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Response: We recognize commenters' concern that HQRP measures reflect quality of care rather than program integrity issues. Comment: We received a comment that we are making many updates in this rule and the resources for them are significant, especially during the COVID-19 Public Health Emergency (PHE). State/County MEDICAID Rate Charts: NHPCO has prepared the . This license will terminate upon notice to you if you violate the terms of this license. A summary of the comments we received regarding HCI and our responses to those comments appear below: Comment: Several commenters expressed the importance of HCI for beneficiary and families that will give them information about care processes and add value to the available information about hospices that identifies aberrant practice when comparing hospices. In the FY 2022 proposed rule (86 FR 19717 through 19719), we proposed to rebase and revise the labor shares for CHC, RHC, IRC and GIP using Medicare cost report (MCR) data for freestanding hospices (collected via CMS Form 1984-14, OMB NO. And these data automatically meet the HQRP requirements for 418.306(b)(2). These specifications list all the information required to calculate each indicator, including the numerator and denominator definitions, different thresholds for receiving credit toward the overall HCI score, and explanations for those thresholds. The AMA does not directly or indirectly practice medicine or dispense medical services. One commenter requested that CMS work with stakeholders and the hospice community to identify the best approaches, and separate worksheets, for GIP and inpatient respite costs, including both hospices that operate a freestanding facility and hospices that have contracted beds. In order to support provider and supplier communities due to the COVID-19 PHE, CMS has issued an unprecedented number of regulatory waivers under our statutory authority set forth at section 1135 of the Act. Numerator: Total sum of minutes provided by the hospice during skilled nursing visits during RHC services days occurring on Saturdays or Sunday within a reporting period. Response: We appreciate the commenter's concern and conducted an additional review of our proposed methodology for appropriately capturing overhead costs in the labor shares. In addition, section 407(a)(2) of the CAA 2021 removes the prohibition on public disclosure of hospice surveys performed be a national accreditation agency in section 1865(b) of the Act, thus allowing the Secretary to disclose such accreditation surveys. The commenter recommended that the current continuous care timeframe change from midnight to midnight to a new time frame of noon to noon and that visits from other providers such as chaplains and home health aides count toward the continuous care timeframe. CMS is working to further the mission to improve the quality of healthcare for hospice beneficiaries through measurement, transparency and public reporting of data. Section III.C of this rule updates the hospice wage index and makes the application of the updated wage data budget neutral for all four levels of hospice care and discusses the FY 2022 hospice payment update percentage of 2.0 percent, updates to the hospice payment rates, as well as the updates to the hospice cap amount for FY 2022 by the hospice payment update percentage of 2.0 percent. A few commenters stated they believe the addendum and the ABN have the potential to decrease transparency and increase confusion for hospice patients, whereas, other commenters recommended expanding the usage of the addendum, which included combining the ABN and addendum, and to include drugs or services which the hospice has determined to be medically unreasonable or no longer necessary. Several other commenters also suggested posting a disclaimer that the HIS Comprehensive measure only comes from the admission item set and may not be reflective of subsequent care. The facilities that remained after this trim reported detailed direct patient care costs and other patient care costs for which we could then derive direct patient care salaries and other patient care salaries per the methodology described earlier. Sections 1812(d), 1813(a)(4), 1814(a)(7), 1814(i), and 1861(dd) of the Act, and the regulations in 42 CFR part 418, establish eligibility requirements, payment standards and procedures; define covered services; and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. As finalized in the FY 2020 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements final rule (84 FR 38484), Start Printed Page 42569we are developing a hospice patient assessment instrument identified as HOPE. This prototype edition of the Validity analyses showed that hospices' HCI scores align with family caregivers' perceptions of hospice quality, as measured by CAHPS Hospice survey responses (NQF endorsed quality measure #2651). A hospice-level score for a given survey item would then be calculated as the average of the individual-level responses, with adjustment for differences in case mix and mode of survey administration. MedPAC. The Centers for Medicare and Medicaid Services (CMS) released the annual change in Medicaid Hospice Payment Rates on September 14, 2022. PDF Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index and The labor shares for IRC and GIP are currently 54.13 percent and 64.01 percent, respectively. Comment: Many commenters questioned the weighting of the components of the star ratings, particularly the decision to weigh the two global questions (Overall Rating and Willingness to Recommend) at 50 percent of the weight for each composite measure. We noted in the FY 2021 Hospice Wage Index & Payment Rate Update final rule that because the beneficiary signature is an acknowledgement of receipt of the addendum, this means the beneficiary would sign the addendum when the hospice provides it, in writing, to the beneficiary or representative (85 FR 47092). Hospice caregivers also welcomed the addition of new quality measures to the HQRP to better differentiate between hospices. https://oig.hhs.gov/oei/reports/oei-02-10-00490.pdf. For example, for HCI, as we discussed in the proposed rule, we compared index scores calculated for the same hospice using annual claims from Federal FY 2017 and 2019. We evaluated measure reliability using the Pearson and Spearman correlation coefficients, which assess the alignment of HHs measure scores between scenarios. [3] Division CC, section 407 of CAA 2021 revises section 1814(i)(5)(A)(i) to increase the payment reduction for hospices who fail to meet hospice quality measure reporting requirements from two percent to four percent beginning with FY 2024. In the FY 2022 Hospice Wage Index and Payment Rate Update proposed rule (86 FR 19720), we proposed the market basket percentage increase of 2.5 percent for FY 2022 using the most current estimate of the inpatient hospital market basket (based on IHS Global Inc.'s fourth-quarter 2020 forecast with historical data through the third quarter 2020). 