Medicare Program; FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements
Proposed rule.
CFR Part: "42 CFR Part 418"
RIN Number: "RIN 0938-AS39"
Citation: "80 FR 25832"
Document Number: "CMS-1629-P"
Page Number: "25832"
"Proposed Rules"
SUMMARY: This proposed rule would update the hospice payment rates and the wage index for fiscal year (FY) 2016, including implementing the last year of the phase-out of the wage index budget neutrality adjustment factor (BNAF). This proposed rule also discusses recent hospice payment reform research and analyses and proposes to differentiate payments for routine home care (RHC) based on the beneficiary's length of stay and to implement a service intensity add-on (SIA) payment for services provided in the last 7 days of a beneficiary's life, if certain criteria are met. In addition, this rule would implement changes to the aggregate cap calculation mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), align the cap accounting year for both the inpatient cap and the hospice aggregate cap with the federal fiscal year starting in FY 2017, make changes to the hospice quality reporting program, and would include a clarification regarding diagnosis reporting on the hospice claim.
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Table of Contents
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Costs, Benefits, and Transfers
II. Background
A.
B. History of the Medicare Hospice Benefit
C. Services Covered by the Medicare Hospice Benefit
D. Medicare Payment for Hospice Care
1. Omnibus Budget Reconciliation Act of 1989
2. Balanced Budget Act of 1997
3. FY 1998 Hospice Wage Index Final Rule
4. FY 2010 Hospice Wage Index Final Rule
5. The Affordable Care Act
6. FY 2012 Hospice Wage Index Final Rule
7. FY 2015 Hospice Rate Update Final Rule
8. Impact Act of 2014
E. Trends in Medicare Hospice Utilization
III. Provisions of the Proposed Rule
A. Hospice Payment Reform: Research and Analyses
1. Pre-Hospice Spending
2. Non-Hospice Spending for Hospice Beneficiaries During an Election
3. Live Discharge Rates
B. Proposed Routine Home Care Rates and Service Intensity Add-On (SIA) Payment
1.
a. U-Shaped Payment Model
b. Tiered Payment Model
c. Visits During the Beginning and End of a Hospice Election
2. Proposed Routine Home Care Rates
3. Proposed Service Intensity Add-on Payment
C. Proposed FY 2016 Hospice Wage Index and Rates Update
1. Proposed FY 2016 Hospice Wage Index
a. Background
b. Elimination of the Wage Index Budget Neutrality Factor (BNAF)
c. Proposed Implementation of New Labor Market Delineations
2. Proposed Hospice Payment Update Percentage
3. Proposed FY 2016 Hospice Payment Rates
4. Hospice Aggregate Cap and the IMPACT Act of 2014
D. Proposed Alignment of the Inpatient and Aggregate Cap Accounting Year with the Federal Fiscal Year
1. Streamlined Method and Patient-by-Patient Proportional Method for Counting Beneficiaries to
2. Proposed Inpatient and Aggregate Cap Accounting Year Timeframe
E. Proposed Updates to the Hospice Quality Reporting Program
1.
2. General Considerations Used for Selection of Quality Measures for the HQRP
3. Proposed Policy for Retention on HQRP Measures Adopted for Previous Payment Determination
4. Previously Adopted Measures for FY 2016 and FY 2017 Payment Determination
5. HQRP Quality Measures and Concepts Under Consideration for Future Years
6. Form, Manner, and Timing of Quality Data Submission
a. Background
b. Proposed Policy for New Facilities to Begin Submitting Quality Data
c. Previously Finalized Data Submission Mechanism, Collection Timelines, and Submission Deadlines for the FY 2017 Payment Determination
d. Proposed Data Submission Timelines and Requirements for FY 2018 Payment Determination and Subsequent Years
e. Proposed HQRP Data Submission and Compliance Thresholds for the FY 2018 Payment Determination and Subsequent Years
7. HQRP Submission Exception and Extension Requirements for the FY 2017 Payment Determination and Subsequent Years
8. Adoption of the
a. Background Description of the Survey
b. Participation Requirements to Meet Quality Reporting Requirements for the FY 2017 APU
c. Participation Requirements to Meet Quality Reporting Requirements for the FY 2018 APU
d. Vendor Participation Requirements for the FY 2017 APU Annual Payment Update
9. Previously Finalized HQRP Reconsideration and Appeals Procedures for the FY 2016 Payment Determination and Subsequent Years
10. Public Display of Quality Measures Data for HQRP
11. Public Display of other Hospice Information
F. Clarification Regarding Diagnosis Reporting on Hospice Claims
1. Background
2. Current Discussions About Hospice Vulnerabilities
3. Medicare Hospice Eligibility Requirements
4. Assessment of Conditions and Comorbidities Required by Regulation
5. Clarification Regarding Diagnosis Reporting on Hospice Claims
IV. Collection of Information Requirements
V. Regulatory Impact Analysis
A. Statement of Need
B. Introduction
C. Overall Impact
1. Detailed Economic Analysis
a. Effects on Hospices
b. Hospice Size
c. Geographic Location
d. Type of Ownership
e. Hospice Base
f. Effects on Other Providers
g. Effects on the
h. Alternatives Considered
i. Accounting Statement
j. Conclusion
2. Regulatory Flexibility Act Analysis
3. Unfunded Mandates Reform Act Analysis
VI. Federalism Analysis and Regulations Text
Acronyms
Because of the many terms to which we refer by acronym in this proposed rule, we are listing the acronyms used and their corresponding meanings in alphabetical order below:
APU Annual Payment Update
ASPE Assistant Secretary of Planning and Evaluation
BBA Balanced Budget Act of 1997
BETOS Berenson-Eggers Types of Service
BIPA Benefits Improvement and Protection Act of 2000
BNAF Budget Neutrality Adjustment Factor
CAHPS(R) Consumer Assessment of Healthcare Providers and Systems
CBSA Core-Based Statistical Area
CCN CMS Certification Number
CFR Code of Federal Regulations
CHC Continuous Home Care
CHF Congestive Heart Failure
COPD Chronic Obstructive Pulmonary Disease
CoPs Conditions of Participation
CPI-U Consumer Price Index-Urban Consumers
CR Change Request
CVA Cerebral Vascular Accident
CWF Common Working File
CY Calendar Year
DME Durable Medical Equipment
FEHC Family Evaluation of Hospice Care
FY Fiscal Year
GAO
GIP General Inpatient Care
HHS
HIPPA Health Insurance Portability and Accountability Act
HIS Hospice Item Set
HQRP Hospice Quality Reporting Program
IACS Individuals Authorized Access to CMS Computer Services
ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modification
ICR Information Collection Requirement
IMPACT Act Improving Medicare Post-Acute Care Transformation Act of 2014
IPPS Inpatient Prospective Payment System
IRC Inpatient Respite Care
LCD Local Coverage Determination
MAC Medicare Administrative Contractor
MFP Multifactor Productivity
MSA Metropolitan Statistical Area
NF Long Term Care Nursing Facility
NOE Notice of Election
NOTR Notice of Termination/Revocation
NP Nurse Practitioner
NPI National Provider Identifier
PS&R Provider Statistical and Reimbursement Report
Pub. L Public Law
QAPI Quality Assessment and Performance Improvement
RHC Routine Home Care
RN Registered Nurse
SIA Service Intensity Add-on
SNF Skilled Nursing Facility
TEFRA Tax Equity and Fiscal Responsibility Act of 1982
UHDDS Uniform Hospital Discharge Data Set
U.S.C. United States Code
I. Executive Summary for This Proposed Rule
A. Purpose
This rule proposes updates to the payment rates for hospices for fiscal year (FY) 2016, as required under section 1814(i) of the Social Security Act (the Act) and reflects the final year of the 7-year Budget Neutrality Adjustment Factor (BNAF) phase-out finalized in the FY 2010 Hospice Wage Index final rule (74 FR 39407). Our proposed update to payment rates for hospices also includes a proposal to change the hospice wage index by incorporating the new
B. Summary of the Major Provisions
Section III.A of this proposed rule provides an update on hospice payment reform research and analysis. As a result of the hospice payment reform research and analysis conducted over the past several years, some of which is described in section III.A of this proposed rule and in various technical reports available on the
In section III.C.1 of this rule, we propose to update the hospice wage index using a 50/50 blend of the existing CBSA designations and the new CBSA designations outlined in a
In section III.E of this rule, we discuss updates to the hospice quality reporting program, including participation requirements for current year (CY) 2015 regarding the Consumer Assessment of Healthcare Providers and Systems (CAHPS(R))
C. Summary of Impacts
Table 1--Impact Summary Table Provision Transfers description FY 2016 Hospice Wage The overall economic impact of this proposed rule Index and Payment Rate is estimated to be$200 million in increased Update payments to hospices during FY 2016.
II. Background
A.
Hospice care is an approach to treatment that recognizes that the impending death of an individual warrants a change in the focus from curative care to palliative care for relief of pain and for symptom management. The goal of hospice care is to help terminally ill individuals continue life with minimal disruption to normal activities while remaining primarily in the home environment. A hospice uses an interdisciplinary approach to deliver medical, nursing, social, psychological, emotional, and spiritual services through use of a broad spectrum of professionals and other caregivers, with the goal of making the individual as physically and emotionally comfortable as possible. Hospice is compassionate patient and family-centered care for those who are terminally ill. It is a comprehensive, holistic approach to treatment that recognizes that the impending death of an individual necessitates a change from curative to palliative care.
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 care is palliative care for individuals with a prognosis of living 6 months or less if the terminal illness runs its normal course. When an individual is terminally ill, many health problems are brought on by underlying condition(s), as bodily systems are interdependent. In the
The goal of hospice care is to make the hospice patient as physically and emotionally comfortable as possible, with minimal disruption to normal activities, while remaining primarily in the home environment. Hospice care uses an interdisciplinary approach to deliver medical, nursing, social, psychological, emotional, and spiritual services through the use of a broad spectrum of professional and other caregivers and volunteers. While the goal of hospice care is to allow for the individual to remain in his or her home environment, circumstances during the end-of-life may necessitate short-term inpatient admission to a hospital, skilled nursing facility (SNF), or hospice facility for procedures necessary for pain control or acute or chronic symptom management that cannot be managed in any other setting. These acute hospice care services are to ensure that any new or worsening symptoms are intensively addressed so that the individual can return to his or her home environment at a home level of care. Short-term, intermittent, inpatient respite services are also available to the family of the hospice patient when needed to relieve the family or other caregivers. Additionally, an individual can receive continuous home care during a period of crisis in which an individual requires primarily continuous nursing care to achieve palliation or management of acute medical symptoms so that the individual can remain at home. Continuous home care may be covered on a continuous basis for as much as 24 hours a day, and these periods must be predominantly nursing care in accordance with our regulations at
Hospices are expected to comply with all civil rights laws, including the provision of auxiliary aids and services to ensure effective communication with patients or patient care representatives with disabilities consistent with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act, and to provide language access for such persons who are limited in English proficiency, consistent with Title VI of the Civil Rights Act of 1964. Further information about these requirements may be found at http://www.hhs.gov/ocr/civilrights.
B. History of the Medicare Hospice Benefit
Before the creation of the
FOOTNOTE 1 Connor, Stephen. (2007). Development of Hospice and Palliative Care in
FOOTNOTE 2 Paolini, DO,
As stated in the
The benefit was originally designed to cover hospice care for a finite period of time that roughly corresponded to a life expectancy of 6 months or less. Initially, beneficiaries could receive three election periods: Two 90-day periods and one 30-day period. Currently,
C. Services Covered by the Medicare Hospice Benefit
One requirement for coverage under the
Section 1814(a)(7)(B) of the Act requires that a written plan for providing hospice care to a beneficiary who is a hospice patient be established before care is provided by, or under arrangements made by, that hospice program and that the written plan be periodically reviewed by the beneficiary's attending physician (if any), the hospice medical director, and an interdisciplinary group (described in section 1861(dd)(2)(B) of the Act). The services offered under the
Before the
* Patient and family know of the terminal condition.
* Further medical treatment and intervention are indicated only on a supportive basis.
* Pain control should be available to patients as needed to prevent rather than to just ameliorate pain.
* Interdisciplinary teamwork is essential in caring for patient and family.
* Family members and friends should be active in providing support during the death and bereavement process.
* Trained volunteers should provide additional support as needed.
The cost data and the findings on what services hospices provided in the demonstration project were used to design the
D. Medicare Payment for Hospice Care
Sections 1812(d), 1813(a)(4), 1814(a)(7), 1814(i), and 1861(dd) of the Act, and our regulations in part 418, establish eligibility requirements, payment standards and procedures, define covered services, and delineate the conditions a hospice must meet to be approved for participation in the
1. Omnibus Budget Reconciliation Act of 1989
Section 6005(a) of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239) amended section 1814(i)(1)(C) of the Act and provided for the following two changes in the methodology concerning updating the daily payment rates: (1) Effective
2. Balanced Budget Act of 1997
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33) amended section 1814(i)(1)(C)(ii)(VI) of the Act to establish updates to hospice rates for FYs 1998 through 2002. Hospice rates were updated by a factor equal to the hospital market basket percentage increase, minus 1 percentage point. Payment rates for FYs from 2002 have been updated according to section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update to the payment rates for subsequent FYs will be the hospital market basket percentage increase for the FY. The Act requires us to use the inpatient hospital market basket to determine hospice payment rates.
3. FY 1998 Hospice Wage Index Final Rule
In the
4. FY 2010 Hospice Wage Index Final Rule
Inpatient hospital pre-floor and pre-reclassified wage index values, as described in the
5. The Affordable Care Act
Starting with FY 2013 (and in subsequent FYs), the market basket percentage update under the hospice payment system referenced in sections 1814(i)(1)(C)(ii)(VII) and 1814(i)(1)(C)(iii) of the Act will be annually reduced by changes in economy-wide productivity, as specified in section 1886(b)(3)(B)(xi)(II) of the Act, as amended by section 3132(a) of the Patient Protection and Affordable Care Act (Pub. L. 111-148) as amended by the Health Care and Education Reconciliation Act (Pub. L. 111-152) (collectively referred to as the Affordable Care 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 as specified in section 1814(i)(1)(C)(v) of the Act).
In addition, sections 1814(i)(5)(A) through (C) of the Act, as amended by section 3132(a) of the Affordable Care Act, require hospices to begin submitting quality data, based on measures to be specified by the Secretary of the
Section 1814(a)(7)(D)(i) of the Act was amended by section 3132(b)(2)(D)(i) of the Affordable Care Act, and requires, effective
6. FY 2012 Hospice Wage Index Final Rule
When the
7. FY 2015 Hospice Rate Update Final Rule
When electing hospice, a beneficiary waives
A hospice "attending physician" is described by the statutory and regulatory definitions as a medical doctor, osteopath, or nurse practitioner whom the patient identifies, at the time of hospice election, as having the most significant role in the determination and delivery of his or her medical care. We received reports of problems with the identification of the patient's designated attending physician and a third of hospice patients had multiple providers submit Part B claims as the "attending physician" using a modifier. The FY 2015 Hospice Rate Update final rule finalized a requirement that the election form must include the beneficiary's choice of attending physician and that the beneficiary provide the hospice with a signed document when he or she chooses to change attending physicians (79 FR 50479).
Hospice providers are required to begin using a Hospice Experience of
Finally, the FY 2015 Hospice Rate Update final rule requires providers to complete their aggregate cap determination within 5 months after the cap year, but not sooner than 3 months after the end of the cap year, and remit any overpayments. Those hospices that do not submit their aggregate cap determinations will have their payments suspended until the determination is completed and received by the Medicare Administrative Contractor (MAC) (79 FR 50503).
8. IMPACT Act of 2014
The Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014 became law on
E. Trends in Medicare Hospice Utilization
Since the implementation of the hospice benefit in 1983, and especially within the last decade, there has been substantial growth in hospice utilization. The number of
There have also been changes in the diagnosis patterns among
Table 2--The Top Twenty Principal Hospice Diagnoses, FY 2002, FY 2007, FY 2013, FY 2014 Rank ICD-9/Reported Count Percentage Principal Diagnosis Year: FY 2002 1 162.9 Lung Cancer 73,769 11 2 428.0 Congestive 45,951 7 Heart Failure 3 799.3 Debility 36,999 6 Unspecified 4 496 COPD 35,197 5 5 331.0 Alzheimer's 28,787 4 Disease 6 436 CVA/Stroke 26,897 4 7 185 Prostate 20,262 3 Cancer 8 783.7 Adult 18,304 3 Failure To Thrive 9 174.9 Breast 17,812 3 Cancer 10 290.0 Senile 16,999 3 Dementia, Uncomp 11153.0 Colon Cancer 16,379 2 12 157.9 Pancreatic 15,427 2 Cancer 13 294.8 Organic 10,394 2 Brain Synd Nec 14 429.9 Heart 10,332 2 Disease Unspecified 15 154.0 Rectosigmoid 8,956 1 Colon Cancer 16 332.0 Parkinson's 8,865 1 Disease 17 586 Renal Failure 8,764 1 Unspecified 18 585 Chronic Renal 8,599 1 Failure (End 2005) 19 183.0 Ovarian 7,432 1 Cancer 20 188.9 Bladder 6,916 1 Cancer Year: FY 2007 1 799.3 Debility 90,150 9 Unspecified 2 162.9 Lung Cancer 86,954 8 3 428.0 Congestive 77,836 7 Heart Failure 4 496 COPD 60,815 6 5 783.7 Adult 58,303 6 Failure To Thrive 6 331.0 Alzheimer's 58,200 6 Disease 7 290.0 Senile 37,667 4 Dementia Uncomp 8 436 CVA/Stroke 31,800 3 9 429.9 Heart 22,170 2 Disease Unspecified 10 185 Prostate 22,086 2 Cancer 11 174.9 Breast 20,378 2 Cancer 12 157.9 Pancreas 19,082 2 Unspecified 13153.9 Colon Cancer 19,080 2 14 294.8 Organic 17,697 2 Brain Syndrome NEC 15 332.0 Parkinson's 16,524 2 Disease 16 294.10 Dementia In 15,777 2 Other Diseases w/o Behav. Dist 17 586 Renal Failure 12,188 1 Unspecified 18 585.6 End Stage 11,196 1 Renal Disease 19 188.9 Bladder 8,806 1 Cancer 20 183.0 Ovarian 8,434 1 Cancer Year: FY 2013 1 799.3 Debility 127,415 9 Unspecified 2 428.0 Congestive 96,171 7 Heart Failure 3 162.9 Lung Cancer 91,598 6 4 496 COPD 82,184 6 5 331.0 Alzheimer's 79,626 6 Disease 6 783.7 Adult 71,122 5 Failure To Thrive 7 290.0 Senile 60,579 4 Dementia, Uncomp 8 429.9 Heart 36,914 3 Disease Unspecified 9 436 CVA/Stroke 34,459 2 10 294.10 Dementia In 30,963 2 Other Diseases w/o Behavioral Dist 11 332.0 Parkinson's 25,396 2 Disease 12153.9 Colon Cancer 23,228 2 13 294.20 Dementia 23,224 2 Unspecified w/o Behavioral Dist 14 174.9 Breast 23,059 2 Cancer 15 157.9 Pancreatic 22,341 2 Cancer 16 185 Prostate 21,769 2 Cancer 17 585.6 End-Stage 19,309 1 Renal Disease 18 518.81 Acute 15,965 1 Respiratory Failure 19 294.8 Other 14,372 1 Persistent Mental Dis.--classified elsewhere 20 294.11 Dementia In 13,687 1 Other Diseases w/Behavioral Dist Year: FY 2014 1 331.0 Alzheimer's 127,438 9 disease 2 428.0 Congestive 106,570 8 heart failure, unspecified 3 162.9 Lung Cancer 89,726 6 4 496 COPD 78,643 6 5 290.0 Senile 40,120 3 dementia, uncomplicated 6 429.9 Heart 36,929 3 disease, unspecified 7 436 CVA/Stroke 33,466 2 8 294.20 Dementia, 33,119 2 unspecified, without behavioral disturbance 9 332.0 Parkinson's 30,070 2 Disease 10153.9 Colon Cancer 23,385 2 11 174.9 Breast 23,343 2 Cancer 12 157.9 Pancreatic 22,521 2 Cancer 13 185 Prostate 22,136 2 Cancer 14 585.6 End stage 21,467 2 renal disease 15 294.10 Dementia in 19,523 1 conditions classified elsewhere w/o behav disturbance 16 331.2 Senile 18,660 1 degeneration of brain 17 518.81 Acute 17,347 1 respiratory failure 18 290.40 Vascular 17,220 1 dementia, uncomplicated 19 491.21 Obstructive 15,985 1 chronic bronchitis with (acute) exacerbation 20 429.2 14,186 1 Cardiovascular disease, unspecified Note(s): The frequencies shown represent beneficiaries that had a least one claim with the specific ICD-9-CM code reported as the principal diagnosis. Beneficiaries could be represented multiple times in the results if they have multiple claims during that time period with different principal diagnoses. Source: FY 2002 and 2007 hospice claims data from theChronic Conditions Data Warehouse (CCW), accessed onFebruary 14 andFebruary 20, 2013 . FY 2013 hospice claims data from the CCW, accessed onJune 26, 2014 and preliminary FY 2014 hospice claims data from the CCW, accessed onJanuary 26, 2015 .
