Medicare Program; FY 2017 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements, 52143-52194 [2016-18221]
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Vol. 81
Friday,
No. 151
August 5, 2016
Part IV
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
42 CFR Part 418
Medicare Program; FY 2017 Hospice Wage Index and Payment Rate
Update and Hospice Quality Reporting Requirements; Final Rule
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Federal Register / Vol. 81, No. 151 / Friday, August 5, 2016 / Rules and Regulations
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Part 418
[CMS–1652–F]
RIN 0938–AS79
Medicare Program; FY 2017 Hospice
Wage Index and Payment Rate Update
and Hospice Quality Reporting
Requirements
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Final rule.
AGENCY:
This final rule will update the
hospice wage index, payment rates, and
cap amount for fiscal year (FY) 2017. In
addition, this rule changes the hospice
quality reporting program, including
adopting new quality measures. Finally,
this final rule includes information
regarding the Medicare Care Choices
Model (MCCM).
DATES: These regulations are effective
on October 1, 2016.
FOR FURTHER INFORMATION CONTACT:
Debra Dean-Whittaker, (410) 786–0848
for questions regarding the CAHPS®
Hospice Survey.
Michelle Brazil, (410) 786–1648 for
questions regarding the hospice quality
reporting program.
Hillary A. Loeffler, (410) 786–0456 for
questions regarding hospice payment
policy.
SUPPLEMENTARY INFORMATION: Wage
index addenda will be available only
through the internet on the CMS Web
site at: (https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
Hospice/.)
SUMMARY:
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Table of Contents
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Impacts
II. Background
A. Hospice Care
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 Wage Index and
Payment Rate Update Final Rule
8. Impact Act of 2014
9. FY 2016 Hospice Wage Index and
Payment Rate Update Final Rule
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E. Trends in Medicare Hospice Utilization
F. Use of Health Information Technology
III. Provisions of the Final Rule
A. Monitoring for Potential Impacts—
Affordable Care Act Hospice Reform
B. FY 2017 Hospice Wage Index and Rates
Update
1. FY 2017 Hospice Wage Index
a. Background
b. FY 2016 Implementation of New Labor
Market Delineations
2. FY 2017 Hospice Payment Update
Percentage
3. FY 2017 Hospice Payment Rates
4. Hospice Cap Amount for FY 2017
C. Updates to the Hospice Quality
Reporting Program
1. Background and Statutory Authority
2. General Considerations Used for
Selection of Quality Measures for the
HQRP
3. Policy for Retention of HQRP Measures
Adopted for Previous Payment
Determination
4. Previously Adopted Quality Measures
for FY 2017 and FY 2018 Payment
Determination
5. Proposed Removal of Previously
Adopted Measures
6. Proposed New Quality Measures for FY
2019 Payment Determinations and
Subsequent Years and Concepts Under
Consideration for Future Years
a. Background and Considerations in
Developing New Quality Measures for
the HQRP
b. New Quality Measures for the FY 2019
Payment Determination and Subsequent
Years
7. Form, Manner, and Timing of Quality
Data Submission
a. Background
b. Previously Finalized 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. Previously Finalized Data Submission
Timelines and Requirements for FY 2018
Payment Determination and Subsequent
Years
e. Previously Finalized HQRP Data
Submission and Compliance Thresholds
for the FY 2018 Payment Determination
and Subsequent Years
f. New Data Collection and Submission
Mechanisms Under Consideration for
Future Years
8. HQRP Submission Exemption and
Extension Requirements for the FY 2017
Payment Determination and Subsequent
Years
9. Hospice CAHPS® Participation
Requirements for the 2019 APU and
2020 APU
a. Background Description of the Survey
b. Participation Requirements To Meet
Quality Reporting Requirements for the
FY 2019 APU
c. Participation Requirements To Meet
Quality Reporting Requirements for the
FY 2020 APU
d. Annual Payment Update
e. Hospice CAHPS® Reconsiderations and
Appeals Process
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10. HQRP Reconsideration and Appeals
Procedures for the FY 2017 Payment
Determination and Subsequent Years
11. Public Display of Quality Measures and
Other Hospice Data for the HQRP
D. The Medicare Care Choices Model
IV. Collection of Information Requirements
V. Economic Analyses
VI. Federalism Analysis and Regulations Text
Acronyms
Because of the many terms to which we
refer by acronym in this final rule, we are
listing the acronyms used and their
corresponding meanings in alphabetical
order:
APU Annual Payment Update
ASPE Assistant Secretary of Planning and
Evaluation
BBA Balanced Budget Act of 1997
BIPA Benefits Improvement and Protection
Act of 2000
BNAF Budget Neutrality Adjustment Factor
BLS Bureau of Labor Statistics
CAHPS® Consumer Assessment of
Healthcare Providers and Systems
CBSA Core-Based Statistical Area
CCN CMS Certification Number
CCW Chronic Conditions Data Warehouse
CFR Code of Federal Regulations
CHC Continuous Home Care
CHF Congestive Heart Failure
CMMI Center for Medicare & Medicaid
Innovation
CMS Centers for Medicare & Medicaid
Services
COPD Chronic Obstructive Pulmonary
Disease
CoPs Conditions of Participation
CPI Center for Program Integrity
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
DRG Diagnostic Related Group
ER Emergency Room
FEHC Family Evaluation of Hospice Care
FR Federal Register
FY Fiscal Year
GAO Government Accountability Office
GIP General Inpatient Care
HCFA Healthcare Financing Administration
HHS Health and Human Services
HIPAA 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
IDG Interdisciplinary Group
IMPACT Act Improving Medicare PostAcute Care Transformation Act of 2014
IOM Institute of Medicine
IPPS Inpatient Prospective Payment System
IRC Inpatient Respite Care
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LCD Local Coverage Determination
LOS Length of Stay
MAC Medicare Administrative Contractor
MAP Measure Applications Partnership
MCCM Medicare Care Choices Model
MedPAC Medicare Payment Advisory
Commission
MFP Multifactor Productivity
MSA Metropolitan Statistical Area
MSS Medical Social Services
NHPCO National Hospice and Palliative
Care Organization
NF Long Term Care Nursing Facility
NOE Notice of Election
NOTR Notice of Termination/Revocation
NP Nurse Practitioner
NPI National Provider Identifier
NQF National Quality Forum
OIG Office of the Inspector General
OACT Office of the Actuary
OMB Office of Management and Budget
PEPPER Program for Evaluating Payment
Patterns Electronic Report
PRRB Provider Reimbursement Review
Board
PS&R Provider Statistical and
Reimbursement Report
Pub. L. Public Law
QAPI Quality Assessment and Performance
Improvement
RHC Routine Home Care
RN Registered Nurse
SBA Small Business Administration
SEC Securities and Exchange Commission
SIA Service Intensity Add-on
SNF Skilled Nursing Facility
TEFRA Tax Equity and Fiscal
Responsibility Act of 1982
TEP Technical Expert Panel
UHDDS Uniform Hospital Discharge Data
Set
U.S.C. United States Code
I. Executive Summary
A. Purpose
This final rule updates the hospice
payment rates for fiscal year (FY) 2017,
as required under section 1814(i) of the
Social Security Act (the Act). This rule
also finalizes new quality measures and
provides an update on the hospice
quality reporting program (HQRP)
consistent with the requirements of
section 1814(i)(5) of the Act, as added
by section 3004(c) 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, the Affordable Care Act).
In accordance with section 1814(i)(5)(A)
of the Act, starting in FY 2014, hospices
that have failed to meet quality
reporting requirements receive a 2
percentage point reduction to their
payments. Finally, this final rule shares
information on the Medicare Care
Choices Model developed in accordance
with the authorization under section
1115A of the Act for the Center for
Medicare and Medicaid Innovation
(CMMI) to test innovative payment and
service models that have the potential to
reduce Medicare, Medicaid, or
Children’s Health Insurance Program
(CHIP) expenditures while maintaining
or improving the quality of care.
B. Summary of the Major Provisions
In section III.B.1 of this rule, we
update the hospice wage index with
updated wage data and make the
application of the updated wage data
budget-neutral for all four levels of
hospice care. In section III.B.2 we
discuss the FY 2017 hospice payment
update percentage of 2.1 percent.
Sections III.B.3 and III.B.4 update the
hospice payment rates and hospice cap
amount for FY 2017 by the hospice
payment update percentage discussed in
section III.B.2.
In section III.C of this rule, we discuss
updates to HQRP, including two new
quality measures as well as of the
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possibility of utilizing a new assessment
instrument to collect quality data. As
part of the HQRP, the new measures,
effective April 1, 2017, will be: (1)
Hospice Visits When Death is Imminent,
assessing hospice staff visits to patients
and caregivers in the last week of life;
and (2) Hospice and Palliative Care
Composite Process Measure, assessing
the percentage of hospice patients who
received care processes consistent with
existing guidelines. In section III.C we
will also discuss the enhancement of the
current Hospice Item Set (HIS) data
collection instrument to be more in line
with other post-acute care settings. This
new data collection instrument will be
a comprehensive patient assessment
instrument, rather than the current chart
abstraction tool. Additionally, in this
section we discuss our plans for sharing
HQRP data publicly during calendar
year (CY) 2016 as well as plans to
provide public reporting via a Compare
Site in CY 2017.
Finally, in section III.D, we are
providing information regarding the
Medicare Care Choices Model (MCCM).
This model is testing a new option for
Medicare and dual eligible beneficiaries
with certain advanced diseases who
meet the model’s other eligibility
criteria to receive hospice-like support
services from MCCM participating
hospices while receiving care from other
Medicare providers for their terminal
illness. This model is designed to: (1)
Increase access to supportive care
services provided by hospice; (2)
improve quality of life and patient/
family/caregiver satisfaction; and (3)
inform new payment systems for the
Medicare and Medicaid programs.
C. Summary of Impacts
TABLE 1—IMPACT SUMMARY TABLE
Provision description
Transfers
FY 2017 Hospice Wage Index and Payment Rate Update .....................
The overall economic impact of this final rule is estimated to be $350
million in increased payments to hospices during FY 2017.
II. Background
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A. Hospice Care
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
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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 beneficiary as
physically and emotionally comfortable
as possible. Hospice is compassionate
beneficiary 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
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necessitates a transition from curative to
palliative care.
Medicare regulations define
‘‘palliative care’’ as ‘‘patient and familycentered 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
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care practices, and is a critical
component of the Medicare hospice
benefit. Also, see Hospice Conditions of
Participation final rule (73 FR 32088
June 5, 2008). The goal of palliative care
in hospice is to improve the quality of
life of beneficiaries, and their families,
facing the issues associated with a lifethreatening illness through the
prevention and relief of suffering by
means of early identification,
assessment, and treatment of pain and
other issues that may arise. This is
achieved by the hospice
interdisciplinary group working with
the beneficiary and family to develop a
comprehensive care plan focused on
coordinating care services, reducing
unnecessary diagnostics, or ineffective
therapies, and offering ongoing
conversations with individuals and
their families about changes in their
condition. The beneficiary’s
comprehensive care plan will shift over
time to meet the changing needs of the
individual, family, and caregiver(s) as
the individual approaches the end of
life.
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 a
beneficiary is terminally ill, many
health problems are brought on by
underlying condition(s), as bodily
systems are interdependent. In the 2008
Hospice Conditions of Participation
final rule, we stated that the medical
director or physician designee must
consider the primary terminal
condition, related diagnoses, current
subjective and objective medical
findings, current medication and
treatment orders, and information about
unrelated conditions when considering
the initial certification of the terminal
illness. (73 FR 32176). 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 Act and our regulations at § 418.3;
that is, the individual’s prognosis is for
a life expectancy of 6 months or less if
the terminal illness runs its normal
course. The certification of terminal
illness must include a brief narrative
explanation of the clinical findings that
supports a life expectancy of 6 months
or less as part of the certification and
recertification forms, as set out at
§ 418.22(b)(3).
While the goal of hospice care is to
allow the beneficiary to remain in his or
her home environment, circumstances
during the end-of-life may necessitate
short-term inpatient admission to a
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hospital, skilled nursing facility (SNF),
or hospice facility for treatment
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 beneficiary can return to his or
her home environment. Limited, shortterm, intermittent, inpatient respite
services are also available to the family/
caregiver of the hospice patient 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
§ 418.204. A minimum of 8 hours of
nursing care, or nursing and aide care,
must be furnished on a particular day to
qualify for the continuous home care
rate (§ 418.302(e)(4)).
Hospices are expected to comply with
all civil rights laws, including the
provision of auxiliary aids and services
to ensure effective communication with
patients and patient care representatives
with disabilities consistent with section
504 of the Rehabilitation Act of 1973
and the Americans with Disabilities Act,
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 https://www.hhs.gov/
civil-rights.
B. History of the Medicare Hospice
Benefit
Before the creation of the Medicare
hospice benefit, hospice programs were
originally operated by volunteers who
cared for the dying. During the early
development stages of the Medicare
hospice benefit, hospice advocates were
clear that they wanted a Medicare
benefit that provided all-inclusive care
for terminally-ill individuals, provided
pain relief and symptom management,
and offered the opportunity to die with
dignity in the comfort of one’s home
rather than in an institutional setting.1
As stated in the August 22, 1983
proposed rule titled ‘‘Medicare Program;
Hospice Care’’ (48 FR 38146), ‘‘the
hospice experience in the United States
has placed emphasis on home care. It
offers physician services, specialized
nursing services, and other forms of care
in the home to enable the terminally ill
individual to remain at home in the
company of family and friends as long
as possible.’’ The concept of a
beneficiary ‘‘electing’’ the hospice
benefit and being certified as terminally
ill were two key components of the
legislation responsible for the creation
of the Medicare Hospice Benefit (section
122 of the Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA),
(Pub. L. 97–248)). Section 122 of TEFRA
created the Medicare Hospice benefit,
which was implemented on November
1, 1983. Under sections 1812(d) and
1861(dd) of the Act, we provide
coverage of hospice care for terminally
ill Medicare beneficiaries who elect to
receive care from a Medicare-certified
hospice. Our regulations at § 418.54(c)
stipulate that the comprehensive
hospice assessment must identify the
beneficiary’s physical, psychosocial,
emotional, and spiritual needs related to
the terminal illness and related
conditions, and address those needs in
order to promote the beneficiary’s wellbeing, comfort, and dignity throughout
the dying process. The comprehensive
assessment must take into consideration
the following factors: 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;
imminence of death; and severity of
symptoms (§ 418.54(c)). The Medicare
hospice benefit requires the hospice to
cover all reasonable and necessary
palliative care related to the terminal
prognosis, as described in the
beneficiary’s plan of care. The December
16, 1983 Hospice final rule (48 FR
56008) requires hospices to cover care
for interventions to manage pain and
symptoms. Additionally, the hospice
Conditions of Participation (CoPs) at
§ 418.56(c) require that the hospice must
provide all reasonable and necessary
services for the palliation and
management of the terminal illness,
related conditions, and interventions to
manage pain and symptoms. Therapy
and interventions must be assessed and
managed in terms of providing
palliation and comfort without undue
symptom burden for the hospice patient
or family.2 In the December 16, 1983
Hospice final rule (48 FR 56010),
regarding what is related versus
1 Connor, Stephen. (2007). Development of
Hospice and Palliative Care in the United States.
OMEGA. 56(1), p. 89–99.
2 Paolini, DO, Charlotte. (2001). Symptoms
Management at End of Life. JAOA. 101(10). p. 609–
615.
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unrelated to the terminal illness, we
stated: ‘‘. . . we believe that the unique
physical condition of each terminally ill
individual makes it necessary for these
decisions to be made on a case by case
basis. It is our general view that
hospices are required to provide
virtually all the care that is needed by
terminally ill patients.’’ Therefore,
unless there is clear evidence that a
condition is unrelated to the terminal
prognosis, all conditions are considered
to be related to the terminal prognosis
and the responsibility of the hospice to
address and treat.
As stated in the December 16, 1983
Hospice final rule, the fundamental
premise upon which the hospice benefit
was designed was the ‘‘revocation’’ of
traditional curative care and the
‘‘election’’ of hospice care for end-of-life
symptom management and
maximization of quality of life (48 FR
56008). After electing hospice care, the
beneficiary typically returns to the
home from an institutionalized setting
or remains in the home, to be
surrounded by family and friends, and
to prepare emotionally and spiritually,
if requested, for death while receiving
expert symptom management and other
supportive services. Election of hospice
care also requires waiving the right to
Medicare payment for curative
treatment for the terminal prognosis,
and instead receiving palliative care to
manage pain or other symptoms.
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,
Medicare beneficiaries can elect hospice
care for two 90-day periods and an
unlimited number of subsequent 60-day
periods; however, at the beginning of
each period, a physician must certify
that the beneficiary has a life
expectancy of 6 months or less if the
terminal illness runs its normal course.
C. Services Covered by the Medicare
Hospice Benefit
One requirement for coverage under
the Medicare Hospice benefit is that
hospice services must be reasonable and
necessary for the palliation and
management of the terminal illness and
related conditions. Section 1861(dd)(1)
of the Act establishes the services that
are to be rendered by a Medicare
certified hospice program. These
covered services include: Nursing care;
physical therapy; occupational therapy;
speech-language pathology therapy;
medical social services; home health
aide services (now called hospice aide
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services); physician services;
homemaker services; medical supplies
(including drugs and biologicals);
medical appliances; counseling services
(including dietary counseling); shortterm inpatient care in a hospital,
nursing facility, or hospice inpatient
facility (including both respite care and
procedures necessary for pain control
and acute or chronic symptom
management); continuous home care
during periods of crisis, and only as
necessary to maintain the terminally ill
individual at home; and any other item
or service which is specified in the plan
of care and for which payment may
otherwise be made under Medicare, in
accordance with Title XVIII of the Act.
Section 1814(a)(7)(B) of the Act
requires that a written plan for
providing hospice care to a beneficiary
who is a hospice patient be established
before care is provided by, or under
arrangements made by, that hospice
program and that the written plan be
periodically reviewed by the
beneficiary’s attending physician (if
any), the hospice medical director, and
an interdisciplinary group (described in
section 1861(dd)(2)(B) of the Act). The
services offered under the Medicare
hospice benefit must be available to
beneficiaries as needed, 24 hours a day,
7 days a week (section 1861(dd)(2)(A)(i)
of the Act). Upon the implementation of
the hospice benefit, Congress expected
hospices to continue to use volunteer
services, though these services are not
reimbursed by Medicare (see section
1861(dd)(2)(E) of the Act and 48 FR
38149). As stated in the August 22, 1983
Hospice proposed rule, the hospice
interdisciplinary group should comprise
paid hospice employees as well as
hospice volunteers (48 FR 38149). This
expectation supports the hospice
philosophy of holistic, comprehensive,
compassionate, end-of-life care.
Before the Medicare hospice benefit
was established, Congress requested a
demonstration project to test the
feasibility of covering hospice care
under Medicare. The National Hospice
Study was initiated in 1980 through a
grant sponsored by the Robert Wood
Johnson and John A. Hartford
Foundations and the Centers for
Medicare & Medicaid Services (CMS)
(then, the Health Care Financing
Administration (HCFA)). The
demonstration project was conducted
between October 1980 and March 1983.
The project summarized the hospice
care philosophy and principles as the
following:
• Patient and family know of the
terminal condition.
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• 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 Medicare hospice benefit.
The identified hospice services were
incorporated into the service
requirements under the Medicare
hospice benefit. Importantly, in the
August 22, 1983 Hospice proposed rule,
we stated ‘‘the hospice benefit and the
resulting Medicare reimbursement is not
intended to diminish the voluntary
spirit of hospices’’ (48 FR 38149).
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
Medicare program. Part 418, subpart G,
provides for a per diem payment in one
of four prospectively-determined rate
categories of hospice care (Routine
Home Care (RHC), Continuous Home
Care (CHC), inpatient respite care, and
general inpatient care), based on each
day a qualified Medicare beneficiary is
under hospice care (once the individual
has elected). This per diem payment is
to include all of the hospice services
needed to manage the beneficiary’s care,
as required by section 1861(dd)(1) of the
Act. There has been little change in the
hospice payment structure since the
benefit’s inception. The per diem rate
based on level of care was established
in 1983, and this payment structure
remains today with some adjustments,
as noted below:
1. Omnibus Budget Reconciliation Act
of 1989
Section 6005(a) of the Omnibus
Budget Reconciliation Act of 1989 (Pub.
L. 101–239) amended section
1814(i)(1)(C) of the Act and provided for
the following two changes in the
methodology concerning updating the
daily payment rates: (1) Effective
January 1, 1990, the daily payment rates
for RHC and other services included in
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hospice care were increased to equal
120 percent of the rates in effect on
September 30, 1989; and (2) the daily
payment rate for RHC and other services
included in hospice care for fiscal years
(FYs) beginning on or after October 1,
1990, were the payment rates in effect
during the previous Federal FY
increased by the hospital market basket
percentage increase.
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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 August 8, 1997 FY 1998
Hospice Wage Index final rule (62 FR
42860), we implemented a new
methodology for calculating the hospice
wage index based on the
recommendations of a negotiated
rulemaking committee. The original
hospice wage index was based on 1981
Bureau of Labor Statistics hospital data
and had not been updated since 1983.
In 1994, because of disparity in wages
from one geographical location to
another, the Hospice Wage Index
Negotiated Rulemaking Committee was
formed to negotiate a new wage index
methodology that could be accepted by
the industry and the government. This
Committee was composed of
representatives from national hospice
associations; rural, urban, large and
small hospices, and multi-site hospices;
consumer groups; and a government
representative. The Committee decided
that in updating the hospice wage
index, aggregate Medicare payments to
hospices would remain budget neutral
to payments calculated using the 1983
wage index, to cushion the impact of
using a new wage index methodology.
To implement this policy, a Budget
Neutrality Adjustment Factor (BNAF)
was computed and applied annually to
the pre-floor, pre-reclassified hospital
wage index when deriving the hospice
wage index, subject to a wage index
floor.
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4. FY 2010 Hospice Wage Index Final
Rule
Inpatient hospital pre-floor and prereclassified wage index values, as
described in the August 8, 1997 Hospice
Wage Index final rule, are subject to
either a budget neutrality adjustment or
application of the wage index floor.
Wage index values of 0.8 or greater are
adjusted by the BNAF. Starting in FY
2010, a 7-year phase-out of the BNAF
began (FY 2010 Hospice Wage Index
final rule, (74 FR 39384, August 6,
2009)), with a 10 percent reduction in
FY 2010, an additional 15 percent
reduction for a total of 25 percent in FY
2011, an additional 15 percent
reduction for a total 40 percent
reduction in FY 2012, an additional 15
percent reduction for a total of 55
percent in FY 2013, and an additional
15 percent reduction for a total 70
percent reduction in FY 2014. The
phase-out continued with an additional
15 percent reduction for a total
reduction of 85 percent in FY 2015, an
additional, and final, 15 percent
reduction for complete elimination in
FY 2016. We note that the BNAF was an
adjustment which increased the hospice
wage index value. Therefore, the BNAF
phase-out reduced the amount of the
BNAF increase applied to the hospice
wage index value. It was not a reduction
in the hospice wage index value itself or
in the hospice payment rates.
5. The Affordable Care Act
Starting with FY 2013 (and in
subsequent FYs), the market basket
percentage update under the hospice
payment system referenced in sections
1814(i)(1)(C)(ii)(VII) and
1814(i)(1)(C)(iii) of the Act is subject to
annual reductions related to changes in
economy-wide productivity, as
specified in section 1814(i)(1)(C)(iv) of
the Act. In FY 2013 through FY 2019,
the market basket percentage update
under the hospice payment system will
be reduced by an additional 0.3
percentage point (although for FY 2014
to FY 2019, the potential 0.3 percentage
point reduction is subject to suspension
under conditions specified in section
1814(i)(1)(C)(v) of the Act).
In addition, sections 1814(i)(5)(A)
through (C) of the Act, as added by
section 3132(a) of the Affordable Care
Act, require hospices to begin
submitting quality data, based on
measures to be specified by the
Secretary of the Department of Health
and Human Services (the Secretary), for
FY 2014 and subsequent FYs. Beginning
in FY 2014, hospices which fail to
report quality data will have their
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market basket update reduced by 2
percentage points.
Section 1814(a)(7)(D)(i) of the Act, as
added by section 3132(b)(2) of the
Affordable Care Act, requires, effective
January 1, 2011, that a hospice
physician or nurse practitioner have a
face-to-face encounter with the
beneficiary to determine continued
eligibility of the beneficiary’s hospice
care prior to the 180th-day
recertification and each subsequent
recertification, and to attest that such
visit took place. When implementing
this provision, we finalized in the CY
2011 Home Health Prospective Payment
System final rule (75 FR 70435) that the
180th-day recertification and
subsequent recertifications would
correspond to the beneficiary’s third or
subsequent benefit periods. Further,
section 1814(i)(6) of the Act, as added
by section 3132(a)(1)(B) of the
Affordable Care Act, authorizes the
Secretary to collect additional data and
information determined appropriate to
revise payments for hospice care and
other purposes. The types of data and
information suggested in the Affordable
Care Act could capture accurate
resource utilization, which could be
collected on claims, cost reports, and
possibly other mechanisms, as the
Secretary determined to be appropriate.
The data collected could be used to
revise the methodology for determining
the payment rates for RHC and other
services included in hospice care, no
earlier than October 1, 2013, as
described in section 1814(i)(6)(D) of the
Act. In addition, we were required to
consult with hospice programs and the
Medicare Payment Advisory
Commission (MedPAC) regarding
additional data collection and payment
revision options.
6. FY 2012 Hospice Wage Index Final
Rule
When the Medicare Hospice benefit
was implemented, Congress included an
aggregate cap on hospice payments,
which limits the total aggregate
payments any individual hospice can
receive in a year. Congress stipulated
that a ‘‘cap amount’’ be computed each
year. The cap amount was set at $6,500
per beneficiary when first enacted in
1983 and has been adjusted annually by
the change in the medical care
expenditure category of the consumer
price index for urban consumers from
March 1984 to March of the cap year
(section 1814(i)(2)(B) of the Act). The
cap year was defined as the period from
November 1st to October 31st. In the
August 4, 2011 FY 2012 Hospice Wage
Index final rule (76 FR 47308 through
47314) for the 2012 cap year and
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subsequent cap years, we announced
that subsequently, the hospice aggregate
cap would be calculated using the
patient-by-patient proportional
methodology. We allowed existing
hospices the option of having their cap
calculated via the original streamlined
methodology. As of FY 2012, new
hospices have their cap determinations
calculated using the patient-by-patient
proportional methodology. The patientby-patient proportional methodology
and the streamlined methodology are
two different methodologies for
counting beneficiaries when calculating
the hospice aggregate cap. A detailed
explanation of these methods is found
in the August 4, 2011 FY 2012 Hospice
Wage Index final rule (76 FR 47308
through 47314). If a hospice’s total
Medicare reimbursement for the cap
year exceeds the hospice aggregate cap,
then the hospice must repay the excess
back to Medicare.
7. FY 2015 Hospice Wage Index and
Payment Rate Update Final Rule
When electing hospice, a beneficiary
waives Medicare coverage for any care
for the terminal illness and related
conditions except for services provided
by the designated hospice and attending
physician. The FY 2015 Hospice Wage
Index and Payment Rate Update final
rule (79 FR 50452) finalized a
requirement that requires the Notice of
Election (NOE) be filed within 5
calendar days after the effective date of
hospice election. If the NOE is filed
beyond this 5-day period, hospice
providers are liable for the services
furnished during the days from the
effective date of hospice election to the
date of NOE filing (79 FR 50474).
Similar to the NOE, the claims
processing system must be notified of a
beneficiary’s discharge from hospice or
hospice benefit revocation. This update
to the beneficiary’s status allows claims
from non-hospice providers to be
processed and paid. Late filing of the
NOE can result in inaccurate benefit
period data and leaves Medicare
vulnerable to paying non-hospice claims
related to the terminal illness and
related conditions and beneficiaries
possibly liable for any cost-sharing
associated costs. Upon live discharge or
revocation, the beneficiary immediately
resumes the Medicare coverage that had
been waived when he or she elected
hospice. The FY 2015 Hospice Wage
Index and Payment Rate Update final
rule also finalized a requirement that
requires hospices to file a notice of
termination/revocation within 5
calendar days of a beneficiary’s live
discharge or revocation, unless the
hospices have already filed a final
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claim. This requirement helps to protect
beneficiaries from delays in accessing
needed care (§ 418.26(e)).
A hospice ‘‘attending physician’’ is
described by the statutory and
regulatory definitions as a medical
doctor, osteopath, or nurse practitioner
whom the beneficiary 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
person’s designated attending physician
and a third of hospice patients had
multiple providers submit Part B claims
as the ‘‘attending physician,’’ using a
claim modifier. The FY 2015 Hospice
Wage Index and Payment Rate Update
final rule finalized a requirement that
the election form include the
beneficiary’s choice of attending
physician and that the beneficiary
provide the hospice with a signed
document when he or she chooses to
change attending physicians (79 FR
50479).
Hospice providers are required to
begin using a Hospice Experience of
Care Survey for informal caregivers of
hospice patients surveyed in 2015. The
FY 2015 Hospice Wage Index and
Payment Rate Update final rule
provided background and a description
of the development of the Hospice
Experience of Care Survey, including
the model of survey implementation,
the survey respondents, eligibility
criteria for the sample, and the
languages in which the survey is
offered. The FY 2015 Hospice Rate
Update final rule also set out
participation requirements for CY 2015
and discussed vendor oversight
activities and the reconsideration and
appeals process for entities that failed to
win CMS approval as vendors (79 FR
50496).
Finally, the FY 2015 Hospice Wage
Index and Payment Rate Update final
rule required providers to complete
their aggregate cap determination not
sooner than 3 months after the end of
the cap year, and not later than 5
months after, and remit any
overpayments. Those hospices that fail
to timely submit their aggregate cap
determinations will have their payments
suspended until the determination is
completed and received by the Medicare
Administrative Contractor (MAC) (79 FR
50503).
8. IMPACT Act of 2014
The Improving Medicare Post-Acute
Care Transformation Act of 2014 (Pub.
L. 113–185) (IMPACT Act) became law
on October 6, 2014. Section 3(a) of the
IMPACT Act mandated that all
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52149
Medicare certified hospices be surveyed
every 3 years beginning April 6, 2015
and ending September 30, 2025. In
addition, section 3(c) of the IMPACT
Act requires medical review of hospice
cases involving beneficiaries receiving
more than 180 days care in select
hospices that show a preponderance of
such patients; section 3(d) of the
IMPACT Act contains a new provision
mandating that the cap amount for
accounting years that end after
September 30, 2016, and before October
1, 2025 be updated by the hospice
payment update rather than using the
consumer price index for urban
consumers (CPI–U) for medical care
expenditures.
9. FY 2016 Hospice Wage Index and
Payment Rate Update Final Rule
In the FY 2016 Hospice Rate Update
final rule, we created two different
payment rates for RHC that resulted in
a higher base payment rate for the first
60 days of hospice care and a reduced
base payment rate for all subsequent
days of hospice care (80 FR 47172). We
also created a Service Intensity Add-on
(SIA) payment payable for services
during the last 7 days of the
beneficiary’s life, equal to the CHC
hourly payment rate multiplied by the
amount of direct patient care provided
by a registered nurse (RN) or social
worker that occurs during the last 7
days (80 FR 47177).
In addition to the hospice payment
reform changes discussed, the FY 2016
Hospice Wage Index and Payment 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 is updated by the
hospice payment update percentage
rather than using the CPI–U. This was
applied to the 2016 cap year, starting on
November 1, 2015 and ending on
October 31, 2016. In addition, we
finalized a provision to align the cap
accounting year for both the inpatient
cap and the hospice aggregate cap with
the FY, for FY 2017 and later (80 FR
47186). This allows for the timely
implementation of the IMPACT Act
changes while better aligning the cap
accounting year with the timeframe
described in the IMPACT Act.
Finally, the FY 2016 Hospice Wage
Index and Payment Rate Update final
rule clarified that hospices must report
all diagnoses of the beneficiary on the
hospice claim as a part of the ongoing
data collection efforts for possible future
hospice payment refinements. Reporting
of all diagnoses on the hospice claim
aligns with current coding guidelines as
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well as admission requirements for
hospice certifications (80 FR 47142).
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 benefit
utilization. The number of Medicare
beneficiaries receiving hospice services
has grown from 513,000 in FY 2000 to
nearly 1.4 million in FY 2015. Similarly,
Medicare hospice expenditures have
risen from $2.8 billion in FY 2000 to an
estimated $15.5 billion in FY 2015.3
Under the economic assumptions from
the 2017 Mid-Session Review,4 our
Office of the Actuary (OACT) projects
that hospice expenditures are expected
to continue to increase, by
approximately 7 percent annually,
reflecting an increase in the number of
Medicare beneficiaries, more beneficiary
awareness of the Medicare Hospice
Benefit for end-of-life care, and a
growing preference for care provided in
home and community-based settings.
There have also been changes in the
diagnosis patterns among Medicare
hospice enrollees. Specifically, as
described in Table 2, there have been
notable increases between 2002 and
2015 in neurologically-based diagnoses,
including various dementia and
Alzheimer’s diagnoses. Additionally,
there had been significant increases in
the use of non-specific, symptomclassified diagnoses, such as ‘‘debility’’
and ‘‘adult failure to thrive.’’ In FY
2013, ‘‘debility’’ and ‘‘adult failure to
thrive’’ were the first and sixth most
common hospice claims-reported
diagnoses, respectively, accounting for
approximately 14 percent of all
diagnoses. Effective October 1, 2014,
hospice claims are returned to the
provider if ‘‘debility’’ and ‘‘adult failure
to thrive’’ are coded as the principal
hospice diagnosis as well as other ICD–
9–CM (and as of October 1, 2015, ICD–
10–CM) codes that are not permissible
as principal diagnosis codes per ICD–9–
CM (or ICD–10–CM) coding guidelines.
In the FY 2015 Hospice Wage Index and
Payment Rate Update final rule (79 FR
50452), we reminded the hospice
industry that this policy would go into
effect and claims would start to be
returned to the provider effective
October 1, 2014. As a result of this,
there has been a shift in coding patterns
on hospice claims. For FY 2015, the
most common hospice principal
diagnoses were Alzheimer’s disease,
Congestive Heart Failure, Lung Cancer,
Chronic Airway Obstruction, and Senile
Dementia which constituted
approximately 35 percent of all claimsreported principal diagnosis codes
reported in FY 2015. In Table 2 we have
updated the information initially
presented in the FY 2017 proposed rule
(81 FR 25504–06).
TABLE 2—THE TOP TWENTY PRINCIPAL HOSPICE DIAGNOSES, FY 2002, FY 2007, FY 2013, FY 2015
Rank
ICD–9
Reported principal diagnosis
Count
Percentage
Year: FY 2002
1 .....................
2 .....................
3 .....................
4 .....................
5 .....................
6 .....................
7 .....................
8 .....................
9 .....................
10 ...................
11 ...................
12 ...................
13 ...................
14 ...................
15 ...................
16 ...................
17 ...................
18 ...................
19 ...................
20 ...................
162.9
428.0
799.3
496
331.0
436
185
783.7
174.9
290.0
153.0
157.9
294.8
429.9
154.0
332.0
586
585
183.0
188.9
Lung Cancer .................................................................................................................
Congestive Heart Failure ..............................................................................................
Debility Unspecified ......................................................................................................
COPD ...........................................................................................................................
Alzheimer’s Disease .....................................................................................................
CVA/Stroke ...................................................................................................................
Prostate Cancer ............................................................................................................
Adult Failure To Thrive .................................................................................................
Breast Cancer ...............................................................................................................
Senile Dementia, Uncomp ............................................................................................
Colon Cancer ................................................................................................................
Pancreatic Cancer ........................................................................................................
Organic Brain Synd Nec ...............................................................................................
Heart Disease Unspecified ...........................................................................................
Rectosigmoid Colon Cancer .........................................................................................
Parkinson’s Disease .....................................................................................................
Renal Failure Unspecified ............................................................................................
Chronic Renal Failure (End 2005) ...............................................................................
Ovarian Cancer ............................................................................................................
Bladder Cancer .............................................................................................................
