compare once the composite measure would be displayed.
Table 21--Mean Measure Score of the Hospice and Palliative Care
Composite Process Measure--Comprehensive Assessment Measure at Admission
and 7 Original HIS Component Measures
------------------------------------------------------------------------
Measure
Measure title score (%)
------------------------------------------------------------------------
Hospice and Palliative Care Composite Process Measure-- 71.3
Comprehensive Assessment at Admission (NQF #3235).........
Component Measure: Treatment Preferences (NQF #1641)....... 98.8
Component Measure: Beliefs/Values (NQF #1647).............. 95.9
Component Measure: Pain Screening (NQF #1634).............. 93.2
Component Measure: Pain Assessment (NQF #1637)............. 72.5
Component Measure: Dyspnea Screening (NQF #1639)........... 98.5
Component Measure: Dyspnea Treatment (NQF #1638)........... 92.8
Component Measure: Bowl Regimen (NQF #1617)................ 97.5
------------------------------------------------------------------------
Further, we believe the reporting of these 7 component measures
alongside the composite measure may be redundant and may result in
confusion and burden for users as they attempt to interpret data
displayed on the Hospice Compare website. However, we also recognize
that the component measures may be useful to some individuals using
Hospice Compare. Therefore, while we intend to no longer directly
display the 7 component measures as individual measures on Hospice
Compare, once the composite measure is displayed, we would still
provide the public the ability to view these component measures in a
manner that avoids confusion on Hospice Compare. We plan to achieve
this by reformatting the display of the component measures so that they
are only viewable in an expandable/collapsible format under the
composite measure itself, thus allowing users the opportunity to view
the component measure scores that were used to calculate the main
composite measure score.
This proposal would change only the display of data on Hospice
Compare for the HIS-based measure(s). This proposal would not change
any current HIS data collection procedures outlined in the FY 2018
Hospice final rule (82 FR 36663 through 36664). Providers would still
collect all HIS items in the current version of the HIS (HIS V2.00.0),
including the 7 aforementioned component measures. Providers would
continue to follow the coding guidelines and policies outlined in the
HIS Manual V2.00, which can be found under the Downloads section of the
HIS page of the HQRP website https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html. Therefore, this proposal would not impact
data collection.
[[Page 20963]]
Additionally, because the composite measure is composed of the 7
aforementioned component measures, these component measures would still
be reported on CASPER QM reports and HIS provider preview reports for
providers' internal quality purposes.
We invite public comment on our proposal to remove from Hospice
Compare the direct display of the 7 original HIS measures, allowing for
the reformatting of the display of these measures under the composite
measure, once the Hospice Comprehensive Assessment Measure is
displayed.
d. Display of Public Use File Data and/or Other Publicly Available CMS
Data on the Hospice Compare Website
In the FY 2016 Hospice Wage Index final rule (80 FR 47199), we
announced that we would make available hospice data in a public data
set, the Medicare Provider Utilization and Payment Data: Physician and
Other Supplier Public Use File (PUF), as part of our ongoing efforts to
make healthcare more transparent, affordable, and accountable. Hospice
data has been available at the provider-level in the Medicare Provider
Utilization and Payment Data: Physician and Other Supplier PUF since
2016 and is located at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Hospice.html. The primary data source for the Hospice PUF is the
CMS Chronic Condition Data Warehouse (CCW), a database with 100 percent
of Medicare enrollment and fee-for-service adjudicated claims data.
These Hospice PUFs serve as a resource for the healthcare community
by providing information on services provided to Medicare beneficiaries
by hospice providers. The Hospice PUF contains information on
utilization, payment (Medicare payment and standard payment), submitted
charges, primary diagnoses, sites of service, and hospice beneficiary
demographics organized by CMS Certification Number (6-digit provider
identification number) and state. While these files are extensively
downloaded by the public and especially researchers, currently the
files are not in a format that would be considered user-friendly for
many of the consumers who would look for hospice information to support
provider selection.
As part of our ongoing efforts to make the Hospice Compare website
more informative to our beneficiaries, loved ones, and their families,
we propose to post information from these PUF and/or other publicly
available CMS data to the Hospice Compare website in a user-friendly
way. We propose to use information available in these public files to
develop a new section of the Hospice Compare website that would provide
additional information along with the HIS and CAHPS[supreg] quality
measures and demographic information already displayed. Other Compare
websites, such as the Nursing Home Compare and the End Stage Renal
Disease Compare websites, have an information section similar to what
we anticipate posting.