III. Provisions of the Proposed Rule
A.
In 2010, the
Since 2010, we have undertaken efforts to collect the data needed to establish what revisions to the methodology for determining the hospice payment rates may be necessary. Effective
FOOTNOTE 3 CMS Transmittal 2864, "Additional Data Reporting Requirements for Hospice claim". Available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2864P.pdf. END FOOTNOTE
FOOTNOTE 4 http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/Hospice-Project-Background.pdf. END FOOTNOTE
The FY 2012 Hospice Wage Index final rule (76 FR 47324) noted our collaboration with the Assistant Secretary of Planning and Evaluation (ASPE) to develop analyses that were used to inform our research efforts. The results from such analyses were used by
The majority of the research and analyses conducted by CMS and summarized in this rule were based on analyses of FY 2013
1. Pre-Hospice Spending
In 1982, the
FOOTNOTE 5 Subcommittee of Health of the
FOOTNOTE 6 Mor V. Masterson-Allen S. (1987): Hospice care systems: Structure, process, costs and outcome.
FOOTNOTE 7 Fogel,
FOOTNOTE 8 Connor, S. (2007). Development of Hospice and Palliative Care in the Unites States. OMEGA. 56(1), 89-99. doi:102190/OM.5.1.h. END FOOTNOTE
Analysis was conducted to evaluate pre-hospice spending for beneficiaries who ever used hospice that died in FY 2013. To evaluate pre-hospice spending, we calculated the median daily
Table 3--Median Pre-Hospice Daily Spending Estimates and Interquartile Range Based on 180, 90, and 30 Day Look-Back Periods Prior toInitial Hospice Admission With Estimates of Average Lifetime Length of Stay (LOS) by Primary Diagnosis at Hospice Admission, FY 2013 Estimates of daily non-hospice Medicare spending prior to first hospice admission 180 day look-back 90 day look-back 25th pct. Median 75th pct. 25th pct. Median 75th pct. All Diagnoses$47.04 $117.73 $240.73 $55.75 $157.89 $337.97 Alzheimer's, 23.39 66.84 162.60 23.06 82.00 220.12 Dementia, and Parkinson's CVA/Stroke 56.18 116.86 239.30 82.32 170.40 352.74 Cancers 62.81 143.56 265.58 78.30 188.08 360.92 Chronic Kidney 94.78 217.46 402.10 126.41 293.18 541.41 Disease Heart (CHF and 61.28 135.48 255.53 80.62 186.52 364.24 Other Heart Disease) Lung (COPD and 65.53 142.78 272.13 90.68 201.02 401.12 Pneumonias) All Other 36.00 99.80 222.25 39.45 132.88 316.15 Diagnoses
Table 3--Median Pre-Hospice Daily Spending Estimates and Interquartile Range Based on 180, 90, and 30 Day Look-Back Periods Prior toInitial Hospice Admission With Estimates of Average Lifetime Length of Stay (LOS) by Primary Diagnosis at Hospice Admission, FY 2013 Estimates of daily non-hospice Medicare Mean spending prior to first hospice admission lifetime LOS 30 day look-back 25th pct. Median 75th pct. All Diagnoses$57.66 $266.84 $545.44 73.8 Alzheimer's, 21.02 105.24 368.30 119.3 Dementia, and Parkinson's CVA/Stroke 150.21 352.41 622.23 47.4 Cancers 81.52 289.85 569.67 47.1 Chronic Kidney 199.01 466.25 820.78 27.3 Disease Heart (CHF and 101.80 325.15 588.50 77.2 Other Heart Disease) Lung (COPD and 126.51 367.68 685.17 67.5 Pneumonias) All Other 38.96 213.84 504.57 85.3 Diagnoses Source: All Medicare Parts A, B, and D claims for FY 2013 from theChronic Conditions Data Warehouse (CCW) retrieved March, 2015. Note(s): Estimates drawn from FY2013 hospice decedents who were first-time hospice admissions, ages 66+ at hospice admission, admitted since 2006, and not enrolled inMedicare Advantage prior to admission. All payments are inflation-adjusted toSeptember 2013 dollars using the Consumer Price Index (Medical Care; All Urban Consumers).
See Illustration in Original Document.
In the FY 2014 Hospice Wage Index and Payment Rate Update proposed and final rules (78 FR 27843 and 78 FR 48272), we discussed whether a case-mix system could be created in future refinements to differentiate hospice payments according to patient characteristics. While we do not have the necessary data on the hospice claim form at this time to conduct more thorough research to determine whether a case-mix system is appropriate, analyzing pre-hospice spending was undertaken as an initial step in determining whether patients required different resource needs prior to hospice based on the principal diagnosis reported on the hospice claim. Table 3 and Figure 1 above indicate that hospice patients with the longest length of stay had lower pre-hospice spending relative to hospice patients with shorter lengths of stay. These hospice patients tend to be those with neurological conditions, including those with Alzheimer's disease, other related dementias and Parkinson's disease. Typically, these conditions are associated with longer disease trajectories, progressive loss of functional and cognitive abilities, and more difficult prognostication. Research has shown that the majority of dementia patients are cared for at home, thereby causing informal costs that put an economic burden on families rather than on healthcare systems. /9/ Additionally, research using the
FOOTNOTE 9 Schaller, S., Mauskopf, J., Kriza, C., Wahlster, P., Kolominsky-Rabas, P. (2015). The main cost drivers in dementia: a systematic review.
FOOTNOTE 10 Ayyagari, P.,
FOOTNOTE 11 http://www.rand.org/pubs/external_publications/EP20040207.html. Accessed on
FOOTNOTE 12 Yang, Z., Zhang, K., Lin, P., Clevenger, C., & Atherly, A. (2012). A Longitudinal Analysis of the Lifetime Cost of Dementia.
2. Non-Hospice Spending for Hospice Beneficiaries During an Election
When a beneficiary elects the
FOOTNOTE 13 Medicare Claims Processing Manual, Chapter 11-Processing Hospice Claims, Section 30.4-Claims from Medicare Advantage Organizations, B-Billing of Covered Services. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c11.pdf. END FOOTNOTE
FOOTNOTE 14 Medicare Claims Processing Manual, Chapter 11-Processing Hospice Claims, Section 30.3-Data Required on the Institutional Claim to Medicare Contractors, Conditions Codes. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c11.pdf. END FOOTNOTE
For FY 2013, we found that
Table 4 below details the various components of Part D spending for patients receiving hospice care. The portion of the
Table 4--Drug Cost Sources for Hospice Beneficiaries' FY 2013 Drugs Received Through Part D Component FY 2013 expenditures (Patient Pay Amount)$50,871,517 (Low Income Cost-Sharing Subsidy) 116,890,745 (Other True Out-of Pocket Amount) 2,125,071 (Patient Liability Reduction due to 6,678,561 Other Payer Amount) (Covered Drug Plan Paid Amount) 230,216,153 (Non-Covered Plan Paid Amount 28,733,518 (Six Payment Amount Totals) 435,515,566 (Unknown/Unreconciled) 3,945,667 (Gross Total Drug Costs, Reported) 439,461,233 Source:Abt Associates analysis of 100% FY 2013 Medicare Claim Files. For more information on the components above and on Part D data, go to theResearch Data Assistance Center's (ResDAC's) Web site at: http://www.resdac.org/.
Non-hospice
FOOTNOTE 15 MedPAC, "Assessing payment adequacy and updating payments: hospice services",
In a recent report, the
FOOTNOTE 16 oig.hhs.gov/oas/region6/61000059.pdf "Medicare Could Be Paying Twice for Prescriptions For Beneficiaries in Hospice". END FOOTNOTE
FOOTNOTE 17 The case studies were developed using CY 2013 claims data for only those beneficiaries with Parts A, B and D coverage throughout their hospice. In identifying services that overlapped with a hospice election, we used two methods. The first method identified a match between the first three diagnosis codes of the hospice claim and the diagnosis codes of the overlapping services in the Part A, Part B, and Part D claim for the same beneficiary. The second method identified a match between the hospice diagnoses and the diagnosis codes of the overlapping services in the Part A, Part B and Part D based on a diagnosis code on the overlapping claim and any diagnosis on the hospice claim mapping to the same
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Across Terminal Conditions
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) products whose use was initiated during a hospice stay are likely related to the terminal prognosis. Table 5 and 6 below summarizes total concurrent billing for DMEPOS products by Berenson-Eggers Types of Service (BETOS) categories and concurrent Durable Medical Equipment (DME) billing by the top 20 principal diagnoses as reported on hospice claims in CY 2013. /18/ These diagnoses comprised 2.3 million hospice stays, and accounted for
FOOTNOTE 18 DMEPOS HCPCS codes are summarized by Berenson-Eggers Types of Service (BETOS) categories. BETOS categories were developed by the
Table 5--Concurrent Payments for All DME Use Initiated During a Hospice Stay by BETOS Category, CY 2013 DMEPOS BETOS category Total payment for related DME Hospital Beds$943,731 Wheelchairs 2,295,038 Oxygen and Supplies 2,412,281 Orthotics and Prosthetics 4,400,353Medical/Surgical Supplies 7,467,616 Other DME 9,585,003 Total 27,104,022
Table 6--Concurrent Payments for All DME Use Initiated During a Hospice Stay by Top 20 Principal Diagnosis Reported on Hospice Claim, CY 2013 Principal diagnosis Total payment for related DME Heart failure$3,365,348 Malignant neoplasm of trachea, bronchus, and lung 1,519,514 Other cerebral degenerations 2,979,399 Other organic psychotic conditions (chronic) 2,540,146 Chronic airways obstruction, not elsewhere classified 2,610,628 Senile and presenile organic psychotic conditions 2,868,760 Other ill-defined and unknown causes of morbidity and 2,349,855 mortality Ill-defined descriptions and complications of heart 1,584,522 disease Acute but ill-defined cerebrovascular disease 1,092,772 Other diseases of lung 412,501 Chronic renal failure 415,800 Symptoms concerning nutrition, metabolism, and 1,390,685 development Malignant neoplasm of pancreas 297,573 Malignant neoplasm of female breast 486,019 Malignant neoplasm of colon 521,690 Parkinson's disease 955,390 Malignant neoplasm of prostate 312,754 Late effects of cerebrovascular disease 559,253 Other forms of chronic ischemic heart disease 670,947 Malignant neoplasm of liver and intrahepatic bile 170,470 ducts
We noted that hospice beneficiaries with hospice claims-reported principal diagnoses of chronic airway obstruction, congestive heart failure, cerebral degeneration and lung cancer were receiving services clinically indicated and recommended for these conditions outside of the hospice benefit, which is in violation of requirements regarding the
Malignant Neoplasm of the Trachea, Bronchus, and Lung
Malignant neoplasm of the trachea, bronchus, and lung (or lung cancer) is defined by ICD-9 diagnosis codes beginning with 162 and describes malignant cancers affecting various part of the pulmonary system. Symptoms for this class of conditions may include chronic and worsening cough, shortness of breath, chest pain, metastatic bone pain, and anorexia and weight loss. Clinical practice guidelines for end-stage cancer recommend treatment and management of refractory symptoms including pain, mucositis, dyspnea, fatigue, depression and anorexia through the use of pharmacological interventions including nonsteroidal anti-inflammatories, corticosteroids, opioids and antidepressants. /19/ Additionally, evidence shows that palliative chemotherapy and radiotherapy can provide symptom relief from bone and brain metastasis. /20/ Recommended interventions for dyspnea include treatment of the underlying reason such as, thoracentesis for pleural effusion, bronchodilators and systemic corticosteroids for inflammation and secretions, and supportive measures such supplemental oxygen, opioids and anxiolytics to decrease the sensation of breathlessness. /21/
FOOTNOTE 19 Qaseem A, Snow V, Shekelle P, Casey DE, Cross JT, Owens DK, et al. Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the
FOOTNOTE 20 Palliative care in lung cancer*: accp evidence-based clinical practice guidelines (2nd edition) Kvale PA, Selecky PA,
FOOTNOTE 21 ibid. END FOOTNOTE
Our assessment of concurrently billed Part D drugs included 89,925 stays for beneficiaries with ICD-9 code 162 listed as a primary diagnosis on the hospice claim. Our assessment of concurrently billed Part B services included 153,199 stays. In CY 2013, concurrent billing for all services related this terminal condition comprised
Table 7--Concurrent Payments for Services Provided to Hospice Beneficiaries With Malignant Neoplasm of the Trachea, Bronchus, and Lung, CY 2013 Type of service Description Total payment Drugs/Part D Common Palliative Drugs$851,639 Drugs/Part D Anti-neoplastics (chemotherapy) 1,321,507 DME Oxygen Equipment and Supplies 454,068 DME Hospital Beds 47,781 DME Wheelchairs 138,316 Part B Inst. Diagnostic Imaging 341,601 Part B Inst. Radiation 250,171 Total 3,405,083
Chronic Airway Obstruction
Chronic airway obstruction is defined by ICD-9 diagnosis codes beginning with 496 and includes chronic lung disease with unspecified cause, and is characterized by inflammation of the lungs and airways. Typical symptoms of these pulmonary diseases include increasing and disabling shortness of breath, labored breathing, increased coughing, increased heart rate, decreased functional reserve, increased infections and unintentional, progressive weight loss. Evidence-based practice supports the benefits of oral opioids, neuromuscular electrical stimulation, chest wall vibration, walking aids, respiratory assist devices and pursed-lip breathing in the management of dyspnea in the individual patient with advanced COPD. /22/ Oxygen is recommended for COPD patients with resting hypoxemia for symptomatic benefit. /23/ Additionally, clinical practice guidelines recommend inhaled bronchodilators, systemic corticosteroids, and pulmonary physiotherapy for the management of COPD exacerbations. /24/ Analysis conducted by
FOOTNOTE 22 DD Marciniuk, D Goodridge, P Hernandez, et al. (2011).
FOOTNOTE 23 ibid END FOOTNOTE
FOOTNOTE 24
FOOTNOTE 25 DMEPOS HCPCS codes are summarized by Berenson-Eggers Types of Service (BETOS) categories. BETOS categories were developed by the
Table 8--Concurrent Payments for Services Provided to Hospice Beneficiaries With Chronic Airway Obstruction, CY 2013 Type of service Description Total payment Drugs/Part D Common Palliative Drugs(26M)$1,757,326 Drugs/Part D Antiasthmatics & Bronchodilators 6,545,089 Drugs/Part D Corticosteroids 141,179 Drugs/Part D Respiratory Agents 148,793 DME Oxygen Equipment and Supplies(27M) 525,276 DME Hospital Beds 480,854 DME Wheelchairs 196,692 Part B Institutional Diagnostic Imaging 605,110 Total 10,400,319
Cerebral Degeneration
Cerebral degeneration is defined by ICD-9 diagnosis codes beginning with 331, and includes conditions such as Alzheimer's disease and Reye's syndrome. These conditions are typically characterized by a progressive loss of cognitive function with symptoms including the loss of memory and changes in language ability, behavior, and personality. Additionally, as these cerebral degenerations progress, other clinical manifestations occur such as dysphagia, motor dysfunction, impaired mobility, increased need for activities of daily living assistance, urinary and fecal incontinence, weight loss and muscle wasting. Individuals with these conditions are also at increased risk for aspiration, falls, pneumonias, decubitus ulcers and urinary tract infections. Clinical practice guidelines for the treatment of cerebral degenerative conditions includes pharmacological interventions including Angiotensin Converting Enzyme inhibitors, memantine or combination therapy depending on severity of disease, as well as antidepressants, antipsychotics, psychostimulants, mood stabilizers, benzodiazepines and neuroleptics, depending on behavioral manifestations. Non-pharmacological interventions recommended include mental, behavioral and cognitive therapy, speech language pathology to address swallowing issues, and other interventions to treat and manage manifestations including pressure ulcers, cachexia and infections. /28/
FOOTNOTE 26 Includes all analgesics, anxiolytics, antiemetics, and laxatives. These four drug types are considered "nearly always covered under the hospice benefit" and as such are rarely expected to be billed separately during a hospice stay. END FOOTNOTE
FOOTNOTE 27 For COPD, we also include respiratory assist devices (RADs) in this category. END FOOTNOTE
FOOTNOTE 28
Our assessment of concurrently billed Part D drugs included 208,346 stays for beneficiaries with ICD-9 code 331 listed as a primary diagnosis on the hospice claim. Our assessment of concurrently billed Part B services included 318,044 stays. In CY 2013, concurrent billing for all services related to this principal diagnosis comprised
Table 9--Concurrent Payments for Services Provided to Hospice Beneficiaries With Cerebral Degeneration, CY 2013 Type of service Description Total payment Drugs/Part D Common Palliative Drugs$1,184,005 Drugs/Part D Antipsychotic/Antimanic 2,336,504 Agents Drugs/Part D Psychotherapeutic & 6,752,270 Neurological Agents DME Hospital Beds 138,249 DME Wheelchairs 252,228 Part B Inst. Diagnostic Imaging 496,790 Total 11,160,046
Congestive Heart Failure
Congestive heart failure (CHF) is defined by ICD-9 diagnosis codes beginning with 428. CHF is characterized by symptoms such as shortness of breath, edema, diminished endurance, angina, productive cough and fatigue. For the management of congestive heart failure, clinical practice guidelines recommend pharmacological interventions including beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, diuretics, anti-platelets, anti-coagulants and digoxin, depending on symptomology and response or nonresponse to other treatments. /29/ Nonpharmacological interventions recommended include continuous positive airway pressure and supplemental oxygen for those with coexisting pulmonary disease. /30/
FOOTNOTE 29 Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic heart failure. A national clinical guideline.