73,769
45,951
36,999
35,197
28,787
26,897
20,262
18,304
17,812
16,999
16,379
15,427
10,394
10,332
8,956
8,865
8,764
8,599
7,432
6,916
11
7
6
5
4
4
3
3
3
3
2
2
2
2
1
1
1
1
1
1
90,150
86,954
77,836
60,815
58,303
58,200
37,667
31,800
22,170
22,086
20,378
19,082
19,080
9
8
7
6
6
6
4
3
2
2
2
2
2
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Year: FY 2007
1 .....................
2 .....................
3 .....................
4 .....................
5 .....................
6 .....................
7 .....................
8 .....................
9 .....................
10 ...................
11 ...................
12 ...................
13 ...................
799.3
162.9
428.0
496
783.7
331.0
290.0
436
429.9
185
174.9
157.9
153.9
Debility Unspecified ......................................................................................................
Lung Cancer .................................................................................................................
Congestive Heart Failure ..............................................................................................
COPD ...........................................................................................................................
Adult Failure To Thrive .................................................................................................
Alzheimer’s Disease .....................................................................................................
Senile Dementia Uncomp .............................................................................................
CVA/Stroke ...................................................................................................................
Heart Disease Unspecified ...........................................................................................
Prostate Cancer ............................................................................................................
Breast Cancer ...............................................................................................................
Pancreas Unspecified ...................................................................................................
Colon Cancer ................................................................................................................
3 FY2000 figures from MedPAC analysis of the
denominator file, the Medicare Beneficiary
Database, and the 100 percent hospice claims
standard analytic file from CMS (https://
www.medpac.gov/documents/reports/chapter-11-
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hospice-services-(march-2012-report).pdf?sfvrsn=4).
FY 2015 hospice claims data from the Chronic
Conditions Data Warehouse (CCW), accessed on
June 20, 2016.
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4 ‘‘Mid-Session Review: Budget of the US
Government.’’ Office of Management and Budget.
July 15, 2016. https://www.whitehouse.gov/sites/
default/files/omb/budget/fy2017/assets/17msr.pdf.
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52151
TABLE 2—THE TOP TWENTY PRINCIPAL HOSPICE DIAGNOSES, FY 2002, FY 2007, FY 2013, FY 2015—Continued
Rank
14
15
16
17
18
19
20
ICD–9
...................
...................
...................
...................
...................
...................
...................
Reported principal diagnosis
Count
294.8
332.0
294.10
586
585.6
188.9
183.0
Organic Brain Syndrome NEC .....................................................................................
Parkinson’s Disease .....................................................................................................
Dementia In Other Diseases w/o Behav. Dist .............................................................
Renal Failure Unspecified ............................................................................................
End Stage Renal Disease ............................................................................................
Bladder Cancer .............................................................................................................
Ovarian Cancer ............................................................................................................
Percentage
17,697
16,524
15,777
12,188
11,196
8,806
8,434
2
2
2
1
1
1
1
127,415
96,171
91,598
82,184
79,626
71,122
60,579
36,914
34,459
30,963
25,396
23,228
23,224
23,059
22,341
21,769
19,309
15,965
14,372
13,687
9
7
6
6
6
5
4
3
2
2
2
2
2
2
2
2
1
1
1
1
196,705
115,111
88,404
80,655
46,843
34,957
31,906
29,172
26,887
23,969
23,844
23,293
23,127
22,990
21,493
20,214
16,937
15,841
15,689
11,648
13
8
6
6
3
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
Year: FY 2013
1 .....................
2 .....................
3 .....................
4 .....................
5 .....................
6 .....................
7 .....................
8 .....................
9 .....................
10 ...................
11 ...................
12 ...................
13 ...................
14 ...................
15 ...................
16 ...................
17 ...................
18 ...................
19 ...................
20 ...................
799.3
428.0
162.9
496
331.0
783.7
290.0
429.9
436
294.10
332.0
153.9
294.20
174.9
157.9
185
585.6
518.81
294.8
294.11
Debility Unspecified ......................................................................................................
Congestive Heart Failure ..............................................................................................
Lung Cancer .................................................................................................................
COPD ...........................................................................................................................
Alzheimer’s Disease .....................................................................................................
Adult Failure to Thrive ..................................................................................................
Senile Dementia, Uncomp ............................................................................................
Heart Disease Unspecified ...........................................................................................
CVA/Stroke ...................................................................................................................
Dementia In Other Diseases w/o Behavioral Dist ........................................................
Parkinson’s Disease .....................................................................................................
Colon Cancer ................................................................................................................
Dementia Unspecified w/o Behavioral Dist ..................................................................
Breast Cancer ...............................................................................................................
Pancreatic Cancer ........................................................................................................
Prostate Cancer ............................................................................................................
End-Stage Renal Disease ............................................................................................
Acute Respiratory Failure .............................................................................................
Other Persistent Mental Dis.-classified elsewhere .......................................................
Dementia In Other Diseases w/Behavioral Dist ...........................................................
Year: FY 2015
1 .....................
2 .....................
3 .....................
4 .....................
5 .....................
6 .....................
7 .....................
8 .....................
9 .....................
10 ...................
11 ...................
12 ...................
13 ...................
14 ...................
15 ...................
16 ...................
17 ...................
18 ...................
19 ...................
20 ...................
331.0
428.0
162.9
496
331.2
332.0
429.9
436
437.0
174.9
153.9
185
157.9
585.6
491.21
518.81
429.2
434.91
414.00
188.9
Alzheimer’s disease ......................................................................................................
Congestive heart failure, unspecified ...........................................................................
Lung Cancer .................................................................................................................
COPD ...........................................................................................................................
Senile degeneration of brain ........................................................................................
Parkinson’s Disease .....................................................................................................
Heart disease, unspecified ...........................................................................................
CVA/Stroke ...................................................................................................................
Cerebral atherosclerosis ...............................................................................................
Breast Cancer ...............................................................................................................
Colon Cancer ................................................................................................................
Prostate Cancer ............................................................................................................
Pancreatic Cancer ........................................................................................................
End stage renal disease ...............................................................................................
Obstructive chronic bronchitis with (acute) exacerbation .............................................
Acute respiratory failure ...............................................................................................
Cardiovascular disease, unspecified ............................................................................
Cerebral artery occlusion, unspecified with cerebral infarction ....................................
Coronary atherosclerosis of unspecified type of vessel ...............................................
Bladder Cancer .............................................................................................................
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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 the Chronic Conditions Data Warehouse (CCW), accessed on February 14 and February
20, 2013. FY 2013 hospice claims data from the CCW, accessed on June 26, 2014, and FY 2015 hospice claims data from the CCW, accessed
on June 20, 2016.
While there has been a shift in the
reporting of the principal diagnosis as a
result of diagnosis clarifications, a
significant proportion of hospice claims
(49 percent) in FY 2014 only reported a
single principal diagnosis, which may
not fully explain the characteristics of
Medicare beneficiaries who are
approaching the end of life. To address
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this pattern of single diagnosis
reporting, the FY 2015 Hospice Wage
Index and Payment Rate Update final
rule (79 FR 50498) reiterated ICD–9–CM
coding guidelines for the reporting of
the principal and additional diagnoses
on the hospice claim. We reminded
providers to report all diagnoses on the
hospice claim for the terminal illness
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and related conditions, including those
that affect the care and clinical
management for the beneficiary.
Additionally, in the FY 2016 Hospice
Wage Index and Payment Rate Update
final rule (80 FR 47201), we provided
further clarification regarding diagnosis
reporting on hospice claims. We
clarified that hospices will report all
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diagnoses identified in the initial and
comprehensive assessments on hospice
claims, whether related or unrelated to
the terminal prognosis of the individual,
effective October 1, 2015. Analysis of
FY 2015 hospice claims show that only
37 percent of hospice claims include a
single, principal diagnosis, with 63
percent submitting at least two
diagnoses and 46 percent including at
least three.
F. Use of Health Information
Technology
The Department of Health and Human
Services (HHS) believes that the use of
certified health IT by hospices can help
providers improve internal care delivery
practices and advance the interoperable
exchange of health information across
care partners to improve
communication and care coordination.
HHS has a number of initiatives
designed to encourage and support the
adoption of health information
technology and promote nationwide
health information exchange to improve
health care. The Office of the National
Coordinator for Health Information
Technology (ONC) leads these efforts in
collaboration with other agencies,
including CMS and the Office of the
Assistant Secretary for Planning and
Evaluation (ASPE). In 2015, ONC
released a document entitled
‘‘Connecting Health and Care for the
Nation: A Shared Nationwide
Interoperability Roadmap’’ (available at:
https://www.healthit.gov/sites/default/
files/hie-interoperability/nationwideinteroperability-roadmap-final-version1.0.pdf), which includes a near-term
focus on actions that will enable a
majority of individuals and providers
across the care continuum to send,
receive, find and use a common set of
electronic clinical information at the
nationwide level by the end of 2017.
The 2015 Edition Health IT Certification
Criteria (2015 Edition) builds on past
rulemakings to facilitate greater
interoperability for several clinical
health information purposes and
enables health information exchange
through new and enhanced certification
criteria, standards, and implementation
specifications. The 2015 Edition also
focuses on the establishment of an
interoperable nationwide health
information infrastructure. More
information on the 2015 Edition Final
Rule is available at: https://
www.healthit.gov/policy-researchersimplementers/2015-edition-final-rule
III. Provisions of the Proposed
Regulations
The proposed rule, titled ‘‘Medicare
Program; FY 2017 Hospice Payment
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Rate Update’’ (81 FR 25497 through
25538), was published in the Federal
Register on April 28, 2016, with a
comment period that ended on June 20,
2016. In that proposed rule, we
proposed to update the hospice wage
index, payment rates, and cap amount
for fiscal year (FY) 2017. In addition, the
proposed rule proposed changes to the
hospice quality reporting program,
including new quality measures. The
proposed rule also solicited feedback on
an enhanced data collection instrument
and described plans to publicly display
quality measures and other hospice data
beginning in the middle of 2017.
Finally, the proposed rule included
information regarding the Medicare Care
Choices Model (MCCM). We received
approximately 56 public comments on
the proposed rule, including comments
from MedPAC, hospice agencies,
national provider associations, patient
organizations, nurses, and advocacy
groups.
In this final rule, we provide a
summary of each proposed provision, a
summary of the public comments
received and our responses to them, and
the policies we are finalizing for the FY
2017 Hospice Payment Rate Update.
Comments related to the paperwork
burden are addressed in the ‘‘Collection
of Information Requirements’’ section in
this final rule. Comments related to the
impact analysis are addressed in the
‘‘Economic Analyses’’ section in this
final rule.
A. Monitoring for Potential Impacts—
Affordable Care Act Hospice Reform
In the FY 2017 Hospice Wage Index
and Rate Update proposed rule (81 FR
25497), we provided a summary of
analysis conducted on pre-hospice
spending, non-hospice spending, live
discharge rates, and skilled visits in the
last days of life. In addition, we also
provided a summary of our plans to
monitor for impacts of hospice payment
reform. We will continue to monitor the
impact of future payment and policy
changes and will provide the industry
with periodic updates on our analysis in
future rulemaking and/or
announcements on the Hospice Center
Web page at: https://www.cms.gov/
Center/Provider-Type/HospiceCenter.html.
We received several comments on the
analysis and CMS’s plans for future
monitoring efforts with regards to
hospice payment reform outlined in the
proposed rule, which are summarized
below.
Comment: A few commenters
expressed concerns regarding whether
pre-hospice spending is an appropriate
standard for comparison for post-
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hospice spending for any diagnosis,
including dementia. The commenters
noted the illness trajectory of dementia
is marked by a slow, progressive
decline, differs from the illness
trajectories of other hospice appropriate
diagnoses, and results in care needs
increasing and extending over longer
periods of time. In turn, it may require
higher spending. The commenters asked
us to recognize the overall care needs of
patients with dementia and other
progressive neurological conditions, and
the costs associated with these patients
and their caregivers. Additionally,
several commenters highlighted the
challenges of and intensive resources
required for short-stay patients, noting
that the current payment system may
not address the unique needs of that
population.
Several commenters suggested that
CMS consider payment refinements that
help to incentivize appropriate timing
on enrollment for hospice. Additional
commenters noted their concern
regarding a potential case-mix payment
system for hospice, as the commenters
believe that the hospice benefit differs
from all other Medicare payment
systems, as it is designed to account for
the patient’s full scope of Medicare
needs.
With regards to non-hospice spending
during a hospice election, several
commenters suggested that CMS take
action to educate other Medicare
provider types in order to increase
understanding of benefits coverage and
claims processing after a beneficiary has
elected hospice. Several commenters
also suggested that CMS investigate
options for preventing other Medicare
providers from billing without checking
the Common Working File and notifying
the hospice for a determination as to
whether or not the care is related to the
terminal prognosis. Several commenters
requested that a greater level of
specificity for Part D data be supplied to
hospice providers, such that they can
track where the billing issues originate
and begin to address them. The
commenters suggested that a
coordinated system would help address
the non-hospice spending.
With regards to hospice live discharge
rates, a few commenters noted concerns
about the difference between two types
of live discharges: A patient-initiated
discharge or revocation versus a
hospice-initiated discharge. The
commenters suggested that analysis of
live discharge rates should exclude the
patient-initiated discharges or
revocations. Commenters suggested that
for hospice-initiated discharges, the
reasons for such discharges should be
reported so that hospice providers can
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make adjustments in their admission
and discharge practices.
With regards to skilled visits during
the last days of life, the number of visits
by RNs and social workers is anticipated
to increase during the last 7 days of a
beneficiary’s life as a result of the
service intensity add-on payment,
implemented on January 1, 2016. A few
commenters stated that hospices take
their cues from patients and families,
who should always have the option to
decline a visit. As such, decisions
regarding visits made by the patient and
family ought to be considered and/or
reflected in the data.
Finally, most commenters supported
our planned analysis to monitor the
impact of hospice payment reform and
would like to use the monitoring results
to target program integrity efforts to
those aberrant individual providers.
Although the analysis and monitoring
efforts described in the proposed rule
did not relate to the timely filing
requirement for the hospice Notice of
Election (NOE), nevertheless a few
commenters expressed concern about
the timely filing requirement and lost
revenue due to data entry errors that
cannot be immediately corrected.
Commenters encouraged CMS to
continue to explore the possibility of
transmitting NOEs through Electronic
Data Interchange rather than through
direct data entry and recommended
that, in the meantime, when the hospice
files the NOE in good faith within the
5-day requirement, but the MAC does
not accept the NOE within 5 days, the
payment for hospice services should be
allowed back to the date of election,
once the MAC has accepted the NOE.
Response: We appreciate these
comments on the ongoing analysis
presented and will continue to monitor
hospice trends and vulnerabilities
within the hospice benefit while also
investigating means by which we can
educate the larger provider community
regarding appropriate billing practices.
Additionally, we continue to explore
options and strategies for addressing
and responding to concerning behavior
in the provider community. We will
also consider these suggestions in any
potential future policy and payment
refinements.
With regards to the comments
received regarding the NOE timely filing
requirement, we recognize that
inadvertent NOE errors, such as
transposed numbers or incorrect
admission dates, will not trigger the
NOE to return to the hospice for
correction. The hospice must wait until
the incorrect information is fully
processed by Medicare systems before
they can correct it, and this could cause
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the NOE to be late. We strongly
encourage hospices to have quality
assurance measures in place regarding
the accuracy of the NOE information to
mitigate any potential untimely NOEs.
Our expectation is that the information
provided on the hospice NOE is
accurate and free of transcribing errors.
To aid in reducing the impact of these
situations on hospices, CMS is currently
conducting an analysis that aims to
redesign the hospice benefit period data
in our systems.
B. FY 2017 Hospice Wage Index and
Rate Update
1. FY 2017 Hospice Wage Index
a. Background
The hospice wage index is used to
adjust payment rates for hospice
agencies under the Medicare program to
reflect local differences in area wage
levels, based on the location where
services are furnished. The hospice
wage index utilizes the wage adjustment
factors used by the Secretary for
purposes of section 1886(d)(3)(E) of the
Act for hospital wage adjustments. Our
regulations at § 418.306(c) require each
labor market to be established using the
most current hospital wage data
available, including any changes made
by the Office of Management and
Budget (OMB) to the Metropolitan
Statistical Areas (MSAs) definitions.
We use the previous FY’s hospital
wage index data to calculate the hospice
wage index values. For FY 2017, the
hospice wage index will be based on the
FY 2016 pre-floor, pre-reclassified
hospital 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 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 (June 6, 2003). This bulletin
announced revised definitions for MSAs
and the creation of micropolitan
statistical areas and combined statistical
areas. The bulletin is available online at
https://www.whitehouse.gov/omb/
bulletins/b03-04.html. When adopting
OMB’s new labor market designations in
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FY 2006, we identified some geographic
areas where there were no hospitals,
and thus, no hospital wage index data,
on which to base the calculation of the
hospice wage index. In the FY 2010
Hospice Wage Index final rule (74 FR
39386), we 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 prefloor, 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, Hinesville-Fort Stewart, Georgia.
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 prefloor, pre-reclassified hospital wage
index data from all contiguous CBSAs to
represent a reasonable proxy for the
rural area. The term ‘‘contiguous’’
means sharing a border (72 FR 50217).
Currently, the only rural area without a
hospital from which hospital wage data
could be derived is Puerto Rico.
However, our policy of imputing a rural
pre-floor, pre-reclassified hospital wage
index value based on the pre-floor, prereclassified hospital wage index (or
indices) of CBSAs contiguous to a rural
area without a hospital from which
hospital wage data could be derived
does not recognize the unique
circumstances of Puerto Rico. In this
final rule, for FY 2017, we will continue
to use the most recent pre-floor, prereclassified hospital wage index value
available for Puerto Rico, which is
0.4047.
As described in the August 8, 1997
Hospice Wage Index final rule (62 FR
42860), the pre-floor and prereclassified hospital wage index is used
as the raw wage index for the hospice
benefit. These raw wage index values
are then subject to application of the
hospice floor to compute the hospice
wage index used to determine payments
to hospices. Pre-floor, pre-reclassified
hospital wage index values below 0.8
are adjusted by a 15 percent increase
subject to a maximum wage index value
of 0.8. For example, if County A has a
pre-floor, pre-reclassified hospital wage
index value of 0.3994, we would
multiply 0.3994 by 1.15, which equals
0.4593. Since 0.4593 is not greater than
0.8, then County A’s hospice wage
index would be 0.4593. In another
example, if County B has a pre-floor,
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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.
b. FY 2016 Implementation of New
Labor Market Delineations
OMB has published subsequent
bulletins regarding CBSA changes. On
February 28, 2013, OMB issued OMB
Bulletin No. 13–01, announcing
revisions to the delineation of MSAs,
Micropolitan Statistical Areas, and
Combined Statistical Areas, and
guidance on uses of the delineation in
these areas. A copy of this bulletin is
available online at: https://
www.whitehouse.gov/sites/default/files/
omb/bulletins/2013/b-13-01.pdf. This
bulletin states that it ‘‘provides the
delineations of all Metropolitan
Statistical Areas, Metropolitan
Divisions, Micropolitan Statistical
Areas, Combined Statistical Areas, and
New England City and Town Areas in
the United States and Puerto Rico based
on the standards published on June 28,
2010, in the Federal Register (75 FR
37246 through 37252) and Census
Bureau data.’’ In the FY 2016 Hospice
Wage Index final rule (80 FR 47178), we
adopted the OMB’s new area
delineations using a 1-year transition. In
the FY 2016 Hospice Wage Index and
Payment Rate Update final rule (80 FR
47178), we stated that beginning
October 1, 2016, the wage index for all
hospice payments would be fully based
on the new OMB delineations.
A summary of the comments we
received regarding the wage index and
our responses to those comments
appears below.
Comment: Several commenters noted
their support for the full adoption of the
new labor market delineations.
Response: We appreciate the
comments in support of the CBSA
delineations finalized in last year’s FY
2016 Hospice Wage Index and Payment
Rate Update final rule (80 FR 47142).
Comment: One commenter disagreed
with fully basing hospice geographic
area wage adjustments on the new OMB
delineations. The commenter was
particularly concerned with the New
York City CBSA and the fact that the
CBSA contains counties from New
Jersey.
Response: In the FY 2016 Hospice
Wage Index and Rate Update final rule
(80 FR 47178), we stated that a 1-year
transition policy would apply to the FY
2016 payment rates and that, beginning
in FY 2017, hospice payments would be
fully-based on the new OMB
delineations. In addition, we believe
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that the OMB’s CBSA designations
reflect the most recent available
geographic classifications and are a
reasonable and appropriate method of
defining geographic areas for the
purposes of wage adjusting the hospice
payment rates. We do not see any
compelling reason to deviate from the
OMB designations.
Comment: A commenter was
concerned with the continued use of the
pre-floor, pre-reclassified hospital wage
index to adjust the hospice payment
rates, because this causes continuing
volatility of the hospice wage index
from one year to the next. The
commenter believes that this volatility
is often based on inaccurate or
incomplete hospital cost report data.
Response: We believe that annual
changes in the wage index reflect real
variations in costs of providing care in
various geographic locations. The wage
index values are based on data
submitted on the inpatient hospital cost
reports. We utilize efficient means to
ensure and review the accuracy of the
hospital cost report data and resulting
wage index. The hospice wage index is
derived from the pre-floor, prereclassified wage index, which is
calculated based on cost report data
from hospitals paid under the Inpatient
Prospective Payment System (IPPS). All
IPPS hospitals must complete the wage
index survey (Worksheet S–3, Parts II
and III) as part of their Medicare cost
reports. Cost reports will be rejected if
Worksheet S–3 is not completed. In
addition, our Medicare contractors
perform desk reviews on all hospitals’
Worksheet S–3 wage data, and we run
edits on the wage data to further ensure
the accuracy and validity of the wage
data. We believe that our review
processes result in an accurate reflection
of the applicable wages for the areas
given.
In addition, we believe that finalizing
our proposal to adopt a hospice wage
index standardization factor will
provide a safeguard to the Medicare
program as well as to hospices because
it will mitigate fluctuations in the wage
index by ensuring that wage index
updates and revisions are implemented
in a budget neutral manner.
Comment: A commenter was
concerned with the lack of parity
between different health care sectors,
each of which utilizes some form of a
hospital wage index, that experience
differing wage index values for specific
geographic areas. The commenter also
stated that hospital reclassifications
create labor market distortions in areas
in which hospice costs are not
reclassified.
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Response: Several post-acute care
payment systems utilize the pre-floor,
pre-reclassified hospital wage index as
the basis for their wage indexes (for
example, the Home Health Prospective
Payment System (HH PPS), the Skilled
Nursing Facility Prospective Payment
System (SNF PPS) and the Inpatient
Rehabilitation Facility Prospective
Payment System (IRF PPS)). The
statutes that govern hospice payment do
not provide any discretion to permit a
mechanism for allowing hospices to
seek geographic reclassification. The
reclassification provision is found in
section 1886(d)(10) of the Act. Section
1886(d)(10)(C)(i) of the Act states, ‘‘The
Board shall consider the application of
any subsection (d) hospital requesting
that the Secretary change the hospital’s
geographic classification . . .’’ This
provision is only applicable to
hospitals, as defined at section 1886(d)
of the Act. In addition, we do not
believe that using hospital
reclassification data would be
appropriate as these data are specific to
the requesting hospitals and the data
may or may not apply to a given hospice
in a given instance.
Comment: One commenter requested
that CMS modify the wage index so that
the area wage index applicable to any
hospice that is located in an urban area
of a state may not be less than the area
wage index applicable to hospices
located in rural areas in that State.
Response: Section 4410(a) of the
Balanced Budget Act of 1997 (Pub. L.
105–33) provides that the area wage
index applicable to any hospital that is
located in an urban area of a state may
not be less than the area wage index
applicable to hospitals located in rural
areas in that state. This rural floor
provision is specific to hospitals.
Because the hospital rural floor applies
only to hospitals, and not to hospices,
we continue to believe the use of the
previous year’s pre-floor and prereclassified hospital wage index results
in the most appropriate adjustment to
the labor portion of the hospice
payment rates. This position is
longstanding and consistent with other
Medicare payment systems (SNF PPS,
IRF PPS, HH PPS, etc.).
Comment: A commenter requested
that CMS explore a wholesale revision
and reform of the hospice wage index.
Response: We are exploring other
methodologies for future reform of the
Medicare wage index. CMS’ ‘‘Report to
Congress: Plan to Reform the Medicare
Wage Index’’ was submitted by the
Secretary on April 11, 2012 and is
available on our Wage Index Reform
Web page at: https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-
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Payment/AcuteInpatientPPS/WageIndex-Reform.html.
Final Action: After considering the
comments received in response to the
proposed rule and for the reasons
discussed above, we are finalizing our
proposal to use the pre-floor, prereclassified hospital inpatient wage
index as the wage adjustment to the
labor portion of the hospice rates. For
FY 2017, the updated wage data are for
hospital cost reporting periods
beginning on or after October 1, 2011
and before October 1, 2012 (FY 2012
cost report data).
The wage index applicable for FY
2017 is available on the CMS Web site
at https://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
Hospice/. As of FY 2012, the
wage index values applicable for the
upcoming fiscal year and subsequent
fiscal years are no longer published in
the Federal Register (77 FR 44242). The
hospice wage index for FY 2017 will be
effective October 1, 2016 through
September 30, 2017.
2. 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 inpatient hospital market basket
index set out under section
1886(b)(3)(B)(iii) of the Act, minus 1
percentage point. Payment rates for FYs
since 2002 have been updated according
to section 1814(i)(1)(C)(ii)(VII) of the
Act, which states that the update to the
payment rates for subsequent FYs must
be the inpatient market basket
percentage 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 10year 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: https://www.cms.gov/
Research-Statistics-Data-and-Systems/
Statistics-Trends-and-Reports/
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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 hospice
payment update percentage for FY 2017
is based on the estimated inpatient
hospital market basket update of 2.7
percent (based on IHS Global Insight,
Inc.’s second quarter 2016 forecast with
historical data through the first quarter
of 2016). Due to the requirements at
sections 1886(b)(3)(B)(xi)(II) and
1814(i)(1)(C)(v) of the Act, the estimated
inpatient hospital market basket update
for FY 2017 of 2.7 percent must be
reduced by a MFP adjustment as
mandated by Affordable Care Act
(currently estimated to be 0.3 percentage
point for FY 2017). The estimated
inpatient hospital market basket update
for FY 2017 is reduced further by 0.3
percentage point, as mandated by the
Affordable Care Act. In effect, the
hospice payment update percentage for
FY 2017 is 2.1 percent.
Currently, the labor portion of the
hospice payment rates is as follows: For
RHC, 68.71 percent; for CHC, 68.71
percent; for General Inpatient Care,
64.01 percent; and for Respite Care,
54.13 percent. The non-labor portion is
equal to 100 percent minus the labor
portion for each level of care. Therefore,
the non-labor portion of the payment
rates is as follows: For RHC, 31.29
percent; for CHC, 31.29 percent; for
General Inpatient Care, 35.99 percent;
and for Respite Care, 45.87 percent.
A summary of the comments we
received regarding the payment rates
and our responses to those comments
appear below.
Comment: Several commenters noted
their support of the hospice payment
update percentage.
Response: We appreciate the
comments in support of the hospice
payment update percentage.
Comment: One commenter suggested
the CMS eliminate the hospice payment
update percentage to hospice payments
for FY 2017, as the commenter
maintains that payment adequacy for
hospice providers is generally positive.
Other commenters noted that the
proposed hospice payment update
percentage is not sufficient to keep pace
with rising costs of providing hospice
care and suggested that CMS revisit the
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proposed hospice payment update
percentage for potential increase.
Response: The payment update
percentage to the hospice rates is
required by statute, as previously
described in detail in this section, and
we do not have regulatory authority to
alter the payment update.
Final Action: We are implementing
the hospice payment update percentage
as discussed in the proposed rule. Based
on IHS Global Insight, Inc.’s updated
forecast, the hospice payment update
percentage for FY 2017 will be 2.1
percent for hospices that submit the
required quality data and 0.1 percent for
hospices that do not submit the required
quality data.
3. FY 2017 Hospice Payment Rates
There are four payment categories that
are distinguished by the location and
intensity of the services provided. The
base payments are adjusted for
geographic differences in wages by
multiplying the labor share, which
varies by category, of each base rate by
the applicable hospice wage index. A
hospice is paid the RHC rate for each
day the beneficiary is enrolled in
hospice, unless the hospice provides
continuous home care, IRC, or general
inpatient care. CHC is provided during
a period of patient crisis to maintain the
person at home; IRC is short-term care
to allow the usual caregiver to rest and
be relieved from caregiving; and General
Inpatient Care (GIP) is to treat symptoms
that cannot be managed in another
setting.
As discussed in the FY 2016 Hospice
Wage Index and Payment Rate Update
final rule (80 FR 47172), we
implemented two different RHC
payment rates, one RHC rate for the first
60 days and a second RHC rate for days
61 and beyond. In addition, in the final
rule, we adopted a Service Intensity
Add-on (SIA) payment, when direct
patient care is provided by a RN or
social worker during the last 7 days of
the beneficiary’s life. The SIA payment
is equal to the CHC hourly rate
multiplied by the hours of nursing or
social work provided (up to 4 hours
total) that occurred on the day of
service. In order to maintain budget
neutrality, as required under section
1814(i)(6)(D)(ii) of the Act, the new RHC
rates were adjusted by a SIA budget
neutrality factor.
As discussed in the FY 2016 Hospice
Wage Index and Payment Rate Update
final rule (80 FR 47177), we will
continue to make the SIA payments
budget neutral through an annual
determination of the SIA budget
neutrality factor (SBNF), which will
then be applied to the RHC payment
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rates. The SBNF will be calculated for
each FY using the most current and
complete FY utilization data available at
the time of rulemaking. For FY 2017, the
budget neutrality adjustment that
applies to days 1 through 60 is
calculated to be 1.0000. The budget
neutrality adjustment that applies to
days 61 and beyond is calculated to be
0.9999.
For FY 2017, we are applying a wage
index standardization factor to the FY
2017 hospice payment rates in order to
ensure overall budget neutrality when
updating the hospice wage index with
more recent hospital wage data. Wage
index standardization factors are
applied in other payment settings such
as under home health Prospective
Payment System (PPS), IRF PPS, and
SNF PPS. Applying a wage index
standardization factor to hospice
payments will eliminate the aggregate
effect of annual variations in hospital
wage data. We believe that adopting a
hospice wage index standardization
factor will provide a safeguard to the
Medicare program as well as to hospices
because it will mitigate fluctuations in
the wage index by ensuring that wage
index updates and revisions are
implemented in a budget neutral
manner. To calculate the wage index
standardization factor, we simulated
total payments using the FY 2017
hospice wage index and compared it to
our simulation of total payments using
the FY 2016 hospice wage index. By
dividing payments for each level of care
using the FY 2017 wage index by
payments for each level of care using
the FY 2016 wage index, we obtain a
wage index standardization factor for
each level of care (RHC days 1–60, RHC
days 61+, CHC, IRC, and GIP).
Lastly, the hospice payment rates for
hospices that submit the required
quality data will be increased by the full
FY 2017 hospice payment update
percentage of 2.1 percent as discussed
in section III.C.3 of this final rule. The
FY 2017 RHC rates are shown in Table
11. The FY 2017 payment rates for CHC,
IRC, and GIP are shown in Table 12.
TABLE 11—FY 2017 HOSPICE RHC PAYMENT RATES
FY 2016
payment rates
Code
Description
651 ....................
651 ....................
Routine Home Care (days 1–60) .....
Routine Home Care (days 61+) .......
$186.84
146.83
SBNF
FY 2017
hospice
payment
update
percentage
Wage index
standardization
factor
× 1.0000
× 0.9999
× 0.9989
× 0.9995
× 1.021
× 1.021
FY 2017
payment rates
$190.55
149.82
TABLE 12—FY 2017 HOSPICE CHC, IRC, AND GIP PAYMENT RATES
FY 2016
payment rates
Code
Description
652 ....................
Continuous Home Care ................................................
Full Rate = 24 hours of care.
$40.19 = FY 2017 hourly rate.
Inpatient Respite Care ..................................................
General Inpatient Care .................................................
655 ....................
656 ....................
Sections 1814(i)(5)(A) through (C) of
the Act require that hospices begin
submitting quality data, based on
measures to be specified by the
Secretary. In the FY 2012 Hospice Wage
Index final rule (76 FR 47320 through
47324), we implemented a Hospice
Quality Reporting Program (HQRP), as
required by section 3004 of the
Wage index
standardization
factor
FY 2017
hospice
payment
update
percentage
FY 2017
payment rates
$944.79
× 1.0000
× 1.021
$964.63
167.45
720.11
× 1.0000
× 0.9996
× 1.021
× 1.021
170.97
734.94
Affordable Care Act. Hospices were
required to begin collecting quality data
in October 2012, and submit that quality
data in 2013. Section 1814(i)(5)(A)(i) of
the Act requires that beginning with FY
2014 and 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. The FY 2017
rates for hospices that do not submit the
required quality data will be updated by
the FY 2017 hospice payment update
percentage of 2.1 percent minus 2
percentage points. These rates are
shown in Tables 13 and 14.
TABLE 13—FY 2017 HOSPICE RHC PAYMENT RATES FOR HOSPICES THAT DO NOT SUBMIT THE REQUIRED QUALITY
DATA
FY 2016
payment rates
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Code
Description
651 ....................
651 ....................
Routine Home Care (days 1–60) .....
Routine Home Care (days 61+) .......
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$186.84
146.83
Fmt 4701
SBNF
× 1.0000
× 0.9999
Sfmt 4700
Wage index
standardization
factor
× 0.9989
× 0.9995
E:\FR\FM\05AUR4.SGM
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FY 2017
hospice
payment
update of
2.1% minus 2
percentage
points = 0.1%
FY 2017
payment rates
× 1.001
× 1.001
$186.82
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TABLE 14—FY 2017 HOSPICE CHC, IRC, AND GIP PAYMENT RATES FOR HOSPICES THAT DO NOT SUBMIT THE
REQUIRED QUALITY DATA
FY 2016
payment rates
Code
Description
652 ....................
Continuous Home Care ................................................
Full Rate = 24 hours of care.
$39.41 = FY 2017 hourly rate.
Inpatient Respite Care ..................................................
General Inpatient Care .................................................
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655 ....................
656 ....................
A summary of the comments we
received regarding the payment rates
and our responses to those comments
appear below.
Comment: A commenter asked if the
application of the standardization factor
is premature or is it part of the
continued progression of hospice
reimbursement from hybrid fee-forservice/health maintenance organization
to a full case-mix or value-based
purchasing (VBP) system.
Response: We believe that applying a
wage index standardization factor to the
hospice rates is appropriate. The
application of the standardization factor
will mitigate any potential effects due to
the annual variations in hospital wage
data. Moreover, this approach creates a
level of protection for the Medicare
program as well as to hospices, as it
minimizes the impacts of any
fluctuations in the wage index.
Comment: Several commenters
requested that the SIA Payment
eligibility requirements be modified to
include additional hospice services,
including visits from licensed practical
nurses (LPNs), music therapists, and
other professionals providing care
during the last 7 days of life. In
addition, several commenters requested
that data be collected in order to
determine if the SIA Payment increased
the number of visits during
beneficiaries’ most intensive time of
need for skilled care (specifically, the
last 7 days of life).
Response: CMS finalized the SIA
payment policy in the FY 2016 Hospice
Wage Index and Payment Update final
rule (80 FR 47141) and we did not
solicit comments on a proposal to
modify these policy parameters in the
FY 2017 Hospice Wage Index and
Payment Rate update proposed rule (81
FR 25498). However, we will continue
to consider and monitor for potential
refinements to this policy, including
current monitoring efforts that were
described in the FY 2017 Hospice Wage
Index and Payment Rate Update
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Wage index
standardization
factor
Frm 00015
Fmt 4701
FY 2017
payment rates
$944.79
× 1.0000
× 1.001
$945.73
167.45
720.11
× 1.0000
× 0.9996
× 1.001
× 1.001
167.62
720.54
proposed rule (81 FR 25498) in response
to these policy changes, and we will
take these comments into account as we
continue to do so.
Comment: One commenter noted that
there have been issues with the
technical implementation of the SIA
payment such that payment adjustments
are not occurring as originally intended.
