Patients electing to receive hospice services should expect quality care and a comprehensive assessment of their needs at admission, which the HIS Comprehensive Assessment Measure reflects. 40. (7) Collection or public reporting of a measure leads to negative unintended consequences other than patient harm. Response: As stated in the FY 2022 hospice proposed rule (86 FR 19717 through 19719) as well as above, we proposed that Direct patient care salaries and contract labor costs be equal to costs reported on Worksheet A-1 (for CHC) or Worksheet A-2 (for RHC) or Worksheet A-3 (for IRC) or Worksheet A-4 (for GIP), column 7, for lines 26 through 37 (86 FR 19718). Section 1814(i)(5)(A)(i) of the Act was amended by the CAA 2021 and the payment reduction for failing to meet hospice quality reporting requirements is increased from 2 percent to 4 percent beginning with FY 2024. Under section 1135 of the Act, the Secretary may temporarily waive or modify certain Medicare, Medicaid, and Children's Health Insurance Program (CHIP) requirements to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the programs in the emergency area and time periods, and that providers who furnish such services in good faith, but who are unable to comply with one or more requirements as described under section 1135(b) of the Act, can be reimbursed and exempted from sanctions for violations of waived provisions (absent any determination of fraud or abuse). Medicare hospice: Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care. For further information, see the hospice center webpage: Hospital Price Transparency Enforcement Updates. As illustrated in Table 11, CY 2020 data submissions compliance impacts the FY 2022 APU. Results for both HCI and HVLDL indicate that using 2 years of data increases reportability. They ask us to consider a more gradual transition to new quality initiatives, staggered and prioritized. The President of the United States manages the operations of the Executive branch of Government through Executive orders. We believe these cost centers (Physician Administrative Services and Nursing Administration) are labor-intensive and vary with the local labor market and, thus, we believe contract labor costs for these services should be included in the labor shares for each level of care. The prior MCR did not collect total costs by level of care or detailed costs by level of care (such as labor and nonlabor). Several existing measures, such as the HIS-based HVWDII measure and its replacement HVLDL, also do not differentiate refused visits. We established our HH QRP Public Display Policy in the CY 2016 HH PPS final rule (80 FR 68709 through 68710). Report to the Congress: Medicare Payment Policy | March 2020. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf?sfvrsn=0. One commenter opposed the proposed labor shares, stating that the data in the cost report do not provide adequate or appropriate measures of labor expenses. The CAHPS Hospice Survey is a component of the CMS HQRP which is used to collect data on the experiences of hospice patients and the primary caregivers listed in their hospice records. 11. In the first stage, we would determine initial cut-points by calculating the clustering algorithm among hospices with 30 or more completed surveys over 2 quarters (that is, 6 months); restricting these calculations to hospices that meet a minimum sample size promotes stability of cut-points. The analysis found that 82.8 percent of providers' scores changed by, at most, one point over the 2 years. Response: We appreciate commenters' concerns that hospice providers continue to recognize and address the unique circumstances of hospice patients. Further, HCI like the other HQRP quality measures validates well with the CAHPS Hospice Survey willingness to recommend, which signifies a quality measure useful for public reporting. Accessed June 13, 2021. In the FY 2014 Hospice Wage Index and Payment Rate Update final rule (78 FR 48234) we stated that reportability of 71 percent through 90 percent is acceptable. CMS DISCLAIMER. Readers who want more information about the development of the survey, originally called the Hospice Experience of Care Survey, may refer to 79 FR 50452 and 78 FR 48261. On July 29, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1754-F) that updates Medicare hospice payments and the aggregate cap amount for FY 2022 in accordance with existing statutory and regulatory requirements. Specifically, we compared submission rates in Q4 2019 to average annual rates (Q4 2018 through Q3 2019) to assess the Start Printed Page 42579extent to which hospices had taken advantage of the exemption, and thus the extent to which data and measure scores might be affected. In addition, some commenters wanted CMS to consider creating a single star rating based on both CAHPS and other measures, such as the HOPE tool. We believe it is important to support consumers by sharing information on the performance of hospices that have lower scores, and to incentivize those hospices to improve. The analysis found that 83% of hospices had HCI scores that were 0-1 percentage points different in FY2019 relative to their FY2017 