FOOTNOTE 30 Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16:475e539. END FOOTNOTE
Our assessment of concurrently billed Part D drugs included 158,220 stays for beneficiaries with ICD-9 code 428 listed as a primary diagnosis on the hospice claim. Our assessment of concurrently billed Part B services included 256,236 stays. In CY 2013, concurrent billing for all services related this terminal condition comprised
Table 10--Concurrent Payments for Services Provided to Hospice Beneficiaries With Congestive Health Failure, CY 2013 Type of service Description Total payment Drugs/Part D Common Palliative Drugs$1,229,748 Drugs/Part D Diuretics 334,700 Drugs/Part D Beta Blockers 363,480 Drugs/Part D Anti-hypertensives 584,799 Drugs/Part D Anti-anginal Agents 468,333 Drugs/Part D Cardiovascular Agents--Misc 799,605 Drugs/Part D Vasopressors 43,496 DME Oxygen Equipment and Supplies 471,376 DME Hospital Beds 96,219 DME Wheelchairs 275,940 Part B Inst. Diagnostic Imaging 690,726 Part B Inst. EKGs 72,933 Part B Inst. Cardiac Devices 242,819 Part B Inst. Diagnostic Clinical Labs 79,999 Part B Prof. Diagnostic Clinical Labs 64,698 Total 5,818,871
Our regulations at
3. Live Discharge Rates
Currently, federal regulations allow a patient who has elected to receive
Federal regulations only provide limited opportunity for a
Between 2000 and 2013, the overall rate of live discharges increased from 13.2 percent in 2000 to 18.3 percent in 2013. Among hospices with 50 or more discharges (discharged alive or deceased), there is significant variation in the rate of live discharge between the 10th and 90th percentiles (see Table 11 below). Most notably, hospices at the 95th percentile discharged 50 percent or more of their patients alive.
Table 11--Distribution of Live Discharge Rates in FY 2013 for Hospices With 50 or More Live Discharges Statistic Live discharge rate (%) 5th Percentile 8.1 10th Percentile 9.5 25th Percentile 12.9 Median 18.3 75th Percentile 26.6 90th Percentile 39.1 95th Percentile 50.0 Note: n=3,096
We analyzed hospices' aggregate cap status to determine whether there is a relationship between live discharge rates and their aggregate cap status. As described in section III.4.C and section III.D, when the Medicare Hospice Benefit was implemented, the
See Illustration in Original Document.
In FY 2013, we found that hospices with high live discharge rates also, on average, provide fewer visits per week. Those hospices with live discharge rates at or above the 90th percentile provide, on average, 3.97 visits per week. Hospices with live discharge rates below the 90th percentile provide, on average, 4.48 visits per week. We also found in FY 2013 that, when focusing on visits classified as skilled nursing or medical social services, hospices with live discharge rates at or above the 90th percentile provide, on average, 1.91 visits per week versus hospices with live discharge rates below the 90th percentile that provide, on average, 2.35 visits per week.
We examined whether there was a relationship between hospices with high live discharge rates, average lengths of stay, and non-hospice spending per beneficiary per day (see Table 12 and Figure 3 below). As described above in section III.A.2, we identified instances, in the aggregate and illustrated by case studies, where
See Illustration in Original Document.
See Illustration in Original Document.
The analytic findings presented above suggests that some hospices may consider the
B. Proposed Routine Home Care Rates and Service Intensity Add-On Payment
1. Statutory Authority and Background
Section 3132(a) of the Affordable Care Act amended 1814(i) of the Act by adding paragraph (6)(D), that instructs the Secretary, no earlier than
This legislation emerged largely in response to MedPAC's
FOOTNOTE 31
As described in section III.A, CMS has transparently conducted payment reform activities and released research findings to the public since 2010. At that time,
Over the past several years, MedPAC, the
FOOTNOTE 32 CMS Transmittal 2864. "Additional Data Reporting Requirements for Hospice Claims". Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2864CP.pdf. END FOOTNOTE
FOOTNOTE 33 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021935.html?DLPage=1&DLSort=0&DLSortDir=ascending. END FOOTNOTE
a. U-Shaped Payment Model
For over a decade, MedPAC and other organizations have reported findings that suggest that the hospice benefit's fixed per-diem payment system is inconsistent with the true variance of service costs over the course of an episode. Specifically, MedPAC cited both academic and non-academic studies, as well as its own analyses (as summarized and articulated in MedPAC's 2002, /34/ 2004, /35/ 2006, /36/ 2008, /37/ and 2009 /38/ Reports to
FOOTNOTE 34 http://www.medpac.gov/documents/contractor-reports/report-to-the-congress-medicare-beneficiaries'-access-to-hospice-(may-2002).pdf. END FOOTNOTE
FOOTNOTE 35 http://www.medpac.gov/documents/reports/June04_ch6.pdf. END FOOTNOTE
FOOTNOTE 36 http://www.medpac.gov/documents/reports/Jun06_Ch03.pdf. END FOOTNOTE
FOOTNOTE 37 http://www.medpac.gov/documents/reports/Jun08_Ch08.pdf. END FOOTNOTE
FOOTNOTE 38 http://www.medpac.gov/documents/reports/Mar09_Ch06.pdf. END FOOTNOTE
FOOTNOTE 39 http://www.medpac.gov/documents/reports/Jun08_Ch08.pdf. END FOOTNOTE
FOOTNOTE 40 Cheung, L.,
FOOTNOTE 41 http://www.medpac.gov/documents/reports/Mar09_Ch06.pdf?sfvrsn=0. END FOOTNOTE
In its
FOOTNOTE 42
In its
FOOTNOTE 43 http://medpac.gov/documents/reports/chapter-12-hospice-services-(march-2015-report).pdf?sfvrsn=0. END FOOTNOTE
Other organizations have also explored the concept of a U-shaped payment model. The ASPE, in conjunction with its contractor,
b. Tiered Payment Model
As required under section 3132(a) of the Affordable Care Act, CMS also explored other options for hospice payment reform. Taking into consideration the research and analysis performed by MedPAC, ASPE, and others, our payment reform contractor,
The groupings in the tiered payment model, presented in Table13 below, were developed through
Table 13--Average Daily Resource Use by Payment Groups in the Tiered Payment Model, CY 2011 Group Days of Implied hospice weight Group 1: RHC Days 1-5 2,800,144 2.3 Group 2: RHC Days 6-10 2,493,004 1.11 Group 3: RHC Days 11-30 7,767,918 0.97 Group 4: RHC Days 31+ 65,958,740 0.86 Group 5: RHC During Last Seven Days, Skilled 2,832,620 2.44 Visits During Last 2 Days Group 6: RHC During Last Seven Days, No Skilled 476,809 0.91 Visits During Last 2 Days Group 7: RHC When Hospice Length of Stay is 5 510,787 3.64 Days or Less, Patient Discharged as "Expired". Total 82,840,022 1.0
The payment weighting scheme in this system, derived from observed resource utilization across the entire episode, would produce higher payments during times when service is more intensive (the beginning of a stay or the end of life) and produce lower payments during times when service is less intensive (such as the "middle period" of the stay). The tiered payment model was discussed in more detail in the FY2014 Hospice Wage Index final rule (78 FR 48271) and in the Hospice Study Technical Report issued in April of 2013. /44/
FOOTNOTE 44 http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/Hospice-Study-Technical-Report.pdf. END FOOTNOTE
c. Visits During the Beginning and End of a Hospice Election
Updated analysis of FY 2013 hospice claims data continues to demonstrate a U-Shaped pattern in of resource use. Increased utilization at both the beginning and end of a stay is demonstrated in Figure 4 below, where FY 2013 resource costs (as captured by wage-weighted minutes) are markedly higher in the first two days of a hospice election and once again in the six days preceding the date of death and on the date of death itself.
See Illustration in Original Document.
Analysis of skilled nursing and social work visits provided on the first day of a hospice election shows that nearly 89 percent of patients received a visit totaling 15 minutes or more, while 11 percent did not receive a skilled nursing visit or social work visit on the first day of a hospice election (see Table 14 below). The percentage of patients that did not receive a skilled nursing or social work visit on a given day increased to nearly 38 percent on the second day of a hospice election. In accordance with the hospice CoPs at
Table 14--Frequency and Length of Skilled Nursing and Social Work Visits (Combined) During the First Seven Days of a Hospice Election, FY 2013 Visit length First Second Third Fourth Fifth Sixth Seventh First day day day day day day day through (per- (per- (per- (per- (per- (per- (per- seventh cent) cent) cent) cent) cent) cent) cent) day (per- cent) No Visit 11.0 37.7 56.0 59.1 62.0 65.6 64.2 49.3 15mins to 1 12.8 27.1 22.2 20.6 20.4 20.1 22.3 20.7 hr 1hr15m to 2 32.0 21.4 14.3 13.4 12.2 10.4 10.2 16.9 hrs 2hrs15m to 3 22.8 8.6 4.8 4.5 3.6 2.5 2.2 7.5 hrs 3hrs15m to 8.5 2.6 1.3 1.2 0.9 0.6 0.5 2.4 3hrs45m 4 or more hrs 13.0 2.6 1.3 1.2 0.9 0.7 0.6 3.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Source: FY 2013 hospice claims data from the Standard Analytic Files for CY 2012 (as ofJune 30, 2013 ) and CY 2014 (as ofDecember 31, 2013 ).
As we noted above, we are concerned that many beneficiaries are not receiving skilled visits during the last few days of life. At the end of life, patient needs typically surge and more intensive services are warranted. However, analysis of FY 2013 claims data shows that on any given day during the last 7 days of a hospice election, nearly 50 percent of the time the patient is not receiving a skilled visit (skilled nursing or social worker visit) (see table 15 below). Moreover, on the day of death nearly 30 percent of beneficiaries did not receive a skilled visit (skilled nursing or social work visit).
Table 15--Frequency and Length of Skilled Nursing and Social Work Visits (Combined) During the Last Seven Days of a Hospice Election, FY 2013 Visit length Day of One day Two Three Four Five Six Last (per-cent) death before days days days days days seven (per- death before before before before before days cent) (per- death death death death death com- cent) (per- (per- (per- (per- (per- bined cent) cent) cent) cent) cent) (per- cent) No Visit 27.8 38.7 45.2 49.8 53.2 55.8 58.0 46.3 15mins to 1 23.9 27.9 26.5 25.1 24.2 23.5 22.8 24.9 hr 1hr15m to 2 24.2 19.3 17.4 15.9 14.5 13.6 12.7 17.1 hrs 2hrs15m to 3 12.3 7.2 5.9 5.1 4.5 4.1 3.8 6.3 hrs 3hrs15m to 4.4 2.4 1.9 1.6 1.4 1.2 1.1 2.1 3hrs45m 4 or more hrs 7.4 4.3 3.0 2.4 2.1 1.9 1.6 3.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Source: FY 2013 hospice claims data from the Standard Analytic Files for CY 2012 (as ofJune 30, 2013 ) and CY 2014 (as ofDecember 31, 2013 ).
We would expect that skilled visits are provided to the patient and family at end of life as the changing condition of the individual and the imminence of death often warrants frequent changes to care to alleviate and minimize symptoms and to provide support for the family. Although previous public comments stated that patients and families sometimes request no visits at the end of life, and there are rare instances where a patient passes away unexpectedly, we would expect that these instances would be rare and represent a small proportion of the noted days without visits at the end of life. However, the data presented in Table 15 above suggests that it is not rare for patients and families to have not received skilled visits (skilled nursing or social work visits) at the end of life. In the FY 2015 Hospice Wage Index and Payment Rate Update final rule, we noted that nearly 5 percent of hospices did not provide any skilled visits in the last 2 days of life to more than 50 percent of their decedents receiving routine home care on those last 2 days and 34 hospices did not make any skilled visits in the last 2 days of life to any of their decedents who died while receiving routine home care (79 FR 50462).
2. Proposed Routine Home Care Rates
RHC is the basic level of care under the Hospice benefit, where a beneficiary receives hospice care, but remains at home. With this level of care, hospice providers are currently reimbursed per day regardless of the volume or intensity of services provided to a beneficiary on any given day. As stated in the FY 2014 Hospice Wage Index and Payment Rate Update final rule (78 FR 48234), "it is CMS' intent to ensure that reimbursement rates under the Hospice benefit align as closely as possible with the average costs hospices incur when efficiently providing covered services to beneficiaries." However, as discussed in section III.B.1 above, there is evidence of a misalignment between the current RHC per diem payment rate and the cost of providing RHC. In order to help ensure that hospices are paid adequately for providing care to patients regardless of their palliative care needs during the stay, while at the same time encouraging hospices to more carefully determine patient eligibility relative to the statutory requirement that the patients' life expectancy be 6 months or less, we are using the authority under section 1814(i)(6)(D) of the Act, as amended by section 3132(a) of the Affordable Care Act to propose a revision to the current RHC per diem payment rate to more accurately align the per diem payments with visit intensity (that is, the cost of providing care for the clinical service (labor) components of the RHC rate). We are proposing, in conjunction with a SIA payment discussed in section III.B.3 below, two different RHC rates that would result in a higher base payment rate for the first 60 days of hospice care and a reduced base payment rate for days 61 or over of hospice care.
The two proposed rates for RHC are based on an extensive body of research concerning visit intensity during a hospice episode as cited throughout this section. We consider a hospice "episode" of care to be a hospice election period or series of election periods. Visit intensity is commonly measured in terms of wage-weighted minutes and reflects variation in the provision of care for the clinical service (labor) components of the RHC rate. The labor components of the RHC rate comprise nearly 70 percent of the RHC rate (78 FR 48272). Therefore, visit intensity is a close proxy for the reasonable cost of providing hospice care absent data on the non-labor components of the RHC rate, such as drugs and DME. As shown in Figures 5 and 6 below, the daily cost of care, as measured wage-weighted minutes, declines quickly for individual patients during their hospice episodes, and for long episode patients, remains low for a significant portion of the episode. Thus, long episode patients are potentially more profitable than shorter episode patients under the current per diem payments system in which the payment rate is the same for the entire episode. At the same time, the percent of beneficiaries that enter hospice less than 7 days prior to death has remained relatively constant (approximately 30 percent) over this time period, meaning the increase in the average episode length can be attributed to an increasing number of long stay patients. We found that the percent of episodes that are more than 6 months in length has nearly doubled from about 7 percent in 1999 to 13 percent in 2013.
Figure 5 displays the pattern of wage-weighted minutes by time period within beneficiary episodes, but excluding the last 7 days of the episode for decedents. The wage-weighted minutes for the last 7 days are displayed separately by the bar furthest to the right of the Figure 5. The visit intensity curve declines rapidly after 7 days and then at a slower rate until 60 days when the curve becomes flat throughout the remainder of episodes (excluding the last 7 days prior to death). It is for this reason we are proposing to pay the higher rate for the first 60 days and a lower rate thereafter. It is clear from the figure that visit utilization is constant from day 61 on, until the last 7 days for decedents. We believe the most important reason for proposing a different RHC rate for the first 60 days versus days 61 and beyond is that we must account for differences in average visit intensity between episodes that will end within 60 days and those that will go on for longer episodes.
See Illustration in Original Document.
As Figure 6 demonstrates, beneficiaries whose entire episode is between 8 and 60 days do have higher wage-weighted minute usage than those with longer stays. Using 60 days for the high RHC rate as opposed to an earlier time assured that hospices would have sufficient resources for providing high quality care to patients (for example, 1 through 60 days) whose average daily visit intensity is higher than for longer stay patients.
See Illustration in Original Document.
The SIA payments based on actual visits provided would be added to the applicable rate during the last 7 days to reflect the rapid increase in visit intensity during that time period.
Table 16 below describes the average wage-weighted minutes for RHC days in FY 2014, calculated both in specific phases within an episode as well as overall.
Table 16--Average Wage Weighted Minutes per RHC Day, FY 2014 Phase of days in Average RHC Days Ratio of wage episode wage-weighted weighted minutes minutes for each row divided by wage weighted minutes for days 1-7 1-7 Days 39.32 5,401,497 1.0000 8-14 Days 20.12 4,276,570 0.5118 15-30 Days 17.96 7,693,966 0.4567 31-60 Days 16.10 10,679,971 0.4095 61-90 Days 15.44 8,061,934 0.3927 91-180 Days 14.93 16,156,969 0.3797 181-272 Days 14.79 10,056,928 0.3762 273-365 Days 14.91 6,844,692 0.3791 365 up Days 15.05 15,962,038 0.3828 Total RHC Days 17.21 85,134,565 0.4377
In Table 16, the average wage-weighted minutes per day for days 1 through 7 describe the baseline for the other phases of care, set at a value of one. Given the demands of the initial care in an episode, resource intensity is highest during this first week of an episode, and resource needs decline steadily over the course of an episode. The overall average wage-weighted minutes per day across all RHC days equals
To calculate the RHC payment rate for days 1 through 60, we compare the average wage-weighted minutes per day for days 1 through 60 to the overall average wage-weighted minutes per day multiplied by the labor portion of the FY 2015 RHC rate (column 4 in Table 17 below), which equals (
Table 17--FY 2015 RHC Rate Revised Labor Portion Calculation (1) (2) (3) (4) (5) (6) FY 2015 RHC Labor- FY 2015 RHC Average wage Revised FY RHC related payment weighted 2015 labor payment rate share rate--labor minutes for portion portion RHC differential rate/ overall RHC average wage weighted minutes Days 1-60$159.34 x 0.6871$109.48 x 1.2603$137.98 ($21.69 /$17.21 ) Days 61+ 159.34 x 0.6871 109.48 x 0.8722 95.48 ($15.01 /$17.21 )
As discussed in section III.C of this rule, currently, the labor-related share of the hospice payment rate for RHC is 68.71 percent. The non-labor share is equal to 100 percent minus the labor-related share, or 31.29 percent. Given the current base rate for RHC for FY 2015 of
Table 18--RHC Budget Neutrality Adjustment for RHC Rates (1) (2) (3) (4) (5) (6) Revised FY Budget Revised FY FY 2015 FY 2015 2015 labor neutrality 2015 labor Non-labor Revised portion factor *1 portion portion RHC with payment budget rates neutrality Days 1-60$137.98 x 0.9985$137.77 $49.86 $187.63 Days 61+ 95.49 x 0.9985 95.35 49.86 145.21 *1 The budget neutrality adjustment is required due to differences in the average wage index for days 1-60 compared to days 61 and over.
The proposed RHC rates for days 1 through 60 and days 61 and over (column 6 of Table 18 above) would replace the current single RHC per diem payment rate with two new RHC per diem rates for patients who require RHC level of care during a hospice election. In order to mitigate potential high rates of discharge and readmissions, we further propose that the count of days follow the patient. For hospice patients who are discharged and readmitted to hospice within 60 days of that discharge, his or her prior hospice days will continue to follow the patient and count toward his or her patient days for the receiving hospice upon hospice election. The hospice days would continue to follow the patient solely to determine whether the receiving hospice may bill at the 1 through 60 or 61+ RHC rate. The proposed policy does not preclude the receiving hospice (same or different hospice) from billing for a per diem payment for each hospice day. Therefore, we consider an "episode" of care to be a hospice election period or series of election periods separated by no more than a 60 day gap. We will monitor this proposal and trends in discharges and revocations for potential future refinements to address perverse incentives. This policy proposal attempts to better align RHC payment rates with resource use and is not intended to place an arbitrary limit on hospice services. We continue to expect hospices to adhere to the long-standing policy to provide "virtually all" care during a hospice election as articulated in the 1983 Hospice Care proposed and final rules as well as most recently in FY 2015 Hospice Wage Index and Payment Rate Update final rule. Furthermore, program integrity and oversight efforts including but not limited to, medical review, MAC audits, Zone Program Integrity Contractor actions, Recovery Auditor activities, or suspension of provider billing privileges, are being considered to address fraud and abuse. We are soliciting public comment on all aspects of the proposed RHC payment rates as articulated in this section as well as this policy in conjunction with the proposed SIA payment described in section III.B.3 below.