Information on the Hospice Compare website for each hospice
includes data from the PUF and/or other publicly available CMS data
displayed in a consumer-friendly format. This means that we may display
the data as shown from the PUF or present the data after additional
calculations. For example, the data could be averaged over multiple
years, displayed as a percentage rather than the raw number so it has
meaning to end-users, or other calculations in a given year or over
multiple years. Any calculation will be performed on data exclusively
from the source file like the PUF or other publicly available CMS data.
The data may be displayed with supporting narrative when needed to make
the data more understandable.
Examples, provided for illustration of how CMS could use the PUF or
other publicly available CMS data, include:
Percent of days a hospice provided routine home care (RHC)
to patients, averaged over multiple years,
Percent of primary diagnosis of patients served by the
hospice (cancer, dementia, circulatory/heart disease, stroke,
respiratory disease) which would be a calculation of the total number
of patients by diagnosis and dividing by the total number of patients
that the hospice served, and
Site of service (long term care or non-skilled nursing
facility, skilled nursing facility, inpatient hospital) with a notation
of yes, based on whether the hospice serves patients in that facility
type.
While these types of information are not quality measures, they
capture information that many consumers seek during the provider
selection process and, therefore, will help them to make an informed
decision. For example, information about conditions treated by the
hospice could show a patient with dementia if a hospice specializes or
is experienced in caring for patients with this condition.
Additionally, if a patient has a specific need, like receiving hospice
care in a nursing home, information from the PUF could help this
patient or their loved ones determine if a provider in their service
area has provided care in this setting. Analyses of the PUF data show
variation between hospice providers in the data points outlined above,
indicating that these data points could be meaningful to consumers in
comparing services provided by hospices based on the factors most
important to them. PUF data can serve as one more piece of information,
along with quality of care metrics from the HIS and CAHPS[supreg]
Hospice Survey, to help consumers effectively and efficiently compare
hospice providers and make an informed decision about their care in a
stressful time.
By averaging or trending data over multiple years, we make it
fairer so that the data applies to hospices broadly regardless of size
or location or other factors. We anticipate that over time and as
appropriate, we may add other items from the PUF or other publicly
available CMS data to the Hospice Compare website via sub-regulatory
processes and would plan to inform the public via regular HQRP
communication strategies, such as Open Door Forums, Medicare Learning
Network, Spotlight announcements and other opportunities. We invite
public comment on these proposals.
IV. Request for Information on Possible Establishment of CMS Patient
Health and Safety Requirements for Hospitals and Other Medicare-
Participating Providers and Suppliers for Electronic Transfer of Health
Information
Currently, Medicare- and Medicaid-participating providers and
suppliers are at varying stages of adoption of health information
technology (health IT). Many hospitals have adopted electronic health
records (EHRs), and the Centers for Medicare & Medicaid Services (CMS)
has provided incentive payments to eligible hospitals, critical access
hospitals (CAHs), and eligible professionals who have demonstrated
meaningful use of certified EHR technology under the Medicare EHR
Incentive Program. As of 2015, 96 percent of Medicare-participating
non-federal acute care hospitals had adopted certified EHRs with the
capability to electronically export a summary of clinical care.\13\
While both adoption of EHRs and electronic exchange of information have
grown substantially among hospitals, significant obstacles to
exchanging electronic health information across the continuum of care
persist. Routine electronic transfer of information post-discharge has
not
[[Page 20964]]
been achieved by providers and suppliers in many localities and regions
throughout the nation.
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\13\ These statistics can be accessed at https://dashboard.healthit.gov/quickstats/pages/FIG-Hospital-EHR-Adoption.php.
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We are firmly committed to the use of certified health IT and
interoperable EHR systems for electronic healthcare information
exchange to effectively help hospitals and other Medicare-participating
providers and suppliers improve internal care delivery practices,
support the exchange of important information across care team members
during transitions of care, and enable reporting of specified
electronically clinical quality measures (eCQMs). The Office of the
National Coordinator for Health Information Technology (ONC) acts as
the principal federal entity charged with coordination of nationwide
efforts to implement and use health IT and the electronic exchange of
health information on behalf of the Department of Health and Human
Services (HHS).
