For FY 2022, we proposed to continue to use the most recent pre-floor, pre-reclassified hospital wage index value available for Puerto Rico, which is 0.4047, subsequently adjusted by the hospice floor. Other patient care salaries are those salaries attributable to patient services including but not limited to patient transportation, labs, and imaging services. We proposed to implement the proposed hospice labor shares in a budget neutral manner which is consistent with our policy of implementing updates to the hospice wage index in a budget neutral manner as well as updates in other perspective payment systems such as the annual recalibration of the case-mix weights in home health and updates to the home health wage index. G-codes are used to identify the SW and RN versus LPN visits. Some comments expressed concern about the public's ability to be aware of and find the seven HIS measure scores in the Provider Data Catalogue. Hospice payments per beneficiary are determined by summing together all payments on hospice claims for a particular reporting year for a particular hospice. Given the importance of structured data and health IT standards for the capture, use, and exchange of relevant health data for improving health equity, the existing challenges providers' encounter for effective capture, use, and exchange of health information, such as data on race, ethnicity, and other social determinants of health, to support care delivery and decision making. First, it would reduce the proportion of hospices that would have CAHPS Hospice Survey data displayed on Care Compare. Medicare claims are administrative records of health care services provided and payments which Medicare (and beneficiaries as applicable) made for those services. In section III.F of this rule, we finalize proposals to the HQRP including the addition of claims-based Hospice Care Index (HCI) measure, and Hospice Visits in the Last Days of Life (HVLDL) measure for public reporting; removal of the seven Hospice Item Set (HIS) measures because a more broadly applicable measure, the NQF #3235 HIS Comprehensive Assessment Measure for the particular topic is available and already publicly reported; and further development of the Hospice Outcome and Patient Evaluation (HOPE) assessment instrument. (3) If there are any changes to the plan of care during the course of hospice care, the hospice must update the addendum and provide these updates, in writing, to the individual (or representative) in order to communicate these changes to the individual (or representative). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. In addition, we are providing a provider-specific impact analysis file, which is available on our website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Regulations-and-Notices.html. And these data automatically meet the HQRP requirements for 418.306(b)(2). %%EOF This means that their scores will not be displayed on Care Compare, and consumers will not have information about them to inform their decisions about selecting a hospice. Additionally, other provider types, such as IPPS hospitals, home health agencies (HHAs), SNFs, IRFs, and the dialysis facilities all use CBSAs to define their labor market areas. New Documents (2016). For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a MSA and has fewer than 100 beds. Comment: Many commenters offered suggestions regarding additional aspects of the election statement addendum for which we did not propose clarifying changes. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. 04/28/2023, 153 In response to public comments, we are adopting the revised hospice labor shares calculated as we proposed with a slight modification to the methodology. This approach to include key aspects of demographics supports hospice feedback provided in the FYs 2017 and 2018 Hospice Wage Index and Payment Rate Update final rule (81 FR 52171 and 82 FR 36669) and CMS' goals for a hospice assessment instrument, as stated in the FY 2018 Hospice Wage Index and Payment Rate Update final rule. Hospice providers suggested that claims may lack sufficient information to adequately reflect individual patient Start Printed Page 42565needs or the full array of hospice practices. However, if additional Medicare hospice claims data points become available, we may consider modifying the measure in light of the new data. Comment: Several commenters expressed concerns that the HCI will overlap with, or be duplicative of, HOPE-based measures. In order to finalize this proposal in time to release the required preview report related to the refresh, which we release 3 months prior to any given refresh (October 2021), we need the rule containing this proposal to finalize by October 2021. For these reasons, we determined the best course of action would be to continue to publicly report the most recent 8 quarters of data, but exempting Q1 and Q2 2020. Particularly during the last few days before death, patients (and caregivers) experience many physical and emotional symptoms, necessitating close care and attention from the hospice team and drawing increasingly on hospice team resources. Response: The freestanding hospice MCR form used for the proposed labor shares (CMS-1984-14; OMB