3. Proposed Service Intensity Add-On (SIA) Payment
Section 1814(i)(1)(A) of the Act states that payment for hospice services must be equal to the costs which are reasonable and related to the cost of providing hospice care or which are based on such other tests of reasonableness as the Secretary may prescribe in regulations. In addition, section 1814(i)(6)(D) of the Act, as amended by section 3132(a) of the Affordable Care Act, requires the Secretary to implement revisions to the methodology for determining the payment rates for RHCs and other services included in hospice care under Medicare Part A as the Secretary determines to be appropriate as described in section III.B.1 above. Given that independent analyses demonstrate a U-shaped cost pattern across hospice episodes, CMS believes that implementing revisions to the payment system that align with this concept supports the requirements of reasonable cost in section 1814(i)(A) of the Act. As articulated above, CMS considered implementing a tiered payment model as described in the FY 2014 Hospice Wage Index final rule (78 FR 48271) and in the Hospice Study Technical Report issued in April of 2013, /45/ in order to better align payments with observed resource use over the length of a hospice stay. However, operational concerns and programmatic complexity led us to explore the concept of a SAI that could be implemented with minimal systems changes that limit reprocessing of hospice claims due to sequential billing requirements. In addition, while the tiered model represented a move toward better aligning payments with resource use, it only accounted for whether skilled services were provided in the last 2 days of life (Groups 5 and 6 in Table 13 above). Section III.B.1.c, above notes that on any given day during the first 7 days of a hospice election and last 7 days of life, only about 50 percent of the time are visits being made. In our view, increasing payments at the beginning of a hospice election and at the end of life for days where visits are not occurring does not align with the requirements of reasonable cost articulated in statute in section 1814(i)(A) of the Act. Therefore, as one of the first steps in addressing the observed misalignment between resource use and associated
FOOTNOTE 45 http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/Hospice-Study-Technical-Report.pdf. END FOOTNOTE
To qualify for the SIA payment, we propose that the following criteria must be met: (1) The day is billed as a RHC level of care day; (2) the day occurs during the last 7 days of life (and the beneficiary is discharged dead); (3) direct patient care is provided by a RN or a social worker (as defined by
CMS would create two separate G-codes for use when billing skilled nursing visits (revenue center 055x), one for a RN and one for a Licensed Practical Nurse (LPN). During periods of crisis, such as the precipitous decline before death, RNs are more highly trained clinicians with commensurately higher payment rates. Moreover, our rules at
In 2011, the OIG published a report that focused specifically on
FOOTNOTE 46 http://oig.hhs.gov/oei/reports/oei-02-10-00070.pdf. END FOOTNOTE
The for-profit provider community has frequently highlighted its concerns regarding the lack of adequate reimbursement for hospice short stays in its public filings with the
FOOTNOTE 47 http://www.medpac.gov/documents/reports/Jun08_Ch08.pdf. END FOOTNOTE
*
FOOTNOTE 48 Health Care Strategic Management. 2004. Hospice companies benefit from favorable
*
FOOTNOTE 49
Short lengths of stay were also cited as a source of financial difficulties for small rural hospices (implying that longer stays were more profitable). /50/ In the FY 2014 Hospice Wage Index and Payment Rate Update proposed rule, we stated that "analysis conducted by
FOOTNOTE 50 Virnig, B. A.,
Although Figure 4 above demonstrates that there is increased resource use during the first 2 days of an election, we are not proposing an additional SIA payment for the first or second day of a hospice election when the length of stay is beyond 7 days. According to MedPAC, the breakeven point for a hospice election is about three weeks after admission. /51/ The proposed SIA payment for the last 7 days of life would provide additional reimbursement to help to mitigate the higher costs for stays lasting 3 weeks or less where spreading out the initial costs in the first 2 days of the election over a smaller number of days is not enough to make the overall stay profitable. Once a hospice stay reaches 3 weeks or more, the initial costs associated with the first 2 days of a hospice election can be spread out over a larger number of days, making the overall stay profitable. A stay of 7 days or less before death would be eligible for SIA payment on all days.
FOOTNOTE 51 http://www.medpac.gov/documents/reports/Jun08_Ch08.pdf. END FOOTNOTE
We believe that the proposed SIA payment helps to address MedPAC and industry concerns regarding the visit intensity at end of life and the concerns associated with the profitability of hospice short stays. The proposed RHC rates described in section III.B2 and SIA payment would advance hospice payment reform incrementally, as mandated by the Affordable Care Act while simultaneously maintaining flexibility for future refinements. Since this approach would be implemented within the current constructs of the hospice payment system, no major overhaul of the claims processing system or related claims/cost report forms would be required, minimizing burden for hospices as well as for
As required by section 1814(i)(6)(D)(ii) of the Act, any changes to the hospice payment system must be made in a budget neutral manner in the first year of implementation. Based on the desire to improve patient care through the promotion of skilled visits at end of life, regardless of the patient's lifetime length of stay, we are proposing to make the SIA payments budget neutral through a reduction to the overall RHC rate. The SIA payment budget neutrality factor (SBNF) used to reduce the overall RHC rate is outlined in section III.C.3 and is reflected in the proposed RHC payment rate tables.
We also propose to continue to make the SIA payments budget neutral through an annual determination of the SBNF, which will then be applied to the RHC payment rate. The SBNF for the SIA payments would be calculated for each FY using the most current and complete fiscal year utilization data available at the time of rulemaking. Finally, we are soliciting public comment on all aspects of the proposed SIA payment as articulated in this section as well as the corresponding proposed changes to the regulations at
C. Proposed FY 2016 Hospice Wage Index and Rate Update
1. Proposed FY 2016 Hospice Wage Index
a. Background
The hospice wage index is used to adjust payment rates for hospice agencies under the
We use the previous fiscal year's hospital wage index data to calculate the hospice wage index values. For FY 2016, the hospice wage index will be based on the FY 2015 hospital pre-floor, pre-reclassified wage index. This means that the hospital wage data used for the hospice wage index is not adjusted to take into account any geographic reclassification of hospitals including those in accordance with section 1886(d)(8)(B) or 1886(d)(10) of the Act. The appropriate wage index value is applied to the labor portion of the payment rate based on the geographic area in which the beneficiary resides when receiving 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 General Inpatient care (GIP) or Inpatient Respite Care (IRC).
In the FY 2006 Hospice Wage Index final rule (70 FR 45130), we adopted the changes discussed in the OMB Bulletin No. 03-04 (
When adopting OMB's new labor market designations in FY 2006, we identified some geographic areas where there were no hospitals, and thus, no hospital wage index data, which to base the calculation of the hospice wage index. In the FY 2010 Hospice Wage Index final rule (74 FR 39386), we also adopted the policy that for urban labor markets without a hospital from which hospital wage index data could be derived, all of the CBSAs within the state would be used to calculate a statewide urban average pre-floor, pre-reclassified hospital wage index value to use as a reasonable proxy for these areas. In FY 2016, the only CBSA without a hospital from which hospital wage data could be derived is 25980,
In the FY 2008 Hospice Wage Index final rule (72 FR 50214), we implemented a new methodology to update the hospice wage index for rural areas without a hospital, and thus no hospital wage data. In cases where there was a rural area without rural hospital wage data, we used 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
b. Elimination of the Wage Index Budget Neutrality Factor (BNAF)
This proposed rule would update the hospice wage index values for FY 2016 using the FY 2015 pre-floor, pre-reclassified hospital wage index. As described in the
The FY 2010 Hospice Wage Index rule finalized a provision to phase-out the BNAF over 7 years, with a 10 percent reduction in the BNAF in FY 2010, and an additional 15 percent reduction in each of the next 6 years, with complete phase out in FY 2016 (74 FR 39384). The 10 percent reduced BNAF for FY 2010 was 0.055598, based on a full BNAF of 0.061775; the additional 15 percent reduced BNAF for FY 2011 (for a cumulative reduction of 25 percent) was 0.045422, based on a full BNAF of 0.060562; the additional 15 percent reduced BNAF for FY 2012 (for a cumulative reduction of 40 percent) was 0.035156, based on a full BNAF of 0.058593; the additional 15 percent reduced BNAF for FY 2013 (for a cumulative reduction of 55 percent) was 0.027197, based on a full BNAF of 0.060438; the additional 15 percent BNAF for FY 2014 (for a cumulative reduction of 70 percent) was 0.018461, based on a full BNAF of 0.061538 and the additional 15 percent reduced BNAF for FY 2015 (for a cumulative reduction of 85 percent) is 0.009313, based on a full BNAF of 0.062804. For FY 2016, the BNAF is reduced by an additional and final 15 percent for a cumulative reduction of 100 percent. Therefore, for FY 2016, the BNAF is completely phased-out and eliminated.
Hospital wage index values which are less than 0.8 are still subject to the hospice floor calculation. The hospice floor equates to 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.
c. Proposed Implementation of New Labor Market Delineations
OMB has published subsequent bulletins regarding CBSA changes. On
While the revisions OMB published on
i. Micropolitan Statistical Areas
As discussed in the FY 2006 Hospice Wage Index proposed rule (70 FR 22397) and final rule (70 FR 45132), CMS considered how to use the Micropolitan Statistical Area definitions in the calculation of the wage index. OMB defines a "Micropolitan Statistical Area" as a CBSA "associated with at least one urban cluster that has a population of at least 10,000, but less than 50,000 (75 FR 37252). We refer to these as Micropolitan Areas. After extensive impact analysis, consistent with the treatment of these areas under the IPPS as discussed in the FY 2005 IPPS final rule (69 FR 49029 through 49032), CMS determined the best course of action would be to treat Micropolitan Areas as "rural" and include them in the calculation of each state's Hospice rural wage index (see 70 FR 22397 and 70 FR 45132). Thus, the hospice statewide rural wage index is determined using IPPS hospital data from hospitals located in non-MSA areas.
Based upon the 2010 Decennial Census data, a number of urban counties have switched status and have joined or became Micropolitan Areas, and some counties that once were part of a Micropolitan Area, have become urban. Overall, there are fewer Micropolitan Areas (541) under the new OMB delineations based on the 2010 Census than existed under the latest data from the 2000 Census (581). We believe that the best course of action would be to continue the policy established in the FY 2006 Hospice Wage Index final rule and include Micropolitan Areas in each state's rural wage index. These areas continue to be defined as having relatively small urban cores (populations of 10,000 to 49,999). Therefore, in conjunction with our proposal to implement the new OMB labor market delineations beginning in FY 2016 and consistent with the treatment of Micropolitan Areas under the IPPS, we are proposing to continue to treat Micropolitan Areas as "rural" and to include Micropolitan Areas in the calculation of each state's rural wage index.
ii. Urban Counties Becoming Rural
If we adopt the new OMB delineations (based upon the 2010 decennial Census data), a total of 37 counties (and county equivalents) that are currently considered urban would be considered rural beginning in FY 2016. Table 19 below lists the 37 counties that would change to rural status if we finalize our proposal to implement the new OMB delineations.
Table 19--Counties That Would Change to Rural Status County State CBSA number from CBSA name FY 2015 hospice wage index Greene County IN 14020 Bloomington, IN. Anson County NC 16740 Charlotte-Gastonia-Rock Hill, NC-SC. Franklin County IN 17140 Cincinnati-Middletown, OH- KY-IN. Stewart County TN 17300 Clarksville, TN-KY. Howard County MO 17860 Columbia, MO. Delta County TX 19124 Dallas-Fort Worth- Arlington, TX. Pittsylvania VA 19260 Danville, VA. County Danville City VA 19260 Danville, VA. Preble County OH 19380 Dayton, OH. Gibson County IN 21780 Evansville, IN-KY. Webster County KY 21780 Evansville, IN-KY. Franklin County AR 22900 Fort Smith, AR-OK. Ionia County MI 24340 Grand Rapids-Wyoming, MI. Newaygo County MI 24340 Grand Rapids-Wyoming, MI. Greene County NC 24780 Greenville, NC. Stone County MS 25060 Gulfport-Biloxi, MS. Morgan County WV 25180 Hagerstown-Martinsburg, MD-WV. San Jacinto TX 26420 Houston-Sugar Land- County Baytown, TX. Franklin County KS 28140 Kansas City, MO-KS. Tipton County IN 29020 Kokomo, IN. Nelson County KY 31140 Louisville/Jefferson County, KY-IN. Geary County KS 31740 Manhattan, KS. Washington OH 37620 Parkersburg-Marietta- County Vienna, WV-OH. Pleasants County WV 37620 Parkersburg-Marietta- Vienna, WV-OH. George County MS 37700 Pascagoula, MS. Power County ID 38540 Pocatello, ID. Cumberland VA 40060 Richmond, VA. County King and Queen VA 40060 Richmond, VA. County Louisa County VA 40060 Richmond, VA. Washington MO 41180 St. Louis, MO-IL. County Summit County UT 41620 Salt Lake City, UT. Erie County OH 41780 Sandusky, OH. Franklin County MA 44140 Springfield, MA. Ottawa County OH 45780 Toledo, OH. Greene County AL 46220 Tuscaloosa, AL. Calhoun County TX 47020 Victoria, TX. Surry County VA 47260 Virginia Beach-Norfolk- Newport News, VA-NC.
iii. Rural Counties Becoming Urban
If we finalize our proposal to implement the new OMB delineations (based upon the 2010 decennial Census data), a total of 105 counties (and county equivalents) that are currently designated rural would be considered urban beginning in FY 2016. Table 20 below lists the 105 counties that would change to urban status.
Table 20--Counties That Would Change to Urban Status County State CBSA number CBSA name Utuado Municipio PR 10380 Aguadilla-Isabela, PR. Linn County OR 10540 Albany, OR. Oldham County TX 11100 Amarillo, TX. Morgan County GA 12060 Atlanta-Sandy Springs- Roswell, GA. Lincoln County GA 12260 Augusta-Richmond County, GA-SC. Newton County TX 13140 Beaumont-Port Arthur, TX. Fayette County WV 13220 Beckley, WV. Raleigh County WV 13220 Beckley, WV. Golden Valley County MT 13740 Billings, MT. Oliver County ND 13900 Bismarck, ND. Sioux County ND 13900 Bismarck, ND. Floyd County VI 13980 Blacksburg-Christiansburg- Radford, VA. De Witt County IL 14010 Bloomington, IL. Columbia County PA 14100 Bloomsburg-Berwick, PA. Montour County PA 14100 Bloomsburg-Berwick, PA. Allen County KY 14540 Bowling Green, KY. Butler County KY 14540 Bowling Green, KY. St. Mary's County MD 15680 California-Lexington Park, MD. Jackson County IL 16060 Carbondale-Marion, IL. Williamson County IL 16060 Carbondale-Marion, IL. Franklin County PA 16540 Chambersburg-Waynesboro, PA. Iredell County NC 16740 Charlotte-Concord- Gastonia, NC-SC. Lincoln County NC 16740 Charlotte-Concord- Gastonia, NC-SC. Rowan County NC 16740 Charlotte-Concord- Gastonia, NC-SC. Chester County SC 16740 Charlotte-Concord- Gastonia, NC-SC. Lancaster County SC 16740 Charlotte-Concord- Gastonia, NC-SC. Buckingham County VA 16820 Charlottesville, VA. Union County IN 17140 Cincinnati, OH-KY-IN. Hocking County OH 18140 Columbus, OH. Perry County OH 18140 Columbus, OH. Walton County FL 18880 Crestview-Fort Walton Beach-Destin, FL. Hood County TX 23104 Dallas-Fort Worth- Arlington, TX. Somervell County TX 23104 Dallas-Fort Worth- Arlington, TX. Baldwin County AL 19300 Daphne-Fairhope-Foley, AL. Monroe County PA 20700 East Stroudsburg, PA. Hudspeth County TX 21340 El Paso, TX. Adams County PA 23900 Gettysburg, PA. Hall County NE 24260 Grand Island, NE. Hamilton County NE 24260 Grand Island, NE. Howard County NE 24260 Grand Island, NE. Merrick County NE 24260 Grand Island, NE. Montcalm County MI 24340 Grand Rapids-Wyoming, MI. Josephine County OR 24420 Grants Pass, OR. Tangipahoa Parish LA 25220 Hammond, LA. Beaufort County SC 25940 Hilton Head Island- Bluffton-Beaufort, SC. Jasper County SC 25940 Hilton Head Island- Bluffton-Beaufort, SC. Citrus County FL 26140 Homosassa Springs, FL. Butte County ID 26820 Idaho Falls, ID. Yazoo County MS 27140 Jackson, MS. Crockett County TN 27180 Jackson, TN. Kalawao County HI 27980 Kahului-Wailuku-Lahaina, HI. Maui County HI 27980 Kahului-Wailuku-Lahaina, HI. Campbell County TN 28940 Knoxville, TN. Morgan County TN 28940 Knoxville, TN. Roane County TN 28940 Knoxville, TN. Acadia Parish LA 29180 Lafayette, LA. Iberia Parish LA 29180 Lafayette, LA. Vermilion Parish LA 29180 Lafayette, LA. Cotton County OK 30020 Lawton, OK. Scott County IN 31140 Louisville/Jefferson County, KY-IN. Lynn County TX 31180 Lubbock, TX. Green County WI 31540 Madison, WI. Benton County MS 32820 Memphis, TN-MS-AR. Midland County MI 33220 Midland, MI. Martin County TX 33260 Midland, TX. Le Sueur County MN 33460 Minneapolis-St. Paul- Bloomington, MN-WI. Mille Lacs County MN 33460 Minneapolis-St. Paul- Bloomington, MN-WI. Sibley County MN 33460 Minneapolis-St. Paul- Bloomington, MN-WI. Maury County TN 34980 Nashville-Davidson- Murfreesboro-Franklin, TN. Craven County NC 35100 New Bern, NC. Jones County NC 35100 New Bern, NC. Pamlico County NC 35100 New Bern, NC. St. James Parish LA 35380 New Orleans-Metairie, LA. Box Elder County UT 36260 Ogden-Clearfield, UT. Gulf County FL 37460 Panama City, FL. Custer County SD 39660 Rapid City, SD. Fillmore County MN 40340 Rochester, MN. Yates County NY 40380 Rochester, NY. Sussex County DE 41540 Salisbury, MD-DE. Worcester County MA 41540 Salisbury, MD-DE. Highlands County FL 42700 Sebring, FL. Webster Parish LA 43340 Shreveport-Bossier City, LA. Cochise County AZ 43420 Sierra Vista-Douglas, AZ. Plymouth County IA 43580 Sioux City, IA-NE-SD. Union County SC 43900 Spartanburg, SC. Pend Oreille County WA 44060 Spokane-Spokane Valley, WA. Stevens County WA 44060 Spokane-Spokane Valley, WA. Augusta County VA 44420 Staunton-Waynesboro, VA. Staunton City VA 44420 Staunton-Waynesboro, VA. Waynesboro City VA 44420 Staunton-Waynesboro, VA. Little River County AR 45500 Texarkana, TX-AR. Sumter County FL 45540 The Villages, FL. Pickens County AL 46220 Tuscaloosa, AL. Gates County NC 47260 Virginia Beach-Norfolk- Newport News, VA-NC. Falls County TX 47380 Waco, TX. Columbia County WA 47460 Walla Walla, WA. Walla Walla County WA 47460 Walla Walla, WA. Peach County GA 47580 Warner Robins, GA. Pulaski County GA 47580 Warner Robins, GA. Culpeper County VA 47894 Washington-Arlington- Alexandria, DC-VA-MD-WV. Rappahannock County VA 47894 Washington-Arlington- Alexandria, DC-VA-MD-WV. Jefferson County NY 48060 Watertown-Fort Drum, NY. Kingman County KS 48620 Wichita, KS. Davidson County NC 49180 Winston-Salem, NC. Windham County CT 49340 Worcester, MA-CT.