In 2015, ONC finalized the 2015 Edition health IT certification
criteria (2015 Edition), the most recent criteria for health IT to be
certified under the ONC Health IT Certification Program. The 2015
Edition facilitates greater interoperability for several clinical
health information purposes and enables health information exchange
through new and enhanced certification criteria, standards, and
implementation specifications. CMS requires eligible hospitals and CAHs
in the Medicare and Medicaid EHR Incentive Programs and eligible
clinicians in the Quality Payment Program to use EHR technology
certified to the 2015 Edition beginning in CY 2019.
In addition, several important initiatives will be implemented over
the next several years to provide hospitals and other participating
providers and suppliers with access to robust infrastructure that will
enable routine electronic exchange of health information. Section 4003
of the 21st Century Cures Act (Pub. L. 114-255), enacted in 2016, and
amended section 3000 of the Public Health Service Act (42 U.S.C.
300jj), requires HHS to take steps to advance the electronic exchange
of health information and interoperability for participating providers
and suppliers in various settings across the care continuum.
Specifically, the Congress directed that ONC ``. . . for the purpose of
ensuring full network-to-network exchange of health information,
convene public-private and public-public partnerships to build
consensus and develop or support a trusted exchange framework,
including a common agreement among health information networks
nationally.'' In January 2018, ONC released a draft version of its
proposal for the Trusted Exchange Framework and Common Agreement,\14\
which outlines principles and minimum terms and conditions for trusted
exchange to enable interoperability across disparate health information
networks (HINs). The Trusted Exchange Framework (TEF) is focused on
achieving the following four important outcomes in the long-term:
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\14\ The draft version of the trusted Exchange Framework may be
accessed at https://beta.healthit.gov/topic/interoperability/trusted-exchange-framework-and-common-agreement).
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Professional care providers, who deliver care across the
continuum, can access health information about their patients,
regardless of where the patient received care.
Patients can find all of their health information from
across the care continuum, even if they don't remember the name of the
professional care provider they saw.
Professional care providers and health systems, as well as
public and private health care organizations and public and private
payer organizations accountable for managing benefits and the health of
populations, can receive necessary and appropriate information on
groups of individuals without having to access one record at a time,
allowing them to analyze population health trends, outcomes, and costs;
identify at-risk populations; and track progress on quality improvement
initiatives.
The health IT community has open and accessible
application programming interfaces (APIs) to encourage entrepreneurial,
user-focused innovation that will make health information more
accessible and improve EHR usability.
ONC will revise the draft TEF based on public comment and
ultimately release a final version of the TEF that will subsequently be
available for adoption by HINs and their participants seeking to
participate in nationwide health information exchange. The goal for
stakeholders that participate in, or serve as, a HIN is to ensure that
participants will have the ability to seamlessly share and receive a
core set of data from other network participants in accordance with a
set of permitted purposes and applicable privacy and security
requirements. Broad adoption of this framework and its associated
exchange standards is intended to both achieve the outcomes described
above while creating an environment more conducive to innovation.
In light of the widespread adoption of EHRs along with the
increasing availability of health information exchange infrastructure
predominantly among hospitals, we are interested in hearing from
stakeholders on how we could use the CMS health and safety standards
that are required for providers and suppliers participating in the
Medicare and Medicaid programs (that is, the Conditions of
Participation (CoPs) and Conditions for Coverage (CfCs)) to further
advance electronic exchange of information that supports safe,
effective transitions of care between hospitals and community
providers. Specifically, CMS might consider revisions to the current
CMS CoPs for hospitals such as: Requiring that hospitals transferring
medically necessary information to another facility upon a patient
transfer or discharge do so electronically; requiring that hospitals
electronically send required discharge information to a community
provider through electronic means if possible and if a community
provider can be identified; and requiring that hospitals make certain
information available to patients or a specified third-party
application (for example, required discharge instructions) through
electronic means if requested.
On November 3, 2015, we published a proposed rule (80 FR 68126) to
implement the provisions of the IMPACT Act and to revise the discharge
planning CoP requirements that hospitals (including Short-Term Acute-
Care Hospitals, Long-Term Care Hospitals (LTCHs), Inpatient
Rehabilitation Hospitals (IRFs), Inpatient Psychiatric Hospitals
(IPFs), Children's Hospitals, and Cancer Hospitals), critical access
hospitals (CAHs), and home health agencies (HHAs) must meet in order to
participate in the Medicare and Medicaid programs. This proposed rule
has not been finalized yet. However, several of the proposed
requirements directly address the issue of communication between
providers and between providers and patients, as well as the issue of
interoperability:
Hospitals and CAHs would be required to transfer certain
necessary medical information and a copy of the discharge instructions
and discharge summary to the patient's practitioner, if the
practitioner is known and has been clearly identified;
Hospitals and CAHs would be required to send certain
necessary medical information to the receiving facility/post-acute care
providers, at the time of discharge; and
Hospitals, CAHs and HHAs, would need to comply with the
IMPACT Act requirements that would require hospitals, CAHs, and certain
post-acute care providers to use data on quality
[[Page 20965]]
measures and data on resource use measures to assist patients during
the discharge planning process, while taking into account the patient's
goals of care and treatment preferences.