NO. In the FY 2017 Hospice Wage Index and Payment Rate Update final rule (81 FR 52160), we finalized new policies and requirements related to the HQRP, including how we would provide updates related to the development of new quality measures. Response: We believe that our proposal to revise the labor shares based on MCR data for hospice providers is a technical improvement to the current labor shares and appreciate the support from the commenters. Specifically, we already post the annual Hospice APU Compliant List on the HQRP Requirements and Best Practices web page. Please. Commenters noted that hospices were not included in the EHR Incentive Program, which provided grants to hospices to develop HIT systems. Moreover, a commenter recommended developing an exceptions process for when hospice providers are unable to provide an addendum because of `exceptional circumstances' that are beyond the control of the hospice. For example, see: Teno J.M., Bowman, J., Plotzke, M., Gozalo, P.L., Christian, T., Miller, S.C., Williams, C., & Mor, V. (2015). Hospice Aide Training and EvaluationUsing Pseudo-Patients, 3. We also rebased IRC per diem rates equal to the estimated FY Start Printed Page 425322019 average costs per day, with a reduction of 5 percent to the FY 2019 average cost per day to account for coinsurance. The SIA payment is in addition to the routine home care rate. If the beneficiary (or representative) refuses to sign the addendum, the hospice must document on the addendum the reason the addendum was not signed and the addendum would become part of the patient's medical record. Therefore, we proposed to include direct patient care salaries and contract labor for social workers and counselors in the calculation of the labor shares. We do not have a policy for `exceptional circumstances' (that is floods, hurricanes, etc.) For questions regarding home health public reporting, contact Charles Padgett (410) 786-2811. Section 4442 of the BBA amended section 1814(i)(2) of the Act, effective for services furnished on or after October 1, 1997, to require that hospices submit claims for payment for hospice care furnished in an individual's home only on the basis of the geographic location at which the service is furnished. Consultant specialty services, when necessary for the palliative care and management of the terminal illness (e.g., radiation for pain relief), are covered separately and are reimbursed only to the elected hospice. The commenter stated that this disregards the essence of the hospice interdisciplinary team which cares for the patient and family as a unit of care. One commenter also stated that they were interested in how the percentage of hospices that operate inpatient facilities can be increased and all costs, including contracted costs, can be included. Comment: A number of commenters suggested that CMS continue providing the option for hospices to view detailed information about the individual measures that make up the HIS Comprehensive Assessment measure to support quality improvement. We are finalizing the following revisions to the hospice CoPs. Additionally, we summarize the comments on the requests for information (RFI) on advancing to digital quality measurement and the use of FHIR and on addressing the White House Executive Order related to health equity in the HQRP. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. Identification of the beneficiary's terminal illness and related conditions; 5. Some commenters recommended adding a disclaimer that the data are two years old and do not reflect the current status of hospice performance. The 'Wage Index' links contain the listing of Core Based Statistical Area (CBSA) codes and the corresponding wage index. By dividing total payments for each level of care (RHC days 1 through 60, RHC days 61+, CHC, IRC, and GIP) using the current labor shares and FY 2022 wage index and payment rates for each level of care by the total payments for each level of care using the final revised labor shares and FY 2022 wage index and payment rates for each level of care, we obtain a labor share standardization factor for each level of care. To the extent that an HHA does not submit data in accordance with this clause, the Secretary shall reduce the home health market basket percentage increase applicable to the HHA for such year by 2 percentage points. It will assess patients in real-time, based on interactions with the patient. These process measures may support or complement the outcome measures. We will continue to evaluate the flexibilities to determine if additional changes are warranted in the future. The commenter stated that they are forced to outsource many nursing functions at high cost, along with paying retention bonuses to current staff. In addition, the measure supports alignment across our programs and with other public and private initiatives. Lastly, one commenter suggested that since an electronically sent addendum could be tracked, a signature should not be required. Font Size: Federal government websites often end in .gov or .mil. We offer many training and education opportunities through our website, which are available 24/7, 365 days per year, to enable hospice staff to learn at the pace and