iv. Urban Counties Moving to a Different Urban CBSA
In addition to rural counties becoming urban and urban counties becoming rural, several urban counties would shift from one urban CBSA to another urban CBSA under our proposal to adopt the new OMB delineations. In other cases, applying the new OMB delineations would involve a change only in CBSA name or number, while the CBSA continues to encompass the same constituent counties. For example, CBSA 29140 (
Table 21--Counties That Would Change to a Different CBSA Previous New CBSA County State CBSA 11300 26900 Madison County IN. 11340 24860 Anderson County SC. 14060 14010 McLean County IL. 37764 15764 Essex County MA. 16620 26580 Lincoln County WV. 16620 26580 Putnam County WV. 16974 20994 DeKalb County IL. 16974 20994 Kane County IL. 21940 41980 Ceiba Municipio PR. 21940 41980 Fajardo Municipio PR. 21940 41980 Luquillo Municipio PR. 26100 24340 Ottawa County MI. 31140 21060 Meade County KY. 34100 28940 Grainger County TN. 35644 35614 Bergen County NJ. 35644 35614 Hudson County NJ. 20764 35614 Middlesex County NJ. 20764 35614 Monmouth County NJ. 20764 35614 Ocean County NJ. 35644 35614 Passaic County NJ. 20764 35084 Somerset County NJ. 35644 35614 Bronx County NY. 35644 35614 Kings County NY. 35644 35614 New York County NY. 35644 20524 Putnam County NY. 35644 35614 Queens County NY. 35644 35614 Richmond County NY. 35644 35614 Rockland County NY. 35644 35614 Westchester County NY. 37380 19660 Flagler County FL. 37700 25060 Jackson County MS. 37964 33874 Bucks County PA. 37964 33874 Chester County PA. 37964 33874 Montgomery County PA. 39100 20524 Dutchess County NY. 39100 35614 Orange County NY. 41884 42034 Marin County CA. 41980 11640 Arecibo Municipio PR. 41980 11640 Camuy Municipio PR. 41980 11640 Hatillo Municipio PR. 41980 11640 Quebradillas Municipio PR. 48900 34820 Brunswick County NC. 49500 38660 Gunica Municipio PR. 49500 38660 Guayanilla Municipio PR. 49500 38660 Penuelas Municipio PR. 49500 38660 Yauco Municipio PR.
v. Transition Period
Overall, we believe that implementing the new OMB delineations would result in wage index values being more representative of the actual costs of labor in a given area. Among the 458 total CBSA and statewide rural areas, 20 (4 percent) would have a higher wage index using the newer delineations. However, 34 (7.4 percent) would have a lower wage index using the newer delineations. Therefore, to remain consistent with the manner in which we ultimately adopted the revised OMB delineations for FY 2006 (70 FR 45138), we are proposing to implement a 1-year transition to the new OMB delineations. Specifically, we propose to apply a blended wage index for one year (FY 2016) for all geographic areas that would consist of a 50/50 blend of the wage index values using OMB's old area delineations and the wage index values using OMB's new area delineations. That is, for each county, a blended wage index would be calculated equal to 50 percent of the FY 2016 wage index using the old labor market area delineation and 50 percent of the FY 2016 wage index using the new labor market area delineation. This results in an average of the two values. We refer to this blended wage index as the FY 2016 hospice transition wage index.
This proposed 1-year transition policy is also consistent with the transition policies adopted by both the FY 2015 SNF PPS (79 FR 25767) and the CY 2015 HH PPS (79 FR 66032). This transition policy would be for a 1-year period, going into effect on
The proposed wage index applicable to FY 2016 is set forth in Addendum A available on the CMS Web site at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html. Addendum A will not be published in the
Addendum A provides a crosswalk between the FY 2016 wage index using the current OMB delineations in effect in FY 2015 and the FY 2016 wage index using the proposed revised OMB delineations, as well as the proposed transition wage index values that would be in effect in FY 2016 if these proposed changes are finalized. Addendum A shows each state and county and its corresponding proposed transition wage index along with the previous CBSA number, the new CBSA number, and the new CBSA name.
Due to the way that the transition wage index is calculated, some CBSAs and statewide rural areas may have more than one transition wage index value associated with that CBSA or rural area. However, each county will have only one transition wage index. For counties located in CBSAs and rural areas that correspond to more than one transition wage index value, the CBSA number will not be able to be used for FY 2016 claims. In these cases, a number other than the CBSA number would be necessary to identify the appropriate wage index value on claims for hospice care provided in FY 2016. These numbers are five digits in length and begin with "50." These codes are shown in the last column of Addendum A in place of the CBSA number where appropriate. For counties located in CBSAs and rural areas that still correspond to only one wage index value, the CBSA number would still be used.
2. Proposed Hospice Payment Update Percentage
Section 4441(a) of the Balanced Budget Act of 1997 (BBA) 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 market basket index, 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 market basket percentage for that FY. The Act requires us to use the inpatient hospital market basket to determine the hospice payment rate update. In addition, section 3401(g) of the Affordable Care Act mandates that, starting with FY 2013 (and in subsequent FYs), the hospice payment update percentage will be annually reduced by changes in economy-wide productivity as specified in section 1886(b)(3)(B)(xi)(II) of the Act. 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) (as projected by the Secretary for the 10-year period ending with the applicable FY, year, cost reporting period, or other annual period) (the "MFP adjustment"). A complete description of the MFP projection methodology is available on our Web site at http://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareProgramRatesStats/MarketBasketResearch.html.
In addition to the MFP adjustment, section 3401(g) of the Affordable Care Act also mandates that in FY 2013 through FY 2019, the hospice payment update percentage will be reduced by an additional 0.3 percentage point (although for FY 2014 to FY 2019, the potential 0.3 percentage point reduction is subject to suspension under conditions specified in section 1814(i)(1)(C)(v) of the Act). The proposed hospice payment update percentage for FY 2016 is based on the estimated inpatient hospital market basket update of 2.7 percent (based on
Currently, the labor portion of the hospice payment rates is as follows: For RHC, 68.71 percent; for CHC, 68.71 percent; for General Inpatient Care, 64.01 percent; and for Respite Care, 54.13 percent. The non-labor portion is equal to 100 percent minus the labor portion for each level of care. Therefore, the non-labor portion of the payment rates is as follows: For RHC, 31.29 percent; for CHC, 31.29 percent; for General Inpatient Care, 35.99 percent; and for Respite Care, 45.87 percent.
3. Proposed FY 2016 Hospice Payment Rates
Historically, the hospice rate update has been published through a separate administrative instruction issued annually in the summer to provide adequate time to implement system change requirements; however, beginning in FY 2014 and for subsequent FY, we are using rulemaking as the means to update payment rates. This change was proposed in the FY 2014 Hospice Wage Index and Payment Rate Update proposed rule and finalized in the FY 2014 Hospice Wage Index and Payment Rate Update final rule (78 FR 48270). It is consistent with the rate update process in other
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 continuous home care, IRC, or general inpatient care. 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 GIP is to treat symptoms that cannot be managed in another setting.
As discussed in section III.B.2, of this proposed rule, we are proposing two different RHC payment rates, one RHC rate for the first 60 days and a second RHC rate for days 60 and beyond. As discussed in section III.B.3, we are proposing to make a SIA payment, in addition to the daily RHC payment, when direct patient care is provided by a RN or social worker during the last 7 days of the patient's life. The SIA payment would be 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. The SIA payment would also be adjusted by the appropriate wage index. In order to maintain budget neutrality, as required under section 1814(i)(6)(D)(ii) of the Act, for the proposed SIA payment, the proposed RHC rates would need to be adjusted by a budget neutrality factor. The budget neutrality adjustment that would apply to days 1 through 60 is equal to 1 minus the ratio of SIA payments for days 1 through 60 to the total payments for days 1 through 60 and is calculated to be 0.9853. The budget neutrality adjustment that would apply to days 61 and beyond is equal to 1 minus the ratio of SIA payments for days 61 and beyond to the total payments for days 61 and beyond and is calculated to be 0.9967. Lastly, the RHC rates would be increased by the proposed FY 2016 hospice payment update percentage of 1.8 percent as discussed in section III.C.3. The proposed FY 2016 RHC rates are shown in Table 22. The proposed FY 2016 payment rates for CHC, IRC, and GIP would be the FY 2015 payment rates increased by 1.8 percent. The proposed rates for these three levels of care are shown in Table 23. The proposed FY 2016 rates for hospices that do not submit the required quality data are shown in Tables 24 and 25. The proposed FY 2016 hospice payment rates would be effective for care and services furnished on or after
Table 22--Proposed FY 2016 Hospice Payment Rates for RHC Code Description Proposed Proposed SIA Proposed FY Proposed FY rates *1 budget 2016 hospice 2016 payment neutrality payment rates factor update adjustment percentage (1-0.0081) 651 Routine Home$187.63 x 0.9853 x 1.018$188.20 Care (days 1-60) 651 Routine Home 145.21 0.9967 x 1.018 147.34 Care (days 61+) *1 See section III.B.2 for the proposed RHC rates for days 1-60, and days 61 and beyond before accounting for the proposed Service Intensity Add-on (SIA) payment budget neutrality factor and the proposed FY 2016 hospice payment update percentage of 1.8 percent as required by section 1814(i)(1)(C) of the Act.
Table 23--Proposed FY 2016 Hospice Payment Rates for CHC, IRC, and GIP Code Description FY 2015 Proposed Proposed payment FY 2016 FY 2016 rates hospice payment payment rate update of 1.8 percent 652 Continuous Home Care$929.91 x 1.018$946.65 Full Rate = 24 hours of care $=39.44 FY 2016 hourly rate 655 Inpatient Respite Care 164.81 x 1.018 167.78 656 General Inpatient Care 708.77 x 1.018 721.53
We reiterate in this proposed rule, that the
Table 24--Proposed FY 2016 Hospice Payment Rates for RHC for Hospices That DO NOT Submit the Required Quality Data Code Description Proposed RHC Proposed SIA Proposed FY Proposed FY rates *1 budget 2016 hospice 2016 payment neutrality payment rates factor update of adjustment 1.8 percent (1-0.0081) minus 2 percentage points = -0.2 percent 651 Routine Home$187.63 x 0.9853 x 0.998$184.50 Care (days 1-60) 651 Routine Home 145.21 0.9967 x 0.998 144.44 Care (days 61+) *1 See section III.B.2 for the proposed RHC rates for days 1-60, and days 61 and beyond before accounting for the proposed Service Intensity Add-on (SIA) payment budget neutrality factor and the proposed FY 2016 hospice payment update percentage of 1.8 percent as required by section 1814(i)(1)(C) of the Act.
Table 25--Proposed FY 2016 Hospice Payment Rates for CHC, IRC, and GIP for Hospices That DO NOT Submit the Required Quality Data Code Description FY 2015 Proposed FY Proposed FY payment rates 2016 hospice 2016 payment payment rate update of 1.8 percent minus 2 percentage points = -0.2 percent 652 Continuous$929.91 x 0.998$928.05 Home Care Full Rate= 24 hours of care $=38.67 hourly rate 655 Inpatient 164.81 x 0.998 164.48 Respite Care 656 General 708.77 x 0.998 707.35 Inpatient Care
4. Hospice Aggregate Cap and the IMPACT Act of 2014
When the
The aggregate cap amount was set at
FOOTNOTE 52
Section 1814(i)(2)(B)(i) and (ii) of the Act, as added by section 3(b) of the IMPACT Act requires, effective for the 2016 cap year (
As a result, we are proposing to update
In accordance with section 1814(i)(2)(B)(i) of the Act, the hospice aggregate cap amount for the 2015 cap year, starting on
Step 1: From the BLS Web site given above, the
Step 2: Divide the
440.020/105.4 = 4.174763
Step 3: Multiply the original cap base amount (
$6,500 x 4.174763 =
As required by section 1814(i)(2)(B)(ii) of the Act, the hospice aggregate cap amount for the 2016 cap year, starting on
D. Proposed Alignment of the Inpatient and Aggregate Cap Accounting Year With the Federal Fiscal Year
As noted in section III.C.4, when the
1. Streamlined Method and Patient-by-Patient Proportional Method for
The aggregate cap amount for any given hospice is established by multiplying the cap amount by the number of
During FY 2012 rulemaking, in addition to the streamlined method, CMS added a "patient-by-patient proportional" method as a way of calculating the number of
2. Proposed Inpatient and Aggregate Cap Accounting Year Timeframe
As stated in section III.C.4, the cap accounting year is currently
In FY 2012, we decided not to finalize changing the cap accounting year to the FY, partly because of a concern that a large portion of providers could still be using the streamlined method. As stated earlier, the streamlined method has a different timeframe for counting the number of beneficiaries than the cap accounting year, allowing those beneficiaries who elected hospice near the end of the cap year to be counted in the year when most of the services were provided. However, for the 2013 cap year, only 486 hospices used the streamlined method to calculate the number of
In shifting the cap accounting year to match the federal fiscal year, we note that new section 1814(i)(2)(B)(ii) of the Act, as added by section 3(b) of the IMPACT Act, requires the cap amount for 2016 to be updated by the hospice payment update percentage in effect "during the FY beginning on the
In shifting the cap year to match the federal fiscal year, we are proposing to also align the timeframes in which beneficiaries and payments are counted for the purposes of determining each individual hospice's aggregate cap amount (see table 26 below) as well as the timeframes in which days of hospice care are counted for the purposes determining whether a given hospice exceeded the inpatient cap. In the year of transition (2017 cap year), for the inpatient cap, we propose to calculate the percentage of all hospice days of care that were provided as inpatient days (GIP care and respite care) from
Table 26--Hospice Aggregate Cap Timeframes for Counting Beneficiaries and Payments for the Proposed Alignment of the Cap Accounting Year With the Federal Fiscal Year Cap year Beneficiaries Payments Streamlined Patient-by- Streamlined Patient-by- method patient method patient proportional proportional method method 2016 9/28/15- 11/1/15- 11/1/15- 11/1/15- 9/27/16 10/31/16 10/31/16 10/31/16 Proposed 2017 9/28/16- 11/1/16- 11/1/16- 11/1/16- (Transition Year) 9/30/17 9/30/17 9/30/17 9/30/17 Proposed 2018 10/1/17- 10/1/17- 10/1/17- 10/1/17- 9/30/18 9/30/18 9/30/18 9/30/18
E. Proposed Updates to the Hospice Quality Reporting Program (HQRP)
1.
Section 3004(c) of the Affordable Care Act amended section 1814(i)(5) of the Act to authorize a quality reporting program for hospices. Section 1814(i)(5)(A)(i) of the Act requires that beginning with FY 2014 and each subsequent FY, the Secretary shall reduce the market basket update by 2 percentage points for any hospice that does not comply with the quality data submission requirements with respect to 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 0.0 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 FY involved. Any such reduction would not be cumulative or be taken into account in computing the payment amount for subsequent FYs. Section 1814(i)(5)(C) of the Act requires that each hospice submit data to the Secretary on quality measures specified by the Secretary. The data must be submitted in a form, manner, and at a time specified by the Secretary.
2. General Considerations Used for Selection of Quality Measures for the HQRP
Any measures selected by the Secretary must be endorsed by the consensus-based entity, which holds a contract regarding performance measurement with the Secretary under section 1890(a) of the Act. This contract is currently held by the
3. Proposed Policy for Retention of HQRP Measures Adopted for Previous Payment Determinations
Beginning with the FY 2018 payment determination, for the purpose of streamlining the rulemaking process, we propose that when we adopt measures for the HQRP beginning with a payment determination year, these measures are automatically adopted for all subsequent years' payment determinations, unless we propose to remove, suspend, or replace the measures.
Quality measures may be considered for removal by CMS if:
* Measure performance among hospices is so high and unvarying that meaningful distinctions in improvements in performance can be no longer be made;
* Performance or improvement on a measure does not result in better patient outcomes;
* A measure does not align with current clinical guidelines or practice;
* A more broadly applicable measure (across settings, populations, or conditions) for the particular topic is available;
* A measure that is more proximal in time to desired patient outcomes for the particular topic is available;
* A measure that is more strongly associated with desired patient outcomes for the particular topic is available; or
* Collection or public reporting of a measure leads to negative unintended consequences.
For any such removal, the public will be given an opportunity to comment through the annual rulemaking process. However, if there is reason to believe continued collection of a measure raises potential safety concerns, we will take immediate action to remove the measure from the HQRP and will not wait for the annual rulemaking cycle. The measures will be promptly removed and we will immediately notify hospices and the public of such a decision through the usual HQRP communication channels, including listening sessions, memos, email notification, and Web postings. In such instances, the removal of a measure will be formally announced in the next annual rulemaking cycle.
CMS is not proposing to remove any measures for the FY 2017 reporting cycle. We invite public comment on our proposal that once a quality measure is adopted, it be retained for use in the subsequent fiscal year payment determinations unless otherwise stated.
4. Previously Adopted Quality Measures for FY 2016 and FY 2017 Payment Determination
As stated in the CY 2013 HH PPS final rule (77 FR 67068, 67133), CMS expanded the set of required measures to include additional measures endorsed by NQF. We also stated that to support the standardized collection and calculation of quality measures by CMS, collection of the needed data elements would require a standardized data collection instrument. In response, CMS developed and tested a hospice patient-level item set, the HIS. Hospices are required to submit an HIS-Admission record and an HIS-Discharge record for each patient admission to hospice on or after
* 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) (modified).
To achieve a comprehensive set of hospice quality measures available for widespread use for quality improvement and informed decision making, and to carry out our commitment to develop a quality reporting program for hospices that uses standardized methods to collect data needed to calculate quality measures, we finalized the HIS effective
Hospices are required to complete and submit an HIS-Admission and an HIS-Discharge record for each patient admission. Hospices failing to report quality data via the HIS in FY 2015 will have their market basket update reduced by 2 percentage points in FY 2017 beginning in
5. HQRP Quality Measures and Concepts Under Consideration for Future Years
We are not currently proposing any new measures for FY 2017. However, we are working with our measure development and maintenance contractor to identify measure concepts for future implementation in the HQRP. In identifying priority areas for future measure enhancement and development, CMS takes into consideration input from numerous stakeholders, including the
FOOTNOTE 53 IOM (
* Patient reported pain outcome measure that incorporates patient and/or proxy report regarding pain management;
* Claims-based measures focused on care practice patterns including skilled visits in the last days of life, burdensome transitions of care for patients in and out of the hospice benefit, and rates of live discharges from hospice;
* Responsiveness of hospice to patient and family care needs;
* Hospice team communication and care coordination.
These measure concepts are under development, and details regarding measure definitions, data sources, data collection approaches, and timeline for implementation will be communicated in future rulemaking. CMS invites comments about these four high priority concept areas for future measure development.
6. 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 with respect to that FY.
b. Proposed Policy for New Facilities To Begin Submitting Quality Data
In the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79 FR 50488) we finalized a policy stating that any hospice that receives its CCN notification letter on or after
We are proposing to modify our policies for the timing of new providers to begin reporting to CMS. Beginning with the FY 2018 payment determination and for each subsequent payment determination, we propose that a new hospice be responsible for HQRP quality data reporting beginning on the date they receive their Certification Number (CCN) (also known as the Medicare Provider Number) notification letter from CMS. Under this proposal, hospices would be responsible for reporting quality data on patient admissions beginning on the date they receive their CCN notification.