We also published another proposed rule (81 FR 39448), on June 16,
2016, that updated a number of CoP requirements that hospitals and CAHs
must meet in order to participate in the Medicare and Medicaid
programs. This proposed rule has not been finalized yet. One of the
proposed hospital CoP revisions in this rule directly addresses the
issues of communication between providers and patients, patient access
to their medical records, and interoperability. We proposed that
patients have the right to access their medical records, upon an oral
or written request, in the form and format requested by such patients,
if it is readily producible in such form and format (including in an
electronic form or format when such medical records are maintained
electronically); or, if not, in a readable hard copy form or such other
form and format as agreed to by the facility and the individual,
including current medical records, within a reasonable time frame. The
hospital must not frustrate the legitimate efforts of individuals to
gain access to their own medical records and must actively seek to meet
these requests as quickly as its record keeping system permits.
Additionally, we specifically invite stakeholder feedback on the
following questions regarding possible new or revised CoPs/CfCs for
interoperability and electronic exchange of health information:
If CMS were to propose a new CoP/CfC standard to require
electronic exchange of medically necessary information, would this help
to reduce information blocking as defined in section 4004 of the 21st
Century Cures Act?
Should CMS propose new CoPs/CfCs for hospitals and other
participating providers and suppliers to ensure a patient's (or his or
her caregiver's or representative's) right and ability to
electronically access his or her health information without undue
burden? Would existing portals or other electronic means currently in
use by many hospitals satisfy such a requirement regarding patient
access as well as interoperability?
Are new or revised CMS CoPs/CfCs for interoperability and
electronic exchange of health information necessary to ensure patients
and other treating providers routinely receive relevant electronic
health information from hospitals on a timely basis or will this be
achieved in the next few years through existing Medicare and Medicaid
policies, Health Insurance Portability and Accountability Act of 1996
(HIPAA), and implementation of relevant policies in the 21st Century
Cures Act?
What would be a reasonable implementation timeframe for
compliance with new or revised CMS CoPs/CfCs for interoperability and
electronic exchange of health information if CMS were to propose and
finalize such requirements? Should these requirements have delayed
implementation dates for specific participating providers and
suppliers, or types of participating providers and suppliers (for
example, participating providers and suppliers that are not eligible
for the Medicare and Medicaid EHR Incentive Programs)?
Do stakeholders believe that new or revised CMS CoPs/CfCs
for interoperability and electronic exchange of health information
would help improve routine electronic transfer of health information as
well as overall patient care and safety?
Under new or revised CoPs/CfCs, should non-electronic
forms of sharing medically necessary information (for example, printed
copies of patient discharge/transfer summaries shared directly with the
patient or with the receiving provider or supplier, either directly
transferred with the patient or by mail or fax to the receiving
provider or supplier) be permitted to continue if the receiving
provider, supplier, or patient cannot receive the information
electronically?
Are there any other operational or legal considerations
(for example, HIPAA), obstacles, or barriers that hospitals and other
providers and suppliers would face in implementing changes to meet new
or revised interoperability and health information exchange
requirements under new or revised CMS CoPs/CfCs if they are proposed
and finalized in the future?
What types of exceptions, if any, to meeting new or
revised interoperability and health information exchange requirements,
should be allowed under new or revised CMS CoPs/CfCs if they are
proposed and finalized in the future? Should exceptions under the
Quality Payment Program including Certified Electronic Health Record
Technology hardship or small practices be extended to new requirements?
Would extending such exceptions impact the effectiveness of these
requirements?
We would also like to directly address the issue of communication
between hospitals (as well as the other providers and suppliers across
the continuum of patient care) and their patients and caregivers.