time of their choice. Therefore, for accounting years that end after September 30, 2016 and before October 1, 2030, the hospice cap amount is updated by the hospice payment update percentage rather than using the CPI-U. As we prepare to update Care Compare for their removal, we will consider ways to revise the measure description for the HIS Comprehensive Measure on Care Compare so that it adequately explains the elements contained in the measure. However, a number of comments suggested that CMS continue providing the option for consumers to view detailed information about the individual measures that make up the HIS Comprehensive Assessment measure for transparency. Some beneficiaries or representatives may have time constraints that prevent them from signing and returning the addendum by a certain deadline, in which case, the date that the hospice furnishes the addendum to the beneficiary may differ from the date that the beneficiary (or representative) signs the addendum. We agree that permitting competency testing of hospice aides utilizing a pseudo-patient will support patient privacy while also assuring a competently trained hospice aide workforce that provide high quality patient care. We believe that by measuring whether hospices actually provided CHC and GIP, the HCI will recognize the extent to which hospices both kept patients at home and recognized the need for inpatient care when necessary. We note that any future revisions to the hospice labor shares will be proposed and subject to public comments in future rulemaking. (2) above, Update on Use of Q4 2019 Data and Data Freeze for Refreshes in 2021). Using the wage information from the Bureau of Labor Statistics (BLS) for medical and health service managers (Code 11-9111); we estimate that the cost of reviewing this rule is $114.24 per hour, including overhead and fringe benefits (https://www.bls.gov/oes/current/oes_nat.htm). The HVLDL measure, as a replacement, will continue to fill an important area in hospice care previously filled by the HVWDII measure pair. Numerator: Total Medicare hospice payments received by a hospice within a reporting period. In Table 15, we explore changes in hospices' relative rankings between the SPR and CAR scenarios. Report to the Congress: Medicare Payment Policy | March 2020. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf?sfvrsn=0. Numerator: The number of decedent beneficiaries receiving a visit by a skilled nurse or social worker for the hospice in the last 3 days of the beneficiary's life within a reporting period. We will consider these comments and suggestions for ongoing monitoring analyses, program integrity efforts, and for potential future rulemaking. We identify skilled nursing visits by the presence of revenue code 055x (Skilled Nursing) on the claim. The revisions and additions read as follows: (c) Content of hospice election statement addendum. A summary of the comments we received on this proposal and our responses to those comments appear below. We have reviewed this rule under these criteria of Executive Order 13132, and have determined that it will not impose substantial direct costs on state or local governments. Using fewer quarters of more recent data, the first option, would require that (1) a sufficient percentage of providers would still likely have enough assessment data to report quality measures (reportability); and (2) fewer quarters would likely produce similar measure scores for hospices, and thus not unfairly represent the quality of care hospices provide during the period reported in a given refresh (reliability). We conducted analyses of those data to ensure that their use was appropriate. Pseudo-patient means a person trained to participate in a role-play situation, or a computer-based mannequin device. Register, and does not replace the official print version or the official Hospices' scores on the HCI can range from zero to ten. The proposed methodology for calculating the labor shares cited by the commenter of using Worksheet A-1 and A-2 column 7, lines 26 through 37 for total labor costs reflects only one component of the proposed calculation of the labor share. Thus, we proceeded with including Q4 2019 data in measure calculations for the October 2020 refresh. We have streamlined our processes as much as possible, and time is needed to go through these steps to ensure accurate publication of quality measure data. We believe that updating the data in January 2022 by more than a year relative to the October 2020 freeze data can assist the public by providing more relevant quality data and allow CMS to display more recent HHA performance. Many waivers and modifications were made effective as of March 1, 2020[4647] in accordance with the president's declaration. This is why the HIS Comprehensive Assessment Measure provides valuable and transparent information about hospice performance. We remind stakeholders that the hospice wage index does include the hospice floor which is applicable to all CBSAs, both rural and urban. The comments pointed out that the process for providers to adapt to the new tool requires at least 6 months or more. Specifically, for IRC, we required total IRC costs (Worksheet B, column 18, line 52) and IRC