Currently, new hospices may experience a lag between
c. Previously Finalized Data Submission Mechanism, Collection Timelines and Submission Deadlines for the FY 2017 Payment Determination
In the FY 15 Hospice Wage Index final rule (79 FR 50486) we finalized our policy requiring that, for the FY 2017 reporting requirements, hospices must complete and submit HIS records for all patient admissions to hospice on or after
The QIES ASAP system provides reports upon successful submission and processing of the HIS records. The final validation report may serve as evidence of submission. This is the same data submission system used by nursing homes, inpatient rehabilitation facilities, home health agencies, and long-term care hospitals for the submission of Minimum Data Set Version 3.0 (MDS 3.0), Inpatient Rehabilitation Facility--Patient Assessment Instrument (IRF-PAI), Outcome Assessment Information Set (OASIS), and Long-Term Care Hospital Continuity Assessment Record & Evaluation Data Set (LTCH CARE), respectively. We have provided hospices with information and details about use of the HIS through postings on the HQRP Web page, Open Door Forums, announcements in the CMS MLN Connects Provider e-News (
d. Proposed Data Submission Timelines and Requirements for FY 2018 Payment Determination and Subsequent Years
Hospices are evaluated for purposes of the quality reporting program based on whether or not they submit data, not on their substantive performance level with respect to the required quality measures. In order for CMS to appropriately evaluate the quality reporting data received by hospice providers, it is essential HIS data be received in a timely manner.
The submission date for any given HIS record is defined as the date on which a provider submits the completed record. The submission date is the date on which the completed record is submitted and accepted by the QIES ASAP system. Beginning with the FY 2018 payment determination, we propose that hospices must submit all HIS records within 30 days of the Event Date, which is the patient's admission date for HIS-Admission records or discharge date for HIS-Discharge records.
* For HIS-Admission records, the submission date should be no later than the admission date plus 30 calendar days. The submission date can be equal to the admission date, or no greater than 30 days later. The QIES ASAP system will issue a warning on the Final Validation Report if the submission date is more than 30 days after the patient's admission date.
* For HIS-Discharge records, the submission date should be no later than the discharge date plus 30 calendar days. The submission date can be equal to the discharge date, or no greater than 30 days later. The QIES ASAP system will issue a warning on the Final Validation Report if the submission date is more than 30 days after the patient's discharge date.
The QIES ASAP system validation edits are designed to monitor the timeliness and ensure that providers submitted records conform to the HIS data submission specifications. Providers are notified when timing criteria have not been met by warnings that appear on their Final Validation Reports. A standardized data collection approach that coincides with timely submission of data is essential in order to establish a robust quality reporting program and ensure the scientific reliability of the data received. We invite comments on the proposal that hospices must submit all HIS records within 30 days of the Event Date, which is the patient's admission date for HIS-Admission records or discharge date for HIS-Discharge records.
e. Proposed HQRP Data Submission and Compliance Thresholds for the FY 2018 Payment Determination and Subsequent Years
In order to accurately analyze quality reporting data received by hospice providers, it is imperative we receive ongoing and timely submission of all HIS-Admission and HIS-Discharge records. To date, the timeliness criteria for submission of HIS Admission and HIS-Discharge records has never been proposed and finalized through rulemaking process. We believe this matter should be addressed by defining a clear standard for timeliness and compliance at this time. In response to input from our stakeholders seeking additional specificity related to HQRP compliance affecting FY payment determinations and, due to the importance of ensuring the integrity of quality data submitted to CMS, we are proposing to set specific HQRP thresholds for timeliness of submission of hospice quality data beginning with data affecting the FY 2018 payment determination and subsequent years.
Beginning with the FY 2018 payment determination and subsequent FY payment determinations, we propose that all HIS records must be submitted within 30 days of the Event Date, which is the patient's admission date or discharge date. To coincide with this requirement, we propose to establish an incremental threshold for compliance with this timeliness requirement; the proposed threshold would be implemented over a 3 year period. To be compliant with timeliness requirements, we propose that hospices would have to submit no less than 70 percent of their total number of HIS-Admission and HIS-Discharge records by no later than 30 days from the Event Date for the FY 2018 APU determination. The timeliness threshold would be set at 80 percent for FY 2019 and at 90 percent for FY 2020 and subsequent years. The threshold corresponds with the overall amount of HIS records received from each provider that fall within the established 30 day submission timeframes. Our ultimate goal is to require all hospices to achieve a timeliness requirement compliance rate of 90 percent or more.
For example, beginning in FY 2018, hospices will have met the timeliness requirement threshold if at the end of the reporting period 70 percent of all their HIS reporting data for the year has been received within the 30 day submission timeframe.
To summarize, we propose to implement the timeliness threshold requirement beginning with all HIS admission and discharge records that occur on or after
* Beginning on or after
* Beginning on or after January 1, 2017 to December 31, 2017, hospices must score at least 80 percent for all HIS records received within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2019.
* Beginning on or after January 1, 2018 to December 31, 2018, hospices must score at least 90 percent for all HIS records received within the 30 day submission timeframe for the year or be subject to a 2 percentage point reduction to their market basket update for FY 2020.
We invite public comment on our proposal to implement the new data submission and compliance threshold requirement, as described previously, for the HQRP.
7. HQRP Submission Exception and Extension Requirements for the FY 2017 Payment Determination and Subsequent Years
In the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79 FR 50488), we finalized our proposal to allow hospices to request and for CMS to grant exemptions/extensions with respect to the reporting of required quality data when there are extraordinary circumstances beyond the control of the provider. When an extension/exception is granted, a hospice will not incur payment reduction penalties for failure to comply with the requirements of the HQRP. For the FY 2016 payment determination and subsequent payment determinations, a hospice may request an extension/exception of the requirement to submit quality data for a specified time period. In the event that a hospice requests an extension/exception for quality reporting purposes, the hospice would submit a written request to CMS. In general, exceptions and extensions will not be granted for hospice vendor issues, fatal error messages preventing record submission, or staff error.
In the event that a hospice seeks to request an exception or extension for quality reporting purposes, the hospice must request an exception or extension within 30 days of the date that the extraordinary circumstances occurred by submitting the request to CMS via email to the HQRP mailbox at [email protected]. Exception or extension requests sent to CMS through any other channel would not be considered as a valid request for an exception or extension from the HQRP's reporting requirements for any payment determination. In order to be considered, a request for an exception or extension must contain all of the finalized requirements as outlined on our Web site at http://www.cms.gov/
If a provider is granted an exception or extension, timeframes for which an exception or extension is granted will be applied to the new timeliness requirement so providers are not penalized. If a hospice is granted an exception, we will not require that the hospice submit any quality data for a given period of time. If we grant an extension to a hospice, the hospice will still remain responsible for submitting quality data collected during the timeframe in question, although we will specify a revised deadline by which the hospice must submit this quality data.
This process does not preclude us from granting extensions/exceptions to hospices that have not requested them when we determine that an extraordinary circumstance, such as an act of nature, affects an entire region or locale. We may grant an extension/exception to a hospice if we determine that a systemic problem with our data collection systems directly affected the ability of the hospice to submit data. If we make the determination to grant an extension/exception to hospices in a region or locale, we will communicate this decision through routine communication channels to hospices and vendors, including, but not limited to, Open Door Forums, ENews and notices on https://www.cms.gov/
8. Hospice CAHPS Participation Requirements for the 2018 APU and 2019 APU
In the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79 FR 50452), we stated that CMS would start national implementation of the CAHPS(R) Hospice Survey as of January 1, 2015. We started national implementation of this survey as planned. The CAHPS(R) Hospice Survey is a component of CMS' Hospice Quality Reporting Program that emphasizes the experiences of hospice patients and their primary caregivers listed in the hospice patients' records. Measures from the survey will be submitted to the National Quality Forum (NQF) for endorsement as hospice quality measures. We refer readers to our extensive discussion of the Hospice Experience of Care Survey in the Hospice Wage Index FY 2015 final rule for a description of the measurements involved and their relationship to the statutory requirement for hospice quality reporting (79 FR 50450 also refer to 78 FR 48261).
a. Background and Description of the Survey
The CAHPS(R) Hospice Survey is the first national hospice experience of care survey that includes standard survey administration protocols that allow for fair comparisons across hospices.
CMS developed the CAHPS(R) Hospice Survey with input from many stakeholders, including other government agencies, industry stakeholders, consumer groups and other key individuals and organizations involved in hospice care. The Survey was designed to measure and assess the experiences of patients who died while receiving hospice care as well as the experiences of their informal caregivers. The goals of the survey are to--
* Produce comparable data on patients' and caregivers' perspectives of care that allow objective and meaningful comparisons between hospices on domains that are important to consumers;
* Create incentives for hospices to improve their quality of care through public reporting of survey results; and
* Hold hospice care providers accountable by informing the public about the providers' quality of care.
The development process for the survey began in 2012 and included a public request for information about publicly available measures and important topics to measure (78 FR 5458, January 25, 2013); a review of the existing literature on tools that measure experiences with end-of-life care; exploratory interviews with caregivers of hospice patients; a technical expert panel attended by survey development and hospice care quality experts; cognitive interviews to test draft survey content; incorporation of public responses to Federal Register notices (78 FR 48234, August 7, 2013) and a field test conducted by CMS in November and December 2013.
The CAHPS(R) Hospice Survey treats the dying patient and his or her informal caregivers (family members or friends) as the unit of care. The Survey seeks information from the informal caregivers of patients who died while enrolled in hospices. Survey-eligible patients and caregivers are identified using hospice records. Fielding timelines give the respondent some recovery time (2 to 3 months), while simultaneously not delaying so long that the respondent is likely to forget details of the hospice experience. The survey focuses on topics that are important to hospice users and for which informal caregivers are the best source for gathering this information. Caregivers are presented with a set of standardized questions about their own experiences and the experiences of the patient in hospice care. During national implementation of this survey, hospices are required to conduct the survey to meet the Hospice Quality Reporting requirements, but individual caregivers will respond only if they voluntarily choose to do so. A survey Web site is the primary information resource for hospices and vendors (www.hospicecahpssurvey.org). The CAHPS(R) Hospice Survey is currently available in English, Spanish, Traditional Chinese, and Simplified Chinese. CMS will provide additional translations of the survey over time in response to suggestions for any additional language translations. Requests for additional language translations should be made to the CMS Hospice CAHPS(R) Project Team at [email protected].
In general, hospice patients and their caregivers are eligible for inclusion in the survey sample with the exception of the following ineligible groups: primary caregivers of patients under the age of 18 at the time of death; primary caregivers of patients who died within 48 hours of admission to hospice care; patients for whom no caregiver is listed or available, or for whom caregiver contact information is not known; patients whose primary caregiver is a legal guardian unlikely to be familiar with care experiences; patients for whom the primary caregiver has a foreign (Non-US or US Territory address) home address; patients or caregivers of patients who request that they not be contacted (those who sign "no publicity" requests while under the care of hospice or otherwise directly request not to be contacted). Identification of patients and caregivers for exclusion will be based on hospice administrative data. Additionally, caregivers under 18 are excluded.
Hospices with fewer than 50 survey-eligible decedents/caregivers during the prior calendar year are exempt from the CAHPS(R) Hospice Survey data collection and reporting requirements for payment determination. Hospices with 50 to 699 survey-eligible decedents/caregivers in the prior year will be required to survey all cases. For hospices with 700 or more survey-eligible decedents/caregivers in the prior year, a sample of 700 will be drawn under an equal-probability design. Survey-eligible decedents/caregivers are defined as that group of decedent and caregiver pairs that meet all the criteria for inclusion in the survey sample.
We moved forward with a model of national survey implementation, which is similar to that of other CMS patient experience of care surveys.
Consistent with many other CMS CAHPS(R) surveys that are publicly reported on CMS Web sites, CMS will publicly report hospice data when at least 12 months of data are available, so that valid comparisons can be made across hospice providers in
b. Participation Requirements To Meet Quality Reporting Requirements for the FY 2018 APU
In section 3004(c) of the Affordable Care Act, the Secretary is directed to establish quality reporting requirements for Hospice Programs. The CAHPS(R) Hospice Survey is a component of the CMS Hospice Quality Reporting Requirements for the FY 2018 APU and subsequent years.
The CAHPS(R) Hospice Survey includes the measures detailed in Table 27. The individual survey questions that comprise each measure are listed under the measure. These measures are in the process of being submitted to the National Quality Forum (NQF).
Table 27--Hospice Experience of Care Survey Quality Measures and Constituent Items Hospice team communication . While your family member was in hospice care, how often did the hospice team keep you informed about when they would arrive to care for your family member? . While your family member was in hospice care, how often did the hospice team explain things in a way that was easy to understand? . How often did the hospice team listen carefully to you when you talked with them about problems with your family member's hospice care? . While your family member was in hospice care, how often did the hospice team keep you informed about your family member's condition? . While your family member was in hospice care, how often did the hospice team listen carefully to you? Getting timely care . While your family member was in hospice care, when you or your family member asked for help from the hospice team, how often did you get help as soon as you needed it? . How often did you get the help you needed from the hospice team during evenings, weekends, or holidays? Treating family member with respect . While your family member was in hospice care, how often did the hospice team treat your family member with dignity and respect? . While your family member was in hospice care, how often did you feel that the hospice team really cared about your family member? Providing emotional support . While your family member was in hospice care, how much emotional support did you get from the hospice team? . In the weeks after your family member died, how much emotional support did you get from the hospice team? Getting help for symptoms . Did your family member get as much help with pain as he or she needed? . How often did your family member get the help he or she needed for trouble breathing? . How often did your family member get the help he or she needed for trouble with constipation? . How often did your family member get the help he or she needed from the hospice team for feelings of anxiety or sadness? Getting hospice care training . Did the hospice team give you the training you needed about what side effects to watch for from pain medicine? . Did the hospice team give you the training you needed about if and when to give more pain medicine to your family member? . Did the hospice team give you the training you needed about how to help your family member if he or she had trouble breathing? . Did the hospice team give you the training you needed about what to do if your family member became restless or agitated? Single Item Measures Providing support for religious and spiritual beliefs . (Support for religious or spiritual beliefs includes talking, praying, quiet time, or other ways of meeting your religious or spiritual needs.) While your family member was in hospice care, how much support for your religious and spiritual beliefs did you get from the hospice team? Information continuity . While your family member was in hospice care, how often did anyone from the hospice team give you confusing or contradictory information about your family member's condition or care? Understanding the side effects of pain medication . Side effects of pain medicine include things like sleepiness. Did any member of the hospice team discuss side effects of pain medicine with you or your family member? Global Measures Overall rating of hospice . Using any number from 0 to 10, where 0 is the worst hospice care possible and 10 is the best hospice care possible, what number would you use to rate your family member's hospice care? Recommend hospice . Would you recommend this hospice to your friends and family?
To comply with CMS's quality reporting requirements for the FY 2018 APU, hospices will be required to collect data using the CAHPS(R) Hospice Survey. Hospices would be able to comply by utilizing only CMS-approved third party vendors that are in compliance with the provisions at
Approved CAHPS(R) Hospice Survey vendors will submit data on the hospice's behalf to the CAHPS(R) Hospice Survey Data Center. The deadlines for data submission occur quarterly and are shown in Table 28 below. Deadlines are the second Wednesday of the submission months, which are August, November, February, and May. Deadlines are final; no late submissions will be accepted. However, in the event of extraordinary circumstances beyond the control of the provider, the provider will be able to request an exemption as previously noted in the Quality Measures for Hospice Quality Reporting Program and Data Submission Requirements for Payment Year FY 2016 and Beyond section. Hospice providers are responsible for making sure that their vendors are submitting data in a timely manner.
Table 28--CAHPS(R) Hospice Survey Data Submission Dates FY2017 APU, FY2018 APU, and FY2019 APU Sample months (that is, month of death) Quarterly data *1 submission deadlines *2 FY2017 APUDry Run January-March 2015 (Q1) August 12, 2015. April-June 2015 (Q2) November 11, 2015. *3 July-September 2015 (Q3) February 10, 2016. October-December 2015 (Q4) May 11, 2016. FY2018 APU January-March 2016 (Q1) August 10, 2016. April-June 2016 (Q2) November 9, 2016. July-September 2016 (Q3) February 8, 2017. October-December 2016 (Q4) May 10, 2017. FY2019 APU January-March 2017 (Q1) August 9, 2017. April-June 2017 (Q2) November 8, 2017. July-September 2017 (Q3) February, 14, 2018. October-December 2017 (Q4) May 9, 2018. *1 Data collection for each sample month initiates two 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 month. *2 Corrected from the Final Rule published August 22, 2014, 79 FR 50493.
In the FY 2014 Hospice Wage Index and Rate Update final rule, we stated that we would exempt very small hospices from CAHPS(R) Hospice Survey requirements. We propose to continue that exemption: Hospices that have fewer than 50 survey-eligible decedents/caregivers in the period from January 1, 2015 through December 31, 2015 are exempt from CAHPS(R) Hospice Survey data collection and reporting requirements for the 2018 APU. To qualify for the survey exemption for the FY 2018 APU, hospices must submit an exemption request form. This form will be available on the CAHPS(R) Hospice Survey Web site http://www.hospicecahpssurvey.org. Hospices are required to submit to CMS their total unique patient count for the period of January 1, 2015 through December 31, 2015. The due date for submitting the exemption request form for the FY 2018 APU is August 10, 2016.
c. Participation Requirements To Meet Quality Reporting Requirements for the FY 2019 APU
To meet participation requirements for the FY 2019 APU, we proposed that hospices collect data on an ongoing monthly basis from January 2017 through December 2017 (inclusive). Data submission deadlines for the 2019 APU will be announced in future rulemaking.
Hospices that have fewer than 50 survey-eligible decedents/caregivers in the period from January 1, 2016 through December 31, 2016 are exempt from CAHPS(R) Hospice Survey data collection and reporting requirements for the FY 2019 payment determination. To qualify, hospices must submit an exemption request form. This form will be available in first quarter 2017 on the CAHPS(R) Hospice Survey Web site http://www.hospicecahpssurvey.org.
Hospices are required to submit to CMS their total unique patient count for the period of January 1, 2016 through December 31, 2016. The due date for submitting the exemption request form for the FY 2018 APU is August 10, 2016.
d. Annual Payment Update
The Affordable Care Act requires that beginning with FY 2014 and each subsequent fiscal year, 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 fiscal year, unless covered by specific exemptions. Any such reduction will not be cumulative and will not be taken into account in computing the payment amount for subsequent fiscal years. In the FY 2015 Hospice Wage Index we added the CAHPS(R) Hospice Survey to the Hospice Quality Reporting Program requirements for the FY 2017 payment determination and determinations for subsequent years.
* To meet the HQRP requirements for the FY 2018 payment determination, hospices would collect survey data on a monthly basis for the months of January 1, 2016 through December 31, 2016 to qualify for the full APU.
* To meet the HQRP requirements for the FY 2019 payment determination, hospices would collect survey data on a monthly basis for the months of January 1, 2017 through December 31, 2017 to qualify for the full APU.
e. CAHPS(R) Hospice Survey Oversight Activities
We propose to continue a requirement that vendors and hospice providers participate in CAHPS(R) Hospice Survey oversight activities to ensure compliance with Hospice CAHPS(R) technical specifications and survey requirements. The purpose of the oversight activities is to ensure that hospices and approved survey vendors follow the CAHPS(R) Hospice Survey technical specifications and thereby ensure the comparability of CAHPS(R) Hospice Survey data across hospices.
We propose that the reconsiderations and appeals process for hospices failing to meet the Hospice CAHPS(R) data collection requirements will be part of the Reconsideration and Appeals process already developed for the Hospice Quality Reporting program. We encourage hospices interested in learning more about the CAHPS(R) Hospice Survey to visit the CAHPS(R) Hospice Survey Web site: http://www.hospicecahpssurvey.org.
9. HQRP Reconsideration and Appeals Procedures for the FY 2016 Payment Determination and Subsequent Years
In the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79 FR 50496), we notified hospice providers on how to seek reconsideration if they received a noncompliance decision for the FY 2016 payment determination and subsequent years. A hospice may request reconsideration of a decision by CMS that the hospice has not met the requirements of the Hospice Quality Reporting Program for a particular period. Reporting compliance is determined by successfully fulfilling both the Hospice CAHPS(R) Survey requirements and the HIS data submission requirements.