48. offers a preview of documents scheduled to appear in the next day's One commenter recommended that CMS maintain the 5 percent cap that was put in place for FY 2021 or lower the cap to 3 percent to protect hospice providers who are already operating with negative or razor thin operating margins. Before sharing sensitive information, make sure youre on a federal government site. Removal of Section O is the sole change from HIS V2.01 and in effect eliminate the HVWDII quality measure pair. 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. Use the PDF linked in the document sidebar for the official electronic format. Providing information for decision-making is all the more important during and in the wake of a COVID-19 PHE, when our health as a nation has been shaken. We then need to generate and check the calculations before posting for confidential reporting. Also, you can decide how often you want to get updates. The link to the Federal Register can be found here: CMS-1747-P CY 2022 Home Health Prospective Payment System Rate Update. Hospital claims-based measures are also updated annually. Department of Health and Human Services, Office of Inspector General. Medicare Program; FY 2022 Hospice Wage Index and Payment Rate Update There are four payment categories that are distinguished by the location and intensity of the hospice services provided. Third, we estimated reliability scores. For example, if the patient elects hospice on December 1st and requests the addendum on December 3rd, the hospice would have until December 8th to furnish the addendum. (2020). This explanation must be clearly noted on the addendum itself, but is not required to be documented in both places. Form, Manner and Timing of Data Collection and Submission, we have provided and will consolidate in the Users' Manual specifications for HCI and HVLDL in time to meet commenters' stated needs. Response: We agree that there are benefits to reporting just one year of data. Most hospices that fail to meet HQRP requirements do so because they miss the 90 percent threshold. For example, if a beneficiary (or representative) requests the addendum on February 22nd, then the hospice will have until February 25th to furnish the addendum, regardless of what time the addendum was requested on February Start Printed Page 4254822nd. Hospices providing services in the Outlying and South Atlantic regions would experience the largest estimated increases in payments of 2.9 percent and 2.5 percent, respectively. 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. The HQRP seeks to align with the other settings. Paragraph (b)(1) will include the existing language on the standardized set of admission and discharge items. While we are committed to provide time for understanding and preparation, we are not committed to ensuring that all hospices achieve high scores on the new measures before publicly reporting them. In addition to the hospice payment reform changes discussed, the FY 2016 Hospice Wage Index and Rate Update final rule implemented changes mandated by the IMPACT Act, in which the cap amount for accounting years that end after September 30, 2016 and before October 1, 2025 would be updated by the hospice payment update percentage rather than using the CPI-U (80 FR 47186). Final Decision: We are finalizing the proposal to add composite HCI measures to the HQRP as of FY 2022 and will monitor the measure. OMB approved the proposal to replace the HVWDII measure with the HVLDL measure and remove Section O from the discharge assessment on February 16, 2021. Some commenters stated that the measure should recognize telehealth visits in the last days of life, as circumstances such as the recent COVID-19 PHE may make in-person visits impossible or undesirable for patients or families. We estimate that the aggregate impact of the payment provisions in this rule will result in an increase of $480 million in payments to hospices, resulting from the hospice payment update percentage of 2.0 percent for FY 2022. Several existing measures, such as the HIS-based HVWDII measure and its replacement HVLDL, also do not differentiate refused visits. In addition, we proposed and finalize in this rule to remove the 7 measures that make up the HIS Comprehensive Assessment Measure section of Care Compare, which displays the seven HIS measures. Response: As described in the FY 2022 Hospice proposed rule (86 FR 17919) and above, the proposed compensation cost weights are equal to the sum of the compensation costs divided by the sum of the total costs for those remaining providers after trimming for outliers. 2016 99902 Before proceeding with the October 2020 refresh, we conducted testing to ensure that publicly displaying Q4 2019 data would still meet our standards despite granting an exception to HH QRP reporting requirements for Q4 2019. The day occurs during the last sevendays of the patient's life, and the patient is discharged. 15. As displayed in Table 21, the percentage of HHAs that met the public display threshold for the OASIS-based measure decreases by 5.5 percentage points or less for all but one QM, the Influenza Immunization for the Current Flu Season in the CAR scenario versus SPR scenario. We noted this revised statutory requirement in our proposed rule (86 FR 19726) and are codifying the revision at 418.306(b)(2). 5. Direct Patient Care Salaries and Contract Labor Costs, f. Total Compensation Costs and Total Costs, 3. We also solicited comments regarding skilled visits in the last week of life, particularly, what factors determine how and when visits are made as an individual approaches the end of life and how hospices make determinations as to what items, services and drugs are related versus unrelated to the terminal illness and related conditions. In addition, we will provide hospices with confidential reporting of their HVLDL and HCI measure scores in the Agency-Level QM report after this rule is finalizedafter August 2021. Section 1814(i)(5)(C) of the Act requires that each hospice submit data to the Secretary on quality measures specified by the Secretary. 