Response: While the technical
implementations issues with regards to
SIA payments have been minimal, we
appreciate this comment and are
working diligently with appropriate
stakeholders to expedite the appropriate
system remediation to ensure accurate
payment to providers.
Comment: One commenter expressed
concern that the RHC rate payment
amount for Days 61 and beyond may
lead to payment inadequacy for patients
with long lengths of stay. One
commenter noted that the episode gap
required by the two RHC rates policy
implemented for FY 2016 could have a
negative impact on those hospices that
accept patients via transfers. Moreover,
the commenter noted that CMS should
consider payment adjustments if a
patient is transferred from one hospice
to another, particularly at or near day 61
of a hospice episode.
Response: We appreciate the
comments and the concern for
appropriate payment for long stay
beneficiaries as well as transfer patients.
The creation of the two RHC rates (one
for days 1–60 and a another for days 61
and beyond) was finalized in the FY
2016 Hospice Wage Index and Payment
Rate Update final rule (80 FR 47141),
and we did not propose any changes for
FY 2017 nor did we solicit comments on
any future changes. In response to
public comments, we stated in the FY
2016 Hospice Wage Index and Payment
Rate Update final rule that allowing for
a higher payment for a new hospice
election (or in transfer situations)
without a gap in hospice care of greater
than 60 days goes against our intent to
mitigate the incentive to discharge and
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FY 2017
hospice
payment
update of
2.1% minus 2
percentage
points = 0.1%
Sfmt 4700
readmit patients (or transfer patients) at
or around day 60 for the purposes of
obtaining a higher payment (80 FR
47168). With regards to the commenter’s
concern regarding reimbursement for
long lengths of stay, we refer the
commenter to the FY 2016 Hospice
Wage Index and Payment Rate Update
final rule (80 FR 47142), where we
discuss the rationale for the creation of
a higher RHC rate for days 1–60 and a
lower rate for days 61 and beyond. In
that final rule, we noted that hospice
stays manifest in a ‘U-Shaped’ pattern
(that is, the intensity of services
provided is higher both at admission
and near death and, conversely, is
relatively lower during the middle
period of the hospice episode). Since
hospice care is most profitable during
the long, low-cost middle portions of an
episode, longer episodes have very
profitable, long middle segments (80 FR
47161). Therefore, in order to better
align hospice payments with service
intensity during a hospice episode of
care, we implemented a higher RHC rate
for days 1–60 and a lower rate for days
61 and beyond, effective January 1,
2016. We also implemented a service
intensity add-on (SIA) payment policy
that reimburses hospices for visits
performed during the last 7 days of a
beneficiary’s life (in addition to RHC per
diem payments), also effective January
1, 2016. We will continue to monitor for
and consider potential refinements to
these policies as appropriate.
Comment: A commenter noted that
Medicaid agencies have encountered
challenges in the implementation of the
payment changes due to hospice reform.
Response: We appreciate this
comment and are working diligently
with appropriate stakeholders and State
Agencies to facilitate effective
implementation of hospice payment
reform.
Final Action: We are implementing
the updates to hospice payment rates as
discussed in the proposed rule.
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4. Hospice Cap Amount for FY 2017
As discussed in the FY 2016 Hospice
Wage Index and Payment Rate Update
final rule (80 FR 47183), we
implemented changes mandated by the
Improving Medicare Post-Acute Care
Transformation Act of 2014 (IMPACT
Act). Specifically, for accounting years
that end after September 30, 2016 and
before October 1, 2025, the hospice cap
is updated by the hospice payment
update percentage rather than using the
consumer price index for urban
consumers (CPI–U). As required by
section 1814(i)(2)(B)(ii) of the Act, the
hospice cap amount for the 2016 cap
year, starting on November 1, 2015 and
ending on October 31, 2016, is equal to
the 2015 cap amount ($27,382.63)
updated by the FY 2016 hospice
payment update percentage of 1.6
percent. As such, the 2016 cap amount
is $27,820.75.
In the FY 2016 Hospice Wage Index
and Payment Rate Update final rule (80
FR 47142), we finalized aligning the cap
accounting year with the federal FY
beginning in 2017. Therefore, the 2017
cap year will start on October 1, 2016
and end on September 30, 2017. Table
26 in the FY 2016 Hospice Wage Index
and Payment Rate Update final rule (80
FR 47185) outlines the timeframes for
counting beneficiaries and payments
during the 2017 transition year. The
hospice cap amount for the 2017 cap
year will be $28,404.99, which is equal
to the 2016 cap amount ($27,820.75)
updated by the FY 2017 hospice
payment update percentage of 2.1
percent.
A summary of public comments and
our responses to comments on the
hospice cap are summarized below:
Comment: One commenter expressed
concerns that the methodology used to
calculate the hospice cap creates an
incentive for rural hospices to inflate
their utilization of the GIP level of care,
as some rural hospices may do this to
gain higher reimbursement by placing
patients at the GIP level of care that may
not qualify for that level of care.
Response: The hospice aggregate cap
is calculated based on total
reimbursement across all levels of care.
In addition, the hospice inpatient cap
limits total payments to the hospice for
inpatient care (general or respite). Total
payments are subject to a limitation that
total inpatient care days for Medicare
patients does not exceed 20 percent of
the total days for which patients had
elected hospice care. We urge providers
to adhere to appropriate guidelines with
respect to the hospice levels of care. We
note that in a March 2016 Office of
Inspector General (OIG) report, OIG
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found that hospices billed one-third of
GIP stays inappropriately, costing
Medicare $268 million in 2012.
According to the report, ‘‘hospices
commonly billed for GIP when the
beneficiary did not have uncontrolled
pain or unmanaged symptoms.’’ (https://
oig.hhs.gov/oei/reports/oei-02-1000491.asp) As such, we will continue to
monitor the use of the various levels of
care in order to identify any aberrant or
problematic behavior.
Final Action: We are implementing
the changes to the hospice cap amount
as discussed in the proposed rule.
C. Proposed Updates to the Hospice
Quality Reporting Program (HQRP)
1. Background and Statutory Authority
Section 3004(c) of the Affordable Care
Act amended section 1814(i)(5) of the
Act to authorize a quality reporting
program for hospices. Section
1814(i)(5)(A)(i) of the Act requires that
beginning with FY 2014 and each
subsequent FY, the Secretary shall
reduce the market basket update by 2
percentage points for any hospice that
does not comply with the quality data
submission requirements for that FY.
Depending on the amount of the annual
update for a particular year, a reduction
of 2 percentage points could result in
the annual market basket update being
less than 0 percent for a FY and may
result in payment rates that are less than
payment rates for the preceding FY. Any
reduction based on failure to comply
with the reporting requirements, as
required by section 1814(i)(5)(B) of the
Act, would apply only for the particular
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, including the
endorsement of quality measures, with
the Secretary under section 1890(a) of
the Act. This contract is currently held
by the National Quality Forum (NQF).
However, section 1814(i)(5)(D)(ii) of the
Act provides that in the case of a
specified area or medical topic
determined appropriate by the Secretary
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for which a feasible and practical
measure has not been endorsed by the
consensus-based entity, the Secretary
may specify measures that are not so
endorsed as long as due consideration is
given to measures that have been
endorsed or adopted by a consensusbased organization identified by the
Secretary. Our paramount concern is the
successful development of an HQRP
that promotes the delivery of high
quality healthcare services. We seek to
adopt measures for the HQRP that
promote person-centered, high quality,
and safe care. Our measure selection
activities for the HQRP take into
consideration input from the Measure
Applications Partnership (MAP),
convened by the NQF, as part of the
established CMS pre-rulemaking
process required under section 1890A of
the Act. The MAP is a public-private
partnership comprised of multistakeholder groups convened by the
NQF for the primary purpose of
providing input to CMS on the selection
of certain categories of quality and
efficiency measures, as required by
section 1890A(a)(3) of the Act. By
February 1st of each year, the NQF must
provide that input to CMS. Input from
the MAP is located at https://
www.qualityforum.org/Setting_
Priorities/Partnership/Measure_
Applications_Partnership.aspx. We also
take into account national priorities,
such as those established by the
National Priorities Partnership at
(https://www.qualityforum.org/npp/), the
HHS Strategic Plan (https://
www.hhs.gov/secretary/about/priorities/
priorities.html), the National Strategy
for Quality Improvement in Healthcare,
(https://www.ahrq.gov/
workingforquality/nqs/
nqs2013annlrpt.htm) and the CMS
Quality Strategy (https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/
QualityInitiativesGenInfo/CMS-QualityStrategy.html). To the extent
practicable, we have sought to adopt
measures endorsed by member
organizations of the National Consensus
Project (NCP), recommended by multistakeholder organizations, and
developed with the input of providers,
purchasers and/or payers, and other
stakeholders.
3. Policy for Retention of HQRP
Measures Adopted for Previous
Payment Determinations
For the purpose of streamlining the
rulemaking process, we finalized our
policy in the FY 2016 Hospice Wage
Index final rule (80 FR 47187) that when
we adopt measures for the HQRP
beginning with a payment
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determination year, these measures
would automatically be adopted for all
subsequent years’ payment
determinations, unless we proposed to
remove, suspend, or replace the
measures. Quality measures would be
considered for removal by CMS for
reasons including, but not limited to:
• Measure performance among
hospices was so high and unvarying that
meaningful distinction in improvements
in performance could no longer be
made;
• Performance or improvement on a
measure did not result in better patient
outcomes;
• A measure did not align with
current clinical guidelines or practice;
• A more broadly applicable measure
(across settings, populations, or
conditions) for the particular topic was
available;
• A measure that was more proximal
in time to desired patient outcomes for
the particular topic was available;
• A measure that was more strongly
associated with desired patient
outcomes for the particular topic was
available; or
• Collection or public reporting of a
measure led to negative unintended
consequences.
For any such removal, the public
would be given an opportunity to
comment through the annual
rulemaking process. However, if there
were reason to believe continued
collection of a measure raised potential
safety concerns, we would take
immediate action to remove the measure
from the HQRP and not wait for the
annual rulemaking cycle. The measures
would be promptly removed, and we
would immediately notify hospices and
the public of such a decision through
the usual CMS HQRP communication
channels, including postings and
announcements on the CMS HQRP Web
site, Medicare Learning Network (MLN)
eNews communications, national
provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums. In such
instances, the removal of a measure
would be formally announced in the
next annual rulemaking cycle.
To further streamline the rulemaking
process, we proposed to codify that if
measures we are using in the HQRP
have non-substantive changes in their
specifications change as part of their
NQF endorsement process, we would
continue to utilize the measure with
their new endorsed status in the HQRP.
As mentioned previously, quality
measures selected for the HQRP must be
endorsed by the NQF unless they meet
the statutory criteria for exception under
section 1814(i)(5)(D)(ii) of the Act. The
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NQF is a voluntary consensus standardsetting organization with a diverse
representation of consumer, purchaser,
provider, academic, clinical, and other
healthcare stakeholder organizations.
The NQF was established to standardize
healthcare quality measurement and
reporting through its consensus measure
development process (https://
www.qualityforum.org/About_NQF/
Mission_and_Vision.aspx). The NQF
undertakes review of: (a) New quality
measures and national consensus
standards for measuring and publicly
reporting on performance, (b) regular
maintenance processes for endorsed
quality measures, (c) measures with
time-limited endorsement for
consideration of full endorsement, and
(d) ad hoc review of endorsed quality
measures, practices, consensus
standards, or events with adequate
justification to substantiate the review.
Through NQF’s measure maintenance
process, NQF-endorsed measures are
sometimes updated to incorporate
changes that we believe do not
substantially change the nature of the
measure. Examples of such changes
could be updated diagnosis or
procedure codes, changes to exclusions
to a particular patient/consumer
population, or definitions. We believe
these types of maintenance changes are
distinct from more substantive changes
to measures. Additionally, since the
NQF endorsement and measure
maintenance process is one that ensures
transparency, public input, and
discussion among representatives across
the healthcare enterprise,5 we believe
that the NQF measure endorsement and
maintenance process itself is
transparent, scientifically rigorous, and
provides opportunity for public input.
Thus, we proposed to codify at
§ 418.312 that if the NQF makes only
non-substantive changes to
specifications for HQRP measures in the
NQF’s re-endorsement process, we
would continue to utilize the measure
in its new endorsed status. If NQFendorsed specifications change and we
do not adopt those changes, then we
would propose the measure as an
application. An application of a NQFendorsed quality measure is utilized in
instances when CMS has identified a
need to use a NQF-endorsed measure in
a QRP but need to use it with one or
more modifications to the quality
measure’s specifications. These
modifications pertain to, but are not
limited to, one or more of the following
5 ‘‘NQF: How Endorsement Happens—National
Quality Forum.’’ 2010. 26 Jan. 2016 https://
www.qualityforum.org/Measuring_Performance/
ABCs/How_Endorsement_Happens.aspx.
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aspects of a NQF-endorsed quality
measure: (a) Numerator, (b)
denominator, (c) setting, (d) look-back
period, (e) calculation period, (f) risk
adjustment, and (g) revisions to data
elements used to collect the data
required for the measure, etc. CMS may
adopt a quality measure for the HQRP
under section 1814(i)(5)(D)(ii) of the
Act, which states, ‘‘In the case of a
specified area or medical topic
determined appropriate by the Secretary
for which a feasible and practical
measure has not been endorsed by [the
NQF], the Secretary may specify a
measure that is not so endorsed as long
as due consideration is given to
measures that have been endorsed or
adopted by a consensus organization
identified by the Secretary.’’ Reasons for
not adopting changes in measure
specifications to a measure may include
any of the aforementioned criteria in
this section, including that the new
specification does not align with
clinical guidelines or practice or that the
new specification leads to negative
unintended consequences. Finally, we
will continue to use rulemaking to
adopt substantive updates made by the
NQF to the endorsed measures we have
adopted for the HQRP. We continue to
make these determinations about what
constitutes a substantive versus nonsubstantive change on a measure-bymeasure basis. A change would be
deemed substantive if the intent of the
measure changes, the facility/setting
changes, the data sources changes, the
level of analysis changes, and/or the
measure is removed. We will continue
to provide updates about changes to
measure specifications as a result of
NQF endorsement or maintenance
processes through the normal CMS
HQRP communication channels,
including postings and announcements
on the CMS HQRP Web site, MLN
eNews communications, national
provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums.
Comment: CMS received two
comments on our proposal to codify that
if measures used in the HQRP undergo
non-substantive changes as part of their
NQF re-endorsement process, we would
utilize the measure with their new
endorsed status without going through a
new notice-and-comment rulemaking
process. One commenter supported the
proposal to codify this policy. Another
commenter was concerned that CMS’s
plan to adopt non-substantive change(s)
approved through the NQF reendorsement process without a noticeand-comment rulemaking process does
not allow providers and vendors the
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opportunity to provide input on changes
to measure specifications. Additionally,
the commenter also had concerns that
adopting non-substantive changes to
measures outside of the rulemaking
process would limit the ability for
hospices and vendors to make necessary
changes to data collection systems to
implement non-substantive updates to
measures.
Response: We thank commenters for
their support of this proposal, and for
their concerns raised. We agree that the
opportunity for the public to provide
input on all changes to measure
specifications (both substantive and
non-substantive) is vital to the measure
development, endorsement, and
maintenance process. We also agree
with the commenter that vendors and
the hospice community need ample
time to implement changes to measure
specifications, especially those that
would warrant updates to Hospice Item
Set (HIS) items or technical
specifications. We would like to
reassure commenters that, as stated in
this rule, we will still propose
substantive changes to measure through
rulemaking. With regard to nonsubstantive measure changes that could
occur as a result of the measure
maintenance and re-endorsement
process, we would like to clarify that
the NQF processes for endorsement and
maintenance of measures includes
review by an expert Standing
Committee, public and Member
comment periods, Member voting,
consideration by the Consensus
Standards Approval Committee (CSAC),
endorsement by the Board of Directors,
and a 30-day appeals period. The NQF
endorsement and maintenance (reendorsement) process allows ample
opportunity for NQF member and
public input, during the measure
development, endorsement and
maintenance phases. We encourage
hospices to participate in these NQF
comment periods to offer their insights
about potential impacts of changes to
measures and measure specifications.
We believe that in instances of nonsubstantive changes to measure
specifications, maximizing the use of
NQF opportunities for public input
allows us to efficiently and expediently
adopt non-substantive, but important
changes to measures. Regarding the
commenter’s concern about whether
this policy will allow providers ample
time to implement and adopt nonsubstantive changes, we would like to
point out that when non-substantive
changes put forth by the NQF are
adopted, we are not required to
immediately implement those changes
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on the date of re-endorsement by NQF.
Once a non-substantive change is
endorsed by NQF, we will consider the
time necessary for providers and
vendors to implement the change. If
newly endorsed non-substantive
changes require updates to data
collection mechanisms (for example,
updates to HIS specifications) or
associated training materials, we will
allow ample time for providers and
vendors to prepare and implement such
changes. As noted in the rule, we will
communicate the endorsement of nonsubstantive changes, decisions about
whether to adopt non-substantive
changes, and timeline for
implementation of non-substantive
changes through regular HQRP
communication channels. Additionally,
CMS welcomes comment on any nonsubstantive changes adopted under this
mechanism through the appropriate
sub-regulatory communication
channels, including but not limited to:
NQF public comment periods held as
part of endorsement processes, feedback
from providers on the Hospice Quality
HelpDesk, and feedback from the
provider community on ODFs and
SODFs. CMS will make such comments
and their responses available to the
public under the appropriate subregulatory communication channels.
Finally, we would like to note that this
policy is consistent with similar policies
in other QRPs.
Comment: We received a few
comments on our previously finalized
policy for measure retention. These
commenters encouraged CMS’s
continued consideration of whether
previously adopted quality measures are
appropriate for retention in the HQRP.
Commenters encouraged CMS to
eliminate measures that are no longer
considered to effectively measure
quality.
Response: We thank commenters for
their suggestions surrounding measure
retention and removal. We agree that
any quality measures proposed and
retained in the HQRP should continue
to provide meaningful data to providers
and consumers on quality of care. We
regularly conduct measure testing
activities according to NQF guidelines
and the Blueprint for the CMS Measures
Management System Version 12.0
(https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-AssessmentInstruments/MMS/Downloads/
Blueprint-120.pdf) to ensure that
measures continue to demonstrate
scientific acceptability (including
reliability and validity) and meet the
goals of the HQRP, which include
distinguishing performance among
hospices and contributing to better
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patient outcomes. As outlined in this
section of the rule, we will propose a
measure for removal if meaningful
distinctions in quality of care can no
longer be made from the measure due to
high and unvarying performance.
Final Action: After consideration of
the comments, we are codifying our
policy that once a quality measure is
adopted, it be retained for use in the
subsequent fiscal year payment
determinations until otherwise stated,
as proposed.
4. Previously Adopted Quality Measures
for FY 2017 and FY 2018 Payment
Determination
As stated in the CY 2013 HH PPS final
rule (77 FR 67068 through 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, tested, and implemented a
hospice patient-level item set, the HIS.
Hospices are required to submit a HISAdmission record and a HIS-Discharge
record for each patient admission to
hospice since July 1, 2014. In
developing the standardized HIS, we
considered comments offered in
response to the CY 2013 HH PPS
proposed rule (77 FR 41548 through
41573). In the FY 2014 Hospice Wage
Index final rule (78 FR 48257), and in
compliance with section 1814(i)(5)(C) of
the Act, we finalized the specific
collection of data items that support the
following 6 NQF-endorsed measures
and 1 modified measure for hospice:
• NQF #1617 Patients Treated with
an Opioid who are Given a Bowel
Regimen,
• NQF #1634 Pain Screening,
• NQF #1637 Pain Assessment,
• NQF #1638 Dyspnea Treatment,
• NQF #1639 Dyspnea Screening,
• NQF #1641 Treatment Preferences,
• NQF #1647 Beliefs/Values
Addressed (if desired by the patient)
(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
July 1, 2014 (78 FR 48258). To meet the
quality reporting requirements for
hospices for the FY 2016 payment
determination and each subsequent
year, we require regular and ongoing
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electronic submission of the HIS data
for each patient admission to hospice
after July 1, 2014, regardless of payer or
patient age (78 FR 48234 through
48258). We finalized a requirement in
the FY 2014 Hospice Wage Index final
rule (78 FR 48258) that hospice
providers collect data on all patients to
ensure that all patients regardless of
payer or patient age are receiving the
same care and that provider metrics
measure performance across the
spectrum of patients.
Hospices are required to complete and
submit a HIS-Admission and a HISDischarge record for each patient
admission. Hospices failing to report
quality data via the HIS for patient
admissions occurring in 2016 will have
their market basket update reduced by
2 percentage points in FY 2018
(beginning in October 1, 2017). In the
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FY 2015 Hospice Wage Index final rule
(79 FR 50485 through 50487), we
finalized the proposal to codify the HIS
submission requirement at § 418.312.
The System of Record (SOR) Notice
titled ‘‘Hospice Item Set (HIS) System,’’
SOR number 09–70–0548, was
published in the Federal Register on
April 8, 2014 (79 FR 19341).
TABLE 15—PREVIOUSLY FINALIZED QUALITY MEASURES AFFECTING THE FY 2017 PAYMENT DETERMINATION AND
SUBSEQUENT YEAR
Quality measure
NQF ID#
Type
Submission method
Data submission deadlines
Process Measure ......
Hospice Item Set .......
Within 30 days of patient admission or
discharge (Event Date).
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Treatment Preferences ..........................
Beliefs/Values Addressed ......................
Pain Screening .......................................
Pain Assessment ...................................
Dyspnea Screening ................................
Dyspnea Treatment ...............................
Patients Treated with an Opioid who
are Given a Bowel Regimen.
1641
1647
1634
1637
1639
1638
1617
Comment: CMS received a comment
regarding the retirement of the seven
day length of stay (LOS) exclusion for
six of the care process measures
currently implemented in the HQRP.
This commenter expressed concern that
in eliminating the LOS exclusion,
provider behavior may shift towards
focusing on completing the HIS
requirements and compliance at the
expense of addressing the needs and
preferences of imminently dying
patients. Additionally, this commenter
recommended that CMS reconsider
eliminating the LOS exclusion or risk
adjust for hospices with an excessive
number of short-stay patients for
patients.
Response: We appreciate the
commenters’ input on the retirement of
the LOS exclusion specification for six
of the quality measures currently
implemented in the HQRP. Developing
and adopting measures that are
meaningful and do not lead to negative
unintended consequences for patients or
providers is important to us. At the time
the measures were developed, technical
experts recommended that short patient
stays be excluded from those measures’
denominators for assessing quality of
care in hospices. However, no national
data regarding the implications of the
LOS exclusion was available to the
Technical Expert Panel (TEP) at that
time. CMS’s contractor analyzed data
from the HIS to examine the
implications of the LOS exclusion on
hospices’ denominator size and quality
measure (QM) scores. Additionally, this
analysis examined the timing of when
hospices perform the care processes
assessed in the quality measures. These
analyses were conducted using HISAdmission and HIS-Discharge records
for stays in July 1, 2014 through March
31, 2015. The results of these analyses
demonstrated that the denominator
sizes for the HQRP QMs are largely
impacted by the current 7-day LOS
exclusion used to calculate the QMs.
Excluding stays with LOS less than 7
days prevents some hospices from being
included in QM score calculations
because they do not have any qualifying
patient stays. Therefore, removing the
LOS exclusion criteria will increase the
number of patients included in the
measures, and thus the number of
hospices that are included in the QM
calculation. The impact of the LOS
exclusions on the distribution of
hospices’ scores is generally small for
all of the QMs. In addition, these
analyses revealed that the care processes
targeted by the QMs are performed on
the day of, or within one day of,
admission for the vast majority of
patient stays. For example, among
patient admissions for which a pain
screening was administered,
approximately 92 percent of screenings
occurred on the day of admission and
close to 99 percent occurred within 1
day of admission. This suggested that
including stays of less than 7 days in
QM calculations (that is, removing the
QM LOS exclusion) could be
appropriate and would not create a
burden on hospices. In response to these
results, the individual QMs were
submitted by the measures’ stewards to
the NQF Palliative Care and End of Life
Project for re-endorsement in February
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2016 and received preliminary
approval. In sum, 6 of the 7 current HIS
measures that were adopted in the FY
2014 Hospice Wage Index final rule
excluded beneficiaries with a LOS of <7
days from the denominator. However,
since these measures were adopted in
the HQRP, they have undergone their
endorsement maintenance with the
NQF. As part of the maintenance
endorsement, the LOS exclusion for the
6 HIS measures was proposed for
removal. NQF has indicated initial
support for the removal of the LOS
exclusion, and pending NQF
maintenance endorsement of the
previously adopted measures, we
anticipate that the entire set of the 7 HIS
measures will no longer exclude any
patients with LOS <7 days in future
public reporting and use in the HQRP.
We appreciate the commenters’
recommendation to risk adjust these
measures and will consider this
recommendation for future measure
development efforts.
Comment: CMS received one
comment requesting additional items or
response options on the HIS V1.00.0 to
capture instances where data regarding
preferences or other care processes
captured on the HIS are not available for
non-verbal patients admitted to hospice
who do not have a formal caregiver or
responsible party available.
Response: We thank the commenter
for their comment. For additional
information on how to respond to
current HIS items when the patient is
nonverbal and/or a caregiver is
unavailable, we refer readers to the HIS
Manual V1.02 available on the Hospice
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Item Set portion of the CMS HQRP Web
site: https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
Hospice-Item-Set-HIS.html. Specifically,
we refer readers to the HIS Manual
Section F Item-Specific Tips, which
specifies roles of responsible parties for
patients unable to self-report. The HIS
Manual states that the ‘‘Responsible
party’’ refers to the legally responsible
or authorized individual, such as the
Health Care Power of Attorney or legal
guardian. In the rare cases where there
is no legal guardian or power of attorney
identified, the hospice should use state
law guidance to identify the appropriate
surrogate decision-maker. Other items
that require patient or caregiver input,
such as the pain assessment items, can
be completed for nonverbal patients
using the nonverbal assessment
processes described in the HIS Manual.
5. Proposed Removal of Previously
Adopted Measures
As mentioned in section III.C.3, a
measure that is adopted and
implemented in the HQRP will be
adopted for all subsequent years, unless
the measure is proposed for removal,
suspension, or replacement by CMS.
Policies and criteria for removing a
measure include those mentioned in
section III.C.3 of this proposed rule.
CMS is not proposing to remove any of
the current HQRP measures at this time.
Any future proposals regarding removal,
suspension, or replacement of measures
will be proposed in this section of
future rules.
6. Proposed New Quality Measures for
FY 2019 Payment Determinations and
Subsequent Years and Concepts Under
Consideration for Future Years
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a. Background and Considerations in
Developing New Quality Measures for
the HQRP
As noted in section III.C.2 of this
proposed rule, CMS’s paramount
concern is to develop quality measures
that promote care that is personcentered, high quality, and safe. In
identifying priority areas for future
measure enhancement and
development, CMS takes into
consideration input from numerous
stakeholders, including the MAP, the
MedPAC, Technical Expert Panels
(TEP), and national priorities, such as
those established by the National
Priorities Partnership, the HHS Strategic
Plan, the National Strategy for Quality
Improvement in Healthcare, and the
CMS Quality Strategy. In addition, CMS
takes into consideration vital feedback
and input from research published by
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our payment reform contractor, as well
as important observations and
recommendations contained in the
Institute of Medicine (IOM) report, titled
‘‘Dying in America,’’ released in
September 2014.6 Finally, the current
HQRP measure set is also an important
consideration for future measure
development areas; future measure
development areas should complement
the current HQRP measure set, which
includes HIS measures and Consumer
Assessment of Healthcare Providers and
Systems (CAHPS®) Hospice Survey
measures.
As stated in the FY 2016 Hospice
Wage Index final rule (80 FR 47188),
based on input from stakeholders, CMS
identified several high priority areas for
future measure development, including:
A patient reported pain outcome
measure; claims-based measures
focused on care practices patterns,
including skilled visits in the last days
of life; responsiveness of the hospice to
patient and family care needs; and
hospice team communication and care
coordination. Of the aforementioned
measure areas, CMS has pursued
measure development for two quality
measures: Hospice Visits when Death is
Imminent Measure Pair, and Hospice
and Palliative Care Composite Process
Measure-Comprehensive Assessment at
Admission. These measures were
included in CMS’ List of Measures
under Consideration (MUC) list for 2015
and discussed at the MAP meeting on
December 14 and 15, 2015. All materials
related to the MUC list and the MAP’s
recommendations for each measure can
be found on the National Quality Forum
Web site, MAP Post-Acute Care/LongTerm Care Workgroup Web page at:
https://www.qualityforum.org/
ProjectMaterials.aspx?projectID=75370.
The MAP supported the direction of
each proposed measure.
Comment: Many comments were
received about the HQRP quality
measures and concepts under
consideration for future years. Overall,
commenters were supportive of CMS’s
efforts to develop a more robust quality
reporting program that includes
development of two new quality
measures, the Hospice Visits when
Death is Imminent Measure Pair, and
Hospice and Palliative Care Composite
Process Measure-Comprehensive
Assessment at Admission. In addition to
the two measures we proposed,
regarding measure development in
future years, commenters urged CMS to
6 IOM (Institute of Medicine). 2014. Dying in
America: Improving quality and honoring
individual preferences near the end of life.
Washington, DC: The National Academies Press.
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focus on meaningful quality measures
and encouraged CMS to move towards
the development of outcome measures.
Several commenters noted the
complexities associated with developing
outcomes measures. These commenters
also recommended that CMS conduct
regular measure testing activities to
ensure that all measures currently
implemented in the HQRP are relevant
and meaningful to providers and
consumers. Finally, some commenters
recommended the development of
future measures of hospice live
discharge rates. Commenters believe
that such measures could contribute to
quality information and hospice
performance.
Response: We appreciate the
commenters’ input and
recommendations for future measure
development areas for the HQRP. We
plan to continue developing the HQRP
to respond to the measure gaps
identified by the MAP and others, and
align measure development with the
National Quality Strategy and the CMS
Quality Strategy. We will take these
comments into consideration in
developing and implementing measures
for future inclusion in the HQRP. We
would like to assure commenters that
we are pursuing opportunities related to
the development of live-discharge
measures through environmental scans,
public engagement, and participation in
special topic panels. We would also like
to assure commenters that for all
measures implemented in the HQRP, we
regularly conduct measure testing
activities according to the Blueprint for
the CMS Measures Management System
Version 12.0 (https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/MMS/
Downloads/Blueprint-120.pdf). This
ensures that measures continue to
demonstrate scientific acceptability
(including reliability and validity) and
meet the goals of the HQRP, which
include distinguishing performance
among hospices and contributing to
better patient outcomes. If measure
testing activities reveal that a measure
meets one of the conditions for removal
that is listed in the proposed rule
(measure performance among hospices
high and unvarying, performance or
improvement in a measure does not
result in better patient outcomes, etc.),
the measure will be considered for
removal from the HQRP to avoid
unintended consequences and to ensure
that providers’ data collection efforts are
meaningful and are contributing to
quality of care. Finally, we would like
to assure commenters that we continue
to explore opportunities to pursue
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hospice outcome measures, and we
appreciate the commenters’ support for
such development efforts.
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b. New Quality Measures for the FY
2019 Payment Determination and
Subsequent Years
We proposed two new quality
measures for the HRQP for the FY 2019
payment determination and subsequent
years: Hospice Visits when Death is
Imminent Measure Pair, and Hospice
and Palliative Care Composite Process
Measure-Comprehensive Assessment at
Admission.
(1) Proposed Quality Measure 1:
Hospice Visits When Death Is Imminent
Measure Pair
Measure Background. This measure
set addresses whether a hospice patient
and their caregivers’ needs were
addressed by the hospice staff during
the last days of life. This measure is
specified as a set of 2 measures.
Measure 1 assesses the percentage of
patients receiving at least 1 visit from
registered nurses, physicians, nurse
practitioners, or physician assistants in
the last 3 days of life. Measure 2
assesses the percentage of patients
receiving at least 2 visits from medical
social workers, chaplains or spiritual
counselors, licensed practical nurses, or
hospice aides in the last 7 days of life.
Measure 1 addresses case management
and clinical care, while Measure 2 gives
providers the flexibility to provide
individualized care that is in line with
the patient, family, and caregiver’s
preferences and goals for care and
contributing to the overall well-being of
the individual and others important in
their life.
Measure Importance. The last week of
life is typically the period in the
terminal illness trajectory with the
highest symptom burden. Particularly
during the last few days before death,
patients experience myriad physical and
emotional symptoms, necessitating
close care and attention from the
integrated hospice team. Hospice
responsiveness during times of patient
and caregiver need is an important
aspect of care for hospice consumers. In
addition, clinician visits to patients at
the end of life have been demonstrated
to be associated with improved
outcomes such as decreased risk of
hospitalization, emergency room visits,
hospital deaths, decreased distress for
caregivers, and higher satisfaction with
care.
Several organizations and panels have
identified care of the imminently dying
patient as an important domain of
palliative and hospice care and
established guidelines and
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recommendations related to this high
priority aspect of healthcare that affects
a large number of people. The NQF 2006
report A Framework for Preferred
Practices for Palliative Care Quality 7
and the NCP Clinical Practice
Guidelines for Quality Palliative Care 8
recommend that signs and symptoms of
impending death are recognized,
communicated and educated, and care
appropriate for the phase of illness is
provided. The American College of
Physicians Clinical Practice Guidelines 9
recommend that clinicians regularly
assess pain, dyspnea, and depression for
patients with serious illness at the end
of life. These measures address this high
priority area by assessing hospice staff
visits to patients and caregivers during
the final days of life when patients and
caregivers typically experience higher
symptom and caregiving burdens, and
therefore a higher need for care.
Measure Impact. The literature shows
that health care providers’ practice is
responsive to quality measuring and
reporting.10 CMS feels this research,
while not specific to hospices,
reasonably predicts the effect of
measures on hospice provider behavior.
Collecting information about hospice
staff visits for measuring quality of care,
in addition to the requirement of
reporting visits from some disciplines
on hospice claims, will encourage
hospices to visit patients and caregivers
and provide services that will address
their care needs and improve quality of
life during the patients’ last days of life.
Performance Gap. The 2014 Abt
Medicare Hospice Payment Reform
Report indicated that 28.9 percent of
Routine Home Care hospice patients did
not receive a skilled visit on the last day
of life.11 The Report defines a ‘skilled
visit’ as a visit from a nurse, social
worker, or therapist. This percentage
could be, in part, a result of rapid
decline and unexpected death. The
report revealed variation in receipt of
7 National Quality Forum. A National Framework
and Preferred Practices for Palliative and Hospice
Care Quality. 2006; Available from: https://
www.qualityforum.org/publications/2006/12/A_
National_Framework_and_Preferred_Practices_for_
Palliative_and_Hospice_Care_Quality.aspx.
8 National Consensus Project, Clinical Practice
Guidelines for Quality Palliative Care. 3rd edition.
2013, National Consensus Project: Pittsburgh, PA.
9 Qaseem, A., 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 American College of
Physicians. Annals of Internal Medicine, 2008.
148(2): p. 141–146.
10 Werner, R., E. Stuart, and D. Polsky, Public
reporting drove quality gains at nursing homes.
Health Affairs, 2010. 29(9): p. 1706–1713.
11 Plotzke, M., et al., Medicare Hospice Payment
Reform: Analyses to Support Payment Reform. May
2014, Abt Associates Inc. Prepared for Centers for
Medicare and Medicaid Services: Cambridge, MA.
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visits at the end of life related to
multiple factors. Patients who died on a
weekday rather than a weekend,
patients with a very short length of stay
(5 days or less), and patients aged 84
and younger were more likely to receive
a skilled visit in the last 2 days of life.
Smaller hospices and hospices in
operation for 5 years or less were
slightly less likely to provide a visit at
the end of life. States with the lowest
rates of no visits in the last days of life
were some of the more rural states (ND,
WI, TN, KS, VT), whereas states with
the highest rates of no visits were more
urban (NJ, MA, OR, WA, MN).
Existing Measures. This quality
measure set will fill a gap by addressing
hospice care provided at the end of life.
No current HQRP measures address care
beyond the hospice initial and
comprehensive assessment period, nor
do any current HQRP measures relate to
the assessment of hospice staff visits to
patients and caregivers in the last week
of life.