We wish to clarify that any hospice that wishes to submit a reconsideration request must do so by submitting an email to CMS containing all of the requirements listed on the HQRP Web site at http://www.cms.gov/
In the past, only hospices found to be non-compliant with the reporting requirements set forth for a given payment determination received a notification of this finding along with instructions for requesting reconsideration in the form of a certified
We propose to disseminate communications regarding the availability of hospice compliance reports in CASPER files through routine channels to hospices and vendors, including, but not limited to issuing memos, emails, Medicare Learning Network (MLN) announcements, and notices on http://www.cms.gov/
We further propose to publish a list of hospices who successfully meet the reporting requirements for the applicable payment determination on the HQRP Web site http://www.cms.gov/
We invite comment on the proposals to add CASPER Reporting as an additional communication mechanism for the dissemination of compliance notifications and to publish a list of compliant hospices on the HQRP Web site.
10. 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. The procedures must ensure that a hospice would have the opportunity to review the data regarding the hospice's respective program before it is made public.
We recognize that public reporting of quality data is a vital component of a robust quality reporting program and are fully committed to developing the necessary systems for public reporting of hospice quality data. We also recognize that it is essential that the data made available to the public be meaningful and that comparing performance between hospices requires that measures be constructed from data collected in a standardized and uniform manner. Hospices have been required to use a standardized data collection approach (HIS) since July 1, 2014. Data from July 1, 2014 onward is currently being used to establish the scientific soundness of the quality measures prior to the onset of public reporting of the seven quality measures implemented in the HQRP. We believe it is critical to establish the reliability and validity of the quality measures prior to public reporting in order to demonstrate the ability of the quality measures to distinguish the quality of services provided. To establish reliability and validity of the quality measures, at least four quarters of data will be analyzed. Typically, the first one or two quarters of data reflect the learning curve of the facilities as they adopt standardized data collection procedures; these data often are not used to establish reliability and validity. We began data collection in CY 2014; the data from CY 2014 for Quarter 3 (Q3) will not be used for assessing validity and reliability of the quality measures. We are analyzing data collected by hospices during Quarter 4 (Q4) CY 2014 and Q1-Q3 CY 2015. Decisions about whether to report some or all of the quality measures publicly will be based on the findings of analysis of the CY 2015 data.
In addition, the Affordable Care Act requires that reporting be made public on a CMS Web site and that providers have an opportunity to review their data prior to public reporting. CMS will develop the infrastructure for public reporting, and provide hospices an opportunity to review their quality measure data prior to publicly reporting information about the quality of care provided by "
As part of our ongoing efforts to make healthcare more transparent, affordable, and accountable, the HQRP is prepared to post hospice data on a public data set, the Medicare Provider Utilization and
Furthermore, to meet the requirement for making such data public, we will develop a CMS Compare Web site for hospice, which will list hospice providers geographically. Consumers can search for all
F. Clarification Regarding Diagnosis Reporting on Hospice Claims
1. Background
During the grass roots movement of hospice growth in
FOOTNOTE 54 Connor, S. (2007). Development of Hospice and Palliative Care in
Both the
2. Current Discussions About Hospice Vulnerabilities
The Institute of Medicine (IOM) recently released the report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. This report discussed vulnerabilities in the current health care system, especially as it relates to those who are approaching the end of life, and stated that one of the largest barriers in providing efficient, quality end-of-life care is the lack of coordination and communication among different components of the health care system. /55/ The report states that better coordination of care is essential in improving patient outcomes and that end-of-life care should be individualized based on patient values, goals, needs, and informed preferences with a recognition that individual service needs and intensity will change over time. /56/
FOOTNOTE 55 Institute of Medicine (IOM), "Dying in America: Improving Quality and Honoring Individual Preferences Near End-of-Life," 2014, p.5-10. END FOOTNOTE
FOOTNOTE 56 Institute of Medicine (IOM), "Dying in America: Improving Quality and Honoring Individual Preferences Near End-of-Life," 2014, p.5-52. END FOOTNOTE
Recent news articles on hospice care highlight the same concerns expressed in the IOM report regarding vulnerabilities in the current health care system. While recent news articles agree that hospice care is a valuable and needed service for patients who are near death, the articles identified issues with hospice quality of care, the lack of services provided, conflicts of interest, and the current
FOOTNOTE 57 http://www.washingtonpost.com/sf/business/collection/business-of-dying/ END FOOTNOTE
As mentioned in previous rules, and in section III.A of this proposed rule, there is data suggesting a significant amount of "unbundling" is occurring for services that should be included in the hospice bundled payment. As discussed previously above, our data analysis shows that $1.3 billion is being paid outside of the
Given the legislative history, the statements provided by hospices during the development of the benefit, and anecdotal reports from non-hospice providers and hospice beneficiaries, we are concerned that some hospices are making determinations of hospice coverage based solely on cost and reimbursement as opposed to being based on patient-centered needs, preferences and goals for those approaching the end of life. We believe this to be counter to the holistic, comprehensive, and coordinated hospice care model promoted during the development of the
FOOTNOTE 58 "Background Materials on Medicare Hospice Benefit Including Description of Proposed Implementing Regulations," September 9, 1983. Committee on Finance,
FOOTNOTE 59 Hoyer, T. (1998). A History of the Medicare Hospice Benefit. The Hospice Journal, 13(1-2), 61-69. END FOOTNOTE
3. Medicare Hospice Eligibility Requirements
The Medicare hospice regulations at
* Diagnosis of the terminal condition of the patient.
* Other health conditions, whether related or unrelated to the terminal condition.
* Current clinically relevant information supporting all diagnoses.
Eligibility for the
As mentioned earlier in this section, the hospice industry has come under increased media scrutiny, much of it related to hospices enrolling patients who may not be eligible for the benefit because they are not terminally ill and enrolling patients with certain diagnoses that typically have a longer length of stay, mainly non-cancer diagnoses. In the December 26, 2013 Washington Post article, "Hospice firms draining billions from
FOOTNOTE 60 http://www.washingtonpost.com/business/economy/medicare-rules-create-a-booming-business-in-hospice-care-for-people-who-arent-dying/2013/12/26/4ff75bbe-68c9-11e3-ae56-22de072140a2_story.html. END FOOTNOTE
4. Assessment of Conditions and Comorbidities Required by Regulation
We have recognized throughout the federal regulations at part 418 that the total person is to be assessed, including acute and chronic conditions, as well as, controlled and uncontrolled conditions, and comorbidities, in order to determine an individual's terminal prognosis. We have also been clear that the original intent of the
Since the implementation of the
Defined at
FOOTNOTE 61 Gijsen, R., Hoeymans, N., Schellevis, F., Ruwaard, Satariano, W., van den Bos, G., (2001). Causes and consequences of comorbidity: A review. Journal of Clinical Epidemiology, 54(2001), 661. END FOOTNOTE
FOOTNOTE 62 Yancik, R.,
Repetto, L., Comandini, D., Mammoliti, S. (2001). Life expectancy, comorbidity and quality of life: The treatment equation in the older cancer patients. Critical Reviews in Oncology/Hematology, 37(2001), 148.
Escarrabill, J., Cataluna, J., Hernandez, C., Servera, E. (2009). Recommendations for End-of-Life Care in Patients with Chronic Obstructive Pulmonary Disease. Archivos de Bronconeumologia, 45(6), 297-303. END FOOTNOTE
* Be admitted to the ER and hospital;
* Die in the hospital;
* Be discharged from hospice. /63/
FOOTNOTE 63 Legler et al. (2011). The effect of comorbidity burden on health care utilization for patients with cancer using hospice. Journal of Palliative Care Medicine. 14(6), 751-756. END FOOTNOTE
It is not an uncommon clinical practice for some clinicians to stop drugs for comorbid conditions arbitrarily because the person has a progressive life-limiting illness; however, withdrawing long term drugs from comorbidities without considering the natural course of the illness can lead to serious problems, such as rebound hypertension, tachycardia, depression and death. /64/ It is imperative for hospice patients with comorbidities to have careful management and for clinicians to consider both the physical and psychological effects of treatment. /65/
FOOTNOTE 64 Stevenson, J., Abernethy, A., Miller, C, Currow, D. (2004). Managing comorbidities in patients at the end of life. British Medical Journal. 324(2004), 909-912. END FOOTNOTE
FOOTNOTE 65 Stevenson, J., Abernethy, A., Miller, C, Currow, D. (2004). Managing comorbidities in patients at the end of life. British Medical Journal. 324(2004), 909-912. END FOOTNOTE
The National Hospice and Palliative Care Organization (NHPCO) recognizes the importance of comorbidities. They define "comorbidity" as known factors or pathological disease impacting on the primary health problem and generally attributed to contributing to increased risk for poor health status outcomes /66/ This aligns with the
FOOTNOTE 66 National Hospice and Palliative Care Organization. (2010). Standards of Practice for Hospice Programs. END FOOTNOTE
* The nature and condition causing admission (including the presence or lack of objective data and subjective complaints).
* Complications and risk factors that affect care planning.
* Functional status, including the patient's ability to understand and participate in his or her own care.
* Imminence of death.
* Severity of symptoms.
* Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy.
* Bereavement. An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care.
* The need for referrals and further evaluation by appropriate health professionals.
The hospice CoPs at
5. Clarification Regarding Diagnosis Reporting on Hospice Claims
International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Coding Guidelines state the following regarding the selection of the principal diagnosis: The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. In the case of selection of a principal diagnosis for hospice care, this would mean the diagnosis most contributory to the terminal prognosis of the individual. In the instance where two or more diagnoses equally meet the criteria for principal diagnosis, ICD-10-CM coding guidelines do not provide sequencing direction, and thus, any one of the diagnoses may be sequenced first, meaning to report all of those diagnoses meeting the criteria as a principal diagnosis. Per ICD-10-CM Coding Guidelines, for diagnosis reporting purposes, the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring:
* Clinical evaluation; or
* therapeutic treatment; or
* diagnostic procedures; or
* extended length of hospital stay; or
* increased nursing care and/or monitoring.
The UHDDS item #11-b defines Other Diagnoses as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. ICD-10-CM coding guidelines are clear that all diagnoses affecting the management and treatment of the individual within the healthcare setting are requirement to be reported. This has been longstanding existing policy. Adherence to coding guidelines when assigning ICD-9-CM and ICD-10-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA) as well as our regulations at 45 CFR 162.1002.
However, though established coding guidelines are required, it does not appear that all hospices are coding on hospice claims per these guidelines. In 2010, over 77 percent of hospice claims reported only one diagnosis. Previous rules have discussed requirements for hospice diagnosis reporting on claims and the importance of complete and accurate coding. Preliminary analysis of FY 2014 claims data demonstrates that hospice diagnosis coding is improving; however, challenges remain. Analysis of FY 2014 claims data indicates that 49 percent of hospice claims listed only one diagnosis. /67/ We conducted additional analysis on instances where only one diagnosis was reported on the FY 2014 hospice claim and found that 50 percent of these beneficiaries had, on average, eight or more chronic conditions and 75 percent had, on average, five or more chronic conditions. /68/ These chronic, comorbid conditions include: Hypertension, anemia, congestive heart failure, chronic obstructive pulmonary disease, ischemic heart disease, depression, diabetes and atrial fibrillation, to name a few.
FOOTNOTE 67 Preliminary FY 2014 hospice claims data from the Chronic Conditions Data Warehouse (CCW), accessed on January 13, 2015. END FOOTNOTE
FOOTNOTE 68 Preliminary FY 2014 hospice claims data from the Chronic Conditions Data Warehouse (CCW), accessed on January 21, 2015. END FOOTNOTE
In the Medicare Program; Hospice Wage Index for Fiscal Year 2013 Notice (77 FR 44248) we stated that hospices should report on hospice claims all coexisting or additional diagnoses that are related to the terminal illness; they should not report coexisting or additional diagnoses that are unrelated to the terminal illness, even though coding guidelines required the reporting of all diagnoses that affect patient assessment and planning. However, as discussed earlier in this section, there is widely varying interpretation as to what factors influence the terminal prognosis of the individual (that is, what conditions render the individual terminally ill and which conditions are related). Furthermore, based on the numerous comments received in previous rulemaking, and anecdotal reports from hospices, hospice beneficiaries, and non-hospice providers discussed above, we are concerned that hospices may not be conducting a comprehensive assessment nor updating the plan of care as articulated by the CoPs to recognize the conditions that affect an individual's terminal prognosis.
Therefore, we are clarifying 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. This is in keeping with the requirements of determining whether an individual is terminally ill. This would also include the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs. Our regulations at
* Diagnosis of the terminal condition of the patient.
* Other health conditions, whether related or unrelated to the terminal condition.
* Current clinically relevant information supporting all diagnoses.
ICD-10-CM Coding Guidelines state that diagnoses should be reported that develop subsequently, coexist or affect the treatment of the individual. Furthermore, having these diagnoses reported on claims falls under the authority of the Affordable Care Act for the collection of data to inform hospice payment reform. Section 3132 a(1)(C) of the Affordable Care Act states that the Secretary may collect the additional data and information on cost reports, claims, or other mechanisms as the Secretary determines to be appropriate. Having adequate data on hospice patient characteristics will help to inform thoughtful, appropriate, and clinically relevant policy for future rulemaking. We will monitor compliance with required coding practices and collaborate with all relevant CMS components to determine whether further policy changes are needed or if additional program integrity oversight actions need to be implemented.
IV. Collection of Information Requirements
This document does not impose information collection requirements, that is, reporting, recordkeeping or third-party disclosure requirements. Consequently, there is no need for review by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995.
V. Regulatory Impact Analysis
A. Statement of Need
This proposed rule meets the requirements of our regulations at
B. Introduction
We have examined the impacts of this proposed 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 Act, section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA, March 22, 1995; Pub. L. 104-4), and the Congressional Review Act (5 U.S.C. 804(2)).
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). Executive Order 13563 emphasizes the importance of quantifying both costs and benefits, of reducing costs, of harmonizing rules, and of promoting flexibility. A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). This proposed rule has been designated as economically significant under section 3(f)(1) of Executive Order 12866 and thus a major rule under the Congressional Review Act. Accordingly, we have prepared a regulatory impact analysis (RIA) that, to the best of our ability, presents the costs and benefits of the rulemaking. This proposed rule was also reviewed by OMB.
C. Overall Impact
The overall impact of this proposed rule is an estimated net increase in Federal Medicare payments to hospices of $200 million, or 1.3 percent, for FY 2016. The $200 million increase in estimated payments for FY 2016 reflects the distributional effects of the 1.8 percent proposed FY 2016 hospice payment update percentage ($290 million increase), the use of updated wage index data and the phase-out of the wage index budget neutrality adjustment factor (-0.7 percent/$120 million decrease) and the proposed implementation of the new OMB CBSA delineations for the FY 2016 hospice wage index with a one-year transition (0.2 percent/$30 million increase). The elimination of the wage index budget neutrality adjustment factor (BNAF) was part of a 7-year phase-out that was finalized in the FY 2010 Hospice Wage Index final rule (74 FR 39384), and is not a policy change. The proposed RHC rates and the proposed SIA payment, outlined in section III.B, would be implemented in a budget neutral manner in the first year of implementation, as required per section 1814(i)(6)(D)(ii) of the Act. In section III.B., we also proposed continuing to make the SIA payments budget neutral annually. The RHC rate budget neutrality factors and the SBNF used to reduce the overall RHC rate are outlined in section III.C.3. Therefore, the proposed RHC rates and the proposed SIA payment would not result in an overall payment impact for the
1. Detailed Economic Analysis
Table 29, Column 3 shows the combined effects of the use of updated wage data (the FY 2015 pre-floor, pre-reclassified hospital wage index) and the phase-out of the BNAF (for a total BNAF reduction of 100 percent), resulting in an estimated decrease in FY 2016 payments of 0.7 percent ($-120 million). Column 4 of Table 29, shows the effects of the proposed 50/50 blend of the FY 2016 hospice wage index values (based on the use of FY 2015 pre-floor, pre-reclassified hospital wage index data) under the old and the new CBSA delineations, resulting in an estimated increase in FY 2016 payments of 0.2 percent ($30 million). Column 5 displays the estimated effects of the proposed RHC rates, resulting in no overall change in FY 2016 payments for hospices as this proposal would be implemented in a budget neutral manner. Column 6 shows the estimated effects of the proposed SIA payment, resulting in no change in FY 2016 payments for hospices as this proposal would be implemented in a budget neutral manner through a reduction to the overall RHC rate for FY 2016. Column 7 shows the effects of the proposed FY 2016 hospice payment update percentage. The proposed 1.8 percent hospice payment update percentage is based on a 2.7 percent inpatient hospital market basket update for FY 2016 reduced by a 0.6 percentage point productivity adjustment and by 0.3 percentage point as mandated by the Affordable Care Act. The estimated effects of the 1.8 percent proposed hospice payment update percentage would result in an increase in payments to hospices of approximately $290 million. Taking into account the 1.8 percent proposed hospice payment update percentage ($290 million increase), the use of updated wage data and the phase-out of the BNAF (-$120 million), and the proposed adoption of the new OMB CBSA delineations with a one-year transition for the FY 2016 hospice wage index ($30 million), Column 8 shows that hospice payments are estimated to increase by $200 million ($290 million - $120 million + $30 million = $200 million), or 1.3 percent, in FY 2016.