MyHealthEData is a government-wide initiative aimed at breaking down
barriers that contribute to preventing patients from being able to
access and control their medical records. Privacy and security of
patient data will be at the center of all our efforts in this area. CMS
must protect the confidentiality of patient data, and CMS is completely
aligned with the Veterans Affairs, the National Institutes of Health,
ONC, and the rest of the federal government, on this objective. While
some Medicare beneficiaries have had, for quite some time, the ability
to download their Medicare claims information, in pdf or Excel formats,
through the CMS Blue Button platform, the information was provided
without any context or other information that would help beneficiaries
understand what the data was really telling them. For beneficiaries,
their claims information is useless if it is either too hard to obtain
or, as was the case with the information provided through previous
versions of Blue Button, hard to understand. In an effort to fully
contribute to the federal government's MyHealthEData initiative, CMS
developed and launched the new Blue Button 2.0, which represents a
major step toward giving patients meaningful control of their health
information in an easy-to-access and understandable way. Blue Button
2.0 is a developer-friendly, standards-based API that enables Medicare
beneficiaries to connect their claims data to secure applications,
services, and research programs they trust. The possibilities for
better care through Blue Button 2.0 data are exciting, and might
include enabling the creation of health dashboards for Medicare
beneficiaries to view their health information in a single portal, or
allowing beneficiaries to share complete medication lists with their
doctors to prevent dangerous drug interactions.
To fully understand all of these health IT interoperability issues,
initiatives, and innovations through the lens of its regulatory
authority, we invite members of the public to submit their ideas on how
best to accomplish the goal of fully interoperable health IT and EHR
systems for Medicare- and Medicaid-participating providers and
suppliers, as well as how best to further contribute to and advance the
MyHealthEData initiative for patients. We are particularly interested
in identifying fundamental barriers to interoperability and health
information exchange, including those specific barriers that prevent
patients from being able to
[[Page 20966]]
access and control their medical records. We also welcome the public's
ideas and innovative thoughts on addressing these barriers and
ultimately removing or reducing them in an effective way, specifically
through revisions to the current CMS CoPs or CfCs for hospitals and
other participating providers and suppliers. We have received
stakeholder input through recent CMS Listening Sessions on the need to
address health IT adoption and interoperability among providers that
were not eligible for the Medicare and Medicaid EHR Incentives program,
including long-term and post-acute care providers, behavioral health
providers, clinical laboratories and social service providers, and we
would also welcome specific input on how to encourage adoption of
certified health IT and interoperability among these types of providers
and suppliers as well.
Please note, this is a Request for Information only. Respondents
are encouraged to provide complete but concise and organized responses,
including any relevant data and specific examples. However, respondents
are not required to address every issue or respond to every question
discussed in this Request for Information to have their responses
considered. In accordance with the implementing regulations of the
Paperwork Reduction Act at 5 CFR 1320.3(h)(4), all responses will be
considered provided they contain information we can use to identify and
contact the commenter, if needed.
This Request for Information is issued solely for information and
planning purposes; it does not constitute a Request for Proposal,
applications, proposal abstracts, or quotations. This Request for
Information does not commit the United States (U.S.) Government to
contract for any supplies or services or make a grant award. Further,
we are not seeking proposals through this Request for Information and
will not accept unsolicited proposals. Responders are advised that the
U.S. Government will not pay for any information or administrative
costs incurred in response to this Request for Information; all costs
associated with responding to this Request for Information will be
solely at the interested party's expense.
We note that not responding to this Request for Information does
not preclude participation in any future procurement, if conducted. It
is the responsibility of the potential responders to monitor this
Request for Information announcement for additional information
pertaining to this request. In addition, we note that CMS will not
respond to questions about the policy issues raised in this Request for
Information. We will not respond to comment submissions in response to
this Request for Information in the FY 2019 IPPS/LTCH PPS final rule.
Rather, we will actively consider all input as we develop future
regulatory proposals or future subregulatory policy guidance. We may or
may not choose to contact individual responders. Such communications
would be for the sole purpose of clarifying statements in the
responders' written responses. Contractor support personnel may be used
to review responses to this Request for Information. Responses to this
notice are not offers and cannot be accepted by the Government to form
a binding contract or issue a grant. Information obtained as a result
of this Request for Information may be used by the Government for
program planning on a non-attribution basis. Respondents should not
include any information that might be considered proprietary or
confidential.
This Request for Information should not be construed as a
commitment or authorization to incur cost for which reimbursement would
be required or sought. All submissions become U.S. Government property
and will not be returned. We may publically post the public comments
received, or a summary of those public comments.
V. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. In
order to fairly evaluate whether an information collection should be
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
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.