Stakeholder Support. A TEP
convened by our measure development
contractor, RTI International, on May 7
and 8, 2015, provided input on the
measure concept. The TEP agreed that
hospice visits when death is imminent
is an important concept to measure and
supported data collection using the HIS.
A second TEP was convened October 19
and 21, 2015, to provide input on the
technical specifications of this quality
measure pair. The TEP supported
development of a measure set rather
than a single measure, using different
timeframes to measure the different
types of care provided, and limiting the
measures to patients receiving routine
home care. The NQF MAP met on
December 14 and 15, 2015, and
provided input to CMS. The MAP
encouraged continued development of
the Hospice Visits when Death is
Imminent Measure Pair in the HQRP.
More information about the MAP’s
recommendations for this measure is
available at https://
www.qualityforum.org/
ProjectMaterials.aspx?projectID=75370.
While this measure is not currently NQF
endorsed, we recognize that the NQF
endorsement process is an important
part of measure development and plan
to submit this measure pair for NQF
endorsement.
Form, Manner, and Timing of Data
Collection and Submission. Data for this
measure would be collected via the
existing data collection mechanism, the
HIS. CMS has proposed that 4 new
items be added to the HIS-Discharge
record to collect the necessary data
elements for this measure. CMS expects
that data collection for this quality
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measure via the 4 new HIS items would
begin no earlier than April 1, 2017.
Thus, under current CMS timelines,
hospice providers would begin data
collection for this measure for patient
admissions and discharges occurring
after April 1, 2017. Prior to the release
of the new HIS data items, CMS will
provide education and training to
hospice providers to ensure all
providers have adequate information
and guidance to collect and submit data
on this measure to CMS.
Since the data collection mechanism
is the HIS, providers would collect and
submit data using the same processes
that are outlined in sections III.C.7c
through III.C.7e of this rule. In brief,
processes in section III.C.7c through
III.C.7e specify that data for the measure
would be submitted to the Quality
Improvement and Evaluation System
(QIES) Assessment Submission and
Processing (ASAP) system, in
compliance with the timeliness criterion
and threshold set out in sections III.C.7c
through III.C.7e.
For more information on the
specifications and data elements for the
measure set, Hospice Visits when Death
is Imminent, we refer readers to the
HQRP Specifications for the Hospice
Item Set-based Quality Measures
document, available on the ‘‘Current
Measures’’ portion of the CMS HQRP
Web site: https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/CurrentMeasures.html. In addition, to facilitate
the reporting of HIS data as it relates to
the implementation of the new measure,
we submitted a request for approval to
OMB for the Hospice Item Set version
2.00.0 under the Paperwork Reduction
Act (PRA) process. The new HIS data
items that would collect this measure
data are also available for public
viewing in the PRA package available at:
https://www.cms.gov/Regulations-andGuidance/Legislation/
PaperworkReductionActof1995/PRAListing.html.
We received multiple comments
pertaining to the Hospice Visits when
Death is Imminent Measure Pair. The
following is a summary of the comments
we received on this topic and our
responses:
Comment: We received many
comments in support of our proposal to
implement the Hospice Visits when
Death is Imminent Measure Pair.
Commenters emphasized the
importance of visits at the end of life,
and stated that this measure pair would
provide a valuable measure of quality.
Commenters also stated that they expect
this measure will improve quality of life
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during patients’ final days and that this
measure could be useful to patients,
families, and the Medicare program.
One commenter said that hospice nurses
are often aware when death is imminent
because they are skilled at recognizing
the final stages of a terminal condition,
and that most individuals and families
are aided and reassured by visits from
some disciplines at the end of life.
Response: We thank the commenters
for their support of the Hospice Visits
when Death is Imminent Measure Pair
in the HQRP. We agree that visits at the
end of life are an important component
of hospice care and that this measure
can help to drive holistic, patient
centered quality improvement. We
believe that this information will be
useful to consumers, providers, and
payers.
Comment: Some commenters
questioned whether the Hospice Visits
when Death is Imminent Measure Pair
would foster better quality for hospice
care patients and requested evidencebased research showing the link
between hospice visits and quality. One
commenter emphasized the important
role that hospices play in helping
prepare patients and caregivers for the
end of life, and stated that if hospices
provide high quality preparation, then
patients and families may need fewer
visits at the end of life. The commenter
stated that a focus on visits at the end
of life may take focus away from
empowering patients and caregivers.
One commenter stated that, as a process
measure, this measure pair does not
adequately reflect high quality care, and
urged CMS to conduct further testing of
the measure. One commenter cautioned
that, while sociodemographic
differences in receipt of visits may
appear to indicate differences in quality,
one must also take into consideration
possible differences in religious beliefs
and cultural values that may affect
desire for visits. One commenter noted
that these measures alone might not be
representative of the quality of care that
hospice beneficiaries and their families
receive.
Response: We thank the commenters
for their feedback. We are committed to
the ensuring that all quality measures
implemented in the HQRP meet the
goals of the program, which include
distinguishing performance among
hospices and contributing to better
patient outcomes.
We believe that provision of hospice
visits at the end of life is an important
component of high quality hospice care
for most patients. The last week of life
is typically the period in the terminal
illness trajectory with the highest
symptom burden and the literature
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supports hospice visits when death is
imminent as a high priority in end-oflife care. Clinician visits to patients at
the end of life have been demonstrated
to be associated with improved
outcomes such as decreased risk of
hospitalization, emergency room visits,
and hospital death; and higher
satisfaction with care.12 13 14
Measurements of visits at the end of life
are already used in the literature as
quality indicators for end of life or
hospice care.15 16 17 Studies focusing on
the expectations of patients and families
also demonstrate the importance of care
and attention from the hospice team in
the days leading up to death. Caregivers
of dying patients agree overwhelmingly
with the importance of preparation at
the end of life. Hospice assistance,
ranging from legal to logistical to
emotional, is paramount in preparing
hospice patients and their families for
imminent death.18 Bereaved family
members and friends from a variety of
settings identified the provision of
physical comfort and emotional support
to dying patients and their families as
fundamental aspects of high-quality
care.19
The literature shows that health care
providers’ practices are responsive to
12 Seow, H., Barbera, L., Howell, D., & Dy, S. M.
(2010). Using more end-of-life homecare services is
associated with using fewer acute care services: a
population-based cohort study. Med Care, 48(2),
118–124. doi:10.1097/MLR.0b013e3181c162ef.
13 Almaawiy, U., Pond, G. R., Sussman, J., Brazil,
K., & Seow, H. (2014). Are family physician visits
and continuity of care associated with acute care
use at end-of-life? A population-based cohort study
of homecare cancer patients. Palliat Med, 28(2),
176–183. doi:10.1177/0269216313493125.
14 Pivodic, L., Harding, R., Calanzani, N.,
McCrone, P., Hall, S., Deliens, L. & Gomes, B.
(2015). Home care by general practitioners for
cancer patients in the last 3 months of life: An
epidemiological study of quality and associated
factors. Palliat Med. doi:10.1177/
0269216315589213.
15 Barbera, L., Seow, H., Sutradhar, R., Chu, A.,
Burge, F., Fassbender, K., . . . Potapov, A. (2015).
Quality Indicators of End-of-Life Care in Patients
With Cancer: What Rate Is Right? J Oncol Pract,
11(3), e279–287. doi:10.1200/jop.2015.004416.
16 Gandhi, S. O. (2012). Differences between nonprofit and for-profit hospices: patient selection and
quality. Int J Health Care Finance Econ, 12(2), 107–
127. doi:10.1007/s10754–012–9109-y.
17 Lorenz, K. A., Ettner, S. L., Rosenfeld, K. E.,
Carlisle, D. M., Leake, B., & Asch, S. M. (2002). Cash
and compassion: profit status and the delivery of
hospice services. J Palliat Med, 5(4), 507–514.
doi:10.1089/109662102760269742.
18 Steinhauser, K. E., Christakis, N. A., Clipp, E.
C., McNeilly, M., McIntyre, L., & Tulsky, J. A.
(2000). Factors considered important at the end of
life by patients, family, physicians, and other care
providers. Jama, 284(19), 2476–2482.
19 Steinhauser, K. E., Christakis, N. A., Clipp, E.
C., McNeilly, M., McIntyre, L., & Tulsky, J. A.
(2000). Factors considered important at the end of
life by patients, family, physicians, and other care
providers. Jama, 284(19), 2476–2482.
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quality measurement and reporting.20
We believe that this research, while not
specific to hospices, reasonably predicts
the effect of measures on hospice
provider behavior. Collecting
information about hospice staff visits for
measuring quality of care, in addition to
the requirement of reporting visits from
some disciplines on hospice claims, will
encourage hospices to visit patients and
caregivers and provide services that will
address their care needs and improve
quality of life during the patients’ last
days of life. While we agree that a
greater number of visits does not always
indicate higher quality care, based on
the published literature and expert
input, we believe that most patients
benefit from some visits near the end of
life. For this reason, this measure set is
specified to measure receipt of at least
1 clinician visit (Measure 1) and at least
2 visits from other staff (Measure 2),
rather than measuring the total number
of visits. A TEP held in October 19 and
21, 2015, by our contractor agreed that
a measure of patients receiving at least
a minimum number of visits would be
a better indicator of quality than a
measure of the total number of visits
provided.
We agree with the commenter that
this measure pair alone may not provide
a full representation of the quality of
care that hospices provide. The
previously finalized measures in the
HQRP address care processes at
admission, and the Hospice CAHPS
survey examines caregiver experience
retrospectively. This measure pair fills
an important gap in the HQRP by
providing a measure of quality of care
provided near the time of death, and it
is intended to be interpreted along with
the other measures in the HQRP to
reflect quality of care provided by
hospices across several domains of care
that are important to patients and other
stakeholders. CMS also plans to analyze
the relationship between this quality
measure pair and other quality measures
to support the validity of this measure
pair (that is, the measure reflects true
quality of care).
Comment: One commenter expressed
concern that the results of the Hospice
Visits when Death is Imminent Measure
Pair may be mischaracterized once they
are publicly reported, if appropriate
disclaimers are absent from the
information provided. Another
commenter requested that CMS remind
measure users that patients/families
have the right to decline services and
that those declinations should not be
20 Werner, R., E. Stuart, and D. Polsky, Public
reporting drove quality gains at nursing homes.
Health Affairs, 2010. 29(9): p. 1706–1713.
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considered an ‘‘under-service’’ by the
hospice provider.
Response: We thank the commenters
for their feedback regarding interpreting
these measures. We agree that it is
important to educate both providers and
consumers on how to use and interpret
these quality measures. Prior to public
reporting of this measure, we will
provide resources through the Hospice
Compare Web site to aid consumers in
interpreting the quality metrics reported
there. CMS has carefully considered
usability by consumers throughout the
measure development process. The
measure specifications take into account
usability feedback from a TEP, caregiver
workgroup, and clinical user panel. We
recognize that some patients may
decline services and that rapid and
unanticipated patient declines do occur;
thus, a score of 100% is not the
expectation for this measure pair.
Comment: Some commenters stated
that it is not always known when a
patient’s death is imminent. One
commenter stated that there is not
always an opportunity for hospices to
provide the visits specified in this
measure set if a patient experiences a
rapid and unanticipated decline.
Response: We understand that it is
not always possible to accurately
predict time of death. However, the last
week of life is typically the period in the
terminal illness trajectory with the
highest symptom burden, especially
during the last few days before death.
We recognize that rapid and
unanticipated patient declines do occur;
thus, a score of 100 percent is not the
expectation for this measure pair. We do
expect that hospices delivering high
quality care will be responsive to the
patient and caregiver needs that arise
during the last days of a patient’s life.
In order to address performance gaps in
this measure, providers may be
motivated to proactively assess
symptom burden, resulting in improved
symptom management and higher
quality of life during the final days.
Comment: We received some
comments related to the structure of the
Hospice Visits when Death is Imminent
Measure Pair and intent of each
measure. Some comments indicated that
commenters might have misinterpreted
the intent of this measure pair. For
example, one commenter stated that
adoption of this measure pair would in
fact create three visit metrics, and
another commenter referenced the
calculation of a composite measure for
visits at the end of life. Some
commenters interpreted the
specifications as not including visits
addressing spiritual or psychosocial
suffering in the 3 days before death.
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Some commenters requested
clarification of the calculation of each of
these measures and of the disciplines
included in each. One commenter
recommended that Measure 1 and
Measure 2 be combined into one
measure in order to streamline data
collection. One commenter requested
that RN visits be included in both
Measure 1 and Measure 2 since some
interventions to manage symptoms may
only be provided by an RN.
Response: We wish to clarify the
intent of this measure pair. The Hospice
Visits when Death is Imminent Measure
Pair will be calculated and reported as
two separate measures. These measures
are intended to be interpreted as a set.
For more information on the
specifications and data elements for the
measure set, Hospice Visits when Death
is Imminent Measure Pair, we refer
readers to the HQRP Specifications for
the Hospice Item Set-based Quality
Measures document, available on the
‘‘Current Measures’’ portion of the CMS
HQRP Web site: https://www.cms.gov/
Medicare/Quality-InitiativesPatientAssessment-Instruments/
HospiceQuality-Reporting/
CurrentMeasures.html.
The two measures are intended to
capture distinct aspects of hospice care
at the end of life. The inclusion of
registered nurses, physicians, nurse
practitioners, and physician assistants
in Measure 1 is intended to capture the
range of clinical disciplines that might
visit a patient, depending on patient and
hospice preferences, and uses a 3-day
timeframe to reflect the active dying
phase. The inclusion of medical social
workers, chaplains or spiritual
counselors, licensed practical nurses,
and hospice aides in Measure 2 is
intended to allow for flexible and
individualized care in line with patient,
family, and caregiver preferences. The
7-day time frame covers both the active
dying phase and the transition period
before, and thus could also capture
important visits related to preparation
for active dying. To clarify, the 7-day
time frame is inclusive of the 3 days
prior to death. Data collection is
conducted at the discipline level in
order to provide us with sufficient
information to conduct reliability and
validity testing and possible future
measure refinement.
Comment: We received some
comments regarding the types of visits
included in the Hospice Visits when
Death is Imminent Measure Pair. Some
commenters requested that all visits on
the date of death be included in the
measures, including postmortem visits,
as this is an important service that
hospices provide. One commenter
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recommended that a new, separate
measure could look at postmortem
visits. Some commenters requested that
phone calls or videoconferencing be
included in the measures. One
commenter stated that phone calls may
be an especially important form of
contact in rural areas. A few
commenters requested clarification of
the definition of a visit counted for
quality purposes, and one inquired what
visit duration is expected.
Response: We thank the commenters
for their feedback regarding the types of
visits included in this measure pair. We
agree that post mortem and bereavement
visits are an important service for
hospices to provide. However, we
believe that these services are outside
the scope of this quality measure pair,
which focusses specifically on visits
when death is imminent. These visits
provided shortly prior to death are
intended to address the increased
symptom burden many patients
experience when death is imminent and
provide an opportunity for proactive
assessment and communication.
We recognize that some providers use
phone calls to supplement care
provided in person and that these calls
can be helpful in facilitating ongoing
care and communication. However, in
agreement with a TEP and based on the
available evidence, we consider these
calls as a supplement to, and not a
replacement for, in-person care,
particularly when death is imminent.
For this reason, phone calls are not
included in the definition of a visit for
this measure pair. Prior to
implementation of the HIS V2.00.0, we
will provide hospices with guidance
and training materials, including an
updated version of the HIS Manual.
These training materials will further
clarify the types of visits included in
this measure pair and other item coding
information.
Comment: We received many
comments regarding the disciplines
included in each of the Hospice Visits
when Death is Imminent measures. One
commenter stated that this measure pair
recognizes the value of the core
interdisciplinary team members and
maintains a holistic approach to care.
Many commenters supported the
inclusion of chaplains or spiritual
counselors and aides in Measure 2, as
they play an important role in the
interdisciplinary team. Some
commenters encouraged CMS to
conduct further research on the types of
visits provided at the end of life and
present a clear rationale for inclusion or
exclusion from this measure. One
commenter recommended that both
measures be amended to include any
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member of the hospice’s
interdisciplinary team.
Many commenters requested that
visits from volunteers be included in
Measure 2. The commenters pointed out
that the use of volunteers is a Medicare
requirement for hospices, and that
volunteers play an important role in the
delivery of hospice care. One
commenter indicated that it might be
burdensome to report data on volunteer
visits, but that inclusion of volunteers
would be valuable. A couple of
commenters requested that visits from
music therapists or massage therapists
be included in Measure 2.
Several commenters noted that
although physician assistant (PA) visits
are included in this quality measure
pair, this discipline is not identified by
CMS as a core or non-core service of a
hospice provider. Some of these
commenters requested that PA visits be
removed from the measure in order to
align with the Conditions of
Participation and Medicare payment
practices. Some of these commenters
supported the inclusion of PAs and
recommended that their role be
clarified. One commenter stated that
since the use of PAs is limited,
inclusion of PA visits would negatively
skew the data.
One commenter noted that a Licensed
Practicing Nurse’s (LPN) scope of
practice varies from state to state, and
asked that CMS consider removing LPN
visits from the measure to make the
measure more uniform nation-wide.
One commenter expressed appreciation
for the inclusion of LPNs and stated that
the discipline is frequently used.
Some commenters requested that
bereavement coordinator or
bereavement counselor visits be
included in this measure pair. One
commenter requested clarification of
whether a visit from a provider
contracted but not employed by a
hospice program would be considered a
visit under this measure pair.
Response: We thank the commenters
for their support of the disciplines
included in this measure, including
chaplains or spiritual counselors and
aides. This measure pair is designed to
allow hospices flexibility to determine
the most appropriate discipline or
disciplines to visit a patient. The
inclusion of registered nurses,
physicians, nurse practitioners, and
physician assistants in Measure 1 is
intended to capture the range of clinical
disciplines that might visit a patient,
depending on patient and family
preferences and emerging care needs in
the last days of life. Similarly, the
inclusion of medical social workers,
chaplains or spiritual counselors,
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licensed practical nurses, and hospice
aides in Measure 2 is intended to allow
for flexible and individualized care in
line with patient, family, and caregiver
preferences. This measure is not
intended to require visits from any
given discipline, but aims to allow
flexibility in the types of visits
provided. The Hospice Conditions of
Participation state that the
interdisciplinary group must include,
but is not limited to, a doctor of
medicine or osteopathy, a registered
nurse, a social worker, and a pastoral or
other counselor. Visits from all of these
disciplines are included in this measure
pair, as well as from some additional
disciplines. We have carefully
researched the topic of which
disciplines to include in this measure
pair, including an environmental scan,
pilot test of this measure in summer
2015, TEP discussions on May 7 and 8,
2015, and October 19 and 21, 2015, and
input from our Clinical Users Panel and
Caregiver Workgroup.
Regarding volunteer visits, we agree
that volunteers play an important role in
high quality hospice care and that their
visits are important to patients and
families. Visits from volunteers were
included in an early version of this
measure, which pilot tested for
feasibility in summer 2015. Many of the
hospices included in the pilot had
trouble reporting data on visits from
volunteers because the records of
volunteer visits were often stored in a
separate system and were frequently
delayed. The data was unreliable, and
hospices reported significant reporting
burden. This topic was discussed with
the TEP, held October 19 and 21, 2015.
After reviewing the results from the
pilot test and thoroughly discussing the
issues, the TEP members did not
support including visits from volunteers
in this measure pair. For the same
reasons, the TEP advised against
including complementary and
alternative therapists such as music or
massage therapists in this measure pair,
though they do provide important
services.
Regarding physician assistant visits,
although Medicare does not provide
separate payments for visits from
physician assistants, these services
would be covered under the hospice per
diem. Additionally, this measure is an
all-payer measure and some states and
other programs may authorize physician
assistants to provide hospice care under
separate payments. This measure pair is
separate from payment and should focus
on services provided by hospices and
not be restricted by the terms of
payment by Medicare. Therefore, the
inclusion of physician assistants in the
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measure specifications provides the
flexibility for hospices that may have
physician assistants to count these
clinical visits as part of Measure 1. We
wish to clarify that the absence of
physician assistant visits will not
negatively skew the data reported in this
measure. Visits from physician
assistants are one of the options
included in Measure 1, but patients will
also be included in the numerator of the
measure if they receive a visit from a
registered nurse, physician, or nurse
practitioner.
We thank the commenters for their
feedback regarding the inclusion of
LPNs in Measure 2. Members of our TEP
agreed that LPNs provide an important
service in hospice care that is distinct
from the role of RNs. For this reason, we
have included visits from LPNs in
Measure 2 of this measure pair.
We appreciate the commenters’
recommendations to include
bereavement coordinators, and agree
that visits from these disciplines are
important for many patients and
families. However, we believe that
bereavement services are outside the
scope of this quality measure pair,
which focusses specifically on visits,
which may address the increased
symptom burden many patients
experience when death is imminent,
and provide an opportunity for
proactive assessment and
communication.
Regarding contracted hospice staff, we
clarify that visits from contracted staff
may be included in this measure pair.
As defined in the HIS Manual V1.02,
hospice staff members may include
volunteers, contractors, and affiliates.
Comment: Some commenters
recommended changes to the Hospice
Visits when Death is Imminent Measure
Pair to further align the two measures.
A few commenters suggested that both
Measure 1 and Measure 2 be measured
over a 7-day timeframe in order to
improve consistency between the
measures and simplify data collection
for providers. A few commenters
recommended that CMS consider
altering Measure 2 such that it includes
in the numerator patients who receive
one visit from medical social workers,
chaplains or spiritual counselors,
licensed practical nurses or hospice
aides in the final seven days of life.
Response: We thank the commenters
for their feedback on the specifications
of the two measures in this measure
pair. As currently specified, Measure 1
uses a 3-day timeframe and Measure 2
uses a 7-day timeframe. A TEP meeting
held October 19 and 21, 2015, provided
input on the timeframes. The TEP
indicated that the 3-day timeframe
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would be reflective of the active dying
phase, and that it would be appropriate
to measure clinical visits provided
during the active dying phase. The 7day time frame covers both the active
dying phase and the transition period
before, and thus could also capture
important visits related to preparation
for active dying. An analysis of
Medicare claims indicates that most
routine home care patients (94 percent)
receive at least one skilled visit from a
nurse, social worker, therapist or
physician in the last four days of life.21
Because of this, there may be a ceiling
effect for these quality measures using a
longer time frame.
The current specification of Measure
2 limits the numerator to patients who
receive at least two visits from those
disciplines in the final 7 days of life.
Using two visits rather than one may
also serve to reduce the expected ceiling
effect that is likely to result from
grouping multiple disciplines together
in Measure 2.
Comment: Many commenters pointed
out that, in keeping with the
individualized and patient-centered
focus of hospice care, patients and
families have the option of declining
visits from hospice providers if they
deem them unnecessary or unwanted.
Commenters indicated that patients and
caregivers might decline a visit for
various reasons: Desire for privacy at the
end of life, adequate preparation for the
end of life such that additional visits are
not necessary, or patient is receiving
receipt of similar services from outside
of the hospice provider. Some
commenters recommended that
revisions be made to the HIS Discharge
form to allow a hospice to indicate that
a patient or family was offered a visit
included in either Measure 1 or Measure
2, but refused or deferred the visit.
Some commenters recommended that
patients who refuse an offered visit be
included in the measure numerator,
while others recommended that these
patients be excluded from the measure
pair, and a few recommended that the
measures be risk adjusted to reflect
patient refusal of services.
Some commenters cautioned that this
measure pair could result in an
unintended consequence: Hospices
might provide unnecessary or unwanted
visits, thus undermining patient and
family preferences and choice. One
21 Plotzke, M. C., T.J.; Axelrod, Elizabeth; Hunt,
Meaghan; Muma, Allison; Gozalo, Pedro; Teno,
Joan. (2015). Medicare Hospice Payment Reform:
Analysis of How the Medicare Hospice Benefit is
Used. Retrieved from https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-Payment/
Hospice/Downloads/December-2015-TechnicalReport.pdf.
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commenter cautioned that specifying
when particular staff must visit would
undermine the flexibility hospices have
in customizing the plan of care. Some
commenters pointed out that, by
respecting the wishes of some patients
to receive fewer visits, a hospice might
have lower scores on this measure pair
but that it would not reflect an issue
with quality of care.
Response: We thank the commenter
for their feedback about patients and
families that may refuse a visit at the
end of life. In a pilot study conducted
by our measure development contractor,
hospices reported that information on
visit refusal is available, but is
burdensome for hospices to report. In
addition, fewer than 4 percent of
patients in the pilot study refused a visit
from a given discipline, and no patients
refused all visits offered. By including
multiple disciplines in each measure,
the Hospice Visits when Death is
Imminent Measure Pair is designed to
allow hospices flexibility to determine
the most appropriate discipline or
disciplines to visit a patient, and to
consider patient and family preferences.
A TEP held by our measure
development contractor did not expect
that there would be wide variation in
the rate of visit refusal across hospices.
The TEP determined that the burden of
data collection would outweigh the
benefit of excluding patients who refuse
visits. For these reasons, we determined
not to require hospices to report data on
visit refusals. Hospices may wish to
track visit refusals internally for quality
improvement purposes. This measure
pair will be tested for reliability and
validity prior to public reporting. We
recognize that some patients may
decline services and that rapid and
unanticipated patient declines do occur;
thus, the expectation is not for hospices
to score 100 percent on this measure
pair. We will take these comments into
account during future measure
development.
Comment: Some commenters
recommended using risk adjustment or
exclusions to account for patient
characteristics in the Hospice Visits
when Death is Imminent Measure Pair.
Some commenters stated that patients
with shorter lengths of stay will likely
receive different visits than patients
with longer lengths of stay. Commenters
requested that CMS examine any
differences, and some requested that the
Hospice Visits when Death is Imminent
Measure Pair be risk adjusted or
stratified for length of stay in hospice.
Another commenter requested that case
mix adjustment be used in the
calculation of this measure pair.
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One commenter recommended that
patients with a length of stay shorter
than 5 days be excluded from Measure
2. This is the length of time allowed by
Hospice Conditions of Participation
requirements for the comprehensive
assessments to be completed, and the
commenter expects that some patients
might not receive two visits from a
medical social worker, chaplain or
spiritual counselor, licensed practical
nurse, or hospice aide before Day 5.
Another commenter recommended that
patients with a length of stay of three
days or fewer be excluded from Measure
1 if the only visit received is the initial
nursing assessment. The commenter
expressed concern that for such short
lengths of stay, the measure would
function as an indicator of compliance
rather than of quality.
Finally, one commenter requested
clarification of whether this measure
pair would be applied across all levels
of care.
Response: We thank the commenters
for their feedback. As currently
specified, this measure set is not risk
adjusted. A TEP convened by our
measure development contractor
discussed possible risk adjustment of
this measure pair, including risk
adjustment by diagnosis or length of
stay. The TEP determined that diagnosis
may not reliably predict symptom
burden at the end of life and therefore
may not reliably predict need for visits.
The TEP members determined that it
might be important to take length of stay
into account in measure calculations.
We will continue to consider this
feedback, and will examine measure
performance, including the potential
need for risk adjustment in the future.
As currently specified, Measure 1
does not include a length of stay
exclusion, while Measure 2 excludes
patients with a length of stay less than
or equal to one day (that is, admitted
and discharged on the same day). The
rationale for excluding patients with a
very short length of stay from Measure
2 is that Measure 2 requires two visits
from select hospice staff, and it may be
difficult or possibly inappropriate to
provide more than one such visit for
patients receiving only one day of
hospice care. We do not exclude these
patients from Measure 1 because
Measure 1 specifies at least one
clinician visit, and it is reasonable to
expect that a hospice would provide at
least one such visit, even for patients
with a very short length of stay. It is
acceptable if this visit is the initial
nursing assessment visit. One of the
goals of this measure pair is to increase
prospective assessment of patient needs
and timely management of symptoms
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prior to death, and this can be
accomplished during the initial nursing
assessment visit as well as other types
of visits provided in the final days to
patients with longer length of stay. We
do not intend to increase burden on
providers or patients by requiring
specific types of visits to meet the goals
of this measure. Patients with short
lengths of stay are expected to have high
symptom burden throughout their short
stay and can benefit from hospice visits.
For these reasons, patients with short
lengths of stay are included in this
measure.
This measure pair currently includes
only patients who received routine
home care. It does not include patients
who received general inpatient care,
respite care, or continuous home care
during the measure timeframes. Routine
home care patients for whom the
hospice receives a service intensity addon payment are included in this
measure, as this payment is an add-on
to the routine home care rate.
Comment: Some commenters
encouraged CMS to obtain NQF
endorsement prior to proposing new
measures. One commenter expressed
appreciation that this measure
development process has included
input from the Measure Applications
Partnership (MAP).
Response: We appreciate the
commenters’ input and support of the
NQF endorsement process. Our
paramount concern is the successful
development of a HQRP that promotes
the delivery of high quality healthcare
services. We seek to adopt measures for
the HQRP that promote patient-centered
and high quality care. Our measure
selection activities for the HQRP take
into consideration input from the MAP,
convened by the NQF, as part of the
established CMS pre-rulemaking
process required under section 1890A of
the Act. The NQF MAP met on
December 14th and 15th, 2015 and
encouraged continued development of
this measure pair. Additionally, while
this measure is not currently NQFendorsed, we recognize that the NQF
endorsement process is an important
part of measure development and plan
to submit this measure for NQF
endorsement. This quality measure will
fill a gap by addressing quality of
hospice care at the end of life.
Furthermore, no current NQF-endorsed
measures address hospice care when
death is imminent, and this measure is
a first step towards that goal. CMS is
establishing the timeline for seeking
NQF endorsement for this quality
measure and will communicate this
timeline to the public in future
rulemaking cycles.
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Comment: One commenter asked
whether CMS would correlate the
Hospice Visits when Death is Imminent
Measure Pair with the Hospice CAHPS
results. Another commenter
recommended that CMS compare
outcomes as measured by the HIS care
processes and the CAHPS survey with
the data collected on visits at the end of
life to guide refinement of this measure
pair.
Response: We plan to conduct
reliability and validity testing of this
measure pair as part of ongoing measure
maintenance and refinement and to
prepare for NQF endorsement. As part
of those efforts, we will examine the
correlations of the paired measures with
other quality measures calculated from
the HIS and possibly from the CAHPS.
Comment: Some commenters
indicated that data collection for the
Hospice Visits when Death is Imminent
Measure Pair would be burdensome for
providers, and potentially duplicative of
the information about visits reported in
Medicare claims. One commenter
requested that claims data be used to
calculate this measure pair in order to
reduce provider burden of data
collection. Another commenter
encouraged CMS to establish a claims
code for spiritual counselor/chaplain
visits so that their visits can be reviewed
for reimbursement and quality
considerations. One commenter
indicated that this measure pair would
be calculated using claims data.
Response: We wish to clarify the data
source for this measure pair. This
measure will be calculated using data
from the HIS V2.00.0, and will not be
a claims-based measure. This HIS-based
measure pair will expand upon
information that would be available in
Medicare hospice claims. The HIS
includes data for all hospice patients,
regardless of payment source, while
claims data capture only Medicare Feefor-service beneficiaries. Therefore, the
use of assessment data allows the
measure to be inclusive of all patients
regardless of payer. Medicare claims
capture visits from certain disciplines,
including skilled nursing, medical
social services, aides, physical therapy,
occupational therapy, and speech
therapy—language pathology. HIS items
will capture hospice visits by members
of additional disciplines that are not
included in the Medicare hospice
claims (for example, chaplains). Finally,
visit information on the HIS can be
assessed and reported in a timelier
manner than Medicare claims,
providing hospices with opportunities
to review and improve care.
Comment: Some commenters
requested that sufficient time be given
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prior to measure implementation of the
Hospice Visits when Death is Imminent
Measure Pair to ensure time for software
vendors to develop new processes, and
hospices to upgrade their EMR systems,
train staff, and conduct testing. One
commenter recommended that CMS
delay initiation of data collection for
this measure pair until October 1, 2016.
One commenter encouraged CMS to
solicit feedback from the hospice
industry and software vendors to
determine whether necessary updates
can be made by April 1, 2017. Other
commenters recommended a period of
data collection on the proposed
measures prior to implementation of the
measures.
Response: We appreciate the
commenters’ feedback regarding the
timeline for implementation and public
reporting of this measure pair. We
would like to clarify the implementation
date proposed in this rule; data used for
calculation of this measure pair will be
collected via the HIS V2.00.0. The HIS
V2.00.0 is undergoing review as part of
a PRA package under OMB number
0938–1153 and will be implemented
April 1, 2017. This measure pair is
proposed for the FY 2019 payment
determination and subsequent years.
The HIS V2.00.0 is currently available
for review by software vendors and
hospice providers. Some of the activities
that are necessary prior to
implementation can be done
concurrently. For example, hospice
education and training in the new items
and data abstraction can be conducted
at the same time as vendor development
of software. As stated in section
III.C.7.c, providers may also use the
Hospice Abstraction Reporting Tool
(HART) software, which is free to
download and use. HART provides an
alternative option for hospice providers
to collect and maintain facility, patient,
and HIS Record information for
subsequent submission to the QIES
ASAP system. We agree it is critical to
establish the reliability and validity of
the quality measures prior to public
reporting. We plan to conduct data
analysis to demonstrate the ability of the
quality measures to distinguish the
quality of services provided. More detail
on public display is provided in section
III.C.11 of this rule.
Comment: Some commenters drew
connections between the Hospice Visits
when Death is Imminent Measure Pair
and the Service Intensity Add-on
payment. Some commenters
recommended delaying implementation
of this measure pair until the impact of
the SIA payment is better understood.
One commenter recommended that
CMS use the data obtained for Measure
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2 to update the payment of the SIA
payment to include visits by licensed
practical nurses and other disciplines.
One commenter stated that CMS should
align financial payment and quality
measures.
Response: We thank the commenters
for their feedback regarding the Hospice
Visits when Death is Imminent Measure
Pair and the SIA. CMS adopted SIA
payments to address the observed
misalignment between resource use and
associated Medicare payments and to
improve patient care through the
promotion of skilled visits at end of life
with minimal claims processing systems
changes. While it may be good for
payment and quality to align when
possible, this measure pair is a measure
of quality, not of practice driven by
reimbursement structure. We will take
into consideration using measure data
for further refinement of the SIA.
Final Action: After consideration of
the comments, we are finalizing our
proposal to implement the Hospice
Visits when Death is Imminent Measure
Pair effective April 1, 2017. Data will be
collected starting on such date, and will,
if not reported, affect payments for FY
2019.
(2) Proposed Quality Measure 2:
Hospice and Palliative Care Composite
Process Measure—Comprehensive
Assessment at Admission
Measure Background. The Hospice
and Palliative Care Composite Process
Measure—Comprehensive Assessment
at Admission is a composite measure
that assesses whether a comprehensive
patient assessment is completed at
hospice admission by evaluating the
number of individual care processes
completed upon admission for each
hospice patient stay. A composite
measure, as defined by the NQF, is a
combination of two or more component
measures, each of which individually
reflects quality of care, fashioned into a
single performance measure with a
single score.22 For more information on
composite measure definitions, guiding
principles, and measure evaluation
criteria, we refer readers to the NQF
Composite Performance Measure
Evaluation Guidance Publication
available at https://www.quality
forum.org/Publications/2013/04/
Composite_Performance_Measure_
Evaluation_Guidance.aspx. A total of 7
individual care processes will be
captured in this composite measure,
which include the 6 NQF-endorsed
quality measures and 1 modified NQF22 National Quality Forum. (2013). Composite
Performance Measure Evaluation Guidance:
National Quality Forum.
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52169
endorsed quality measure currently
implemented in the HQRP. Thus, the
Hospice and Palliative Care Composite
Process quality measure will use the
current HQRP quality measures as its
components. These individual
component measures address care
processes around hospice admission
that are clinically recommended or
required in the hospice CoPs.23 This
measure calculates the percentage of
patients who received all care processes
at admission. To calculate this measure,
the individual components of the
composite measure are assessed
separately for each patient and then
aggregated into one score for each
hospice.