compensation costs to be greater than zero. de la Cruz, M., et al. 30. However, as discussed in the CMS-10390 Supporting Statement published October 23, 2020 and HIS V3.00 approved by OMB on February 16, 2021, our analysis comparing HVWDII and HVLDL with CAHPS would recommend scores demonstrates that HVLDL results in higher validity and variability testing results compared to HVWDII. Comment: Several commenters raised issues about the eight quarters of data included in public reporting. We observed that the HIS data submission rate for Q4 2019 was in fact 1.8 percent higher than the previous CY (Q4 2018). The QM report will also include results of the individual indicators used to calculate the single HCI score, and provide details on the indicators and HCI overall score to support hospices in interpreting the information. Since 0.4593 is not greater than 0.8, then County A's hospice wage index would be 0.4593. (or the day of death); One day prior to death is calculated as A0270 minus 1, and two days prior to death is calculated as A0270 minus 2. In the March 27, 2020 Guidance Memorandum, we stated that we should not include any PAC quality data that are greatly impacted by the exception granted in the quality reporting programs. We encourage commenters to provide us input and comments on these provisions in response to that rule. Collection of Information Requirements, https://www.federalregister.gov/d/2021-16311, MODS: Government Publishing Office metadata, https://www.whitehouse.gov/wp-content/uploads/2020/03/Bulletin-20-01.pdf, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Wage-Index.html, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Wage-Index, https://www.cms.gov/About-CMS/Components/CPI, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/MMF/General-info-Sub-Page.html, https://data.cms.gov/provider-data/topics/hospice-care, https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Provider-of-Services, http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=94893, https://www.cms.gov/regulations-and-guidancelegislationpaperworkreductionactof1995pra-listing/cms-10390, https://www.cms.gov/files/document/hqrphospice-visits-when-death-imminent-testing-re-specification-reportoctober-2020.pdf, https://www.qualityforum.org/Publications/2020/02/MAP_2020_Considerations_for_Implementing_Measures_Final_Report_-_PAC_LTC.aspx, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS, https://www.cms.gov/files/document/hospice-visits-last-days-life-hvldl-measure-specifications.pdf, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HOPE.html, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures, https://www.cms.gov/files/document/12042020-information-gathering-oy1508.pdf, https://www.cms.gov/files/document/2020-hqrp-tep-summary-report.pdf, https://www.qualityforum.org/Measures_Reports_Tools.aspx, https://hospicecahpssurvey.org/en/scoring-and-analysis/, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/HQRP-Requirements-and-Best-Practices, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Reporting-Training-Training-and-Education-Library, https://www.govinfo.gov/content/pkg/FR-2021-07-07/pdf/2021-13763.pdf, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Public-Reporting-HIS-Preview-Reports-and-Requests-for-CMS-Review-of-HIS-Data, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/PAC2017, https://www.cms.gov/files/document/hhqrp-pr-tip-sheet081320final-cx-508.pdf, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Regulations-and-Notices.html, https://www.bls.gov/oes/current/oes_nat.htm, https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/circulars/A4/a-4.pdf, https://www.medscape.com/viewarticle/925769#vp_1, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R3P243.pdf, http://www.medpac.gov/docs/default-source/reports/Jun07_EntireReport.pdf, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/IPPS-Regulations-and-Notices, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index, http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf, http://www.medpac.gov/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf?sfvrsn=0, https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_1204, https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_1302, https://oig.hhs.gov/oei/reports/oei-02-10-00490.pdf, https://oig.hhs.gov/oei/reports/oei-02-17-00020.pdf?utm_source=summary-page&utm_medium=web&utm_campaign=OEI-02-17-00020-PDF, https://www.qualityforum.org/Projects/c-d/Cost_and_Resource_Project/2158.aspx, https://oig.hhs.gov/oei/reports/oei-02-10-00491.pdf, https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_156, https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_176, https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_1100, https://oig.hhs.gov/oei/reports/oei-02-10-00490.asp, https://oig.hhs.gov/oei/reports/oei-02-10-00491.asp, https://oig.hhs.gov/oas/reports/region9/91803022.pdf, http://www.medpac.gov/docs/default-source/reports/Mar09_Ch06.pdf?sfvrsn=0, http://www.medpac.gov/docs/default-source/reports/Mar11_Ch11.pdf?sfvrsn=0, http://www.medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf?sfvrsn=0, http://www.qualityforum.org/Publications/2020/02/MAP_2020_Considerations_for_Implementing_Measures_Final_Report_-_PAC_LTC.aspx, https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf, https://www.phe.gov/emergency/news/healthactions/section1135/Pages/covid19-13March20.aspx, http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf?sfvrsn=0. Specifically, we used historical data to calculate HIS-based quality measures under two scenarios: The HIS Comprehensive Assessment Measure is based on the receipt of care processes at the time of admission. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING. Resources can be found at https://www.cms.gov/About-CMS/Components/CPI. 38. The appropriate wage index value is applied to the labor portion of the hospice payment rate based on the geographic area in which the beneficiary resides when receiving RHC or CHC. The current labor shares did not reflect this differential in utilization as the same labor share was used for both levels of care. We believe that updating the data in February 2022 by more than a year relative to the November 2020 freeze data would assist consumers by providing more relevant quality data and allow hospices to demonstrate more recent performance. In order to calculate the labor share standardization factor, we simulate total payments using FY 2020 hospice utilization claims data with the FY 2022 hospice wage index and the current labor shares and compare it to our simulation of total payments using the FY 2022 hospice wage index with the final revised labor shares. Others noted that the delay could allow time for additional analysis of the measure, and for more transparency about the rationale for it. The commenters recommended that CMS look further into reporting all pharmacy and medical supply costs as direct patient care costs on future cost reports. This analysis must conform to the provisions of section 604 of the RFA. Section 1871(b)(2)(C) of the Act and 5 U.S.C. The 2020-2021 MAP 2020 Final Recommendations can be found at: http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=94893. It is these four quality measures, the HIS Comprehensive Assessment Measure, HCI, HVLDL, and CAHPS Hospice Survey that make up the FY 2022 HQRP requirements. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf. NQF endorsed six composite measures and two overall measures from the CAHPS Hospice Survey. The HCI indicators, through the composite, will add new information to HQRP that was either directly recommended for CMS to publicly report by Federal stakeholders[1112] or identified as areas for improvement during information gathering activities. The HQRP proposals would not change provider burden or costs. One commenter recommended that CMS explore ways to educate hospice providers about how they can inform their beneficiaries (or representative) when items, services, or drugs are considered related, but non-covered due to reasons such as not reasonable or necessary for the palliation and management of the terminal illness and related conditions. Hospice caregivers also welcomed the addition of new quality measures to the HQRP to better differentiate between hospices. The optional data submission for Q4 2019 results in publicly reporting of that data since the CAHPS Hospice Survey from that quarter were not impacted. Pre-floor, pre-reclassified hospital wage index values below 0.8 are adjusted by a 15 percent increase subject to a maximum wage index value of 0.8. Also, you can decide how often you want to get updates. In conjunction with the Care Compare launch, we have made additional improvements to other CMS data tools, to help Medicare beneficiaries compare costs. This will allow us to report the maximum amount of new data, maintain reliability of the data, and permit the maximum number of hospices to receive scores. One commenter stated that their hospice utilizes general inpatient contracts, as they do not have our own facility. One commenter stated that there are no checks and balances on whether cost reporting data are accurate. Comment: We received several comments out of scope of the proposal suggesting CMS allow for use of the spiritual care HCPCS code approved for Veteran Administration use. [10] PDF Medicaid Hospice Rates Fast Healthcare Interoperability Resources (FHIR) in Support of Digital Quality Measurement in Post-Acute Care Quality Reporting ProgramsRequest for Information. The types of data and information suggested in the PPACA could capture accurate resource utilization, which could be collected on claims, cost reports, and possibly other mechanisms, as the Secretary determined to be appropriate. We appreciate all the comments and interest in this topic. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. We sought public comment on quality measure concepts and considerations for developing hybrid measures based on a combination of data sources. We are designating that system as the data submission system for the Hospice QRP. While CMS agrees that all patient visits are meaningful, based on our analyses, we found that RN and medical social worker visits correlate well with the CAHPS quality measures for would recommend the hospice. Items, Services, and Drugs Related and Unrelated to the Terminal Illness and Related Conditions, 2.
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