We are soliciting public comment on each of these issues for the
following sections of this document that contain information collection
requirements.
A. ICRs Regarding 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
In section III.E of this proposed rule, we propose removal of the 7
original HIS measures from public reporting display on Hospice Compare.
This proposal would not change any current HIS data collection
procedures outlined in the FY 2018 Hospice final rule (82 FR 36663
through 36664). The HIS V2.00.0 was approved by the OMB on April 17,
2017 under control number 0938-1153 for 1 year. The information
collection request (ICR) is currently pending OMB approval for 3 years.
We are not proposing any new updates or additional collections of
information in this proposed rule in regards to the HIS.
B. ICRs Regarding CAHPS[reg] Hospice Survey Information Collection
Requirements
National Implementation of the Hospice Experience of Care Survey
(CAHPs Hospice Survey) data measures (82 FR 36672) would not impose any
new or revised reporting, recordkeeping, or third-party disclosure
requirements and therefore, does not require additional OMB review
under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C.
3501 et seq.). The information collection requirements and burden have
been approved by OMB through December 31, 2020 under OMB control number
0938-1257.
C. Submission of PRA-Related Comments
We have submitted a copy of this proposed rule to OMB for its
review of
[[Page 20967]]
the rule's information collection and recordkeeping requirements. The
requirements are not effective until they have been approved by OMB.
We invite public comments on these information collection
requirements. If you wish to comment, please identify the rule (CMS-
1692-P) and, where applicable, the ICR's CFR citation, CMS ID number,
and OMB control number.
To obtain copies of a supporting statement and any related forms
for the proposed collection(s) summarized in this notice, you may make
your request using one of following:
1. Access our website address at https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
2. Email your request, including your address, phone number, OMB
number, and CMS document identifier, to [email protected].
3. Call the Reports Clearance Office at (410) 786-1326. See this
rule's DATES and ADDRESSES sections for the comment due date and for
additional instructions.
VI. 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.
VII. Regulatory Impact Analysis
A. Statement of Need
This proposed rule meets the requirements of our regulations at
Sec. 418.306(c), which requires annual issuance, in the Federal
Register, of the hospice wage index based on the most current available
CMS hospital wage data, including any changes to the definitions of
Core-Based Statistical Areas (CBSAs), or previously used Metropolitan
Statistical Areas (MSAs). This proposed rule would also update payment
rates for each of the categories of hospice care, described in Sec.
418.302(b), for FY 2018 as required under section
1814(i)(1)(C)(ii)(VII) of the Act. The payment rate updates are subject
to changes in economy-wide productivity as specified in section
1886(b)(3)(B)(xi)(II) of the Act. In addition, the payment rate updates
may 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). Lastly, section 3004 of the Affordable
Care Act amended the Act to authorize a quality reporting program for
hospices and this rule discusses changes in the requirements for the
hospice quality reporting program in accordance with section 1814(i)(5)
of the Act.
B. Overall Impacts
We estimate that the aggregate impact of the payment provisions in
this proposed rule would result in an increase of $340 million in
payments to hospices, resulting from the hospice payment update
percentage of 1.8 percent. The impact analysis of this proposed rule
represents the projected effects of the changes in hospice payments
from FY 2018 to FY 2019. Using the most recent data available at the
time of rulemaking, in this case FY 2017 hospice claims data, we apply
the current FY 2018 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 2018 payments. Then, using the same FY 2017
data, we apply the FY 2019 wage index and labor-related share values to
simulate FY 2019 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 Medicare program is
such that the changes may interact, and the complexity of the
interaction of these changes could make it difficult to predict
accurately the full scope of the impact upon hospices.
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 Regulatory Flexibility Act (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 greater than 5 percent of
providers reach a threshold of 3 to 5 percent or more of total revenue
or total costs. The effect of the FY 2018 hospice payment update
percentage results in an overall increase in estimated hospice payments
of 1.8 percent, or $340 million. Therefore, the Secretary has
determined that this proposed rule would not create a significant
economic impact on a substantial number of small entities.
[[Page 20968]]
In addition, section 1102(b) of the Social Security 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 603 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 would only affect 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. The 2018 UMRA
threshold is $150 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 $150 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 would 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.