Measure Importance. This composite
quality measure for comprehensive
assessment at admission addresses high
priority aspects of quality hospice care
as identified by both leading hospice
stakeholders and beneficiaries receiving
hospice services. The NCP for Quality
Palliative Care Clinical Practice
Guidelines for Quality Palliative Care
established 8 core palliative care
domains, and this composite measure
captures 4 of those domains.24 The 4
domains captured by this composite
measure are the Structure and Process of
Care Domain; the Physical Aspects of
Care Domain; the Spiritual, Religious,
and Existential Aspects of Care Domain,
and the Ethical and Legal Aspects of
Care Domain. The NCP guidelines
placed equal weight on both the
physical and psychosocial domains,
emphasizing a comprehensive approach
to patient care. For more information on
the NCP domains for palliative care,
refer to https://www.nationalconsensus
project.org/guidelines_download2.aspx.
In addition, the Medicare Hospice CoPs
require that hospice comprehensive
assessments identify patients’ physical,
psychosocial, emotional, and spiritual
needs and address them to promote the
hospice patient’s comfort throughout
the end-of-life process. Furthermore, the
person-centered, family, and caregiver
perspective align with the domains
identified by the CoPs and NCP, as
patients and their families/caregivers
also place value on physical symptom
management and spiritual/psychosocial
care as important factors at the end of
23 Medicare and Medicaid Programs: Hospice
Conditions of Participation, Part 418 subpart 54.
Centers for Medicare and Medicaid Services, June
5, 2008.
24 The National Consensus Project for Quality
Palliative Care Clinical Practice Guidelines for
Quality Palliative Care 3rd edition 2013.
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life.25 26 A composite measure serves to
ensure all hospice patients receive a
comprehensive assessment for both
physical and psychosocial needs at
admission.
Measure Impact. The literature
indicates that health care providers’
practice is responsive to quality
measures reported.27 CMS feels this
research, while not specific to hospices,
reasonably predicts the effect of
measures on hospice provider behavior.
Collecting information about the total
number of care processes conducted for
each patient will incentivize hospices to
conduct all desirable care processes for
each patient and provide services that
will address their care needs and
improve quality during the time he or
she is receiving hospice care.
Additionally, creating a composite
quality measure for comprehensive
assessment at admission will provide
consumers and providers with a single
measure regarding the overall quality
and completeness of assessment of
patient needs at hospice admission,
which can then be used to meaningfully
and easily compare quality across
hospice providers and increase
transparency.
Performance Gap. Analyses
conducted by our measure development
contractor, RTI International, show that
hospice performance scores on the
current 7 HQRP measures are high (a
score of 90 percent or higher on most
measures); however, these analyses also
revealed that, on average, a much lower
percentage of patient stays in a hospice
had documentation that all of these
desirable care processes were completed
at admission. Thus, by assessing
hospices’ performance of
comprehensive assessment, the
composite measure sets a higher
standard of care for hospices and reveals
a larger performance gap. A similar
effect has been shown in the literature
where facilities are achieving more than
90 percent compliance with individual
measures, but compliance numbers
decrease when multiple measures are
combined as one.28 29 The performance
25 Singer PA, Martin DK, Kelner M. Quality Endof-Life Care: Patients’ Perspectives. JAMA.
1999;281(2):163–168. doi:10.1001/jama.281.2.163.
26 Steinhauser KE, Christakis NA, Clipp EC,
McNeilly M, McIntyre L, Tulsky JA. Factors
Considered Important at the End of Life by Patients,
Family, Physicians, and Other Care Providers.
JAMA. 2000;284(19):2476–2482. doi:10.1001/
jama.284.19.2476.
27 Werner, R., E. Stuart, and D. Polsky, Public
reporting drove quality gains at nursing homes.
Health Affairs, 2010. 29(9): p. 1706–1713.
28 Nolan, T., & Berwick, D. M. (2006). All-or-none
measurement raises the bar on performance. JAMA
[H.W. Wilson—GS], 295(10), 1168.
29 Agency for Healthcare Research and Quality.
(2004). National Healthcare Quality Report.
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gap identified by the composite measure
creates opportunities for quality
improvement and may motivate
providers to conduct a greater number
of high priority care processes for as
many patients as possible upon
admission to hospice.
Existing Measures. The Family
Evaluation of Hospice Care (FEHC),
NQF #0208, is a precursor of the
Hospice CAHPS®. The surveys cover
some similar domains. However, a
major difference between them is the
detailed requirements for survey
administration of the CAHPS® Hospice
Survey, which allow for comparison of
hospice programs, The Hospice
CAHPS® survey quality measure is not
yet endorsed by NQF. CMS has recently
submitted the CAHPS® Hospice Survey
(experience of care) measure (NQF
#2651) to be considered for
endorsement under the Palliative and
End-of-Life Care Project 2015–2016. For
more information regarding this project
and the measure submitted, we refer
readers to https://
www.qualityforum.org/ProjectMeasures.
aspx?projectID=80663. In addition, we
refer readers to section III.C.9 of this
rule for more information on the
Hospice CAHPS® survey and associated
quality measures. The CAHPS®-based
quality measures submitted to NQF
include patient and caregiver
experience of care outcome measures
and CMS plans to propose these
measures as part of the HQRP measure
set in future rulemaking cycles. A key
difference between the FEHC, Hospice
CAHPS® and the Hospice and Palliative
Care Composite Process Measure is that
the FEHC and Hospice CAHPS® focus
on the consumer’s perspective of their
health agency and experience, whereas
the Hospice and Palliative Care
Composite Process Measure focuses on
the clinical care processes that are
actually delivered by the hospice to
each patient.
Stakeholder Support. A TEP
convened by our measure development
contractor, RTI International, on
December 2, 2015, provided input on
this measure concept. The TEP
unanimously agreed that a
comprehensive hospice composite
measure is an important measure and
supported data collection using the HIS.
The NQF MAP met on December 14th
and 15th, 2015 and provided input to
CMS. In their final recommendation, the
MAP encouraged continued
development of the Hospice and
Palliative Care Composite Process
Measure—Comprehensive Assessment
at Admission measure. More
information about the MAP’s
recommendations for this measure is
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available at https://www.qualityforum.
org/ProjectMaterials.aspx
?projectID=75370.
While this measure is not currently
NQF-endorsed, we recognize that the
NQF endorsement process is an
important part of measure development
and plan to submit this measure for
NQF endorsement. As noted, this
quality measure will fill a gap by
holding hospices to a higher standard of
care and will motivate providers to
conduct a greater number of high
priority care processes for as many
beneficiaries as possible upon
admission as hospice patients.
Furthermore, no current NQF-endorsed
measures address the completion of a
comprehensive care assessment at
hospice admission.
Form, Manner, and Timing of Data
Collection and Submission. The data
source for this measure will be currently
implemented HIS items that are
currently used in the calculation of the
7 component measures. These items and
quality measure algorithms for the 7
component measures can be found in
the HQRP Specifications for the Hospice
Item Set-based Quality Measures
document, which is available in the
‘‘Downloads’’ section of the ‘‘Current
Measures’’ portion of the CMS HQRP
Web site: https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/CurrentMeasures.html. Since the proposed
measure is a composite measure whose
components are currently adopted
HQRP measures, no new data collection
will be required; data for the composite
measure will come from existing items
from the existing 7 HQRP component
measures. CMS proposes to begin
calculating this measure using existing
data items, beginning April 1, 2017; this
means patient admissions occurring
after April 1, 2017 would be included in
the composite measure calculation.
Since the composite measure
components are existing HIS data items,
providers are already collecting the data
needed to calculate the composite
measure. Data collection will continue
in accordance with processes outlined
in sections III.C.7c through III.C.7e of
this rule.
For more information on the
specifications and data elements for the
measure, Hospice and Palliative Care
Composite Process MeasureComprehensive Assessment at
Admission, we refer readers to the
https://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
Current-Measures.html document,
available on the ‘‘Current Measures’’
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portion of the CMS HQRP Web site:
https://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
Current-Measures.html.
We received multiple comments
pertaining to the Hospice and Palliative
Care Composite Process Measure. The
following is a summary of the comments
we received on this topic and our
responses.
Comment: CMS received many
comments in support of the proposed
Hospice and Palliative Care Composite
Process Measure—Comprehensive
Assessment at Admission quality
measure. Commenters appreciated that
the measure demonstrates greater
variation in hospice performance than
the individual component measures,
and that it can be used to differentiate
performance across hospices.
Commenters also appreciated that
CMS’s measure selection activities for
the HQRP take into consideration input
from stakeholders such as the Measure
Applications Partnership (MAP).
Several commenters were supportive of
CMS’s approach to quality measure
development in the HQRP, specifically,
the use of Technical Expert Panels (TEP)
to obtain expert and other stakeholder
input.
Response: We thank commenters for
their support of the proposed Hospice
and Palliative Care Composite Process
Measure—Comprehensive Assessment
at Admission quality measure, herein
after referred to as the ‘Composite QM’.
Comment: Many comments were
received regarding the retirement of the
seven day length of stay exclusion for
six of the care process measures that
comprise the Composite QM.
Commenters’ primary concern focused
on the impact of removing this
exclusion on provider behavior;
specifically, commenters suggested that
eliminating the LOS exclusion may
inappropriately incentivize providers to
focus on completion and compliance
with the HIS requirements at the
expense of addressing the needs and
preferences of imminently dying
patients. Commenters noted that upon
admission for imminently dying
patients, a comprehensive assessment is
not in the interest of patients and
caregivers, nor may it be feasible for
hospices to deliver because the focus is
on appropriately directed to other
priorities. One commenter stated that
the level and intensity of hospices
services are different for patients with
short LOS and that the items captured
in this measure are not reflective of
quality of care for patients imminently
dying. Finally, one commenter
indicated that this measure might
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complicate data collection efforts and
processes already in place at hospices,
noting that different members of the
interdisciplinary team often complete
different sections of the HIS at different
times. This commenter believed that
hospices would therefore need to
establish new data collection processes
when addressing urgent patient/family
needs should be the priority. In
response to these concerns, commenters
requested that provisions be made to
account for patients with short LOS and
suggested alternative approaches to do
so. Namely, commenters recommended
that CMS risk adjust or stratify for
patients with a 2-day or less, 3-day or
less, or 5-day or less LOS, while other
comments recommended that CMS
maintain the current 7-day LOS
exclusion. Another commenter
recommended that a new measure be
created to capture data for short LOS
patients, rather than including them in
this measure. Commenters requested
clarification on why the measure was
not created with risk adjustment in its
current specifications.
Response: We appreciate the
commenters’ input on the Composite
QM LOS exclusion specifications.
Developing and adopting measures that
benefit patient outcomes and do not
lead to negative unintended
consequences of the utmost importance
to CMS. We would like to take this
opportunity to respond to commenters’
concerns about the impact of retiring the
LOS exclusion, first by describing the
history of the LOS exclusion and the
reason for retiring it from the individual
measures. As many commenters noted,
6 of the 7 component quality measure
(QMs) exclude patient stays that are less
than 7 days from the measure
denominator. At the time the measures
were developed, no national data
regarding the implications of the LOS
exclusion was available at that time, and
technical experts recommended that
short patient stays be excluded from
those measures’ denominators for
assessing quality of care. Since the
implementation of the HIS, we have
performed descriptive analyses to
examine the implications of the LOS
exclusion on hospices’ denominator size
and QM scores. Additionally, this
analysis also examined the timing of
when hospices perform the care
processes assessed in the quality
measures. The results of these analyses
demonstrated that the denominator
sizes for the HQRP QMs are largely
impacted by the current 7 day LOS
exclusion used to calculate the QMs.
Excluding stays with LOS less than 7
days result in many hospices not having
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sufficient denominator size to allow for
public display of their quality scores.
Although the LOS exclusion has a
sizable impact on the number of
hospices eligible to have their data
publicly displayed, the impact of the
LOS exclusions on the distribution of
hospices’ scores is generally small for
all of the QMs. Therefore, removing the
LOS exclusion criteria will increase the
number of hospices eligible for public
reporting while having a minimal
impact on the QM scores. In addition,
these analyses revealed that the care
processes targeted by the QMs are
performed on the day of or within one
day of admission for the vast majority of
patient stays. For example, among
patient admissions for which a pain
screening was administered,
approximately 92 percent of screenings
occurred on the day of admission and
close to 99 percent occurred within 1
day of admission. This suggests that
including stays of less than 7 days in
QM calculations (that is, removing the
QM LOS exclusion) may be appropriate
and would not create a burden on
hospices. In response to these results,
the measure developer and steward
submitted the individual QMs to the
NQF Palliative Care and End of Life
Project for re-endorsement in February
2016 without the LOS exclusion.
Because of the anticipated removal of
the LOS exclusion for the current HQRP
measures (component measures for this
Composite QM), this Composite QM
was proposed without the LOS
exclusion in order to be consistent with
the individual measure components.
Our contractor convened a TEP in
December 2015 to inform the
development of the Composite QM. The
TEP, presented with the results of the
LOS analysis, strongly recommended
that the Composite QM maintain the
same measure specifications as the
individual measures. Additionally, this
TEP considered the creation of a
separate measure specifically for short
LOS patients, as recommended by a
commenter, but ultimately agreed that
such a measure would not capture
comprehensive care for short LOS
patients as the current proposed
measure would. Furthermore, we
remind commenters that because the
Composite QM is based on the 7 current
HIS measures that are already endorsed
by NQF, risk adjustment for the
Composite QM will be consistent with
any risk adjustment created and applied
for the individual measures. Any
additional risk adjustment applied to
the individual measures will first be
developed and tested for in
coordination with the NQF prior to
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implementation. We will keep the
commenters’ recommendations and
concerns regarding short LOS in mind
for future development efforts and data
analysis.
Comment: CMS received comments
regarding the contribution of this
measure to quality of care. While
commenters did not object to the
development and implementation of
this measure, many were concerned
whether this measure is truly reflective
of comprehensive care at admission and
whether it will provide patients and
families with meaningful information.
Response: We appreciate the
commenters’ concern regarding the
impact and relevance of the Composite
QM. We are committed to the ensuring
that all quality measures implemented
in the HQRP meet the goals of the
HQRP, which include distinguishing
performance among hospices and
improving patient outcomes. We
regularly conduct measure testing and
evaluation activities to ensure that
measures continue to demonstrate
improvements in-patient care. We
would like to convey to commenters
that a primary motivation in developing
the Composite QM is to provide
interpretable and meaningful
information to consumers. We believe
that, above and beyond information
provided by the individual component
QMs, the Composite QM accomplishes
this by providing consumers with a
single measure regarding the overall
quality and completeness of assessment
of patient needs at hospice admission,
which can then be used to compare
quality across hospice providers and
increase transparency, while also
accessing information about hospice
performance on each of the individual
measures that comprise the Composite
QM. As also noted in this rule, the
Composite QM demonstrates greater
variation in hospice performance than
individual measures. Hospice
performance scores on the current 7
HQRP measures are high (a score of 90
percent or higher on most measures);
however, on average, a much lower
percentage of patient stays in a hospice
had documentation that all 7 of these
care processes were completed at
admission. Additionally, we would like
to reiterate that the Composite QM for
comprehensive assessment at admission
addresses high priority aspects of
comprehensive quality hospice care as
identified by both leading hospice
stakeholders and beneficiaries receiving
hospice services, all of which
emphasize attention to physical,
psychosocial, emotional, and spiritual
needs of patients.
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Comment: CMS received a few
comments recommending that CMS
attain NQF endorsement of the
Composite QM prior to implementation.
Response: We appreciate the
commenters’ input and support of the
NQF endorsement process. Our
paramount concern is the successful
development of a HQRP that promotes
the delivery of high quality healthcare
services. We seek to adopt measures for
the HQRP that promote patient-centered
and high quality care. Our measure
selection activities for the HQRP take
into consideration input from the
Measure Applications Partnership
(MAP), convened by the NQF, as part of
the established CMS pre-rulemaking
process required under section 1890A of
the Act. The NQF MAP met on
December 14th and 15th, 2015 and
encouraged continued development of
this measure. Additionally, while this
measure is not currently NQF-endorsed,
we recognize that the NQF endorsement
process is an important part of measure
development and plan to submit this
measure for NQF endorsement. This
quality measure will fill a gap by
holding hospices to a higher standard of
care and will motivate providers to
conduct a greater number of high
priority care processes for as many
beneficiaries as possible upon
admission as hospice patients—a
unique contribution to hospices.
Furthermore, no current NQF-endorsed
measures address the completion of a
comprehensive care assessment at
hospice admission, and this measure is
a first step towards that goal. We are
establishing the timeline for seeking
NQF endorsement for this quality
measure and will communicate this
timeline to the public in future
rulemaking cycles.
Comment: CMS received one
comment requesting clarification on the
logic behind including NQF #1617
Patients Treated with an Opioid Who
Are Given a Bowel Regimen measure as
a component measure of the proposed
Composite QM. This commenter
indicated that the NQF #1617 measure
does not collect data representative of
comprehensive care on the first day of
admission and, therefore, does not serve
this measure well as a component.
Response: We would like to clarify
that the Composite QM is not designed
to focus on care processes completed on
the first day of admission; rather, this
measure is intended to capture all
comprehensive assessment activities
around the time of hospice admission.
This timeframe is in line with
guidelines identified the Medicare
Hospice Conditions of Participation
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(CoPs).30 The Medicare CoPs mandate
that an initial assessment be completed
within 48 hours after the election of
hospice care and that a comprehensive
assessment be completed no later than
5 calendar days after the election of
hospice care is in accordance with
§ 418.24. Therefore, by collecting data
beyond the first day of admission, this
measure aligns with the practices
recommended by the CoPs and with
national guidelines and clinical
recommendations. The Medicare CoPs
require that both the hospice initial and
comprehensive assessments identify
patients’ physical needs and address
them to promote the hospice patients’
well-being and comfort throughout the
dying process. Additionally, the Quality
Palliative Care Clinical Practice
Guidelines 31 produced by the National
Consensus Project (NCP) established
eight core palliative care domains, one
of which emphasizes the assessment
and management of pain and/or other
physical symptoms. This measure
captures care processes related to bowel
management and opioid use. Most
patients prescribed opioids to manage
pain or other symptoms develop some
degree of constipation after opioid
initiation or dose increases. Reducing
opioid-induced constipation can reduce
patient discomfort and improve quality
of life. Properly assessing and managing
symptoms related to bowel management
are critical components of the
comprehensive assessment. Therefore,
by including the NQF #1617 measure in
this comprehensive assessment, we
address high priority aspects of quality
hospice care as identified by leading
hospice stakeholders.
Comment: CMS received one
comment recommending that the title of
this measure, specifically the term ‘‘at
admission’’, be clarified or replaced.
The commenter believed that the use of
the phrase ‘‘at admission’’ was
misleading since it seemed to imply that
the measure captures care processes
completed on the day of admission.
Since the composite measure in fact
captures care processes completed
during the initial and/or comprehensive
assessment (which, per CoP
requirements, must be completed within
2 and 5 days from admission,
respectively), the commenter believed
the title of the measure could be
misleading since care processes that are
components of the measure may be
completed beyond the day of admission.
30 Medicare and Medicaid Programs: Hospice
Conditions of Participation, Part 418 subpart 54.
Centers for Medicare and Medicaid Services (2008).
31 Clinical Practice Guidelines for Quality
Palliative Care. National Consensus Project for
Quality Palliative Care (2013).
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Response: We would like to thank this
commenter for their recommendation.
We would like to clarify that this
measure title was developed based on
the CoP requirement for the
comprehensive assessment. While it is
true that the CoPs require the first
comprehensive assessment to be
completed within 5 days of admission,
the CoPs also require hospices to update
the comprehensive assessment as
frequently as the condition of the
patient requires, but no less frequently
than every 15 days. Thus, we used the
phrase Comprehensive Assessment ‘‘at
Admission’’ to denote that this measure
and the data it captures refers to care
processes delivered during the first
comprehensive assessment completed
upon admission to hospice and not any
subsequent comprehensive assessment
updates.
Comment: CMS received a few
comments regarding the measure
specifications of the Composite QM.
Commenters requested clarification on
the composite measure score
calculation, construction, and
components.
Response: The Composite QM is a
composite measure that assesses
whether a comprehensive patient
assessment is completed at hospice
admission by evaluating whether seven
critical individual care processes were
completed upon admission for each
hospice patient stay. A composite
measure, as defined by the NQF, is a
combination of two or more component
measures, each of which individually
reflects quality of care, into a single
performance measure with a single
score. For more information on
composite measure definitions, guiding
principles, and measure evaluation
criteria, we refer readers to the NQF
Composite Performance Measure
Evaluation Guidance Publication
available at https://www.qualityforum.
org/Publications/2013/04/Composite_
Performance_Measure_Evaluation_
Guidance.aspx. A total of 7 individual
care processes will be captured in this
Composite QM, which include the 6
NQF endorsed quality measures and 1
modified NQF endorsed quality
measure currently implemented in the
HQRP. This Composite QM calculates
the percentage of patients who received
all applicable care processes at
admission. For additional details on the
draft Composite QM specifications, we
refer readers to the HQRP Specifications
for HIS-Based QM document, available
on the ‘‘Current Measures’’ portion of
the CMS HQRP Web site: https://
www.cms.gov/Medicare/QualityInitiatives-PatientAssessmentInstruments/HospiceQuality-Reporting/
CurrentMeasures.html. This measure,
therefore, reflects the variation in
hospices’ performance on all 7 quality
measures for each patient at admission.
We will continue the development and
analyses of the Composite QM. Potential
refinement to the measure specifications
will be communicated with the public
via HQRP communication channels,
including postings and announcements
on the CMS HQRP Web site, MLN
eNews communications, national
provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums.
Comment: CMS received a few
comments recommending that CMS be
mindful of public awareness of
differences between process and
outcome measures when creating a
composite measure. Two commenters
stated that although this measure
concept is valuable and consistent with
existing clinical guidelines, knowledge
about differences in hospice measure
types is minimal among the public. The
commenter noted that the public might
not be able to understand the
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relationship of hospice performance on
the Composite QM to quality of care
delivery at the hospice. Additionally,
two commenters recommended that to
aid consumer understanding of
information from the Composite QM,
CMS should supplement this data with
information from the hospice CAHPS
survey.
Response: We appreciate the
commenters’ feedback on public
usability of the Composite QM. We
would like to highlight that one primary
motivation for creating this Composite
QM was to provide interpretable and
meaningful information to consumers.
We believe the Composite QM may be
easier for consumers to understand
because it provides the public with a
single metric regarding care processes at
admission as compared to the
individual component QMs. As such,
QM scores can be easily used to
compare quality across providers and
make informed decisions. We are
committed to providing all users with
the necessary information to understand
the intent and application of measures
in the HQRP. As with other measures,
we will conduct measure testing and
reportability analysis to determine if the
Composite QM is appropriate for public
reporting. Should we determine the
Composite QM is appropriate for public
reporting, we would take necessary
steps to ensure that any data publicly
reported is meaningful and
understandable by the public. Such
steps may include usability testing and
cognitive interviewing. We also plan to
make hospice CAHPS quality measures
publicly available to consumers.
Final Action: After consideration of
the comments, we are finalizing our
proposal to implement the Hospice and
Palliative Care Composite Process
Measure—Comprehensive Assessment
at Admission effective April 1, 2017.
TABLE 16—PROPOSED QUALITY MEASURES AND DATA COLLECTION PERIOD AFFECTING THE FY 2019 PAYMENT
DETERMINATION AND SUBSEQUENT YEARS
NQF ID No.
Type
Submission method
Hospice Visits when Death is Imminent ....................................
Hospice and Palliative Care Composite Process Measure .......
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Quality measure
TBD .............
TBD.
Process Measure ......
Hospice Item Set .......
7. 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
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manner, and at a time specified by the
Secretary. Section 1814(i)(5)(A)(i) of the
Act requires that beginning with the FY
2014 and for each subsequent FY, the
Secretary shall reduce the market basket
update by 2 percentage points for any
hospice that does not comply with the
quality data submission requirements
for that FY.
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Data collection
to begin
04/01/2017
b. Previously Finalized Policy for New
Facilities To Begin Submitting Quality
Data
In the FY 2015 Hospice Wage Index
final rule (79 FR 50488), we finalized a
policy stating that any hospice that
receives its CMS Certification Number
(CCN) (also known as the Medicare
Provider Number) notification letter
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dated on or after November 1 of the
preceding year involved is excluded
from any payment penalty for quality
reporting purposes for the following FY.
This requirement was codified at
§ 418.312.
In the FY 2016 Hospice Wage Index
final rule (80 FR 47189), we further
clarified and finalized our policy for the
timing of new providers to begin
reporting data to CMS. The clarified
policy finalized in the FY 2016 Hospice
Wage Index final rule (80 FR 47189)
distinguished between when new
hospice providers are required to begin
submitting HIS data and when providers
will be subject to the potential 2
percentage point annual payment
update (APU) reduction for failure to
comply with HQRP requirements. In
summary, the policy finalized in the FY
2016 Hospice Wage Index final rule (80
FR 47189 through 47190) clarified that
providers must begin submitting HIS
data on the date listed in the letterhead
of the CCN Notification letter received
from CMS but will be subject to the
APU reduction based on whether the
CCN Notification letter was dated before
or after November 1 of the reporting
year involved. Thus, beginning with the
FY 2018 payment determination and for
each subsequent payment
determination, we finalized our policy
that a new hospice be responsible for
HQRP quality data submission
beginning on the date of the CCN
notification letter; we retained our prior
policy that hospices not be subject to
the APU reduction if the CCN
notification letter was dated after
November 1 of the year involved. For
example, if a provider receives their
CCN notification letter and the date in
the letterhead is November 5, 2016, that
provider will begin submitting HIS data
for patient admissions occurring after
November 5, 2016. However, since the
CCN notification letter was dated after
November 1st, they would not be
evaluated for, or subject to any payment
penalties for, the relevant FY APU
update (which in this instance is the FY
2018 APU, which is associated with
patient admissions occurring 1/1/16–12/
31/16).
This policy allows CMS to receive
HIS data on all patient admissions on or
after the date a hospice receives their
CCN notification letter, while at the
same time allowing hospices flexibility
and time to establish the necessary
accounts for data submission before
they are subject to the potential APU
reduction for a given reporting year.
Currently, new hospices may experience
a lag between Medicare certification and
receipt of their actual CCN Number.
Since hospices cannot submit data to
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the QIES ASAP system without a valid
CCN Number, CMS proposed that new
hospices begin collecting HIS quality
data beginning on the date noted on the
CCN notification letter. We believe this
policy will provide sufficient time for
new hospices to establish appropriate
collection and reporting mechanisms to
submit the required quality data to
CMS. Requiring quality data reporting
beginning on the date listed in the
letterhead of the CCN notification letter
aligns CMS policy for requirements for
new providers with the functionality of
the HIS data submission system (QIES
ASAP).
c. Previously Finalized Data Submission
Mechanism, Collection Timelines, and
Submission Deadlines for the FY 2017
Payment Determination
In the FY 2015 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
after July 1, 2014. For each HQRP
program year, we require that hospices
submit data on each of the adopted
measures in accordance with the
reporting requirements specified in
sections III.C.7c through III.C.7e of that
rule for the designated reporting period.
This requirement applies to previously
finalized and adopted measures, as well
as new measures proposed through the
rulemaking process. Electronic
submission is required for all HIS
records. Although electronic submission
of HIS records is required, hospices do
not need to have an electronic medical
record to complete or submit HIS data.
In the FY 2014 Hospice Wage Index
final rule (78 FR 48258), we finalized a
provision requiring that providers can
use either the Hospice Abstraction
Reporting Tool (HART) (which is free to
download and use) or vendor-designed
software to complete HIS records. HART
provides an alternative option for
hospice providers to collect and
maintain facility, patient, and HIS
Record information for subsequent
submission to the QIES ASAP system.
Once HIS records are complete,
electronic HIS files must be submitted
to CMS via the QIES ASAP system.
Electronic data submission via the QIES
ASAP system is required for all HIS
submissions; there are no other data
submission methods available. Hospices
have 30 days from a patient admission
or discharge to submit the appropriate
HIS record for that patient through the
QIES ASAP system. CMS will continue
to make HIS completion and submission
software available to hospices at no cost.
We provided details on data collection
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and submission timing under the
downloads section of the HIS Web site
on the CMS.gov Web site at https://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
Hospice-Item-Set-HIS.html.
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 site, Open Door
Forums, announcements in the CMS
MLN Connects Provider e-News (ENews), and provider training.
d. Previously Finalized 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
for 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 is the date on
which the completed record is
submitted and accepted by the QIES
ASAP system. In the FY 2016 Hospice
Wage Index final rule (80 FR 47191),
CMS finalized our policy that beginning
with the FY 2018 payment
determination 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 must 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.
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For HIS-Discharge records, the
submission date must 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 of submission 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 to
establish a robust quality reporting
program and ensure the scientific
reliability of the data received.
In the FY 2016 Hospice Wage Index
final rule (80 FR 47191), CMS also
clarified the difference between the
completion deadlines and the
submission deadlines. Current subregulatory guidance produced by CMS
(for example, HIS Manual, HIS
trainings) states that the completion
deadlines for HIS records are 14 days
from the Event Date for HIS-Admission
records and 7 days from the Event Date
for HIS-Discharge records. Completion
deadlines continue to reflect CMS
guidance only; these guidelines are not
statutorily specified and are not
designated through regulation. These
guidelines are intended to offer clear
direction to hospice agencies in regards
to the timely completion of HISAdmission and HIS-Discharge records.
The completion deadlines define only
the latest possible date on which a
hospice should complete each HIS
record. This guidance is meant to better
align HIS completion processes with
clinical workflow processes; however,
hospices may develop alternative
internal policies to complete HIS
records. Although it is at the discretion
of the hospice to develop internal
policies for completing HIS records,
CMS continues to recommend that
providers complete and attempt to
submit HIS records early, prior to the
previously finalized submission
deadline of 30 days, beginning in FY
2018. Completing and attempting to
submit records early allows providers
ample time to address any technical
issues encountered in the QIES ASAP
submission process, such as correcting
fatal error messages. Completing and
attempting to submit records early will
ensure that providers are able to comply
with the 30 day submission deadline.
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HQRP guidance documents, including
the CMS HQRP Web site, HIS Manual,
HIS trainings, Frequently Asked
Questions, and Fact Sheets, continue to
offer the most up-to-date CMS guidance
to assist providers in the successful
completion and submission of HIS
records. Availability of updated
guidance will be communicated to
providers through the usual CMS HQRP
communication channels, including
postings and announcements on the
CMS HQRP Web site, MLN eNews
communications, national provider
association calls, and announcements
on Open Door Forums and Special Open
Door Forums.
e. Previously Finalized HQRP Data
Submission and Compliance Thresholds
for the FY 2018 Payment Determination
and Subsequent Years
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. In the FY 2016 Hospice Wage
Index final rule (80 FR 47192), CMS
finalized the timeliness criteria for
submission of HIS-Admission and HISDischarge records. The finalized
timeliness criteria was 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.
Last year, we finalized our policy (80
FR 47191 through 47192) that beginning
with the FY 2018 payment
determination and subsequent FY
payment determinations, all HIS records
would have to be submitted within 30
days of the event date, which is the
patient’s admission date or discharge
date. In conjunction with this
requirement, we also finalized our
policy (80 FR 47192) to establish an
incremental threshold for compliance
over a 3-year period. To be compliant
for the FY 2018 APU determination,
hospices must submit no less than 70
percent of their total number of HISAdmission and HIS-Discharge records
by no later than 30 days from the event
date. The timeliness threshold is set at
80 percent for the FY 2019 APU
determination and at 90 percent for the
FY 2020 APU determination 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 compliance rate of 90 percent or more.
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To summarize, in the FY 2016
Hospice Wage Index final rule (80 FR
47193), we finalized our policy to
implement the timeliness threshold
requirement beginning with all HIS
admission and discharge records that
occur after January 1, 2016, in
accordance with the following schedule.
• Beginning January 1, 2016 to
December 31, 2016, hospices must
submit at least 70 percent of all required
HIS records 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
2018.
• Beginning January 1, 2017 to
December 31, 2017, hospices must
submit at least 80 percent of all required
HIS records 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 January 1, 2018 to
December 31, 2018, hospices must
submit at least 90 percent of all required
HIS records 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.
Timely submission of data is
necessary to accurately analyze quality
measure data received by providers. To
support the feasibility of a hospice to
achieve the compliance thresholds,
CMS’s measure development contractor
conducted some preliminary analyses of
Quarter 3 and Quarter 4 HIS data from
2014. According to this analysis, the
vast majority of hospices (92 percent)
would have met the compliance
thresholds at 70 percent. Moreover, 88
percent and 78 percent of hospices
would have met the compliance
thresholds at 80 percent and 90 percent,
respectively. CMS believes this analysis
is further evidence that the compliance
thresholds are reasonable and
achievable by hospice providers.
The current reports available to
providers in the Certification and
Survey Provider Enhanced Reports
(CASPER) system do allow providers to
track the number of HIS records that are
submitted within the 30 day submission
timeframe. Currently, submitting an HIS
record past the 30 day submission
timeframe results in a non-fatal
(warning) error. In April 2015, CMS
made available 3 new Hospice Reports
in CASPER, which include reports that
can list HIS Record Errors by Field by
Provider and HIS records with a specific
error number. CMS is working on
expanding this functionality of CASPER
reports to include a timeliness
compliance threshold report that
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providers could run to determine their
preliminary compliance with the
timeliness compliance requirement.
CMS expects these reports to be
available by late fall of 2016.
In the FY 2016 Hospice Wage Index
final rule (80 FR 47192 through 47193),
CMS provided clarification regarding
the methodology used in calculating the
70 percent/80 percent/90 percent
compliance thresholds. In general, HIS
records submitted for patient
admissions and discharges occurring
during the reporting period (January 1st
to December 31st of the reporting year
involved) will be included in the
denominator for the compliance
threshold calculation. The numerator of
the compliance threshold calculation
would include any records from the
denominator that were submitted within
the 30 day submission deadline. In the
FY 2016 Hospice Wage Index final rule
(80 FR 47192), CMS also stated we
would make allowances in the
calculation methodology for two
circumstances. First, the calculation
methodology will be adjusted following
the applicable reporting period for
records for which a hospice is granted
an extension or exemption by CMS.
Second, adjustments will be made for
instances of modification/inactivation
requests (Item A0050. Type of Record =
2 or 3). Additional helpful resources
regarding the timeliness compliance
threshold for HIS submissions can be
found under the downloads section of
the Hospice Item Set Web site at
CMS.gov at https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/Hospice-Item-SetHIS.html. Lastly, as further details of the
data submission and compliance
threshold are determined by CMS, we
anticipate communicating these details
through the regular CMS HQRP
communication channels, including
postings and announcements on the
CMS HQRP Web site, MLN eNews
communications, national provider
association calls, and announcements
on Open Door Forums and Special Open
Door Forums.
Comment: A few commenters
commented on our previously finalized
policies for form, manner, and timing of
data collection. One commenter raised
concern about the ability of hospices to
comply with the incremental 70
percent/80 percent/90 percent
timeliness compliance threshold in
cases of natural disasters. Specifically,
the commenter was concerned that in
the case of protracted natural disasters
(for example, Hurricane Sandy), hospice
organizations may not be able to email
CMS within the 30-day timeframe to
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request an extension or exemption as
appropriate, and that, in turn, failure to
submit a timely request for extension or
exemption may put a hospice at risk of
non-compliance with the timeliness
threshold. Another commenter stated
they believed the process for HIS data
collection and submission, which relies
heavily on chart abstraction, was errorridden and outdated. The commenter
encouraged CMS to automate data
collection and submission processes via
electronic submission of HIS data.
Response: We thank the commenters
for their comments on our previously
finalized policies for form, manner, and
timing of data collection. Regarding the
first commenter’s concern about ability
to submit a timely extension or
exemption request to maintain
compliance with the 70/80/90
timeliness compliance thresholds in the
case of extended natural disasters, CMS
refers readers to our previously finalized
policies for extensions and exemptions,
addressed in section III.C.8 of this rule.