scores. A commenter stated that as currently structured, the penalty is a negative incentive to furnish the addendum in a timely manner if a hospice misses the initial required timeframe. This public reporting threshold protects the privacy Start Printed Page 42585of patients who seek care at smaller hospices. Given the exemptions provided due to COVID-19 PHE in the March 27, 2020 Guidance Memorandum,[45] A few commenters stated they believe the addendum and the ABN have the potential to decrease transparency and increase confusion for hospice patients, whereas, other commenters recommended expanding the usage of the addendum, which included combining the ABN and addendum, and to include drugs or services which the hospice has determined to be medically unreasonable or no longer necessary. In OMB Bulletin No. The comment suggested that the HIS Comprehensive Assessment measure would be likely to top out due to high scoring trends among hospices. As of FY 2012, new hospices have their cap determinations calculated using the patient-by-patient proportional methodology. February 26, 2020. https://www.medscape.com/viewarticle/925769#vp_1. Response: We appreciate these comments and agree that the utilization of pseudo-patients and simulation will facilitate more timely completion of training requirements for newly hired hospice aides as well as allowing hospices to target specific competency training for hospice aides noted to have deficient skill(s) on the supervisory visit. 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 HIS Comprehensive Assessment Measure captures whether multiple key care processes were delivered upon patients' admissions to hospice in one measure as described in the Table 6. This rate is designed to cover "room and board" which includes performance of personal care services, including assistance in the activities of daily living, administration of medication, maintaining the cleanliness of the member's environment, and supervision and assistance in the use of durable medical equipment and prescribed therapies. Changes in a hospices' quintile from the SPR to CAR scenario would indicate a re-ranking of hospices when using 3 quarters compared to 4 quarters. Department of Health and Human Services, Office of Inspector General. We received many comments emphasizing that financial incentives would encourage providers to adopt new HIT systems and work to reduce burden using FHIR and EHR. This final rule makes changes to the hospice CoPs regarding hospice aide competency evaluation standards. (2020). NQF endorsed six composite measures and two overall measures from the CAHPS Hospice Survey. Other commenters requested that this measure recognize visits offered during CHC or GIP care. We are also finalizing regulatory changes that are not directly related to PHE waivers that will clarify or align some policies that have been raised as concerns by stakeholders. While many commenters indicated that the proposed changes increase efficiency of training, none provided specific information or data to describe a change in burden. The draft of HOPE has undergone cognitive and pilot testing, and will undergo field testing to establish reliability, validity, and feasibility of the assessment instrument. Our analyses have determined that the optimal balance between these two goals is at 75 completed surveys per hospice. Measure scores will be updated annually in the QM Report as they will in the Preview Report and on Care Compare and the Provider Data Catalogue. 30. Specifically, we conducted a simulation using 2 years of data. Use the QPS tool and search for NQF number 2651. In the FY 2019 Hospice Wage Index and Rate Update final rule (83 FR 38622), we also adopted an eighth factor for removal of a measure. If regulations impose administrative costs on private entities, such as the time needed to read and interpret this rule, we should estimate the cost associated with regulatory review. This indicator identifies whether a hospice is below the 90th percentile in terms of the percentage of live Start Printed Page 42561discharges that are followed by a hospitalization (within two days of hospice discharge) and then the patient dies in the hospital. The HQRP will post a revised QM Users' Manual that contains HCI and HVLDL no later than October 1, 2021 at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures. No fee schedules, basic unit, relative values or related listings are included in CPT. Response: As stated previously, we recommend that hospices use data from their vendors for quality improvement, rather than wait for publicly-reported data. For more information about Care Compare, please see the Update on the Hospice Quality Reporting Requirements for FY 2022 in section D. Since 2017, we have increased and improved available information about the care hospices provide for consumers. Section III.D finalizes clarifying regulations text changes regarding the election statement addendum requirements that were finalized in the FY 2020 Hospice Wage Index and Rate Update final rule (84 FR 38484). The exception granted under the March 27, 2020 CMS Guidance Memo impacted the HH QRP public display schedule. documents in the last year, 887 http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf. 3. The size exemption is only valid for the year on the size exemption request form. The following sections provide the results of our testing and explain how we used the results to develop a plan that we believe allows us to achieve these objectives as best as possible. hbbd```b``"gH mX,$M0! 