a. Effects on Hospices
This section discusses our analysis of the estimated impacts on FY 2016 payments to hospices due to: (1) The use of updated wage index data for the proposed FY 2016 hospice wage index (using FY 2015 hospital pre-floor, pre-reclassified hospital wage data) and the phase-out of the BNAF, (2) the proposed FY 2016 hospice wage index that adopts the new OMB CBSA delineations with a one-year transition, (3) the proposed RHC rates, (4) the proposed SIA payment, and (5) the proposed 1.8 percent hospice payment update percentage. Table 29 below shows the results of our analysis. For the purposes of our impact analysis, we use the utilization observed in the most complete hospice claims data available at the time of rulemaking (FY 2014 hospice claims submitted as of December 31, 2014). Presenting these data gives the hospice industry a more complete picture of the effects on their total revenue based on the use of updated hospital wage index data and the BNAF phase-out, the proposed adoption of the new OMB CBSA delineations with a one-year transition, the proposed SIA payment, and the proposed FY 2016 hospice payment update percentage as discussed in this proposed rule. 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
Table 29--Estimated Hospice Impacts by Facility Type and Area of the Country, FY 2016 Provid- Updated Proposed Proposed Proposed Proposed Total FY ers FY 2016 50/50 routine FY 2016 FY 2016 2016 wage blend of home SIA hospice proposed index FY 2016 care payment payment policies data and wage rates (% update (% phase- index (days 1 change) percent- change) out of values thru 60 age BNAF under and days (% (% old and 61+) change) change) new CBSA (%) delinea- tions (% change) (1) (2) (3) (4) (5) (6) (7) (8) All Hospices 4,010 -0.7 0.2 0.0 0.0 1.8 1.3 Urban Hospices 3,015 -0.7 0.3 0.0 0.0 1.8 1.4 Rural Hospices 995 -0.3 -0.2 0.4 0.0 1.8 1.7 Urban 140 0.0 0.1 1.3 -0.1 1.8 3.1 Hospices--New England Urban 251 -0.7 -0.2 0.8 0.0 1.8 1.7 Hospices-- Middle Atlantic Urban 410 -1.1 0.3 -0.7 -0.1 1.8 0.2 Hospices-- South Atlantic Urban 388 -0.8 0.7 -0.2 0.0 1.8 1.5 Hospices--East North Central Urban 165 -0.7 0.5 -0.3 0.0 1.8 1.3 Hospices--East South Central Urban 221 -0.7 0.6 0.7 0.0 1.8 2.4 Hospices--West North Central Urban 593 -1.1 0.6 -1.2 -0.2 1.8 -0.1 Hospices--West South Central Urban 299 -0.6 0.2 -0.4 0.0 1.8 1.0 Hospices-- Mountain Urban 511 -0.1 0.0 1.0 0.2 1.8 2.9 Hospices-- Pacific Urban 37 0.0 0.3 -1.1 -0.2 1.7 0.7 Hospices-- Outlying Rural 24 -0.3 0.0 3.3 0.3 1.8 5.1 Hospices--New England Rural 42 0.3 -0.1 1.8 0.5 1.8 4.3 Hospices-- Middle Atlantic Rural 141 -0.6 0.1 -0.2 0.0 1.8 1.1 Hospices-- South Atlantic Rural 135 -0.7 -0.4 0.8 0.2 1.8 1.7 Hospices--East North Central Rural 133 -0.1 -0.1 -0.9 -0.2 1.8 0.5 Hospices--East South Central Rural 184 -0.3 -0.1 2.2 -0.1 1.8 3.5 Hospices--West North Central Rural 184 -0.1 -0.1 -1.0 -0.2 1.8 0.4 Hospices--West South Central Rural 102 -1.4 -0.7 0.3 0.1 1.8 0.1 Hospices-- Mountain Rural 47 2.1 0.1 3.3 0.3 1.8 7.6 Hospices-- Pacific Rural 3 -0.8 -0.2 1.9 0.2 1.8 2.9 Hospices-- Outlying 0-3,499 RHC 840 -0.5 0.1 3.0 0.1 1.8 4.5 Days (Small) 3,500-19,999 1,924 -0.6 0.2 0.6 0.0 1.8 2.0 RHC Days (Medium) 20,000+ RHC 1,246 -0.7 0.3 -0.2 0.0 1.8 1.2 Days (Large) Non-Profit 1,070 -0.6 0.2 1.2 0.1 1.8 2.7 Ownership For Profit 2,398 -0.7 0.3 -1.0 -0.1 1.8 0.3 Ownership Govt/Other 542 -0.6 0.3 0.6 0.1 1.8 2.2 Ownership Freestanding 3,016 -0.7 0.3 -0.4 0.0 1.8 1.0 Facility Type HHA/Facility- 994 -0.4 0.2 1.8 0.2 1.8 3.6 Based Facility Type Rate of RHC 1,002 -0.5 0.1 0.7 0.0 1.8 2.1 NF/SNF Days is in Lowest Quartile (Less than or equal to 3.1%) Rate of RHC 1,003 -0.6 0.1 0.4 0.2 1.8 1.9 NF/SNF Days is in 2nd Quartile (Greater than 3.1 and Less than or equal to 16.7%) Rate of RHC 1,003 -0.7 0.3 -0.1 0.0 1.8 1.3 NF/SNF Days is in 3rd Quartile (Greater than 16.7 and less than or equal to 35.5%) Rate of RHC 1,002 -0.7 0.4 -0.6 -0.2 1.8 0.7 NF/SNF Days is in Highest Quartile (Greater than 35.5%) Source: FY 2014 hospice claims data from the Standard Analytic Files for CY 2013 (as of June 30, 2014) and CY 2014 (as of December 31, 2014). Note: The proposed 1.8 percent hospice payment update percentage for FY 2016 is based on an estimated 2.7 percent inpatient hospital market basket update, reduced by a 0.6 percentage point productivity adjustment and by 0.3 percentage point. Starting with FY 2013 (and in subsequent fiscal years), the market basket percentage update under the hospice payment system as described in section 1814(i)(1)(C)(ii)(VII) or section 1814(i)(1)(C)(iii) of the Act will be annually reduced by changes in economy-wide productivity as set out at section 1886(b)(3)(B)(xi)(II) 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 set out under section 1814(i)(1)(C)(v) of the Act). 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 .
Table 29 above also presents the impact of the changes in this proposed rule according to the type of hospice, geographic location, type of ownership, hospice base, size, and percentage of RHC days in a SNF/NF. The majority of hospice payments are made at the routine home care rate; therefore, we based the size of each individual hospice's program on the number of routine home care days provided in FY 2014. As indicated in column 2 of Table 29, there are 4,010 hospices included in the regulatory impact analysis. Approximately 40 percent of
b. Hospice Size
The use of updated wage data combined with the BNAF phase-out is anticipated to decrease FY 2016 payments to large hospices by 0.7 percent and to decrease payments to small and medium hospices by 0.5 percent and 0.6 percent respectively (column 3). The proposed 50/50 Blend for FY 2016 wage index values under the old and the new CBSA delineations is anticipated to result in an increase in payments to small hospices of 0.1 percent, an increase in payments to medium hospices of 0.2 percent, and an increase to large hospices of 0.3 percent (column 4). The proposed RHC rates are projected to increase payments by 3.0 percent for small hospices and 0.6 percent for medium hospices. The proposed RHC rates are anticipated to decrease payments by 0.2 percent for large hospices. The proposed FY 2016 SIA payment is projected to result in an increase in FY 2016 payments of 0.1 percent for small hospices and no change in payments for medium and large hospices (column 6).
c. Geographic Location
Column 3 of Table 29 shows the combined estimated effects of using updated wage data and the BNAF phase-out and results in a decrease in FY 2016 payments of 0.7 percent for urban hospices and 0.3 percent for rural hospices. Urban hospices can anticipate a decrease in payments ranging from 1.1 percent in the
Column 4 shows the effect of the proposed 50/50 Blend of the FY2016 wage index values under the old and the new CBSA delineations. Overall, hospices are anticipated to experience a 0.2 percent increase in payments, with urban hospices experiencing an estimated increase of 0.3 percent and rural hospices experiencing an estimated decrease of 0.2 percent. All urban areas other than Middle Atlantic and
Column 5 shows the anticipated effects of the proposed RHC rates, that is, paying separate rates for days 1 through 60 and days beyond 60. Overall, hospices would experience no change in overall payments for FY 2016 due to the proposed RHC rates. FY 2016 payments are estimated to range from an increase of 3.3 percent for rural hospices in
Column 6 shows the effects of proposed FY 2016 SIA Payment. Overall, hospices are anticipated to experience no change in overall payments for FY 2016. However, FY 2016 payments are estimated to range from an increase of 0.5 percent for rural hospices in the Middle Atlantic region to a decrease of 0.2 percent for urban hospices in the West South Central region and the Outlying region.
Column 8 shows the total anticipated impact of the FY 2016 proposed policy changes. Overall, all hospices are anticipated to receive a 1.3 percent increase in payment. Rural hospices in the
d. Type of Ownership
Column 3 demonstrates the effect of the use of updated wage data and BNAF phase-out on estimated FY 2016 payments. We estimate that using the updated wage data and BNAF phase-out would decrease estimated payments to voluntary (non-profit) and government hospices by 0.6 percent. Proprietary (for-profit) hospices are expected to have a decrease in payments of 0.7 percent. Column 4 demonstrates the effects of the proposed 50/50 Blend of FY 2016 wage index values under the old and the new CBSA delineations. Estimated FY 2016 payments to voluntary (non-profit), proprietary (for-profit) and government hospices are anticipated to increase by 0.2 percent, 0.3 percent and 0.3 percent, respectively. Column 5 shows the anticipated impacts for the two proposed RHC rates. Estimated FY 2016 payments are anticipated to increase for voluntary (non-profit) and government hospices by 1.2 percent and 0.6 percent respectively and to decrease for proprietary (for-profit) hospices by 1.0 percent. Column 6 shows the estimated effects of the proposed SIA payment. Estimated FY 2016 payments are anticipated to increase for voluntary (non-profit) and government hospices by 0.1 percent and decrease for proprietary (for-profit) hospices by 0.1 percent.
e. Hospice Base and Percentage of RHC Days in a SNF/NF
Column 3 demonstrates the combined effects of using the updated wage data and the BNAF phase-out on estimated payments for FY 2016. Estimated payments are anticipated to decrease for freestanding hospices by 0.7 percent and decrease for HHA/facility-based hospices by 0.4 percent. Column 4 shows the effects of the proposed 50/50 Blend of FY 2016 wage index values under the old and new CBSA delineations. Payments are estimated to increase by 0.3 percent for freestanding hospices and by 0.2 percent for HHA/facility-based hospices. Column 5 shows the effects of the proposed RHC rates. Payments to freestanding hospices are expected to decrease by 0.4 percent while payments to HHA/facility-based hospices are expected to increase by 1.8 percent. Column 6 shows the effects of the proposed SIA payment. Payments to freestanding hospices are expected to neither increase nor decrease due to the SIA proposal, while payments for HHA/facility-based hospices are expected to increase by 0.2 percent.
Table 29 also shows the effects of the proposed changes in this rule by the rate of RHC NF/SNF days in quartiles. Column 3 shows that all four quartiles (lowest quartile being less than or equal to 3.1 percent of RHC days in a SNF/NF to the highest quartile being greater than 35.5 percent of RHC days in a SNF/NF) are anticipated to experience a decrease in payments ranging from 0.5 percent for the first quartile to 0.7 percent for the third and fourth quartiles. Column 4 shows the effect of the proposed 50/50 Blend of FY 2016 wage index values under the old and the new CBSA delineations. All four quartiles are anticipated to experience an increase in payments under this proposal with the first and second quartiles anticipated to experience increases of 0.1percent, the third quartile anticipated to experience an increase of 0.3 percent, and the highest quartile to experience an increase in payments of 0.4 percent. Column 5 shows the anticipated impact of the proposed RHC rates on hospices by their rates of RHC days in a SNF/NF. The first and second quartiles are anticipated to see an increase in payments of 0.7 percent and 0.4 percent respectively. The third and fourth quartiles are anticipated to see decreases of 0.1 percent and 0.6 percent respectively due to the proposed RHC rates. Column 6 shows the anticipated effect of the proposed FY 2016 SIA payment on hospices by their rates of RHC days in a SNF/NF. The second quartile is anticipated to see an increase in payments of 0.2 percent. The first and third quartile is expected to experience no change in payments under the FY 2016 SIA payment proposal and the highest quartile is anticipated to experience a decrease in FY 2016 payments of 0.2 percent under this proposal.
f. Effects on Other Providers
This proposed rule would only affect
g. Effects on the
This proposed rule only affects
h. Alternatives Considered
For the FY 2016 proposed rule, we considered several alternatives to the proposals articulated in section III.B. As described in Table 13 in section III.B.1 of this preamble, previous work on a tiered payment model indicates that a different RHC payment could begin at day 31. Therefore, we considered proposing that the higher rate of the RHC payment to be the first 30 days of hospice care given the results above and given that MedPAC identified in their 2008 Report to
For the SIA payment, we considered allowing the first two days of a new hospice election with a unique hospice provider to also be eligible for the SIA payment. The reason for not proposing to allow the SIA payment to apply to the first two days of a new hospice election with a unique hospice was outlined in section III.B. In addition, because the SIA payment is required to be implemented in a budget neutral manner in the first year of implementation, per section 1814(i)(6)(D)(ii), allowing the first two days of the hospice election with a unique hospice provider to be eligible for the SIA payment would result in a larger decrease to the RHC rate for all hospice providers. We estimate that the RHC would need to be reduced by 1.26 percent (rather than the proposed 0.81 percent).
i. Accounting Statement
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 30 below, we have prepared an accounting statement showing the classification of the expenditures associated with this proposed rule. Table 30 provides our best estimate of the increase in Medicare payments under the hospice benefit as a result of the changes presented in this proposed rule for 3,879 hospices in our impact analysis file constructed using FY 2014 claims as of December 31, 2014.
Table 30--Accounting Statement: Classification of Estimated Transfers, From FY 2015 to FY 2016 [In $millions] Category Transfers FY 2015 Hospice Wage Index and Payment Rate Update Annualized Monetized Transfers $200. From Whom to Whom? Federal Government to Hospices.
j. Conclusion
In conclusion, the overall effect of this proposed rule is an estimated $200 million increase in Medicare payments to hospices. The $200 million increase in estimated payments for FY 2016 reflects the distributional effects of the 1.8 percent proposed FY 2016 hospice payment update percentage ($290 million increase), the use of updated wage index data and the phase-out of the wage index budget neutrality adjustment factor (-0.7 percent/$120 million decrease) and the proposed implementation of the new OMB CBSA delineations for FY 2016 hospice wage index with a one-year transition (0.2 percent/$30 million increase). The proposed SIA payment does not result in aggregate changes to estimate hospice payments for FY 2016 as this proposal would be implemented in a budget neutral manner through an overall reduction to the RHC payment rate for all hospices.
2. Regulatory Flexibility Act Analysis
The RFA requires agencies to analyze options for regulatory relief of small businesses if a rule has a significant impact on a substantial number of small entities. The great majority of hospitals and most other health care providers and suppliers are small entities by meeting the Small Business Administration (SBA) definition of a small business (in the service sector, having revenues of less than $7.5 million to $38.5 million in any 1 year), or being nonprofit organizations. For purposes of the RFA, we consider all hospices as small entities as that term is used in the RFA. HHS's practice in interpreting the RFA is to consider effects economically "significant" only if they reach a threshold of 3 to 5 percent or more of total revenue or total costs. As noted above, the combined effect of the updated wage data and the BNAF phase-out (-0.7 percent decrease or -$120 million) the proposed implementation of the new OMB CBSA delineations for FY 2016 hospice wage index with a one-year transition (0.2 percent increase or $30 million), the proposed SIA payment (no estimated aggregate impact on payments), and the proposed FY 2016 hospice payment update percentage (1.8 percent increase or $290 million) results in an overall increase in estimated hospice payments of 1.3 percent, or $200 million, for FY 2016. Therefore, the Secretary has determined that this proposed rule will not create a significant economic impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan statistical area and has fewer than 100 beds. This proposed rule only affects hospices. Therefore, the Secretary has determined that this proposed rule would not have a significant impact on the operations of a substantial number of small rural hospitals.
3. Unfunded Mandates Reform Act Analysis
Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. In 2015, that threshold is approximately $144 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 $144 million or more.
VI. Federalism Analysis and Regulations Text
Executive Order 13132, Federalism (August 4, 1999) requires an agency to provide federalism summary impact statement when it promulgates a proposed rule (and subsequent final rule) that has federalism implications and which imposes substantial direct requirement costs on State and local governments which are not required by statute. We have reviewed this proposed rule under these criteria of Executive Order 13132, and have determined that it will not impose substantial direct costs on State or local governments.
List of Subjects in 42 CFR Part 418
Health facilities, Hospice care, Medicare, Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare and Medicaid Services propose to amend 42 CFR chapter IV as set forth below:
PART 418--HOSPICE CARE
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).
Subpart G--Payment for Hospice Care
2. Section 418.302 is amended by--
a. Adding paragraphs (b)(1)(i) and (ii).
b. Amending paragraphs (d)(1), (d)(2), (e) introductory text, (f)(2) and (f)(5)(ii) by removing the word "intermediary" and adding in its place the words "Medicare Administrative Contractor".
c. Revising paragraph (e)(1).
The revisions and additions read as follows:
SEC 418.302 Payment procedures for hospice care.
* * * * *
(b) * * *
(1) * * *
(i) Service intensity add-on. Except as provided in paragraph (b)(1)(ii) of this section, routine home care days that occur during the last 7 days of a hospice election ending with a patient discharged as "expired" are eligible for a service intensity add-on payment. Such payment must be equal to the continuous home care hourly payment rate, as described in paragraph (e)(4) of this section, multiplied by the amount of direct patient care provided by a RN and/or social worker, up to 4 hours total per day.
(ii) Routine home care days provided to patients residing in a skilled nursing facility (SNF) or a long-term care nursing facility (NF) are not eligible for the service intensity add-on payment.
* * * * *
(e) * * *
(1) Payment is made to the hospice for each day during which the beneficiary is eligible and under the care of the hospice, regardless of the amount of services furnished on any given day (except as set out in paragraph (b)(1)(i) of this section).
* * * * *
3. Section 418.306 is amended by revising the section heading and paragraphs (a), (b), and (c) to read as follows:
SEC 418.306 Annual update of the payment rates and adjustment for area wage differences.
(a) Applicability. CMS establishes payment rates for each of the categories of hospice care described in SEC 418.302(b). The rates are established using the methodology described in section 1814(i)(1)(C) of the Act and in accordance with section 1814(i)(6)(D) of the Act.
(b) Annual update of the payment rates. The payment rates for routine home care and other services included in hospice care are the payment rates in effect under this paragraph during the previous fiscal year increased by the hospice payment update percentage increase (as defined in sections1814(i)(1)(C) of the Act), applicable to discharges occurring in the fiscal year.
(1) For fiscal year 2014 and subsequent fiscal years, per section 1814(i)(5)(A)(i) of the Act, in the case of a Medicare-certified hospice that submits hospice quality data, as specified by the Secretary, the payment rates are equal to the rates for the previous fiscal year increased by the applicable hospice payment update percentage increase.
(2) For fiscal year 2014 and subsequent fiscal years, per section 1814(i)(5)(A)(i) of the Act, in the case of a Medicare-certified hospice that does not submit hospice quality data, as specified by the Secretary, the payment rates are equal to the rates for the previous fiscal year increased by the applicable hospice payment update percentage increase, minus 2 percentage points. Any reduction of the percentage change will apply only to the fiscal year involved and will not be taken into account in computing the payment amounts for a subsequent fiscal year.
(c) Adjustment for wage differences. Each hospice's labor market is determined based on definitions of Metropolitan Statistical Areas (MSAs) issued by OMB. CMS will issue annually, in the Federal Register , a hospice wage index based on the most current available CMS hospital wage data, including changes to the definition of MSAs. The urban and rural area geographic classifications are defined in SEC 412.64(b)(1)(ii)(A) through (C) of this chapter. The payment rates established by CMS are adjusted by the Medicare contractor to reflect local differences in wages according to the revised wage data.
* * * * *
SEC 418.308 [Amended]
4. Section 418.308(c) is amended by removing the phrase "(that is, by March 31st)".
5. Section 418.309 is amended by revising the introductory text and paragraph (a) to read as follows:
SEC 418.309 Hospice aggregate cap.
A hospice's aggregate cap is calculated by multiplying the adjusted cap amount (determined in paragraph (a) of this section) by the number of Medicare beneficiaries, as determined by one of two methodologies for determining the number of Medicare beneficiaries for a given cap year described in paragraphs (b) and (c) of this section.
(a) Cap amount. The cap amount was set at $6,500 in 1983 and is updated using one of two methodologies described in paragraphs (a)(1) and (2) of this section.
(1) For accounting years that end on or before September 30, 2016 and end on or after October 1, 2025, the cap amount is adjusted for inflation by using the percentage change in the medical care expenditure category of the Consumer Price Index (CPI) for urban consumers that is published by the Bureau of Labor Statistics. This adjustment is made using the change in the CPI from March 1984 to the fifth month of the cap year.
(2) For accounting years that end after September 30, 2016, and before October 1, 2025, the cap amount is the cap amount for the preceding accounting year updated by the percentage update to payment rates for hospice care for services furnished during the fiscal year beginning on the October 1 preceding the beginning of the accounting year as determined pursuant to section 1814(i)(1)(C) of the Act (including the application of any productivity or other adjustments to the hospice percentage update).
* * * * *
Dated: April 23, 2015.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
Approved: April 27, 2015.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2015-10422 Filed 4-30-15; 4:15 pm]
BILLING CODE 4120-01-P
Notice of Funds Availability (NOFA) Inviting Applications for the FY 2015 Funding Round of the Bank Enterprise Award Program (BEA Program)
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