As noted in section III.C.8, in instances
of extraordinary circumstances (like
widespread natural disasters), we may
grant an extension/exemption to
hospices that have not requested them,
which may include instances where
hospices are unable to make the request
within the 30-day timeframe due to
extenuating circumstances. Regarding
the second commenter’s request for
electronic data collection and
submission processes for the HIS, we
would like to clarify that, as noted in
section III.C.7.c of this rule, electronic
submission of HIS records is already
required; no other data submission
methods are available. Hospices are
required to submit all HIS records
through the QIES ASAP system. We also
provide electronic software to hospices
free of charge that allows hospices to
complete HIS records electronically;
alternatively, hospices may choose to
use vendor-designed software to
complete HIS records. As noted by the
commenter, we believe this electronic
process of data completion and
submission minimizes burden on
providers and helps ensure data quality
through the HIS record validation
process. We refer readers to section
III.C.7.c for more information on
mechanisms of data submission for the
HIS.
f. New Data Collection and Submission
Mechanisms Under Consideration for
Future Years
CMS has made great progress in
implementing the objectives set forth in
the quality reporting and data collection
activities required by sections 3004 of
the Affordable Care Act. To date, CMS
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has established the HQRP, which
includes 7 NQF-endorsed quality
measures that are collected via the HIS.
As stated in this rule, data on these
measures are expected to be publicly
reported sometime in 2017.
Additionally, CMS has also
implemented the Hospice CAHPS® as
part of the HQRP to gather important
input on patient experience of care in
hospice. Over the past several years,
CMS has conducted data collection and
analysis on hospice utilization and
trends to help reform the hospice
payment system. In the FY 2016
Hospice Wage Index final rule, we
finalized payment reform measures,
including changes to the RHC payment
rate and the implementation of a Service
Intensity Add-On (SIA) payment,
effective January 1st, 2016. As part of
payment reform and ongoing program
integrity efforts, we will continue
ongoing monitoring of utilization trends
for any future refinements.
To facilitate continued progress
towards the requirements set forth in
section 3004 of the Affordable Care Act,
CMS is considering developing a new
data collection mechanism for use by
hospices. This new data collection
mechanism would be a hospice patient
assessment instrument, which would
serve 2 primary objectives concordant
with the Affordable Care Act legislation:
(1) To provide the quality data
necessary for HQRP requirements and
the current function of the HIS; and (2)
provide additional clinical data that
could inform future payment
refinements.
CMS believes that the development of
a hospice patient assessment tool could
offer several benefits over the current
mechanisms of data collection for
quality and payment purposes, which
include the submission of HIS data and
the submission of claims data. For
future payment refinements, a hospice
patient assessment tool would allow
CMS to gather more detailed clinical
information, beyond the patient
diagnosis and comorbidities that are
currently reported on hospice claims.
As stated in the FY 2016 Hospice Wage
Index final rule (80 FR 47203), detailed
patient characteristics are necessary to
determine whether a case mix payment
system could be achieved. A hospice
patient assessment tool would allow
CMS to capture information on
symptom burden, functional status, and
patient, family, and caregiver
preferences, all of which will inform
future payment refinements.
While systematic assessment is vital
throughout the continuum of care,
including palliative and end-of-life care,
documentation confirming completion
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of systematic assessment in hospice
settings is often inadequate or absent.32
The value of the introduction of
structured approaches via a clinical
assessment is well established, as it
enables a more comprehensive and
consistent way of identifying and
meeting patient needs.33
Moreover, symptoms are the leading
reason that people seek medical care in
the first place and frequently serve as
the basis for establishing a diagnosis.
Measures of physical function and
disease burden have been used to
identify older adults at high-risk for
excess health care utilization, disability,
or mortality.34 Currently, data collected
on claims includes line-item visits by
discipline, General Inpatient Care (GIP)
visit reporting to hospice patients in
skilled nursing facilities or hospitals,
post-mortem visits, injectable and noninjectable drugs and infusion pumps.
Industry representatives have
communicated to CMS that required
claims information is not sufficiently
comprehensive to accurately reflect the
provision and the cost of hospice care.
For quality data collection, a hospice
patient assessment instrument would
support the goals of the HQRP as new
quality measures are developed and
adopted. Since the current quality data
collection tool (HIS) is a chart
abstraction tool, not a hospice patient
assessment instrument, CMS is limited
in the types of data that can be collected
via the HIS. Instead of retrospective data
collection elements, a hospice patient
assessment tool would include data
elements designed to be collected
concurrent with provision of care. As
such, CMS believes a hospice patient
assessment tool would allow for more
robust data collection that could inform
development of new quality measures
that are meaningful to hospice patients,
their families and caregivers, and other
stakeholders.
Finally, a hospice patient assessment
tool that provides clinical data that is
used for both payment and quality
purposes would align the hospice
benefit with other care settings that use
similar approaches, such as nursing
homes, inpatient rehabilitation
facilities, and home health agencies
32 McMillan, S., Small, B., & Haley, W. (2011).
Improving Hospice Outcomes through Systematic
Assessment: A Clinical Trial. Cancer Nursing, 34(2),
89–97.
33 Bourbonnais, F.F., Perreault, A., & Bouvette, M.
(2004). Introduction of a pain and symptom
assessment tool in the clinical setting—lessons
learned. Journal of Nursing Management, 12(3),
194–200.
34 Sha, M., Callahan, C., Counsell, S.,
Westmoreland, G., Stump, T., Kroenke, K. (2005).
Physical symptoms as a predictor of health care use
and mortality among older adults. 118, 301–306.
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which submit data via the MDS 3.0,
IRF–PAI, and OASIS, respectively.
CMS envisions the hospice patient
assessment tool itself as an expanded
HIS. The hospice patient assessment
tool would include current HIS items, as
well as additional clinical items that
could be used for payment refinement
purposes or to develop new quality
measures. The hospice patient
assessment tool would not replace
existing requirements set forth in the
Medicare Hospice CoPs (such as the
initial nursing and comprehensive
assessment), but would be designed to
complement data that are collected as
part of normal clinical care. If such a
patient assessment were adopted, the
new data collection effort would replace
the current HIS, but would not replace
other HQRP data collection efforts (that
is, the Hospice CAHPS® survey), nor
would it replace regular submission of
claims data. CMS envisions that patient
assessment data would be collected
upon a patient’s admission to and
discharge from any Medicare-certified
hospice provider; additional interim
data collection efforts are also possible.
Should CMS develop and implement a
hospice patient assessment tool, CMS
would provide several training
opportunities to ensure providers are
able to comply with any new
requirements.
CMS is not proposing a hospice
patient assessment tool at this time; we
are still in the early stages of
development of an assessment tool to
determine if it would be feasible to
implement under the Medicare Hospice
Benefit. In the development of such a
hospice patient assessment tool, CMS
will continue to receive stakeholder
input from MedPAC and ongoing input
from the provider community, Medicare
beneficiaries, and technical experts. It is
of the utmost importance to CMS to
develop a hospice patient assessment
tool that is scientifically rigorous and
clinically appropriate, thus we believe
that continued and transparent
involvement of stakeholders is critical.
Additionally, it is of the utmost
importance to CMS to minimize data
collection burden on providers; in the
development of any hospice patient
assessment tool, CMS will ensure that
patient assessment data items are not
duplicative or overly burdensome to
providers, patients, caregivers, or their
families.
We received multiple comments
pertaining to a potential hospice patient
assessment tool to collect quality,
clinical and other data with the ability
to be used to inform future payment
refinement efforts. The following is a
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summary of the comments we received
on this topic and our responses.
Comment: CMS received many
comments about the potential new data
collection mechanism—a
comprehensive, standardized hospice
patient assessment instrument—under
consideration for future years. Overall,
the vast majority of commenters were
supportive of CMS’s efforts to develop
a patient assessment tool. Commenters
believed that a patient assessment tool
capturing information on symptom
burden, functional status, and patient,
family, and caregiver preferences has
the potential to more accurately inform
future payment refinements and quality
measure development based on the
needs of the populations served.
Commenters noted that the
development of a patient assessment
tool would be an integral step in
improving care management and
coordination across settings, providing
standardized data on the services that
patients and families receive to better
understand the complex patient
characteristics. One of the commenters,
MedPAC, supported the development of
a patient assessment instrument, noting
its potential value in capturing more
meaningful quality data, as well as
providing more detailed clinical
information that might be useful for
payment policy.
Commenters offered several
suggestions for CMS to consider in
moving forward with the development
of a patient assessment tool. Suggestions
focused on two main themes: (1)
Considerations for the content of any
patient assessment tool (2)
considerations for the process used by
CMS to develop and test a patient
assessment tool. Beyond these two
themes, commenters also listed other
considerations, including cross-setting
considerations (experience with other
assessment tools and relationship to the
IMPACT Act), burden and costs, use for
future payment refinements, and general
concerns.
Regarding considerations for the
content of a patient assessment tool,
overall, commenters emphasized the
unique nature and care goals of hospice,
urging CMS to bear in mind these
complexities in the development of a
patient assessment. Specifically,
commenters stated that the patient
assessment tool should reflect the
holistic nature of hospice care delivery
to the patient and their loved ones and
should include physical, psychosocial,
and spiritual components. Commenters
also noted that the unit of care in
hospice is the patient and family, and
that the initial and ongoing assessment,
as well as care planning and
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interventions, address the holistic care
needs of both the patient and family.
Commenters urged CMS not to limit the
focus of a patient assessment tool to the
clinical, ‘‘head-to-toe’’ nursing
assessment, since care plans in hospice
are often ‘‘more personal than medical’’
with emphasis on the patient’s family
and environment. Similarly,
commenters pointed out the
interdisciplinary nature of hospice, and
recommended that any patient
assessment tool include information
from the entire hospice team. In
consideration of all of these factors,
commenters ultimately urged CMS to
develop data elements that are relevant
and meaningful to hospice practice.
In addition to comments about the
nature and goals of hospice care, several
commenters also had specific content
suggestions for CMS to consider in the
development of a patient assessment
tool:
• Several commenters recommended
that the assessment tool recognize the
patient’s right to refuse or defer offered
services and the importance of an
individualized plan of care.
• Several commenters recommended
that the assessment tool accommodate
care delivered in various settings,
including nursing homes, assisted living
facilities, hospitals, hospice facilities,
and the patient’s home.
• Several commenters recommended
that the assessment tool allow for
modified assessment of patients who are
imminently dying to facilitate a focus on
the urgent and immediate needs of the
patient and family. Commenters noted
that for imminently dying patients, the
focus is the management of symptoms
and the family’s emotions, not
necessarily a detailed medical history
and physical assessment of the patient.
• Several commenters noted that the
assessment tool should preserve the
integrity of the hospice philosophy by
allowing hospice interdisciplinary team
members to individualize assessments
and care based on their best clinical
judgment. Additionally, commenters
recommended that CMS not place
overly restrictive limits on members of
the interdisciplinary team that are
permitted to complete the assessment
tool. Commenters recommended that
CMS allow several disciplines to
contribute patient information and goals
on the assessment, noting that this was
a limitation of other assessment tools.
• One commenter recommended that
CMS collect assessment data beyond the
admission and discharge time points
discussed in the proposed rule (81 FR
25528). The commenter noted the
importance of measuring care
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throughout the entire stay, not just at
admission and discharge.
• Commenters recommended that any
outcome measure derived from the
assessment be risk-adjusted.
• A couple of commenters suggested
that any ‘‘Reason for Discharge’’ item(s)
on the assessment tool differentiate the
reason behind any live discharges (for
example, revoked vs. moved out of
service area).
• One commenter recommended CMS
consider the International Classification
of Function (ICF), in the development of
a patient assessment tool. The
commenter noted that the ICF provides
a scientific basis for understanding
health and health-related states as well
as outcomes, related to both physical as
well as social determinants, and could
be a way to determine appropriate
outcomes more quickly. Finally, the
commenter noted that the ICF is already
integrated into the ICD–10 and ICD–11
taxonomy internationally.
• Another commenter recommended
that CMS align any new hospice
assessment tool with the National
Consensus Project for Quality Palliative
Care Clinical Practice Guidelines for
Quality Palliative Care.
Commenters had several suggestions
regarding the process for development
of any patient assessment tool. The
majority of comments on the process for
assessment tool development focused
on systematically and comprehensively
gathering input from hospice providers
and other stakeholders with respect to
what is appropriate and relevant to
include in the assessment tool.
Commenters offered specific suggestions
of ways to involve the provider
community, including CMS-convened
technical expert panels (TEP) that
include representation from hospices,
physicians, and other members of the
hospice Interdisciplinary Team (IDT). In
addition to TEPs, one commenter
suggested that CMS consider extending
opportunities for input beyond TEPs
and employ widespread processes for
gathering provider input. Commenters
also had suggestions for testing and
refinement of a patient assessment tool.
Commenters recommended piloting the
tool with a wide variety of hospices, to
ensure that the assessment tool is tested
with variation in hospice size, rurality,
state regulatory environments, and
organization type (that is, hospital
based, freestanding, those with inpatient
facilities vs. those who contract for
inpatient care, etc.). Commenters
recommended a pilot testing process
that is thorough and includes a dry-run
period or phased-in implementation
approach. Finally, commenters
encouraged CMS to provide thorough
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and ongoing education and support for
hospices as the patient assessment tool
is implemented. Commenters
specifically requested that educational
materials include clear definitions of
patient assessment items and data
collection procedures.
Several commenters also discussed
their experience with assessment tools
in other care settings (for example, the
OASIS in home health and the MDS in
nursing homes). Some commenters
expressed concerns about potential
overreliance on existing assessment
instrument items citing the difference in
care goals between hospice and other
post-acute care settings. These
commenters emphasized the importance
of creating an assessment tool tailored to
the unique needs of hospice. On the
other hand, commenters also urged CMS
to create an assessment tool that is
aligned and consistent with other
assessment tools to facilitate care
coordination and planning across the
care continuum.
A few commenters offered
considerations on potential burden and
costs of a new assessment instrument.
Commenters urged CMS to pursue
efforts that would limit administrative
burden, reduce redundancy, and ensure
the use of definitions consistent with
other assessment tools. Commenters
noted that the assessment would likely
be completed by different staff than
those who are currently completing the
HIS-Admission and HIS-Discharge
records and that the assessment would
likely be more time-intensive than the
current HIS. Commenters urged CMS to
consider increased costs to providers
and to take into consideration the time
and resources necessary to complete the
assessment.
One commenter suggested that CMS—
as appropriate—consider harmonizing
measures from the IMPACT Act. The
commenter noted that such
harmonization would facilitate
communication among providers and to
measure the care of patient populations
across setting measures. With respect to
use of the patient assessment for future
payment refinements, a few commenters
noted the importance of rigorous testing
of assessment items for inter-rater
reliability and validity.
Beyond the support and suggestions
offered, some commenters did raise
concerns about a patient assessment
tool. Commenters cautioned against a
patient assessment tool that would lead
to ‘‘checklist’’ assessments and undue
restrictions on patient eligibility and the
freedom to employ clinical judgment.
Finally, one commenter had concerns
about the flexibility of electronic
medical record systems to capture
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assessment items in a structured and
minimally burdensome manner.
Response: First, we thank the
commenters for their support of the
development of a patient assessment
tool. We agree that development of a
patient assessment tool is a critical next
step in refining quality data collection
efforts and to inform future refinements
to the hospice payment system. Second,
we greatly appreciate the thoughtful
input and recommendations from the
hospice community. We believe the
initial input from our stakeholders
regarding the content and process for
development of a patient assessment
tool is aligned with our vision and
guiding principles for moving forward
with developing this new data
collection mechanism. We would like to
assure the provider community that we
wholeheartedly agree with commenters
regarding the unique nature of hospice
care, and we intended to keep the
hospice philosophy as the foundation of
the patient assessment tool. We seek to
develop an assessment tool that reflects
the distinctive aspects of hospice care,
including the palliative, rather than
curative, focus of hospice care. We agree
with the points raised by commenters
about the overall focus of an assessment
tool and aims to develop a tool that
addresses the holistic nature of hospice,
incorporating important medical,
psychosocial, spiritual, and other
aspects of care that are important for
patients and their caregivers. We also
appreciate commenters’ specific
suggestions regarding the content of a
patient assessment tool including the
need for a flexible assessment, which
would incorporate input from various
members of the IDT and accommodate
circumstances unique to hospice such
as care of the imminently dying and
patient/caregivers’ right to decline
services or treatment.
With respect to commenters’
suggestions about the process for
development of a patient assessment
tool, we would again like to thank the
hospice community for their detailed
input and careful consideration. Again,
we would like to assure the provider
community that it is our intent to use a
development process that is transparent
and includes multiple opportunities for
stakeholder input. Feedback from the
provider community is vital to the
development of a patient assessment
tool that is meaningful and not unduly
burdensome on providers. As noted by
commenters and discussed in this rule,
CMS plans to hold TEPs to inform the
development, testing, and refinement of
the patient assessment. CMS also plans
to provide other opportunities for
stakeholders to provide input through
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venues such as special open door
forums and other regular HQRP
communication channels. We are
committed to a development process
that will ensure rigorous and iterative
testing of the patient assessment tool in
hospices with varying organizational
characteristics, patient populations,
settings of care delivery, and levels of
care. We recognize the emphasis that we
will need to place on thorough testing
and analysis of items for reliability and
validity, particularly for purposes of any
future payment refinements. Finally, we
agree that ongoing training and
education will be vital, and we will
ensure access to regular HQRP
education and outreach outlets, such as
training webinars, manuals and access
to various Helpdesks.
We also appreciate commenters’
suggestions on cross-setting
harmonization and for sharing their
experience with assessment tools in
other care settings. We would like to
assure commenters that we recognize
the unique nature of hospice care; it is
not our intent to develop an assessment
tool that inappropriately relies on items
from existing tools, such as the
Minimum Data Set (MDS) and Outcome
and Information Assessment
Information Set (OASIS). We will work
diligently with the provider community
to gather information on current
assessment practices in hospice and to
ensure that a hospice assessment tool
would capture the goals of hospice care
and be complementary to current
clinical practice. Regarding the
commenters’ suggestion to harmonize
assessment items and resulting quality
measure with the IMPACT Act quality
measures, we appreciate the
commenter’s suggestion and will take it
under consideration for future measure
and assessment development.
Finally, with respect to concerns
raised by commenters about costs and
administrative burden, as stated in the
rule, it is our goal to minimize data
collection burden on providers and
ensure that patient assessment items are
not duplicative or overly burdensome to
providers, patients, or their families. We
believe that regular, ongoing input from
the provider community will aide in the
development of an assessment that is
not overly burdensome. We expect that
development of the patient assessment
will take into account the ongoing
movement toward use of certified EHRs
and other interoperable health IT across
all patient settings. We expect that our
consultations with providers and with
technical experts including health IT
experts will include assessing and
taking advantage of opportunities to
develop and deploy the instrument in a
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way that integrates with hospice work
flows and with the potential of health IT
to help providers improve care,
communication and coordination across
the interdisciplinary care team while
reducing burden on clinicians and other
care team members by streamlining data
collection and management. In addition,
any patient assessment tool would be
submitted to OMB as required by the
Paperwork Reduction Act, the purpose
of which is to ensure that Federallysponsored data collection efforts pose
no undue burden on the public.
We appreciate the input from the
public regarding the development of a
patient assessment tool for hospice. We
will continue to inform our stakeholders
on any progress and proposals regarding
the patient assessment tool through
future rulemaking cycles.
8. HQRP Submission Exemption and
Extension Requirements for the FY 2017
Payment Determination and Subsequent
Years
In the FY 2015 Hospice Wage Index
final rule (79 FR 50488), we finalized
our proposal to allow hospices to
request, and for CMS to grant,
exemptions/extensions for the reporting
of required HIS quality data when there
are extraordinary circumstances beyond
the control of the provider. When an
extension/exemption 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/
exemption of the requirement to submit
quality data for a specified time period.
In the event that a hospice requests an
extension/exemption for quality
reporting purposes, the hospice would
submit a written request to CMS. In
general, exemptions 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 exemptions or extension for
quality reporting purposes, the hospice
must request an exemption 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
HospiceQRPReconsiderations@
cms.hhs.gov. Exception or extension
requests sent to CMS through any other
channel will not be considered valid.
The request for an exemption or
extension must contain all of the
finalized requirements as outlined on
our Web site at https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospice-
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If a hospice is granted an exemption
or extension, timeframes for which an
exemption or extension is granted will
be applied to the new timeliness
requirement so such hospices are not
penalized. If a hospice is granted an
exemption, we will not require that the
hospice submit any quality data for a
given period of time. By contrast, 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 these quality
data.
This process does not preclude us
from granting extensions/exemptions 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/
exemption 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/exemption to hospices in a
region or locale, we will communicate
this decision through routine CMS
HQRP communication channels,
including postings and announcements
on the CMS HQRP Web site, MLN
eNews communications, national
provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums.
9. Hospice CAHPS® Participation
Requirements for the 2019 APU and
2020 APU
National Implementation of the
Hospice CAHPS® Survey started
January 1, 2015 as stated in the FY 2015
Hospice Wage Index and Payment Rate
Update final rule (79 FR 50452). The
CAHPS® 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. Readers who
want more information are referred 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® Hospice Survey is the
first national hospice experience of care
survey that includes standard survey
administration protocols that allow for
fair comparisons across hospices.
Consistent with many other CMS
CAHPS® 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 the United
States, in order to help patients, family,
friends, and caregivers choose the right
hospice program.
The goals of the CAHPS® Hospice
Survey are to:
• Produce comparable data on
hospice 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.
• Hold hospice care providers
accountable by informing the public
about the providers’ quality of care.
Details regarding CAHPS® Hospice
Survey national implementation, and
survey administration as well as
participation requirements, exemptions
from the survey requirement, hospice
patient and caregiver eligibility criteria,
fielding schedules, sampling
requirements, and the languages in
which is questionnaire, are available on
the CAHPS® Web site,
www.HospiceCAHPSsurvey.org and in
the Quality Assurance Guidelines
(QAG) manual, which is also on the
same site and is available for download.
Measures from the survey will be
submitted to the NQF for endorsement.
b. Participation Requirements To Meet
Quality Reporting Requirements for the
FY 2019 APU
To meet participation requirements
for the FY 2019 APU, hospices must
collect survey data on an ongoing
monthly basis from January 2017
through December 2017 (inclusive).
Data submission deadlines for the 2019
APU can be found in Table 17. The data
must be submitted by the deadlines
listed in Table 17 by the hospice’s
authorized approved CMS vendor.
Hospices provide lists of the patients
who died under their care to form the
sample for the Hospice CAHPS® Survey.
We emphasize the importance of
hospices providing complete and
accurate information to their vendors in
a timely manner. Hospices must
contract with an approved Hospice
CAHPS® Survey vendor to conduct the
survey on their behalf. The hospice is
responsible for making sure their vendor
meets all data submission deadlines.
Vendor failure to submit data on time
will be the responsibility of the hospice.
TABLE 17—CAHPS® HOSPICE SURVEY DATA SUBMISSION DATES FY 2018 APU, FY 2019 APU, AND FY 2020 APU
Quarterly data
submission
deadlines 2
Sample months
(that is, month of death) 1
FY 2018 APU
January–March 2016 (Q1) .......................................................................................................................................................
April–June 2016 (Q2) ..............................................................................................................................................................
July–September 2016 (Q3) .....................................................................................................................................................
October–December 2016 (Q4) ................................................................................................................................................
August 10, 2016.
November 9, 2016.
February 8, 2017.
May 10, 2017.
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FY 2019 APU
January–March 2017 (Q1) .......................................................................................................................................................
April–June 2017 (Q2) ..............................................................................................................................................................
July–September 2017 (Q3) .....................................................................................................................................................
October–December 2017 (Q4) ................................................................................................................................................
August 9, 2017.
November 8, 2017.
February 14, 2018.
May 9, 2018.
FY 2020 APU
January–March 2018 (Q1) .......................................................................................................................................................
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TABLE 17—CAHPS® HOSPICE SURVEY DATA SUBMISSION DATES FY 2018 APU, FY 2019 APU, AND FY 2020 APU—
Continued
Quarterly data
submission
deadlines 2
Sample months
(that is, month of death) 1
April–June 2018 (Q2) ..............................................................................................................................................................
July–September 2018 (Q3) .....................................................................................................................................................
October–December 2018 (Q4) ................................................................................................................................................
November 14, 2018.
February 13, 2019.
May 8, 2019.
1 Data collection for each sample month initiates 2 months following the month of patient death (for example, in April for deaths occurring in
January).
2 Data submission deadlines are the second Wednesday of the submission months, which are Augst, November, February, and May.
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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® 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® Hospice Survey Web site
https://www.hospiceCAHPSsurvey.org.
Hospices that want to claim the size
exemption 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 2019 APU is August 10, 2017.
CMS proposed that hospices that
received their CCN after January 1, 2017
are exempted from the FY 2019 APU
Hospice CAHPS® requirements due to
newness. This exemption will be
determined by CMS. The exemption is
for 1 year only.
c. Participation Requirements To Meet
Quality Reporting Requirements for the
FY 2020 APU
To meet participation requirements
for the FY 2020 APU, hospices must
collect survey data on an ongoing
monthly basis from January 2018
through December 2018 (inclusive).
Data submission deadlines for the 2020
APU can be found in Table 17. The data
must be submitted by the deadlines in
Table 17 by the hospice’s authorized
approved CMS vendor.
Hospices that have fewer than 50
survey-eligible decedents/caregivers in
the period from January 1, 2017 through
December 31, 2017 are exempt from
CAHPS® Hospice Survey data collection
and reporting requirements for the FY
2020 payment determination. To
qualify, hospices must submit an
exemption request form. This form will
be available in first quarter 2018 on the
CAHPS® Hospice Survey Web site
https://www.hospiceCAHPSsurvey.org.
Hospices that want to claim the size
exemption are required to submit to
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CMS their total unique patient count for
the period of January 1, 2017 through
December 31, 2017. The due date for
submitting the exemption request form
for the FY 2020 APU is August 10, 2018.
CMS proposed that hospices that
received their CCN after January 1, 2018
are exempted from the FY 2020 APU
Hospice CAHPS® requirements due to
newness. This exemption will be
determined by CMS. The exemption is
for 1 year only.
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 for 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 final
rule, we added the CAHPS® 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.
• To meet the HQRP requirements for
the FY 2020 payment determination,
hospices would collect survey data on a
monthly basis for the months of January
1, 2018 through December 31, 2018 to
qualify for the full APU.
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e. Hospice CAHPS® Reconsiderations
and Appeals Process
Hospices are required to monitor their
respective Hospice CAHPS® Survey
vendors to ensure that vendors submit
their data on time. The hospice CAHPS®
data warehouse provides reports to
vendors and hospices, including reports
on the status of their data submissions.
Details about the reports and emails
received after data submission should
be referred to the Quality Assurance
Guidelines Manual. If a hospice does
not know how to retrieve their reports,
or lacks access to the reports, they
should contact Hospice CAHPS®
Technical Assistance at
hospiceCAHPSsurvey@hcqis.org or call
them at 1–844 –472 –4621. Additional
information can be found on page 113
of the Hospice CAHPS® Quality
Assurance Guidelines manual Version
2.0 which is available on the Hospice
CAHPS® Web site,
www.hospicecahpssurvey.org.
In the FY 2017 payment
determination and subsequent years,
reporting compliance is determined by
successfully fulfilling both the Hospice
CAHPS® Survey requirements and the
HIS data submission requirements.
Providers would use the same process
for submitting a reconsideration request
that are outlined in section III.C.10 of
this rule.
We received multiple comments
pertaining to the Hospice CAHPS®
Survey. The following is a summary of
the comments we received on this topic
and our responses.
Comment: One commenter expressed
concern about the length of the survey
and described it as a tool that is 36
pages in length and fraught with
arduous stipulations of its delivery. In
addition, the commenter stated that it
would be very difficult for CMS to
monitor compliance with how hospices
are portraying the survey and described
the survey as cumbersome for bereaved
families to complete.
Response: The Hospice CAHPS
Survey consists of a total of 47
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questions, some of which are only asked
when the patient received services in a
specific setting. The Hospice CAHPS
Survey has fewer questions than
NHPCO’s well-known Family
Evaluation of Hospice Care (FEHC)
survey, which has 54 items. We offer a
36-page document on the CAHPS
Survey Web site that contains survey
materials
(www.hospicecahpssurvey.org). The
document packages three copies of the
questionnaire, each set up for a different
optical scanning program. This is
offered for the convenience of the
survey vendors. Vendors will use only
one of these versions. In addition, the
file includes some sample letters for
vendors’ use. We have implemented
detailed specifications for the survey
vendors to follow. This ensures
standardization of survey
administration procedures across
vendors. Standardization is important
for accurate data quality and to ensure
that the data from different vendors is
comparable for public reporting. While
it is true that we have no way to monitor
the way hospices are portraying the
survey, we offer guidelines in the
Quality Assurance Guidelines manual
on the survey Web site
(www.hospicecahpssurvey.org). We rely
on the professionalism of the providers
to cooperate with the survey’s
requirements.
The commenter also states that the
survey is burdensome for bereaved
families to complete. We thank the
commenters for their comments; we
have not received complaints from
respondents regarding the survey being
burdensome. Responses are voluntary
and at the discretion of the person
receiving the survey. If they find the
survey too burdensome, they simply do
not need to respond.
Comment: A few commenters stated
that it is unclear whether public
reporting will use only the eligible HIS
quality measures or will also use the
Hospice CAHPS results. Commenters
claim that the inclusion of Hospice
CAHPS results is essential if Hospice
Compare is to provide a meaningful
reflection of hospice care quality.
Response: We thank the commenters
for their comments. We are currently
building the infrastructure for the new
Hospice Compare site and are
evaluating the best method to include
both the Hospice Item Set measures and
the results of the Hospice CAHPS
Survey.
Comment: One commenter made the
point that, for smaller hospices, Hospice
CAHPS data is likely to be more
vulnerable to variations numerator size
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and variability than comparable data for
larger hospices.
Response: We agree that smaller
hospices may be subject to greater
variability than large ones. We plan to
report an eight-quarter rolling average
for Hospice CAHPS public reporting.
For the initial report, we may include
fewer quarters, but we will build up to
eight quarters and continue on an
ongoing basis. These plans are intended
to counterbalance concerns about
variability of the data while at the same
time including as many hospices as
possible on the Compare site.
Comment: One commenter
recommended that CMS conduct
analysis to determine how CAHPS
results are affected by survey eligibility
requirements and response rates.
Specifically, they express concern about
the relationship between Hospice
CAHPS data and the data that would be
obtained if survey eligibility rules were
modified.
Response: We thank the commenter
for their comments. When a sample is
taken, it is a random sample to represent
the care of all eligible hospice patients.
We do exclude patients who have been
in hospice care for fewer than 48 hours
since their caregivers do not have
enough experience to evaluate the care
provided by the hospice. We intend to
conduct a variety of special and ongoing
analyses of Hospice CAHPS data, as
well as other related data available to
the agency, including analyses of how
non-responders differ from responders
to determine if we need to control for
non-response bias. Generally, the
adjustment is already completed for
differences in the mix of patients across
providers also controls for any nonresponse bias. We will, however,
continue to monitor how eligibility
requirements and response rates impact
the character of the data reported and
whether changes in requirements need
to be made.
Comment: A few commenters
commented that hospices not included
in public reporting might be
disadvantaged.
Response: As mentioned previously,
we are aware that hospices might want
to be included in the Hospice Compare
Web site. We are increasing the number
of quarters included in the rolling
average that will be reported on the
public reporting site. The goal of this
process is to make it possible for a larger
proportion of hospices to be included
on the site, while at the same time
limiting the variability of the results for
smaller hospices.
Comment: One commenter requested
that CMS use two individual questions
from the survey, the hospice rating item
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and the ‘‘willingness to recommend’’
item, on the Hospice Compare Web site.
Response: We plan to include both
the hospice rating question and the
willingness to recommend question as
part of the Hospice CAHPS data
reported on Hospice Compare.
Final Action: After consideration of
comments, we are finalizing our
proposals that hospices that receive
their CCN after January 1, 2017 for the
FY 2019 APU and January 1, 2018 for
the FY 2020 APU are exempted from the
Hospice CAHPS® requirements due to
newness.
10. HQRP Reconsideration and Appeals
Procedures for the FY 2017 Payment
Determination and Subsequent Years
In the FY 2015 Hospice Wage Index
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.
We clarified 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 https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
Reconsideration-Requests.html.
Electronic email sent to
HospiceQRPReconsiderations@
cms.hhs.gov is the only form of
submission that will be accepted. Any
reconsideration requests received
through any other channel including the
United States Postal Service or phone
will not be considered as a valid
reconsideration request. We codified
this process at § 418.312(h). In addition,
we codified at § 418.306(b)(2) that
beginning with FY 2014 and each
subsequent FY, the Secretary shall
reduce the market basket update by 2
percentage points for any hospice that
does not comply with the quality data
submission requirements for that FY
and solicited comments on all of the
proposals and the associated regulations
text at § 418.312 and in § 418.306 in
section VI. Official instructions
regarding the payment reduction
reconsideration process can be located
under the Regulations and Guidance,
Transmittals, 2015 Transmittals Web
site at https://www.cms.gov/
Regulations-and-Guidance/Guidance/
Transmittals/2015-Transmittals-Items/
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R52QRI.html?DLPage=1&DLEntries
=10&DLSort=4&DLSortDir=descending.
In the past, only hospices found to be
non-compliant with the reporting
requirements set forth for a given
payment determination received a
notification from CMS of this finding
along with instructions for requesting
reconsideration in the form of a United
States Postal Service (USPS) letter. In
the FY 2016 Hospice Wage Index final
rule (80 FR 47198), we stated that we
would use the QIES CASPER reporting
system as an additional mechanism to
communicate to hospices regarding
their compliance with the reporting
requirements for the given reporting
cycle. We will implement this
additional communication mechanism
via the QIES CASPER timeliness
compliance reports referenced in
section III.C.7e of this final rule. As
stated in section III.C.7e of the rule,
these QIES CASPER reports will be
automated reports that hospices will be
able to generate at any point in time to
determine their preliminary compliance
with HQRP requirements, specifically,
the timeliness compliance threshold for
the HIS. We believe the QIES CASPER
timeliness compliance reports meet
CMS’s intent of developing a method to
communicate as quickly, efficiently, and
broadly as possible with hospices
regarding their preliminary compliance
with reporting requirements. We will
continue to send notification of
noncompliance via delivery of a letter
via the United States Postal Service.
Requesting access to the CMS systems is
performed in 2 steps. Details are
provided on the QIES Technical
Support Office Web site at https://
www.qtso.com/hospice.html. Providers
may access the CMS QIES Hospice
Users Guides and Training by going to
the QIES Technical Support Office Web
site and selecting Hospice and then
selecting the CASPER Reporting Users
Guide at https://www.qtso.com/
hospicetrain.html. Additional
information about how to access the
QIES CASPER reports will be provided
prior to the availability of these new
reports.
We proposed to disseminate
communications regarding the
availability of hospice compliance
reports in CASPER files through CMS
HQRP communication channels,
including postings and announcements
on the CMS HQRP Web site, MLN
eNews communications, national
provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums. We
further proposed to publish a list of
hospices who successfully meet the
reporting requirements for the
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applicable payment determination on
the CMS HQRP Web site https://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
index.html. We proposed updating the
list after reconsideration requests are
processed on an annual basis. We
clarified that the published list of
compliant hospices on the CMS HQRP
Web site would include limited
organizational data, such as the name
and location of the hospice. Finalizing
the list of compliant providers for any
given year is most appropriately done
after the final determination of
compliance is made. It is our intent for
the published list of compliant hospices
to be as complete and accurate as
possible, giving recognition to all
providers who were compliant with
HQRP requirements for that year.
Finalizing the list after requests for
reconsideration are reviewed and a final
determination of compliance is made
allows for a more complete and accurate
listing of compliant providers than
developing any such list prior to
reconsideration. Developing the list
after the final determination of
compliance has been made allows
providers whose initial determination of
noncompliance was reversed to be
included in the list of compliant
hospices for that year. We believe that
finalizing the list of compliant hospices
annually after the reconsideration
period will provide the most accurate
listing of hospices compliant with
HQRP requirements.
11. 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. Such procedures shall ensure
that a hospice program has the
opportunity to review the data that is to
be made public for the hospice program
prior to such data being made public.
The Secretary shall report quality
measures that relate to hospice care
provided by hospice programs on the
CMS Web site.
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 transparent 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
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52183
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 7
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 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 1 or 2 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) was not used for assessing validity
and reliability of the quality measures.