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. The 90-percent threshold is hereafter referred to as the timeliness compliance threshold. (2013). A summary of the comments we received on this proposal and our responses to those comments appear below: Comment: We received many comments supporting HH QRP reporting to resume beginning January 2022. For more information on the policies we have adopted for the HH QRP, we refer readers to the following rules: Section 1895(b)(3)(B)(v)(III) of the Act requires the Secretary to establish procedures for making HH QRP data, including data submitted under sections 1899B(c)(1) and 1899B(d)(1) of the Act, available to the public. Hospices in Montgomery County, Maryland may provide RHC and CHC to patients in the Washington-Arlington-Alexandria, DC-VA CBSA and to patients in the Baltimore-Columbia-Towson, Maryland CBSA. Regarding the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey, CMS 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 CAHPS requirements due to newness (81 FR 52182). Comment: We received seven comments in support of the proposed hospice update percentage of 2.3 percent. Comment: One commenter recommended CMS broaden its view of nurses to include licensed practical nurses (LPNs) for conducting aide supervisory visits. We identify skilled nursing visits by the presence of revenue code 055x (Skilled Nursing) on the claim. State/County MEDICAID Rate Charts: NHPCO has prepared the . We considered several factors to determine the number of years to include in measure calculations. This indicator identifies whether a hospice is above the 10th percentile in terms of the average number of skilled nursing minutes provided on RHC days during the reporting period examined. To estimate overhead salaries for each level of care, we first proposed to calculate noncapital nonbenefit overhead costs for each level of care to be equal to Worksheet B, column 18, less the sum of Worksheet B, columns 0 through 3, for line 50 (CHC), or line 51 (RHC) or line 52 (IRC) or line 53 (GIP). For HVLDL, where higher scores indicate better quality of care, the national average score was 65.5 percent in FY 2019, where 965 hospices did not meet the reportability threshold. In addition, section 407(a)(1) of the CAA 2021 adds new requirements in a newly added section 1822(a)(2) to require each state and local survey agency, and each national accreditation body with an approved hospice accreditation program, to submit information regarding any survey or certification made with respect to a hospice program. Instead, we will continue to post state and national averages for HH QRP measures. Providing information for decision-making is all the more important during and in the wake of a COVID-19 PHE, when our health as a nation has been shaken. Response: We appreciate commenters' interest in having the HCI reflect how prepared hospices are to provide key services to patients. For example, for HCI, as we discussed in the proposed rule, we compared index scores calculated for the same hospice using annual claims from Federal FY 2017 and 2019. While we are committed to provide time for understanding and preparation, we are not committed to ensuring that all hospices achieve high scores on the new measures before publicly reporting them. Final Decision: We are finalizing our proposal to use the FY 2022 pre-floor, pre-reclassified hospital wage index data as the basis for the FY 2022 hospice wage index. CMS' sub-regulatory Quality Measure Users' Manual on the CMS HQRP Current Measures web page will include specifications for each indicator and scoring for HVLDL, and the HIS Comprehensive Assessment measure (NQF #3235). The commenter stated that it appears that the percentage of hospice cost reports used for determining GIP and respite total costs and labor-component costs is based on a small population of hospice providers with a significant risk of error; therefore, the commenter recommended that CMS rethink its approach for GIP and respite labor costs. 13. We noted several categories, including: culture, spiritual beliefs, food insecurity, access to interpreter services, health literacy, Start Printed Page 42600caregiving, housing scarcity, marital status, and socioeconomic status. Our proposal to use the 2018 MCR data recognizes that providers have had 4 years to familiarize themselves with the form and, thereby, improve the accuracy of the data. In addition, CMS was required to Start Printed Page 42531consult with hospice programs and the Medicare Payment Advisory Commission (MedPAC) regarding additional data collection and payment revision options. Therefore using 3 quarters of data for the HIS Comprehensive Assessment Measure would achieve acceptable reportability shown in Table 14. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. They also requested that Care Compare provide information to users explaining that the published data included pre-COVID quarters. For each hospice, we divide the number of stays with at least one gap of eight or more days without a nursing visit (for stays of 30 or more days) by the number of stays of 30 or more days. COVID-19 Affected Reporting (CAR) Scenario: We calculated OASIS-based measures using 3 quarters of HH QRP CY 2019 data to simulate using only Q3 2020, Q4 2020, and Q1 2021 data for public reporting. Like HIS, our goal is to report as much of the most recent CAHPS Hospice Survey data as possible, to display data for as many hospices as possible, and to maintain the reliability of the data. We will continue to take all concerns, comments, and suggestions into account as we consider Fast Healthcare Interoperability Resources (FHIR) in support of Digital Quality Measurement in Post-Acute Care Quality Reporting Programs. This process will be necessary for each IP address you wish to access the site from, requests are valid for approximately one quarter (three months) after which the process may need to be repeated. documents in the last year, 825 The proposed rule also solicited comments from the public, hospice providers, patients and advocates regarding hospice utilization and spending patterns. 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. This indicator includes both RN and LPN visits to recognize the frequency of skilled nursing visits and to maintain consistency in HCI when using revenue center code 055X. Section 418.312 is amended by revising paragraph (b) to read as follows: (b) Submission of Hospice Quality Reporting Program data. Denominator: Total skilled nursing minutes provided by the hospice during RHC service days within a reporting period. Some commenters requested that LPNs count for the measure, in addition to RNs. We will consider this comment when working on any future modifications to the hospice cost report. The testing helped us develop a plan for displaying HH QRP data that are as up-to-date as possible and that also meet scientifically-acceptable standards for publicly displaying those data. The Office of Management and Budget (OMB) approved the collection of information to remove Section O of the HIS expiring on February 29, 2024, (OMB Control Number: 0938-1153, CMS-10390). Thus, inpatient services on line 25 are not captured. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/IPPS-Regulations-and-Notices. Medicare fee-for-service inpatient claims with through dates on and between January 1, 2016 and December 31, 2019 to determine dates of hospitalization. A summary of the comments we received on this proposal and our responses to those comments appear below: Comment: A few commenters expressed concern that hospices would not be able to view data close to real time, which might inhibit the ability to use the score to inform continuous quality improvement. During the spring and summer of 2020, we conducted testing to inform decisions about publicly reporting data for those refreshes which include exempt data. We included the HH QRP policy in this rulemaking in order to resume public reporting for the HH QRP with the January 2022 refresh of Care Compare. Hospices that intend to claim the size exemption are required to submit to CMS their completed exemption request form by December 31, of the data collection year. CMS believes that advancing our work with use of these programs standard offers the potential for supporting quality improvements and reporting which will improve care for our beneficiaries. While we recognize the additional context that state survey data would provide, we believe the claims data used to calculate the HCI will provide valuable information to consumers on their own. documents in the last year, by the National Oceanic and Atmospheric Administration Comment: One commenter had concerns with the inconsistent reporting of certain types of overhead expenses among hospices. Effective 10/01/2022, Hospice Go tohttps://www.mmis.georgia.gov/portal/to access the Hospice Manual. HOPE will enable CMS and hospices to understand the care needs of people through the dying process, supporting provider care planning and quality improvement efforts, and ensuring the safety and comfort of individuals enrolled in hospice nationwide. This simulation included Q2 through Q4 of 2019, which crosses the flu season. Response: We appreciate the support from commenters as well as MedPAC's concerns. We expect that hospices would take steps in working with patients and their representatives to better understand which methods (that is, in person, mail, etc.) We also received several comments responding to how CMS should incentivize the use of HIT. Comment: We received comments in support of the proposal to use two years of data for publicly reporting HVLDL and HCI. [50] Azar, A. M. (2020 March 15). Therefore, while we proposed to adopt the updates set forth in OMB Bulletin No. CMS maintains its proposal to weight Willingness to Recommend and Overall Rating at 50 percent each for the purpose of calculating an overall CAHPS Hospice Survey star