Using the wage information from the Bureau of Labor Statistics
(BLS) for medical and health service managers (Code 11-9111), we
estimate that the cost of reviewing this rule is $107.38 per hour,
including overhead and fringe benefits (https://www.bls.gov/oes/current/oes_nat.htm). Assuming an average reading speed of 250 words
per minute, we estimate that it would take approximately one hour for
the staff to review half of this proposed rule which consists of
approximately 30,000 words. For each hospice that reviews the rule, the
estimated cost is $107.38 (1 hour x $107.38). Therefore, we estimate
that the total cost of reviewing this regulation is $9,664.20 ($107.38
x 90 reviewers).
As we noted in section III.C of this proposed rule, we are making
optional the requirement to submit specific, detailed data regarding
drugs on hospice claims, which could result in a significant reduction
of burden to Medicare hospices. We estimate that the total number of
lines on hospice claims could be reduced by 21.5 million in the
aggregate, which corresponds to an average reduction in the total
number of lines on hospices claims by 5,000 per hospice.
D. Detailed Economic Analysis
The FY 2019 hospice payment impacts appear in Table 22. We tabulate
the resulting payments according to the classifications in Table 22
(for example, facility type, geographic region, facility ownership),
and compare the difference between current and future 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 FY 2019 hospice wage
index. The aggregate impact of this change is zero percent, due to the
hospice wage index standardization factor. However, there are
distributional effects of the FY 2019 hospice wage index.
The fourth column shows the effect of the hospice payment update
percentage for FY 2019. The proposed FY 2019 hospice payment update
percentage of 1.8 percent is mandated by section 1814(i)(1)(C) of the
Act, and is constant for all providers.
The fifth column shows the effect of all the proposed changes on FY
2019 hospice payments. It is projected that aggregate payments would
increase by 1.8 percent, assuming hospices do not change their service
and billing practices.
As illustrated in Table 22, the combined effects of all the
proposals vary by specific types of providers and by location.
Table 22--Projected Impact to Hospices for FY 2019
----------------------------------------------------------------------------------------------------------------
FY 2019 hospice
Number of Updated wage payment update FY 2019 total
providers data (%) (%) change (%)
(1) (2) (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
All Hospices............................ 4,408 0.0 1.8 1.8
Urban Hospices.......................... 3,523 0.0 1.8 1.8
Rural Hospices.......................... 885 0.1 1.8 1.9
Urban Hospices--New England............. 124 -0.1 1.8 1.7
Urban Hospices--Middle Atlantic......... 249 0.1 1.8 1.9
Urban Hospices--South Atlantic.......... 443 -0.2 1.8 1.6
Urban Hospices--East North Central...... 397 -0.1 1.8 1.7
Urban Hospices--East South Central...... 149 0.0 1.8 1.8
Urban Hospices--West North Central...... 241 0.2 1.8 2.0
Urban Hospices--West South Central...... 691 0.4 1.8 2.2
Urban Hospices--Mountain................ 354 -0.3 1.8 1.5
Urban Hospices--Pacific................. 835 0.2 1.8 2.0
[[Page 20969]]
Urban Hospices--Outlying................ 40 0.4 1.8 2.2
Rural Hospices--New England............. 27 1.5 1.8 3.3
Rural Hospices--Middle Atlantic......... 35 0.0 1.8 1.8
Rural Hospices--South Atlantic.......... 108 0.0 1.8 1.8
Rural Hospices--East North Central...... 137 0.0 1.8 1.8
Rural Hospices--East South Central...... 111 0.0 1.8 1.8
Rural Hospices--West North Central...... 167 0.3 1.8 2.1
Rural Hospices--West South Central...... 160 0.2 1.8 2.0
Rural Hospices--Mountain................ 92 -0.4 1.8 1.4
Rural Hospices--Pacific................. 42 0.1 1.8 1.9
Rural Hospices--Outlying................ 6 -0.3 1.8 1.5
0-3,499 RHC Days (Small)................ 975 0.3 1.8 2.1
3,500-19,999 RHC Days (Medium).......... 2,036 0.1 1.8 1.9
20,000+ RHC Days (Large)................ 1,397 0.0 1.8 1.8
Non-Profit Ownership.................... 1,026 0.0 1.8 1.8
For Profit Ownership.................... 2,830 0.0 1.8 1.8
Government Ownership.................... 141 0.2 1.8 2.0
Other Ownership......................... 411 0.0 1.8 1.8
Freestanding Facility Type.............. 3,608 0.0 1.8 1.8
HHA/Facility-Based Facility Type........ 800 -0.1 1.8 1.7
----------------------------------------------------------------------------------------------------------------
Source: FY 2017 hospice claims from the Chronic Conditions Data Warehouse (CCW) Research Identifiable Files
(RIFs) as of February 2, 2018.