We analyzed data collected by hospices
during Quarter 4 (Q4) CY 2014 and Q1
through Q3 CY 2015. Preliminary
analyses of HIS data show that all 7
quality measures that can be calculated
using HIS data are eligible for public
reporting (NQF #1634, NQF #1637, NQF
#1639, NQF #1638, NQF #1641,
modified NQF #1647, NQF #1617).
Based on analyses conducted to
establish reportability of the measures,
71 percent through 90 percent of all
hospices would be able to participate in
public reporting, depending on the
measure. For additional details
regarding analysis, we refer readers to
the Measure Testing Executive
Summary document available on the
‘‘Current Measures’’ section of the CMS
HQRP Web site: https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/CurrentMeasures.html. Although analyses show
that many hospices perform well on the
7 measures from the HIS measure set,
the measures still show variation,
especially among hospices with
suboptimal performance, indicating that
these measures are still meaningful for
comparing quality of care across hospice
providers. In addition to conducting
quantitative analysis to establish
scientific acceptability of the HIS
measures, CMS’s measure development
contractor conducted interviews with
family and caregivers of hospice
patients. The purpose of these
interviews was to determine what
information patients and caregivers
would find useful in selecting hospices,
as well as gathering input about patient
and caregiver experience with hospice
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care. Results from these interviews
indicate that all 7 HIS quality measures
provide consumers with useful
information. Interview participants
stated that quality measure data would
be especially helpful in identifying poor
quality outliers that inform
beneficiaries, families, caregivers, and
other hospice stakeholders.
To inform which of the HIS measures
are eligible for public reporting, CMS’s
measure development contractor, RTI
International, examined the distribution
of hospice-level denominator size for
each quality measure to assess whether
the denominator size is large enough to
generate the statistically reliable scores
necessary for public reporting. This goal
of this analysis is to establish the
minimum denominator size for public
reporting, which is referred to as
‘‘reportability’’ analysis. Reportability
analysis is necessary since small
denominators may not yield statistically
meaningful QM scores. Thus, for other
quality reporting programs, such as
Nursing Home Compare,35 CMS sets a
minimum denominator size for public
reporting, as well as the data selection
period necessary to generate the
minimum denominator size.
Reportability analysis showed that
calculating and publicly displaying
measures based on 12 months of data
would allow for sufficient measure
denominator size. Having ample
denominator size ensures that quality
measure scores that are publicly
reported are reliable and stable; a
minimum sample size of 20 stays is
commonly applied to assessment-based
quality measures in other reporting
programs. The 12-month data selection
period produced significantly larger
mean and median sample sizes among
hospices, which will generate more
reliable quality measure scores.
Additionally, our analysis revealed that
when applying a minimum sample size
of 20 stays, using rolling 12 months of
data to create QMs would only exclude
about 10 percent through 29 percent of
hospices from public reporting,
depending on the measure. For more
information on analyses conducted to
determine minimum denominator size
and data selection period, we refer
readers to the Reportability Analysis
Section of the Measure Testing
Executive Summary, available on the
‘‘Current Measures’’ portion of the CMS
HQRP Web site: https://www.cms.gov/
Medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospice35 ‘‘CMS Nursing Home Quality Initiative—
Centers for Medicare . . .’’ 2011. 25 Jan. 2016
https://www.cms.gov/nursinghomequalityinits/45_
nhqimds30trainingmaterials.asp.
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Quality-Reporting/CurrentMeasures.html.
Based on reportability analysis and
input from other stakeholders, we have
determined that all 7 HIS measures are
eligible for public reporting. Thus, we
plan to publicly report all 7 HIS
measures on a CMS Compare Web site
for hospice agencies. For more details
on each of the 7 measures, including
information on measure background,
justification, measure specifications,
and measure calculation algorithms, we
refer readers to the HQRP QM User’s
Manual, which is available on the
downloads portion of the Current
Measures CMS HQRP Web site: https://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
Current-Measures.html. Individual
scores for each of the 7 HIS measure
scores would be reported on a new
publicly available CMS Hospice
Compare Web site. Current reportability
analysis indicates that a minimum
denominator size of 20 based on 12
rolling months of data would be
sufficient for public reporting of all HIS
quality measures. Under this
methodology, hospices with a quality
measure denominator size of smaller
than 20 patient stays would not have the
quality measure score publicly
displayed since a quality measure score
on the basis of small denominator size
may not be reliable. We will continue to
monitor quality measure performance
and reportability and will adjust public
reporting methodology in the future if
needed.
Reportability analysis is typically
conducted on a measure-by-measure
basis. We would like to clarify that any
new measure adopted as part of the
HQRP will undergo reportability
analysis to determine: (1) If the measure
is eligible for public reporting; and (2)
the data selection period and minimum
denominator size for the measure.
Results of reportability analyses
conducted for new measures will be
communicated through future
rulemaking.
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. We are
currently developing the infrastructure
for public reporting and will provide
hospices an opportunity to review their
quality measure data prior to publicly
reporting information about the quality
of care provided by Medicare-certified
hospice agencies throughout the nation.
These quality measure data reports or
‘‘preview reports’’ will be made
available in the CASPER system prior to
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public reporting and will offer providers
the opportunity to review their quality
measure data prior to public reporting
on the CMS Compare Web site for
hospice agencies. Under this process,
providers would have the opportunity
to review and correct data they submit
on all measures that are derived from
the Hospice Item Set. Reports would
contain the provider’s performance on
each measure calculated based on HIS
submission to the QIES ASAP system.
The data from the HIS submissions
would be populated into reports with all
data that have been submitted by the
provider. CMS will post preview reports
with sufficient time for providers to be
able to submit, review data, make
corrections to the data, and view their
data. Providers are encouraged to
regularly evaluate their performance in
an effort to ensure the most accurate
information regarding their agency is
reflected.
We also plan to make available
additional provider-level feedback
reports, which are separate from public
reporting and will be for provider
viewing only, for the purposes of
internal provider quality improvement.
As is common in other quality reporting
programs, quality reports would contain
feedback on facility-level performance
on quality metrics, as well as
benchmarks and thresholds. For the CY
2015 Reporting Cycle, several new
quality reporting provider participation
reports were made available in CASPER.
Providers can access a detailed list and
description of each of the 12 reports
currently available to hospices on the
QIES Web site, under the Training &
Education Selections, CASPER
Reporting Users Guide at https://
www.qtso.com/hospicetrain.html. We
anticipate that providers would use the
quality reports as part of their Quality
Assessment and Performance
Improvement (QAPI) efforts.
Furthermore, to meet the requirement
for making such data public, we are
developing a CMS Hospice Compare
Web site, which will provide valuable
information regarding the quality of care
provided by Medicare-certified hospice
agencies throughout the nation.
Consumers would be able to search for
all Medicare approved hospice
providers that serve their city or zip
code (which would include the quality
measures and CAHPS® Hospice Survey
results) and then find the agencies
offering the types of services they need,
along with provider quality information.
Based on the efforts necessary to build
the infrastructure for public reporting,
we anticipate that public reporting of
the eligible HIS quality measures on the
CMS Compare Web site for hospice
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agencies will begin sometime in the
spring/summer of CY 2017. To help
providers prepare for public reporting,
we will offer opportunities for
stakeholder engagement and education
prior to the rollout of a Hospice
Compare site. We will offer outreach
opportunities for providers through the
MLN eNews, Open Door Forums and
Special Open Door Forums; we will also
post additional educational materials
regarding public reporting on the CMS
HQRP Web site. Finally, we will offer
training to all hospice providers on the
systems and processes for reviewing
their data prior to public reporting;
availability of trainings will be
communicated through the regular CMS
HQRP communication channels,
including postings and announcements
on the CMS HQRP Web site, MLN
eNews communications, national
provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums.
Like other CMS Compare Web sites,
the Hospice Compare Web site will, in
time, feature a quality rating system that
gives each hospice a rating of between
1 and 5 stars. Hospices will have
prepublication access to their own
agency’s quality data, which enables
each agency to know how it is
performing before public posting of data
on the Hospice Compare Web site.
Public comments regarding how the
rating system would determine a
hospice’s star rating and the methods
used for calculations, as well as a
proposed timeline for implementation
will be announced via regular CMS
HQRP communication channels,
including postings and announcements
on the CMS HQRP Web site, MLN
eNews communications, provider
association calls, and announcements
on Open Door Forums and Special Open
Door Forums. We will announce the
timeline for development and
implementation of the star rating system
in future rulemaking.
Lastly, as part of our ongoing efforts
to make healthcare more transparent,
affordable, and accountable for all
hospice stakeholders, the HQRP is
prepared to post hospice data on a
public data set, the Data.Medicare.gov
Web site, and directory located at
https://data.medicare.gov. This site
includes the official datasets used on
the Medicare.gov Compare Web sites
provided by CMS. In addition, this data
will serve as a helpful resource
regarding information on Medicarecertified hospice agencies throughout
the nation. In an effort to move toward
public reporting of hospice data, we will
initially post demographic data of
hospice agencies that have been
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registered with Medicare. This list will
include high-level demographic data for
each agency including, provider name,
address, phone numbers, ownership
type, CMS Certification Number (CCN),
profit status, and date of original CMS
certification. The posting of this new
hospice data directory occurred on June
14, 2016. Information can be located at
https://data.medicare.gov/data/hospicedirectory. Additional details regarding
hospice datasets will be announced via
regular CMS HQRP communication
channels, including postings and
announcements on the CMS HQRP Web
site, MLN eNews communications,
national provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums. In
addition, we have provided the list of
CASPER/ASPEN and Regional Office
coordinators in the event the Medicarecertified agency is either not listed in
the database or the characteristics/
administrative data (name, address,
phone number, services, or type of
ownership) are incorrect or have
changed. To continue to meet Medicare
enrollment requirements, all Medicare
providers are required to report changes
to their information in their enrollment
application as outlined in the ProviderSupplier Enrollment Fact Sheet Series
located at https://www.cms.gov/
Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/
downloads/MedEnroll_InstProv_
FactSheet_ICN903783.pdf.
Comment: CMS received several
comments that were supportive of
public reporting of hospice quality
measures. Commenters noted that they
were in favor of CMS’s efforts to
publicly report hospice quality data to
support the timely and transparent
reporting of HQRP data. One commenter
shared that public reporting of valid and
reliable quality data demonstrates value,
underpins compliance, and provides
structure for hospice care. Several
commenters did have suggestions,
recommendations, and concerns about
specific aspects of the public display of
hospice quality measure data. These
specific comments are summarized
below.
Response: We appreciate the
commenters’ support of public reporting
of hospice quality measures. We address
commenters’ specific concerns with
respect to public reporting reports
below.
Comment: CMS received a few
comments expressing concerns that
many hospice providers have high
scores on the current HIS measures and
some Hospice CAHPS measures. The
potential lack of variation in scores for
these measures may make
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differentiating between hospice
providers’ performance challenging for
consumers. Given the limited range of
scores, commenters thought that
presenting data as rankings or
percentiles may present results in a way
that does not provide valuable
information to consumers. One
commenter suggested that CMS consider
risk-adjusting quality measures reported
on the Compare Web site.
Response: We agree that all publicly
reported data should be presented in a
manner that is meaningful and
understandable to the general public.
We will take steps and use recognized
practices to ensure that any publicly
reported data is displayed in an
appropriate and meaningful manner. We
are developing the format and content
for public display of quality measure
data on the Hospice Compare site. We
appreciate the commenters input on
how to most meaningfully display
quality measure data and will take these
suggestions into consideration as we
finalize the format of public reporting
(that is, whether to report scores or the
percentiles for each quality measure
(QM)).
Regarding commenters’ concerns
about the lack of variation in current
HIS measure scores, the overall
distribution and variability of the seven
currently adopted HIS QMs is an
indicator that most hospices are
providing the required and
recommended care to the majority of the
patients around hospice admission,
demonstrating overall high quality of
care. However, the seven measures
demonstrate room for improvement.
Analysis conducted by our measure
development contractor demonstrates
that a low percentage of hospices have
perfect scores for most measures and a
small percentage of hospices have very
low scores. We believe this is valuable
and important information to
communicate to consumers as well as to
providers to motivate quality
improvement. Additionally, we are
working on the specific format for
publicly reporting these 7 QMs and will
take commenters’ suggestions into
consideration. We agree that given the
skewed distribution, presenting hospice
scores in formats like percentiles may
provide misleading information.
Presenting hospices’ quality scores may
provide information that is more
straightforward for consumers and
providers. Finally, input that we have
received from hospice caregivers will
also inform our strategy for public
reporting of quality measure data. Our
measure development contractor
interviewed hospice caregivers about
public display of quality data and what
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types of data would be most meaningful
to consumers. In these interviews,
respondents supported the continued
data collection and reporting of the
individual HIS measures, noting that
information on the individual measures
is valuable to consumers. Respondents
also noted that although overall
performance on the 7 HIS measures is
high, public display of these scores
would still be meaningful as a way to
identify low-performing hospices.
With respect to the commenter’s
suggestion to risk adjust quality
measures reported on the Hospice
Compare Web site, we would like to
point out that both the current HIS
measure set (NQF #1634, NQF #1637,
NQF #1639, NQF #1638, NQF #1617,
NQF #1641 and NQF #1647) and
Hospice CAHPS quality measures are
currently under review by the National
Quality Forum (NQF) for maintenance
endorsement and endorsement,
respectively. NQF criteria for review
and endorsement includes
consideration of risk adjustment. As
stated in section III.C.3 of this rule, it is
CMS’s intent to implement endorsed
quality measures, using the
specifications as endorsed by the NQF.
Comment: A few commenters
suggested that CMS provide quarterly
benchmark data to hospices for at least
1 year in advance of publicly reporting
the data. Commenters believed the
benchmark data would demonstrate to
individual hospices how they perform
compared to all hospices on the existing
measures and allow opportunity for
improvement prior to the onset of
public reporting. One commenter shared
that hospices have found stable
benchmark scores for comparison to be
far more useful for setting goals and
tracking performance improvement.
Response: We appreciate the
commenters’ suggestion to provide
quarterly benchmark data. As we
previously stated, we plan to make
available additional provider-level
feedback reports prior to public
reporting; these reports will help
hospices with their quality assessment
and performance improvement efforts.
As is common in other quality reporting
programs, these reports would provide
feedback on facility-level performance
on quality metrics, as well as national
benchmarks. Additionally, national
means of the HIS quality measures,
based on Q4 2014 through Q3 2015 HIS
data, are reported in the Hospice
Quality Reporting Program: Executive
Summary of Measure Testing and
Validation, available on the ‘‘Current
Measures’’ portion of the CMS HQRP
Web site: https://www.cms.gov/
Medicare/Quality-Initiatives-Patient-
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Assessment-Instruments/HospiceQuality-Reporting/CurrentMeasures.html.
Comment: One commenter urged
CMS to not only showcase quality
measures from HIS and Hospice
CAHPS, but also demonstrate the scope
and level of services provided by
different hospice programs. The
commenter stated that while hospices
are required to be able to provide certain
services, patient and family access to
these services varies, especially for the
non-clinical services. In addition, this
commenter stated that there is variation
in how well hospices meet the
requirements. Moreover, the commenter
stated that and a lack of enforcement
allowed lower quality programs to
minimally comply with requirements, if
at all. For example, many hospice
programs send mailings to families on
bereavement; while this technically
meets the bereavement requirements
under the benefit; other hospices offer
and provide robust, individualized
bereavement support. The commenter
thought that it would be important for
consumers to have information about
these services to help them select a
hospice.
Response: We appreciate the
commenter’s recommendation to report
quality metrics and hospice information
beyond HIS and Hospice CAHPS
measures. We recognize that
information regarding the scope and
level services provided would be
valuable to consumers and hospice
providers; however, we note that such
information may not be readily available
to us through billing records or other
reporting mechanisms, and we are
cognizant of the burden additional
reporting could place on providers. We
will take this recommendation into
consideration as we move forward with
the development for future HQRP
measures.
Comment: The majority of
commenters supported the minimum
denominator size for public reporting.
Although commenters were generally
supportive of this requirement, some
commenters had concerns about the
possible negative impact on small
hospices for which quality information
is not included in public reporting due
to not meeting the minimum
denominator size. Commenters noted
that hospices who do not meet the
threshold of 20 stays for the HIS-based
QMs or the size exemption for Hospice
CAHPS® Survey, which is less than 50survey eligible patients in the previous
year, would not be included in all or
part of public reporting. Commenters
raised concerns that a lack of displayed
data on Hospice Compare may
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disadvantage these smaller providers.
Commenters believed that consumers
using Hospice Compare to search for a
provider might disregard hospices that
do not have some or all of their data
displayed due to size issues, and that,
in turn, consumers may be more likely
to seriously consider only those
hospices for which quality information
is presented. One commenter expressed
concerns that there are some important
statistical considerations, in addition to
denominator size, that should be
addressed in creating a means for public
display of hospice quality data.
Specifically, the commenter noted that
a small denominator that meets the
minimum denominator size is more
sensitive to fluctuations in the
numerator than a large denominator.
Smaller hospices are likely to have
smaller denominators and are more
vulnerable to numerator size and
variability than larger hospices. The
commenters suggested that CMS create
a means to counterbalance the potential
negative consequences for those
hospices for which quality information
is not included in public reporting.
Response: We thank the commenters
for their support of our recommendation
to set a minimum denominator size for
public reporting. We appreciate
commenters sharing concerns regarding
the possible negative impact on small
hospices. To establish the minimum
denominator size, we examined the
national hospice-level denominator size
for the HIS quality measures. The
determination of the minimum
denominator size balanced the necessity
of yielding statistically meaningful QM
scores and the goal of allowing as many
hospices to have their quality measure
scores publicly displayed as possible.
To be consistent with other quality
reporting programs’ public reporting
policies, we set a minimum
denominator size for public reporting of
quality measures, as well as the data
selection period necessary to generate
the minimum denominator size. The
minimum denominator size is
determined based on a hospice’s patient
stays over a 12-month period. Analysis
conducted by RTI International shows
that only about 10 percent of hospices
would not have accumulated 20 patient
stays to have any HIS quality measure
publicly displayed. RTI’s analysis also
shows that quality measures calculated
based on 12 months of data are stable
and robust against fluctuation. These
results were summarized in the Measure
Testing Executive Summary document
referenced in this section of the rule and
posted on the ‘‘Current Measures’’
portion of the CMS HQRP Web site:
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https://www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
Current-Measures.html. On the Hospice
Compare Web site, CMS plans to
indicate in some manner (for example,
through a footnote or some other
statement) instances where data is not
displayed due to denominator size
issues. We believe this will minimize
any potential negative impact on small
providers and signal to consumers that
in such instances, the lack of data is a
result of the hospice having too few
admissions to allow for reporting of a
valid quality measure, and is not in and
of itself an indicator of hospice quality.
Finally, we will take the commenters
suggestion regarding creating a means to
counterbalance the potential negative
consequences for small hospices as we
move forward with the development
and launch of Hospice Compare.
Comment: CMS received several
comments regarding data sources that
would be included in the launch of
Hospice Compare. Overall, commenters
offered two main considerations. First,
commenters brought up concerns about
the limitations of HIS data for consumer
decision-making. Second, commenters
requested clarification from and
encouraged CMS to include Hospice
CAHPS data in the launch of Hospice
Compare. Regarding the first concern,
commenters noted that HIS data alone
might provide inadequate information
to aid in consumer decision-making.
Commenters noted that all HIS
measures are process of care measures
and, as such, do not address important
issues such as whether the patient/
family was treated with respect or felt
supported by the hospice team. They
strongly recommended that the Hospice
CAHPS results be reported along with
HIS measures to provide consumers
with the most meaningful and
comprehensive picture of quality of
care. Finally, commenters encouraged
CMS to provide appropriate disclaimers
about the hospice quality data and
information, outlining the limitations of
the data and its utility.
Response: We appreciate the
commenters’ feedback on public
reporting of HIS and Hospice CAHPS
data. We agree with commenters that
HIS and Hospice CAHPS data are
complementary and, together, provide a
more meaningful and comprehensive
view of quality of care provided by
hospices. As noted in section III.C.9 of
this rule, we plan to include both HIS
and Hospice CAHPS data in the launch
of Hospice Compare. Reporting both
data sources will address commenters’
concerns and mirrors the approach for
public reporting used in other CMS
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Compare sites. We will communicate
additional plans for the public reporting
of hospice quality data through the
usual CMS HQRP communication
channels, including postings and
announcements on the CMS HQRP Web
site, MLN eNews communications,
national provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums.
Comment: A few commenters
expressed concerns that consumers will
not understand the difference between a
process measure and an outcome
measure and be able to draw
conclusions about the experience of
hospice care from just the composite
process measure. One commenter
shared that CMS needs to provide
education and resources to help the
public understand what the measures
mean.
Response: We agree that any publicly
reported data should be presented in a
manner that is meaningful and
understandable by the public. We
intend to take steps and use recognized
practices to ensure that any publicly
reported data is displayed in an
appropriate and meaningful manner. We
intend to work with our Web site
development contractor to ensure that
the Hospice Compare site has been
tested for usability, readability, and
navigation, and that consumers and
stakeholders are continuously involved
and have opportunities for input
throughout the development process.
We will write in plain language, with
awareness of variations in health and
general literacy, and solicit input from
key stakeholders and technical experts
in the development of the presentation
of publicly available quality data.
Comment: CMS received a few
comments regarding concerns about the
publicly reported HIS measures because
they are constructed using HIS data that
is self-reported by hospice providers.
Commenters had concerns about the
validity of this data and encouraged
CMS to determine methods to monitor
the veracity of the data being submitted.
Commenters noted that the launch of
Hospice Compare might create perverse
incentives for hospices to submit false
data to avoid unfavorable scores being
publicly reported on the Compare Web
site.
Response: We acknowledge
commenters’ concerns regarding the
validity of self-reported HIS measures.
Publicly reported quality measure data
relies on the submission of valid and
reliable data at the patient level. Our
measure development contractor
conducts ongoing testing and validation
of the quality measure data to identify
data irregularities and trends. We will
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52187
consider additional validation processes
for future rulemaking cycles.
Comment: CMS received a few
comments expressing providers’ desire
to review data prior to publication. One
commenter inquired about the process
for correcting data errors.
Response: We appreciate the
commenters’ interest in reviewing data
prior to public reporting. We would like
to take this opportunity to clarify the
processes available to providers for
reviewing and making changes to HIS
data, and for previewing QM scores
prior to public display. First, as outlined
in the HIS Manual, providers have the
opportunity to make corrections to HIS
data through HIS record modification
and inactivation processes. HIS record
modifications and inactivations are
available if a provider finds an error in
HIS data that has been submitted and
accepted by the QIES ASAP system.
Further details on processes for
modifications and inactivations are
available in Chapter 3 of the HIS
Manual, available on the HIS portion of
the CMS HQRP Web site: https://
www.cms.gov/Medicare/QualityInitiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/
Hospice-Item-Set-HIS.html. It is vital for
providers to correct any errors in HIS
data to ensure information in the QIES
ASAP system accurately reflects the
patient’s hospice record and HIS-related
care processes delivered to the patient;
this initial corrections process for errors
in HIS data helps ensure QM scores and
any publicly displayed data are
accurate.
In addition to modification and
inactivation processes available in QIES
ASAP, as we previously stated, we are
currently developing the infrastructure
to provide hospices with the
opportunity to view their quality
measure data via CASPER providerlevel feedback reports. These internal
provider-level feedback reports will
provide hospices an initial opportunity
to review QM score data in CASPER.
Provider-level feedback reports are
confidential and separate from the
public reporting processes. The purpose
of provider-level feedback reports is to
provide hospices with QM score data
that can be used at the individual
facility level and for internal quality
improvement. We are planning for
release of the QM provider-level
feedback reports sometime in December
of 2016. Availability of the new
CASPER QM reports will be
communicated to providers through the
usual CMS HQRP communication
channels, including postings and
announcements on the CMS HQRP Web
site, MLN eNews communications,
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national provider association calls, and
announcements on Open Door Forums
and Special Open Door Forums.
Finally, we will ensure providers
have the opportunity to preview QM
score data to be displayed on Hospice
Compare, prior to public posting of the
data. Prior to public reporting, quality
measure data ‘‘preview’’ reports will be
made available in CASPER system.
Hospices will have a 30-day preview
period prior to public display during
which they can preview the
performance information on their
measures that will be made public. The
‘‘preview’’ reports will be made
available using the Certification and
Survey Provider Enhanced Reporting
(CASPER) System because hospices are
familiar with this system. In line with
other PAC QRPs, hospices will have 30
days to review this information,
beginning from the date on which they
can access the preview report.
Corrections to the underlying data
would not be permitted during this
time; however, hospices would be able
to ask for a correction to their measure
calculations during the 30-day preview
period. If we determine that the
measure, as it is displayed in the
preview report, contains a calculation
error, we would suppress the data on
the public reporting Web site,
recalculate the measure and publish the
corrected rate at the time of the next
scheduled public display date. This
process is consistent with informal
processes used in the Hospital IQR and
other PAC programs. Technical details
for how and when providers may
contest their measure calculations, as
well as the process for submitting a
suppression request will be conveyed
through the usual CMS HQRP
communication channels.
Comment: CMS received a comment
in support of the initiative to make
available additional provider-level
feedback reports in the CASPER
reporting system. The commenter
requested CMS consider additional
reports to display quality metric scores
that would be available 2 days after HIS
records are submitted and accepted by
the QIES ASAP system.
Response: We appreciate the
commenter’s support of the initiative to
provide additional provider-level
feedback reports in CASPER. We agree
that providing timely feedback to
hospice providers is a critical step in the
process of quality improvement since
providers need data about their
performance to inform QAPI and other
performance improvement efforts. We
will continue to refine the providerlevel feedback reports to make timely
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data available to providers within the
CASPER system.
Comment: One commenter expressed
concerns regarding consumers leaving
anonymous negative comments or
grievances on the Hospice Compare
Web site. The commenter noted that
there is no manner for the hospice to
respond to or rebut negative comments
or grievances.
Response: We would like to thank the
commenters for taking the time to
convey their concerns regarding
consumers leaving anonymous negative
comments or grievances on the Hospice
Compare Web site. Consumers will only
be able to search for hospice providers
and review quality data; they will not be
able to post comments or grievances on
the CMS Hospice Compare Web site.
Comment: Though commenters were
generally supportive of public reporting
of quality data, several commenters
expressed concerns over the
methodology for the star rating system
to be used in the future as part of the
Hospice Compare Web site. One
commenter urged CMS to be
conservative and cautious about the use
of star ratings when applied to Hospice
CAHPS data because patient and family
experience with care data is typically
positively skewed. A few commenters
cautioned CMS against evaluating
hospice providers along a bell curve
rather than on a grading scale when
developing star ratings for hospice
providers. They shared that the use of
a bell curve creates confusion for
consumers and may misrepresent the
quality of the care provided by hospices.
Commenters encouraged CMS to
develop a star-rating methodology that
incorporates both HIS and Hospice
CAHPS data. A few commenters
suggested that CMS provide sufficient
time for stakeholders to review the star
ratings model. One commenter voiced
concerns about star-rating
methodologies used in other care
settings and recommended CMS take
into consideration lessons learned about
unintended consequences when
developing the hospice star rating
system. One commenter recommended
that CMS take a criterion approach to
constructing the CMS Hospice Compare
Web site and determining the
methodology to be used for calculating
star ratings. Another commenter stated
that any star rating system developed
should reflect care provided by the
entire interdisciplinary team and should
be risk adjusted to account for
individualized care, short lengths of
stay and patient right to refuse care.
Response: We appreciate the thorough
and detailed input on the development
of a Hospice Compare Web site and the
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future development of a star rating
system for hospices. We would like to
assure commenters that it is of
paramount concern to develop a star
rating methodology that is valid, is
reliable, and presents quality data that
is meaningful to stakeholders. As with
the development of star methodology in
other care programs, we will allow
continued opportunities for the provider
community and other stakeholders to
comment on and provide input to the
proposed rating system. In addition to
regular HQRP communication channels,
we will solicit input from the public
regarding star methodology through
special listening sessions, invitation to
submit comments via a Help Desk
mailbox, Open Door Forums, a
Technical Expert Panel, and other
opportunities. Additionally, we will
benefit from lessons learned from the
development and implementation of
star ratings in other QRPs to help guide
the hospice star rating initiative.
D. The Medicare Care Choices Model
We want to remind the provider
community that the Medicare Care
Choices Model (MCCM) is testing a new
option for Medicare beneficiaries with
certain advanced diseases to receive
hospice-like support services from
MCCM hospices while receiving care
from other Medicare providers for their
terminal condition. This 5 year model is
being tested to encourage greater and
earlier use of the Medicare and
Medicaid hospice benefit to determine
whether it can improve the quality of
life and care received by Medicare
beneficiaries, increase beneficiary,
family, and caregiver satisfaction, and
reduce Medicare or Medicaid
expenditures. Participation in the model
is limited to Medicare and dual eligible
beneficiaries with advanced cancers,
chronic obstructive pulmonary disease,
congestive heart failure, and Human
Immunodeficiency Virus/Acquired
Immune Deficiency Syndrome who
qualify for the Medicare or Medicaid
hospice benefit and meet the eligibility
requirements of the model. The model
includes more than 130 hospices from
39 states across the country and is
projected to serve 100,000 beneficiaries
by 2020. The first cohort of MCCM
participating hospices began providing
services under the model in January
2016, and the second cohort will begin
to provide services under the model in
January 2018. The last patient will be
accepted into the model 6 months
before the December 31, 2020 model
end date.
For more information, see the MCCM
Web site: https://innovation.cms.gov/
initiatives/Medicare-Care-Choices/.
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IV. Collection of Information
Requirements
Under the Paperwork Reduction Act
of 1995, we are required to provide 60day notice in the Federal Register and
solicit public comment before a
collection of information requirement is
submitted to the Office of Management
and Budget (OMB) for review and
approval. To fairly evaluate whether an
information collection should be
approved by OMB, section 3506(c)(2)(A)
of the Paperwork Reduction Act of 1995
requires that we solicit comment on the
following issues:
• The need for the information
collection and its usefulness in carrying
out the proper functions of our agency.
• The accuracy of our estimate of the
information collection burden.
• The quality, utility, and clarity of
the information to be collected.
• Recommendations to minimize the
information collection burden on the
affected public, including automated
collection techniques.
We solicited public comment on each
of the following information collection
requirements (ICRs).
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A. Information Collection Requirements
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, manner,
and at a time specified by the Secretary.
In the FY 2014 Hospice Wage Index
final rule (78 FR 48257), and in
compliance with section 1814(i)(5)(C) of
the Act, we finalized the specific
collection of data items that support the
following six NQF-endorsed measures
and one modified measure for hospice:
• NQF #1617 Patients Treated with
an Opioid who are Given a Bowel
Regimen,
• NQF #1634 Pain Screening,
• NQF #1637 Pain Assessment,
• NQF #1638 Dyspnea Treatment,
• NQF #1639 Dyspnea Screening,
• NQF #1641 Treatment Preferences,
• NQF #1647 Beliefs/Values
Addressed (if desired by the patient)
(modified).
Data for the aforementioned 7
measures is collected via the HIS. Data
collection for the 7 NQF-endorsed
measures via the HIS V1.00.0 was
approved by the Office of Management
and Budget April 3, 2014 (OMB control
number 0938–1153—Hospice Quality
Reporting Program). As outlined in this
final rule, we continue data collection
for these 7 NQF-endorsed measures.
In this final rule, we finalized the
implementation of two new measures.
The first measure is the Hospice and
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Palliative Care Composite Process
Measure—Comprehensive Assessment
at Admission. Seven individual care
processes will be captured in this
composite measure, which includes the
six NQF-endorsed quality measures and
one modified NQF-endorsed quality
measure currently implemented in the
HQRP. Thus, the Hospice and Palliative
Care Composite Process quality measure
will use the current HQRP quality
measures as its components. The data
source for this measure will be currently
implemented HIS items that are
currently used in the calculation of the
7 component measures. Since the
measure is a composite measure created
from components, which are currently
adopted HQRP measures, no new data
collection will be required; data for the
composite measure will come from
existing items from the existing 7 HQRP
component measures. CMS will begin
calculating this measure using existing
data items, beginning April 1, 2017; this
means patient admissions occurring on
or after April 1, 2017 will be included
in the composite measure calculation.
The second measure is the Hospice
Visits when Death is Imminent Measure
Pair. Data for this measure will be
collected via the existing data collection
mechanism, the HIS. Four new items
will be added to the HIS-Discharge
record to collect the necessary data
elements for this measure. CMS expects
that data collection for this quality
measure via the 4 new HIS items will
begin no earlier than April 1, 2017.
Thus, under current CMS timelines,
hospice providers will begin data
collection for this measure for patient
admissions and discharges occurring on
or after April 1, 2017.
The HIS V2.00.0 will fulfill the data
collection requirements for the 7
currently adopted NQF measures and
the 2 new measures. The HIS V2.00.0
contains:
• All items from the HIS V1.00.0,
which are necessary to calculate the 7
adopted NQF measures (and thus the
composite measure), plus the HIS
V1.00.0 administrative items necessary
for patient identification and record
matching,
• One new item for measure
refinement of the existing measure NQF
#1637 Pain Assessment,
• New items to collect data for the
Hospice Visits when Death is Imminent
measure pair,
• New administrative items for
patient record matching and future
public reporting of hospice quality data.
Hospice providers will submit an HISAdmission and an HIS-Discharge for
each patient admission. Using HIS data
for assessments submitted October 1,
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2014 through September 30, 2015, we
have estimated that there will be
approximately 1,248,419 discharges
across all hospices per year and,
therefore, we would expect that there
should be 1,248,419 Hospice Item Sets
(consisting of one admission and one
discharge assessment per patient)
submitted across all hospices yearly.
Over a three-year period, we expect
3,745,257 Hospice Item Sets across all
hospices. There were 4,259 certified
hospices in the U.S. as of January
2016; 36 we estimate that each
individual hospice will submit on
average 293 Hospice Item Sets annually,
which is approximately 24 Hospice
Items Sets per month or 879 Hospice
Item Sets over 3 years.
The Hospice Item Set consists of an
admission assessment and a discharge
assessment. As noted above, we
estimate that there will be 1,248,419
hospice admissions across all hospices
per year. Therefore, we expect there to
be 2,496,838 Hospice Item Set
assessment submissions (admission and
discharge assessments counted
separately) submitted across all
hospices annually, which is 208,070
across all hospices monthly, or
7,490,514 across all hospices over three
years. We further estimate that there
will be 586 Hospice Item Set
submissions by each hospice annually,
which is approximately 49 submissions
monthly or 1,759 submissions over
three years.
For the Admission Hospice Item Set,
we estimate that it will take 14 minutes
of time by a clinician, such as a
Registered Nurse, at an hourly wage of
$67.10 37 to abstract data for Admission
Hospice Item Set. This would cost the
facility approximately $15.66 for each
admission assessment. We further
estimate that it will take 5 minutes of
time by clerical or administrative staff
person, such as a medical data entry
clerk or medical secretary, at an hourly
wage of $32.24 38 to upload the Hospice
Item Set data into the CMS system. This
would cost each facility approximately
$2.69 per assessment. For the Discharge
Hospice Item Set, we estimate that it
36 Quality Improvement and Evaluation System
(QIES) List of Hospice Providers, January 2016.
37 The adjusted hourly wage of $67.10 per hour
for a Registered Nurse was obtained using the mean
hourly wage from the U.S. Bureau of Labor
Statistics, $33.55. This mean hourly wage is
adjusted by a factor of 100 percent to include fringe
benefits. See https://www.bls.gov/oes/current/
oes291141.htm.
38 The adjusted hourly wage of $32.24 per hour
for a Medical Secretary was obtained using the
mean hourly wage from the U.S. Bureau of Labor
Statistics, $16.12. This mean hourly wage is
adjusted by a factor of 100 percent to include fringe
benefits. See https://www.bls.gov/oes/current/
oes436013.htm.
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will take 9 minutes of time by a
clinician, such as a nurse, at an hourly
wage of $67.10 to abstract data for
Discharge Hospice Item Set. This would
cost the facility approximately $10.07.
We further estimate that it will take 5
minutes of time by clerical or
administrative staff, such as a medical
data entry clerk or medical secretary, at
an hourly wage of $32.24 to upload data
into the CMS system. This would cost
each facility approximately $2.69. The
estimated cost for each full Hospice
Item Set submission (admission
assessment and discharge assessment) is
$31.10.