rating. In addition, section 407(a)(2) of the CAA 2021 removes the prohibition on public disclosure of hospice surveys performed be a national accreditation agency in section 1865(b) of the Act, thus allowing the Secretary to disclose such accreditation surveys. For HIS, the quarters are defined based on submission of HIS admission or discharge assessments. This license will terminate upon notice to you if you violate the terms of this license. We are finalizing our proposal to remove the seven HIS process measures no earlier than May 2022 refresh from public reporting on Care Compare and from the Preview Reports but continue to have it publicly available in the data catalogue at https://data.cms.gov/provider-data/topics/hospice-care. We are finalizing our proposal to remove the seven individual HIS process measures from the HQRP, no longer publicly reporting them as individual measures on Care Compare beginning with FY 2022. on We believe that updating the data in January 2022 by more than a year relative to the October 2020 freeze data can assist the public by providing more relevant quality data and allow CMS to display more recent HHA performance. We previously finalized a one-time newness exemption for hospices that meet the criteria as stated in the FY 2017 Hospice Wage Index and Payment Rate Update final rule (81 FR 52181). The second column shows the number of hospices in each of the categories in the first column. Comment: Several comments suggested that CMS differentiate circumstances in which a patient refused a service measured by the HCI from circumstances in which the hospice did not offer the service to the patient. In the HIS V3.00 Paperwork Reduction Act Submission (OMB control number: 0938-1153, CMS-10390), we finalized a proposal to adopt HVLDL into the HQRP for FY 2021. The commenter recommended that the current continuous care timeframe change from midnight to midnight to a new time frame of noon to noon and that visits from other providers such as chaplains and home health aides count toward the continuous care timeframe. This does not constitute a change to the requirements of the CoPs. Hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to the annual hospice payment update percentage increase for the year. This could include a special open door forum or other venues for interaction. We appreciate the concern that consumers may not know about the component measure scores in the Provider Data Catalogue. To address the inclusion of administrative data, such as Medicare claims used for hospice claims-based measures like the HVLDL and HCI in the HQRP and correct technical errors identified in the FY 2016 and 2019 Hospice Wage Index and Payment Rate Update final rules, we proposed and finalize in this rule the regulation at 418.312(b) by adding paragraphs (b)(1) through (3). The last candidate measure discussed by the TEP was Timely Reduction of Symptoms which measures the percentage of patients who experience a reduction in the impact of symptoms other than pain. As a result of this rule, the HQRP will contain four quality measures that capture care across the hospice stay, including a new measure called the Hospice Care Index. 2016 99902 Comment: The majority of commenters supported the removal of the seven HIS process measures no earlier than May 2022. a. We also continued those requirements in all subsequent years (84 FR 38526). These specifications will now be contained in the revised HQRP QM User's Manual V4.00 located on the CMS HQRP Current measures web page. Therefore, we proposed conforming regulations text changes at 418.24(c) to reflect this policy. The quality, utility, and clarity of the information to be collected. Modest differences in ICC scores between scenarios would suggest that using fewer quarters of data does not impact the internal reliability of the results. Section 418.76 is amended by revising paragraphs (c)(1) and (h)(1)(iii) to read as follows: (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. We also received six comments on the use of the labor share standardization factor including hospices, national industry associations. We solicited public comment on the proposal to remove the seven HIS process quality measures as individual measures from the HQRP no earlier than May 2022, and to continue including the seven HIS process measures in the confidential quality measure (QM) Reports which are available to hospices. Thus, we believe that indicators five and indicator six of the HCI are necessary to differentiate concerning behaviors affecting patient care. Twenty unique stakeholders submitted their comments on the proposal to rebase the hospice labor shares. Journal of Hospice & Palliative Nursing: December 2018Volume 20Issue 6p 507. Our reweighted compensation cost weights for IRC and GIP were similar (less than one percentage point in absolute terms) to our proposed compensation cost weights for IRC and GIP (as shown in Table 1) and, therefore, we believe our sample is representative of freestanding hospices providing inpatient hospice care. Response: Star Ratings are easy for consumers to understand and interpret and are used in a variety of settings.