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. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 23, we have
prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this proposed rule.
Table 23 provides our best estimate of the possible changes in Medicare
payments under the hospice benefit as a result of the policies in this
proposed rule. This estimate is based on the data for 4,408 hospices in
our impact analysis file, which was constructed using FY 2017 claims
available in February 2018. All expenditures are classified as
transfers to hospices.
Table 23--Accounting Statement: Classification of Estimated Transfers
and Costs, From FY 2018 to FY 2019
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ $ 340 million.*
From Whom to Whom?........................ Federal Government to
Medicare Hospices.
------------------------------------------------------------------------
*The net increase of $340 million in transfer payments is a result of
the 1.8 percent hospice payment update compared to payments in FY
2018.
F. Regulatory Reform Analysis Under E.O. 13771
Executive Order 13771, entitled ``Reducing Regulation and
Controlling Regulatory Costs,'' was issued on January 30, 2017 (82 FR
9339, February 3, 2017) and requires that the costs associated with
significant new regulations ``shall, to the extent permitted by law, be
offset by the elimination of existing costs associated with at least
two prior regulations.'' It has been determined that this proposed rule
is an action that primarily results in transfers and does not impose
more than de minimis costs as described above and thus is not a
regulatory or deregulatory action for the purposes of Executive Order
13771.
G. Conclusion
We estimate that aggregate payments to hospices in FY 2019 will
increase by $340 million, or 1.8 percent, compared to payments in FY
2018. We estimate that in FY 2019, hospices in urban and rural areas
will experience, on average, 1.8 percent and 1.9 percent increases,
respectively, in estimated payments compared to FY 2018. Hospices
providing services in the urban West South Central and Outlying regions
and the rural New England region would experience the largest estimated
increases in payments of 2.2 percent and 3.3 percent, respectively.
Hospices serving patients in rural areas in the Mountain region would
experience, on average, the lowest estimated increase of 1.4 percent in
FY 2019 payments.
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
List of Subjects in 42 CFR Part 418
Health facilities, Hospice care, Medicare, Reporting and
recordkeeping requirements.
[[Page 20970]]
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services proposes to amend 42 CFR chapter IV as set forth
below:
PART 418--HOSPICE CARE
0
1. The authority citation for part 418 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
0
2. Section 418.3 is amended by revising paragraph (1) of the definition
of ``Attending physician'' and revising the definition of ``Cap
period'' to read as follows:
Sec. 418.3 Definitions.
* * * * *
Attending physician * * *
(1)(i) Doctor of medicine or osteopathy legally authorized to
practice medicine and surgery by the State in which he or she performs
that function or action; or
(ii) Nurse practitioner who meets the training, education, and
experience requirements as described in Sec. 410.75 (b) of this
chapter; or
(iii) Physician assistant who meets the requirements of Sec.
410.74 (c) of this chapter.
* * * * *
Cap period means the twelve-month period ending September 30 used
in the application of the cap on overall hospice reimbursement
specified in Sec. 418.309.
* * * * *
0
3. Section 418.304 is amended by revising the section heading and
adding paragraph (f) to read as follows:
Sec. 418.304 Payment for physician, and nurse practitioner, and
physician assistant services.
* * * * *
(f)(1) Effective January 1, 2019, Medicare pays for attending
physician services provided by physician assistants to Medicare
beneficiaries who have elected the hospice benefit and who have
selected a physician assistant as their attending physician. This
applies to physician assistants without regard to whether they are
hospice employees.
(2) The employer or a contractor of a physician assistant must bill
and receive payment for physician assistant services only if the--
(i) Physician assistant is the beneficiary's attending physician as
defined in Sec. 418.3;
(ii) Services are medically reasonable and necessary;
(iii) Services are performed by a physician in the absence of the
physician assistant and, the physician assistant services are furnished
under the general supervision of a physician; and
(iv) Services are not related to the certification of terminal
illness specified in Sec. 418.22.
(3) The payment amount for physician assistant services when
serving as the attending physician for hospice patients is 85 percent
of what a physician is paid under the Medicare physician fee schedule.
Dated: April 16, 2018.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
Dated: April 17, 2018.
Alex M. Azar II,
Secretary, Department of Health and Human Services.
[FR Doc. 2018-08773 Filed 4-27-18; 4:15 pm]
BILLING CODE 4120-01-P