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. However, while a hospice can choose to document the reason for an unsigned addendum in the medical record, as well as on the addendum, it is not required. The labor shares showing the revised methodology are provided in Table 1. Fewer hospices, 2,328 (46.2 percent), would have had 30+ completes if 4 quarters of data were used to calculate scores and 1,970 (39.1 percent) would have 30+ completes if 3 quarters were used to calculate scores. For this indicator, we identified hospice stays that included 30 or more consecutive days of hospice. 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. We then simultaneously removed those providers whose total IRC costs per day fall in the top and bottom one percent of total IRC costs per day for all IRC providers as well remove those providers whose compensation cost weight falls in the top and bottom five percent of compensation cost weights for all IRC providers. We have examined the impacts of this rule as required by Executive Order 12866 on Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. Hospice is compassionate beneficiary and family/caregiver-centered care for those who are terminally ill. As referenced in our regulations at 418.22(b)(1), to be eligible for Medicare hospice services, the patient's attending physician (if any) and the hospice medical director must certify that the individual is terminally ill, as defined in section 1861(dd)(3)(A) of the Social Security Act (the Act) and our regulations at 418.3; that is, the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. Similar to other CAHPS programs, we proposed that the cut-points used to determine the stars be constructed using statistical clustering procedures that minimize the score differences within a star category and maximize the differences across star categories. Additionally, we acknowledged that hospices have noted that there is not a timeframe in regulations regarding the patient signature on the addendum. Response: We acknowledge and appreciate the commenters' concerns regarding labor costs and understand the challenges created by the PHE. Finally, we proposed to publish the details of the Star Ratings methodology on the CAHPS Hospice Survey website, www.hospicecahpssurvey.org. Hospice providers previously completed MCR form (CMS-1984-89, OMB NO. In fact, on weekends, patients' caregivers are more likely to be around and could prefer privacy from hospice staff. While using more years of data would allow us to report measures for even more hospices, it would involve sharing data that are no longer relevant, and display scores that do not reflect recent hospice improvement efforts. CY 2019 HH PPS final rule with comment period (. In particular, claims do not fully capture patients' clinical conditions, patient and caregiver preferences, or hospice activities such as telehealth, chaplain visits, and specialized services such as massage or music therapy. Public Health Emergency. For example, the commenters provided that some hospices track mileage allowances enabling them to be reported on Worksheet A-1 and A-2 while other hospices allocate these mileage reimbursement costs via Worksheet B and B-1 using miles traveled. 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. This distinction explains why most hospices receive the maximum possible score on each of the 7 HIS measures, but not on the HIS Comprehensive Assessment Measure. and publicly reported by CMS for other care settings. This reimbursement is in addition to the per diem rate. Final Decision: In summary, in response to public comments, we are adopting the revised hospice labor shares calculated as we proposed with a slight modification to the methodology to derive the overhead benefit calculations as described previously. on FederalRegister.gov Rather, the HCI will serve as a useful measure to add value to the HQRP by providing more information to patients and family caregivers and better empowering them to make informed health care decisions. The services offered under the Medicare hospice benefit must be available to beneficiaries as needed, 24 hours a day, 7 days a week (section 1861(dd)(2)(A)(i) of the Act). The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) (Pub. We will consider this comment when working on any future modifications to the hospice cost report. In such instances, the removal of a measure will be formally announced in the next annual rulemaking cycle. 17. 4, Update on Use of Q4 2019 HH QRP Data and Data Freeze for Refreshes in 2021. Response: We are mindful of the burden related to our updates. In the FY 2008 Hospice Wage Index final rule (72 FR 50217 through 50218), we implemented a methodology to update the hospice wage index for rural areas without hospital wage data. The OFR/GPO partnership is committed to presenting accurate and reliable (2) Performance or improvement on a measure does not result in better patient outcomes. The change in reportability for the Influenza Immunization for the Current Flu Season measure is related to the seasonality of this measure, which includes cases that occur during the flu season only. Its removal would not only leave HQRP without this important admission quality of care measure but also result in HQRP having only two claims-based measures, HCI and HVLDL, and the CAHPS Hospice Survey. While changing the data included in claims is outside the scope of this proposed measure, we believe that using the claims data that currently exists still provides new and useful information not currently available to patients, families, and caregivers with the existing HQRP measures. Therefore, we are not seeking OMB approval for any information collection or recordkeeping activities that may be conducted in connection with the revisions to 418.76(h). 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. (Please see Table 18.) 19. The hospice CoPs at 418.56(b) require hospices to educate each patient and their primary caregivers(s) on services identified on the plan of care and document the patient's (or representative's) level of understanding involvement and agreement with the plan of care. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4.

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