We estimate that the total nursing
time required for completion of both the
admission and discharge assessments is
23 minutes at a rate of $67.10 per hour.
The cost across all hospices for the
nursing/clinical time required to
complete both the admission and
discharge Hospice Item Sets is estimated
to be $32,111,417 annually, or
$96,334,252 over 3 years, and the cost
to each individual hospice is estimated
to be $7,539.66 annually, or $22,618.98
over 3 years. The estimated time burden
to hospices for a medical data entry
clerk to complete the admission and
discharge Hospice Item Set assessments
is 10 minutes at a rate of $32.24 per
hour. The cost for completion of the
both the admission and discharge
Hospice Item Sets by a medical data
entry clerk is estimated to be $6,708,171
across all hospices annually, or
$20,124,514 across all hospices over 3
years, and $1,575.06 to each hospice
annually, or $4,725.17 to each hospice
over 3 years.
The total combined time burden for
completion of the Admission and
Discharge Hospice Item Sets is
estimated to be 33 minutes. The total
cost across all hospices is estimated to
be $38,819,589 annually or
$116,458,766 over 3 years. For each
individual hospice, this cost is
estimated to be $9,114.72 annually or
$27,344.16 over 3 years. See Table 18
for breakdown of burden and cost by
assessment form.
TABLE 18—SUMMARY OF BURDEN HOURS AND COSTS
Regulation
section(s)
Burden
per response
(hours)
Total annual
burden
(hours)
Hourly labor
cost of
reporting
($)
1,248,419 per
year.
0.233 clinician
hours; 0.083
clerical hours.
395,333 hours ...
4,259
1,248,419 per
year.
0.150 clinician
hours; 0.083
clerical hours.
291,298 hours ...
4,259
7,490,514 ..........
0.55 hours .........
2,059,891 hours
Clinician at $67.10
per hour; Clerical
staff at $32.24 per
hour.
Clinician at $67.10
per hour; Clerical
staff at $32.24 per
hour.
Clinician at $67.10
per hour; Clerical
staff at $32.24 per
hour.
OMB
Control No.
Number of
respondents
Number of
responses
Hospice Item Set
Admission Assessment.
0938–1153
4,259
Hospice Item Set
Discharge Assessment.
0938–1153
3-year Total .........
0938–1153
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C. Submission of PRA-Related
Comments
We have submitted a copy of this final
rule to OMB for its review of the rule’s
information collection and
recordkeeping requirements. These
requirements are not effective until they
have been approved by the OMB.
To obtain copies of the supporting
statement and any related forms for the
collections discussed above, please visit
CMS’s Web site at https://www.cms.gov/
RegulationsandGuidance/Legislation/
PaperworkReductionActof1995/
PRAListing.html, or call the Reports
Clearance Office at 410–786–1326.
We invited public comments on these
potential information collection
requirements. If you wish to comment,
please submit your comments
electronically as specified in the
ADDRESSES section of this final rule and
identify the rule (CMS–1652–F) the
ICR’s CFR citation, CMS ID number, and
OMB control number.
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Public Comments Received for PRA
Package (CMS Form Number—CMS–R–
245)
Comment: CMS received one
supportive comment indicating that the
additional data sought by CMS for the
calculation of the Hospice Visits when
Death is Imminent Measure Pair does
not represent a significant burden on
providers and may result in useful
information. Other commenters stated
that CMS’s burden estimates
underestimate the costs of completing
the HIS. One commenter stated that the
typical admission assessment time is 45
minutes to 1 hour, and that staff travel
can significantly increase costs. Another
commenter stated that the costs of
training and operational processes to
support valid data abstraction should be
included in the burden estimate.
Response: We thank the commenters
for their feedback regarding the burden
of the HIS V2.00.0, and the support of
the new items used to collect data for
the Hospice Visits when Death is
Imminent Measure Pair. Regarding the
cost estimates for the HIS Admission
form, the HIS is a set of data elements
that can be used to calculate 7 NQF
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Total cost
($)
$22,900,166
15,919,423
116,458,766
endorsed quality measures and 2 new
measures adopted in this rule. The HIS
is not a patient assessment that would
be directly administered to the patient
and/or family or caregivers during the
initial assessment or comprehensive
assessment visit. Since the HIS is not
intended to replace the initial/
comprehensive assessment, the PRA
burden estimates, by definition, do not
include the time spent assessing the
patient. HIS PRA burden estimates are
intended to reflect only the time needed
to complete HIS items, independent of
clinical time spent assessing the patient.
Similarly, PRA burden estimates
include the Annualized Cost to the
Federal Government related to the HIS
V2.00.0 for provider training,
preparation of HIS V2.00.0 manuals and
materials, receipt and storage of data,
data analysis, and upkeep of data
submission software. In order to
mitigate costs of operational processes,
providers may use the Hospice
Abstraction Reporting Tool (HART)
software, which is free to download and
use, to collect and maintain facility,
patient, and HIS Record information for
subsequent submission to the QIES
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ASAP system. Burden estimates for
completing the HIS data items were
based on the HIS V1.00.0 and HIS
V2.00.0 pilot tests. We recognize
additional activities and efforts will be
required to implement and use the HIS
V2.00.0 as part of the quality reporting
program. We agree that it is important
for hospices to learn about and
understand the new HIS, and we plan
to provide hospices with training
resources to facilitate implementation of
the HIS.
Comment: One commenter stated that
the addition of new items to the HIS
Discharge record will require vendor
software development and testing,
hospice implementation, education and
training, and internal validation. The
commenter stated that the target
implementation date of April 1, 2017
may not provide adequate time for
implementation.
Response: We appreciate the
commenter’s feedback regarding the
timeline for implementation and of the
HIS V2.00.0. The HIS V2.00.0 is
undergoing review as part of a PRA
package under OMB number 0938–1153
and will be implemented April 1, 2017.
We believe the April 1, 2017
implementation date will allow
sufficient time for providers to update
their clinical documentation systems
and train staff on new HIS items. The
timeline for implementation of the HIS
V2.00.0 is consistent with the timeline
from prior years when the HIS V1.00.0
was implemented. We expect training
and implementation activities to take
considerably less time for the HIS
V2.00.0 compared to the HIS V1.00.0
since the HIS V2.00.0 can capitalize on
existing infrastructures used by
stakeholders for the HIS V1.00.0 and
contains only 17 new item components
(compared to the 60 item components
that were implemented in the HIS
V1.00.0). Moreover, we encourage
providers to begin preparations for HIS
V2.00.0 implementation as soon as
possible. The HIS V2.00.0 is currently
available for review by software vendors
and hospice providers. Some of the
activities that are necessary prior to
implementation can be done
concurrently. For example, hospice
education and training on the new items
and data abstraction can be conducted
at the same time as vendor development
of software.
We are aware of the effort hospices
and vendors will have to make to
prepare for implementation of the HIS.
The HIS pilot showed that
implementing the HIS is feasible and
that hospices are most likely already
collecting the information needed to
complete the HIS data items. A draft
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version of the HIS technical data
specifications was posted on the CMS
Web site on May 19, 2016. Thus,
vendors have been provided with more
than adequate time to develop products
for their clients. We expect vendors to
begin reviewing the draft technical data
specifications as soon as they are
posted. We encourage vendors to submit
questions and comments to the HIS
technical email box:
HospiceTechnicalIssues@cms.hhs.gov.
Software vendors should not be waiting
for final technical data specifications to
be posted to begin development of their
own products. Therefore, we believe
that vendors have been provided with
adequate time and resources to meet the
April 1, 2017 implementation date of
the HIS. For providers that currently use
a vendor-designed software to complete
HIS records, if a provider has concerns
about the timeliness of release of HIS
V2.00.0 items in vendor-designed
software, CMS reminds providers that
alternative means of completing HIS
records (HART software) are available to
all providers free of charge. Although
electronic submission of HIS records is
required, hospices do not need to have
an electronic medical record to
complete or submit HIS data. In the FY
2014 Hospice Wage Index, final rule (78
FR 48258) we finalized that to complete
HIS records providers can use either the
HART software, which is free to
download and use, or vendor-designed
software. HART provides an alternative
option for hospice providers to collect
and maintain facility, patient, and HIS
Record information for subsequent
submission to the QIES ASAP system.
Once HIS records are complete,
electronic HIS files must be submitted
to CMS via the QIES ASAP system.
Electronic data submission via the QIES
ASAP system is required for all HIS
submissions; there are no other data
submission methods available. Hospices
have 30 days from a patient admission
or discharge to submit the appropriate
HIS record for that patient through the
QIES ASAP system. We will continue to
make HIS completion and submission
software available to hospices at no cost.
We provided details on data collection
and submission timing under the
downloads section of the HIS Web page
on the CMS.gov Web site at https://
www.cms.gov/Medicare/QualityInitiatives-PatientAssessmentInstruments/HospiceQuality-Reporting/Hospice-Item-SetHIS.html.
Comment: One commenter stated that
although the burden associated with the
HIS assessment may not be unduly
burdensome, the collective burden of
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52191
various reporting requirements makes a
large fiscal impact on hospices.
Response: We thank the commenters
for taking the time to convey their
concerns about the burden and cost of
data collection for the HQRP and other
regulatory requirements. We attempted
to reduce the regulatory burden of our
quality reporting programs to the
greatest extent possible. The estimated
burden for completing the HIS V2.00.0
can be viewed here: (https://
www.cms.gov/Regulations-andGuidance/Legislation/
PaperworkReductionActof1995/PRAListing.html). Specifically, CMS
estimates 19 minutes per response for
the Admission HIS and 14 minutes per
response for the Discharge HIS. Details
regarding the estimate can be found at
https://cms.gov/Regulations-andGuidance/Legislation/
PaperworkReductionActof1995/PRAListing.html. Comments concerning the
accuracy of the time estimate(s) or
suggestions for improving the HIS can
be directed to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4–26–05, Baltimore,
Maryland 21244–1850. With respect to
the commenter’s concern about
additional expenses incurred as part of
quality reporting, any additional costs
incurred as part of quality reporting
programs should be reported on the cost
reports. Cost report data may be
considered in future payment reform.
Comment: One commenter stated that
the addition of the J0905 Pain Active
Problem item to the HIS V2.00.0 would
be burdensome to hospice providers
since it requires an update to the
Admission HIS documentation and the
item will not be used in calculation of
the Pain Assessment measure. The
commenter suggested adding the item
when a Patient Reported Outcome Pain
Measure is implemented or when a
Hospice Patient Assessment Instrument
is developed.
Response: We thank the commenter
for their comments regarding the new
item J0905, Pain Active problem. CMS
would like to clarify our reasoning and
intent behind the addition of the J0905
Pain Active Problem item. Since the HIS
V1.00.0 was implemented on July 1,
2014, CMS has received an
overwhelming amount of feedback from
the provider community regarding the
items in Section J: Pain of the HIS
V1.00.0 (J0900. Pain Screening and
J0910. Comprehensive Pain
Assessment). These items correspond to
the National Quality Forum (NQF)
#1634 Pain Screening quality measure
and the NQF #1637 Pain Assessment
quality measure, respectively. NQF
#1634 calculates the percentage of
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patients who were screened for pain
within two days of admission. Patients
who screen positive for pain are
included in the denominator for NQF
#1637, which measures the percentage
of patients who screened positive for
pain who received a comprehensive
pain assessment within 1 day.
Under current specifications for NQF
#1634 and NQF #1637, if a patient is not
in pain at the time of the first screening,
that patient is not included in the
denominator for NQF #1637—even if
pain is an active problem for the patient.
As such, if a patient is not in current
pain at the time of the first pain
screening, HIS V1.00.0 skip patterns
direct providers to skip Item J0910, the
comprehensive pain assessment item.
RTI received feedback from the provider
community that the measure
specifications and associated skip
pattern between J0900 and J0910 do not
align with clinical practice, as clinicians
will often complete a comprehensive
pain assessment for patients when pain
is an active problem but the patient is
not in pain at the time of the screening.
Providers further noted that some
vendor-designed software built HIS skip
patterns into clinical documentation
systems and the skip pattern between
J0900 and J0910 was thus restricting the
ability of clinicians to document
comprehensive assessments that were
conducted per clinical best practice but
not required for the purposes of the HIS
pain quality measures. Due to these
factors, CMS has received feedback from
the provider community to consider
changing items in the pain section to
align HIS pain items with current
clinical practice.
Thus, directly in response to feedback
from providers, CMS added the J0905
Pain Active Problem item to the HIS
V2.00.0. We believe this addition will
actually reduce burden on providers
since it is better aligned with current
clinical practice. The addition of J0905
also better aligns items in the pain
section with items in Section J:
Respiratory Status. CMS plans to
analyze data from J0905 to inform future
potential refinements to the NQFendorsed pain quality measures.
ICR-related comments are due
October 4, 2016.
V. Economic Analyses
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A. Regulatory Impact Analysis
1. Introduction
We have examined the impacts of this
final rule as required by Executive
Order 12866 on Regulatory Planning
and Review (September 30, 1993),
Executive Order 13563 on Improving
Regulation and Regulatory Review
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(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
final 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 final rule was also
reviewed by OMB.
2. Statement of Need
This final rule meets the requirements
of our regulations at § 418.306(c), which
requires annual issuance, in the Federal
Register, of the hospice wage index
based on the most current available
CMS hospital wage data, including any
changes to the definitions of Core-Based
Statistical Areas (CBSAs), or previously
used Metropolitan Statistical Areas
(MSAs). This final rule will also update
payment rates for each of the categories
of hospice care described in § 418.302(b)
for FY 2017 as required under section
1814(i)(1)(C)(ii)(VII) of the Act. The
payment rate updates are subject to
changes in economy-wide productivity
as specified in section
1886(b)(3)(B)(xi)(II) of the Act. In
addition, the payment rate updates may
be reduced by an additional 0.3
percentage point (although for FY 2014
to FY 2019, the potential 0.3 percentage
point reduction is subject to suspension
under conditions specified in section
1814(i)(1)(C)(v) of the Act). In 2010, the
Congress amended section 1814(i)(6) of
the Act with section 3132(a) of the
Affordable Care Act. The amendment
authorized the Secretary to revise the
methodology for determining the
payment rates for routine home care and
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other services included in hospice care,
no earlier than October 1, 2013. In the
FY 2016 Hospice Wage Index and Rate
Update final rule (80 FR 47164), we
finalized the creation of two different
payment rates for RHC that resulted in
a higher base payment rate for the first
60 days of hospice care and a reduced
base payment rate for days 61 and over
of hospice and created a SIA payment,
in addition to the per diem rate for the
RHC level of care, equal to the CHC
hourly payment rate multiplied by the
amount of direct patient care provided
by an RN or social worker that occurs
during the last 7 days of a beneficiary’s
life, if certain criteria are met. Finally,
section 3004 of the Affordable Care Act
amended the Act to authorize a quality
reporting program for hospices, and this
rule discusses changes in the
requirements for the hospice quality
reporting program in accordance with
section 1814(i)(5) of the Act.
3. Overall Impacts
We estimate that the aggregate impact
of this final rule will be an increase of
$350 million in payments to hospices,
resulting from the hospice payment
update percentage of 2.1 percent. The
impact analysis of this final rule
represents the projected effects of the
changes in hospice payments from FY
2016 to FY 2017. Using the most recent
data available at the time of rulemaking,
in this case FY 2015 hospice claims
data, we apply the current FY 2016
wage index and labor-related share
values to the level of care per diem
payments and SIA payments for each
day of hospice care to simulate FY 2016
payments. Then, using the same FY
2015 data, we apply the FY 2017 wage
index and labor-related share values to
simulate FY 2017 payments. Certain
events may limit the scope or accuracy
of our impact analysis, because such an
analysis is susceptible to forecasting
errors due to other changes in the
forecasted impact time period. The
nature of the Medicare program is such
that the changes may interact, and the
complexity of the interaction of these
changes could make it difficult to
predict accurately the full scope of the
impact upon hospices.
4. Detailed Economic Analysis
The FY 2017 hospice payment
impacts appear in Table 19. We tabulate
the resulting payments according to the
classifications in Table 19 (for example,
facility type, geographic region, facility
ownership), and compare the difference
between current and proposed
payments to determine the overall
impact.
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The first column shows the
breakdown of all hospices by urban or
rural status, census region, hospitalbased or freestanding status, size, and
type of ownership, and hospice base.
The second column shows the number
of hospices in each of the categories in
the first column.
The third column shows the effect of
the annual update to the wage index.
This represents the effect of using the
FY 2017 hospice wage index. The
aggregate impact of this change is zero
percent, due to the hospice wage index
standardization factor. However, there
are distributional effects of the FY 2017
hospice wage index.
The fourth column shows the effect of
the hospice payment update percentage
for FY 2017. The 2.1 percent hospice
payment update percentage for FY 2017
is based on an estimated 2.7 percent
inpatient hospital market basket update,
reduced by a 0.3 percentage point
productivity adjustment and by a 0.3
percentage point adjustment mandated
by the Affordable Care Act, and is
constant for all providers.
The fifth column shows the effect of
all the changes on FY 2017 hospice
payments. It is projected that aggregate
52193
payments will increase by 2.1 percent,
assuming hospices do not change their
service and billing practices in
response.
As illustrated in Table 19, the
combined effects of all the proposals
vary by specific types of providers and
by location. For example, due to the
changes in this rule, the estimated
impacts on FY 2017 payments range
from a 1.1 percent increase for hospices
providing care in the rural West North
Central region to a 2.8 percent increase
for hospices providing care in the rural
Pacific region.
TABLE 19—PROJECTED IMPACT TO HOSPICES FOR FY 2017
Number of
providers
Updated wage
data
(%)
Proposed
hospice
payment
update
(%)
FY 2017
total change
(%)
(2)
(3)
(4)
(5)
(1)
mstockstill on DSK3G9T082PROD with RULES4
All Hospices .....................................................................................................
Urban Hospices ...............................................................................................
Rural Hospices ................................................................................................
Urban Hospices—New England ......................................................................
Urban Hospices—Middle Atlantic ....................................................................
Urban Hospices—South Atlantic .....................................................................
Urban Hospices—East North Central ..............................................................
Urban Hospices—East South Central .............................................................
Urban Hospices—West North Central .............................................................
Urban Hospices—West South Central ............................................................
Urban Hospices—Mountain .............................................................................
Urban Hospices—Pacific .................................................................................
Urban Hospices—Outlying ..............................................................................
Rural Hospices—New England .......................................................................
Rural Hospices—Middle Atlantic .....................................................................
Rural Hospices—South Atlantic .......................................................................
Rural Hospices—East North Central ...............................................................
Rural Hospices—East South Central ..............................................................
Rural Hospices—West North Central ..............................................................
Rural Hospices—West South Central .............................................................
Rural Hospices—Mountain ..............................................................................
Rural Hospices—Pacific ..................................................................................
Rural Hospices—Outlying ................................................................................
0–3,499 RHC Days (Small) .............................................................................
3,500–19,999 RHC Days (Medium) ................................................................
20,000+ RHC Days (Large) .............................................................................
Non-Profit Ownership ......................................................................................
For Profit Ownership ........................................................................................
Govt Ownership ...............................................................................................
Other Ownership ..............................................................................................
Freestanding Facility Type ..............................................................................
HHA/Facility-Based Facility Type ....................................................................
4,177
3,179
998
138
252
422
399
162
220
616
313
618
39
23
42
136
141
129
186
184
107
47
3
912
2,004
1,261
1,071
2,553
160
393
3,184
993
0.0
0.0
¥0.1
0.4
0.2
¥0.1
¥0.1
¥0.1
¥0.5
¥0.2
¥0.3
0.6
¥0.7
¥0.4
¥0.2
0.2
0.1
¥0.1
¥1.0
¥0.1
¥0.2
0.7
¥0.2
0.0
0.0
0.0
0.1
¥0.1
0.5
¥0.1
0.0
0.2
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.1
2.0
2.5
2.3
2.0
2.0
2.0
1.6
1.9
1.8
2.7
1.4
1.7
1.9
2.3
2.2
2.0
1.1
2.0
1.9
2.8
1.9
2.1
2.1
2.1
2.2
2.0
2.6
2.0
2.1
2.3
Source: FY 2015 hospice claims data from the Standard Analytic Files for CY 2014 (as of June 30, 2015) and CY 2015 (as of March 31,
2016).
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.
5. Alternatives Considered
Since the hospice payment update
percentage is determined based on
statutory requirements, we did not
VerDate Sep<11>2014
18:41 Aug 04, 2016
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consider not updating hospice payment
rates by the payment update percentage.
The 2.1 percent hospice payment
update percentage for FY 2017 is based
PO 00000
Frm 00051
Fmt 4701
Sfmt 4700
on a 2.7 percent inpatient hospital
market basket update for FY 2017,
reduced by a 0.3 percentage point
productivity adjustment and by an
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additional 0.3 percentage point.
Payment rates since FY 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 years must be the
market basket percentage for that FY.
Section 3401(g) of the Affordable Care
Act also mandates that, starting with FY
2013 (and in subsequent years), 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. In addition, section 3401(g) of the
Affordable Care Act 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).
We considered not adopting a hospice
wage index standardization factor.
However, as discussed in section III.C.1
of this final rule, we believe that
adopting a hospice wage index
standardization factor would provide a
safeguard to the Medicare program, as
well as to hospices, because it will
mitigate changes in overall hospice
expenditures due to annual fluctuations
in the hospital wage data from year-toyear by ensuring that hospice wage
index updates and revisions are
implemented in a budget neutral
manner. We estimate that if the hospice
wage index standardization factor is not
finalized, total payments in a given year
would increase or decrease by as much
as 0.3 percent or $50 million.
mstockstill on DSK3G9T082PROD with RULES4
6. Accounting Statement
As required by OMB Circular A–4
(available at https://
www.whitehouse.gov/omb/circulars/
a004/a-4.pdf), in Table 20, we have
prepared an accounting statement
showing the classification of the
expenditures associated with the
provisions of this final rule. Table 20
provides our best estimate of the
possible changes in Medicare payments
under the hospice benefit as a result of
the policies in this final rule. This
estimate is based on the data for 4,177
hospices in our impact analysis file,
which was constructed using FY 2015
claims available as of March 31, 2016.
All expenditures are classified as
transfers to hospices.
VerDate Sep<11>2014
18:41 Aug 04, 2016
Jkt 238001
TABLE 20—ACCOUNTING STATEMENT:
CLASSIFICATION
OF
ESTIMATED
TRANSFERS, FROM FY 2016 TO FY
2017
[in $Millions]
Category
Transfers
FY 2017 Hospice Wage Index and Payment
Rate Update
Annualized Monetized Transfers.
From Whom to
Whom?
$350 *
Federal Government
to Medicare Hospices.
* The net increase of $350 million in transfer
payments is a result of the 2.1 percent hospice payment update percentage compared to
payments in FY 2016.
7. Conclusion
We estimate that aggregate payments
to hospices in FY 2017 would increase
by $350 million, or 2.1 percent,
compared to payments in FY 2016. We
estimate that in FY 2017, hospices in
urban and rural areas would experience,
on average, a 2.1 percent and a 2.0
percent increase, respectively, in
estimated payments compared to FY
2016. Hospices providing services in the
urban Pacific and rural Pacific regions
would experience the largest estimated
increases in payments of 2.7 percent
and 2.8 percent, respectively. Hospices
serving patients in rural areas in the
West North Central region would
experience the lowest estimated
increase of 1.1 percent in FY 2017
payments.
B. 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. The effect of the final FY 2017
hospice payment update percentage
results in an overall increase in
estimated hospice payments of 2.1
PO 00000
Frm 00052
Fmt 4701
Sfmt 9990
percent, or $350 million. Therefore, the
Secretary has determined that this final
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 final rule only
affects hospices. Therefore, the
Secretary has determined that this final
rule will not have a significant impact
on the operations of a substantial
number of small rural hospitals.
C. 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 2016, that threshold is approximately
$146 million. This final rule is not
anticipated to have an effect on State,
local, or tribal governments, in the
aggregate, or on the private sector of
$146 million or more.
VI. Federalism Analysis
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 final rule
under these criteria of Executive Order
13132, and have determined that it will
not impose substantial direct costs on
state or local governments.
Dated: July 18, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare
& Medicaid Services.
Dated: July 25, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human
Services.
[FR Doc. 2016–18221 Filed 7–29–16; 4:15 pm]
BILLING CODE 4120–01–P
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Agencies
[Federal Register Volume 81, Number 151 (Friday, August 5, 2016)]
[Rules and Regulations]
[Pages 52143-52194]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-18221]
[[Page 52143]]
Vol. 81
Friday,
No. 151
August 5, 2016
Part IV
Department of Health and Human Services
-----------------------------------------------------------------------
Centers for Medicare & Medicaid Services
-----------------------------------------------------------------------
42 CFR Part 418
Medicare Program; FY 2017 Hospice Wage Index and Payment Rate Update
and Hospice Quality Reporting Requirements; Final Rule
Federal Register / Vol. 81 , No. 151 / Friday, August 5, 2016 / Rules
and Regulations
[[Page 52144]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 418
[CMS-1652-F]
RIN 0938-AS79
Medicare Program; FY 2017 Hospice Wage Index and Payment Rate
Update and Hospice Quality Reporting Requirements
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Final rule.
-----------------------------------------------------------------------
SUMMARY: This final rule will update the hospice wage index, payment
rates, and cap amount for fiscal year (FY) 2017. In addition, this rule
changes the hospice quality reporting program, including adopting new
quality measures. Finally, this final rule includes information
regarding the Medicare Care Choices Model (MCCM).
DATES: These regulations are effective on October 1, 2016.
FOR FURTHER INFORMATION CONTACT: Debra Dean-Whittaker, (410) 786-0848
for questions regarding the CAHPS[supreg] Hospice Survey.
Michelle Brazil, (410) 786-1648 for questions regarding the hospice
quality reporting program.
Hillary A. Loeffler, (410) 786-0456 for questions regarding hospice
payment policy.
SUPPLEMENTARY INFORMATION: Wage index addenda will be available only
through the internet on the CMS Web site at: (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/.)
Table of Contents
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Impacts
II. Background
A. Hospice Care
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 Wage Index and Payment Rate Update Final Rule
8. Impact Act of 2014
9. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule
E. Trends in Medicare Hospice Utilization
F. Use of Health Information Technology
III. Provisions of the Final Rule
A. Monitoring for Potential Impacts--Affordable Care Act Hospice
Reform
B. FY 2017 Hospice Wage Index and Rates Update
1. FY 2017 Hospice Wage Index
a. Background
b. FY 2016 Implementation of New Labor Market Delineations
2. FY 2017 Hospice Payment Update Percentage
3. FY 2017 Hospice Payment Rates
4. Hospice Cap Amount for FY 2017
C. Updates to the Hospice Quality Reporting Program
1. Background and Statutory Authority
2. General Considerations Used for Selection of Quality Measures
for the HQRP
3. Policy for Retention of HQRP Measures Adopted for Previous
Payment Determination
4. Previously Adopted Quality Measures for FY 2017 and FY 2018
Payment Determination
5. Proposed Removal of Previously Adopted Measures
6. Proposed New Quality Measures for FY 2019 Payment
Determinations and Subsequent Years and Concepts Under Consideration
for Future Years
a. Background and Considerations in Developing New Quality
Measures for the HQRP
b. New Quality Measures for the FY 2019 Payment Determination
and Subsequent Years
7. Form, Manner, and Timing of Quality Data Submission
a. Background
b. Previously Finalized 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. Previously Finalized Data Submission Timelines and
Requirements for FY 2018 Payment Determination and Subsequent Years
e. Previously Finalized HQRP Data Submission and Compliance
Thresholds for the FY 2018 Payment Determination and Subsequent
Years
f. New Data Collection and Submission Mechanisms Under
Consideration for Future Years
8. HQRP Submission Exemption and Extension Requirements for the
FY 2017 Payment Determination and Subsequent Years
9. Hospice CAHPS[supreg] Participation Requirements for the 2019
APU and 2020 APU
a. Background Description of the Survey
b. Participation Requirements To Meet Quality Reporting
Requirements for the FY 2019 APU
c. Participation Requirements To Meet Quality Reporting
Requirements for the FY 2020 APU
d. Annual Payment Update
e. Hospice CAHPS[supreg] Reconsiderations and Appeals Process
10. HQRP Reconsideration and Appeals Procedures for the FY 2017
Payment Determination and Subsequent Years
11. Public Display of Quality Measures and Other Hospice Data
for the HQRP
D. The Medicare Care Choices Model
IV. Collection of Information Requirements
V. Economic Analyses
VI. Federalism Analysis and Regulations Text
Acronyms
Because of the many terms to which we refer by acronym in this
final rule, we are listing the acronyms used and their corresponding
meanings in alphabetical order:
APU Annual Payment Update
ASPE Assistant Secretary of Planning and Evaluation
BBA Balanced Budget Act of 1997
BIPA Benefits Improvement and Protection Act of 2000
BNAF Budget Neutrality Adjustment Factor
BLS Bureau of Labor Statistics
CAHPS[supreg] Consumer Assessment of Healthcare Providers and
Systems
CBSA Core-Based Statistical Area
CCN CMS Certification Number
CCW Chronic Conditions Data Warehouse
CFR Code of Federal Regulations
CHC Continuous Home Care
CHF Congestive Heart Failure
CMMI Center for Medicare & Medicaid Innovation
CMS Centers for Medicare & Medicaid Services
COPD Chronic Obstructive Pulmonary Disease
CoPs Conditions of Participation
CPI Center for Program Integrity
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
DRG Diagnostic Related Group
ER Emergency Room
FEHC Family Evaluation of Hospice Care
FR Federal Register
FY Fiscal Year
GAO Government Accountability Office
GIP General Inpatient Care
HCFA Healthcare Financing Administration
HHS Health and Human Services
HIPAA 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
IDG Interdisciplinary Group
IMPACT Act Improving Medicare Post-Acute Care Transformation Act of
2014
IOM Institute of Medicine
IPPS Inpatient Prospective Payment System
IRC Inpatient Respite Care
[[Page 52145]]
LCD Local Coverage Determination
LOS Length of Stay
MAC Medicare Administrative Contractor
MAP Measure Applications Partnership
MCCM Medicare Care Choices Model
MedPAC Medicare Payment Advisory Commission
MFP Multifactor Productivity
MSA Metropolitan Statistical Area
MSS Medical Social Services
NHPCO National Hospice and Palliative Care Organization
NF Long Term Care Nursing Facility
NOE Notice of Election
NOTR Notice of Termination/Revocation
NP Nurse Practitioner
NPI National Provider Identifier
NQF National Quality Forum
OIG Office of the Inspector General
OACT Office of the Actuary
OMB Office of Management and Budget
PEPPER Program for Evaluating Payment Patterns Electronic Report
PRRB Provider Reimbursement Review Board
PS&R Provider Statistical and Reimbursement Report
Pub. L. Public Law
QAPI Quality Assessment and Performance Improvement
RHC Routine Home Care
RN Registered Nurse
SBA Small Business Administration
SEC Securities and Exchange Commission
SIA Service Intensity Add-on
SNF Skilled Nursing Facility
TEFRA Tax Equity and Fiscal Responsibility Act of 1982
TEP Technical Expert Panel
UHDDS Uniform Hospital Discharge Data Set
U.S.C. United States Code
I. Executive Summary
A. Purpose
This final rule updates the hospice payment rates for fiscal year
(FY) 2017, as required under section 1814(i) of the Social Security Act
(the Act). This rule also finalizes new quality measures and provides
an update on the hospice quality reporting program (HQRP) consistent
with the requirements of section 1814(i)(5) of the Act, as added by
section 3004(c) 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, the Affordable Care Act). In
accordance with section 1814(i)(5)(A) of the Act, starting in FY 2014,
hospices that have failed to meet quality reporting requirements
receive a 2 percentage point reduction to their payments. Finally, this
final rule shares information on the Medicare Care Choices Model
developed in accordance with the authorization under section 1115A of
the Act for the Center for Medicare and Medicaid Innovation (CMMI) to
test innovative payment and service models that have the potential to
reduce Medicare, Medicaid, or Children's Health Insurance Program
(CHIP) expenditures while maintaining or improving the quality of care.
B. Summary of the Major Provisions
In section III.B.1 of this rule, we update the hospice wage index
with updated wage data and make the application of the updated wage
data budget-neutral for all four levels of hospice care. In section
III.B.2 we discuss the FY 2017 hospice payment update percentage of 2.1
percent. Sections III.B.3 and III.B.4 update the hospice payment rates
and hospice cap amount for FY 2017 by the hospice payment update
percentage discussed in section III.B.2.
In section III.C of this rule, we discuss updates to HQRP,
including two new quality measures as well as of the possibility of
utilizing a new assessment instrument to collect quality data. As part
of the HQRP, the new measures, effective April 1, 2017, will be: (1)
Hospice Visits When Death is Imminent, assessing hospice staff visits
to patients and caregivers in the last week of life; and (2) Hospice
and Palliative Care Composite Process Measure, assessing the percentage
of hospice patients who received care processes consistent with
existing guidelines. In section III.C we will also discuss the
enhancement of the current Hospice Item Set (HIS) data collection
instrument to be more in line with other post-acute care settings. This
new data collection instrument will be a comprehensive patient
assessment instrument, rather than the current chart abstraction tool.
Additionally, in this section we discuss our plans for sharing HQRP
data publicly during calendar year (CY) 2016 as well as plans to
provide public reporting via a Compare Site in CY 2017.
Finally, in section III.D, we are providing information regarding
the Medicare Care Choices Model (MCCM). This model is testing a new
option for Medicare and dual eligible beneficiaries with certain
advanced diseases who meet the model's other eligibility criteria to
receive hospice-like support services from MCCM participating hospices
while receiving care from other Medicare providers for their terminal
illness. This model is designed to: (1) Increase access to supportive
care services provided by hospice; (2) improve quality of life and
patient/family/caregiver satisfaction; and (3) inform new payment
systems for the Medicare and Medicaid programs.
C. Summary of Impacts
Table 1--Impact Summary Table
------------------------------------------------------------------------
Provision description Transfers
------------------------------------------------------------------------
FY 2017 Hospice Wage Index and Payment The overall economic impact of
Rate Update. this final rule is estimated
to be $350 million in
increased payments to hospices
during FY 2017.
------------------------------------------------------------------------
II. Background
A. Hospice Care
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 beneficiary as physically and emotionally comfortable as possible.
Hospice is compassionate beneficiary 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 transition 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
[[Page 52146]]
care practices, and is a critical component of the Medicare hospice
benefit. Also, see Hospice Conditions of Participation final rule (73
FR 32088 June 5, 2008). The goal of palliative care in hospice is to
improve the quality of life of beneficiaries, and their families,
facing the issues associated with a life-threatening illness through
the prevention and relief of suffering by means of early
identification, assessment, and treatment of pain and other issues that
may arise. This is achieved by the hospice interdisciplinary group
working with the beneficiary and family to develop a comprehensive care
plan focused on coordinating care services, reducing unnecessary
diagnostics, or ineffective therapies, and offering ongoing
conversations with individuals and their families about changes in
their condition. The beneficiary's comprehensive care plan will shift
over time to meet the changing needs of the individual, family, and
caregiver(s) as the individual approaches the end of life.
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 a beneficiary is terminally ill, many health
problems are brought on by underlying condition(s), as bodily systems
are interdependent. In the 2008 Hospice Conditions of Participation
final rule, we stated that the medical director or physician designee
must consider the primary terminal condition, related diagnoses,
current subjective and objective medical findings, current medication
and treatment orders, and information about unrelated conditions when
considering the initial certification of the terminal illness. (73 FR
32176). As referenced in our regulations at Sec. 418.22(b)(1), to be
eligible for Medicare hospice services, the patient's attending
physician (if any) and the hospice medical director must certify that
the individual is ``terminally ill,'' as defined in section
1861(dd)(3)(A) of the Act and our regulations at Sec. 418.3; that is,
the individual's prognosis is for a life expectancy of 6 months or less
if the terminal illness runs its normal course. The certification of
terminal illness must include a brief narrative explanation of the
clinical findings that supports a life expectancy of 6 months or less
as part of the certification and recertification forms, as set out at
Sec. 418.22(b)(3).
While the goal of hospice care is to allow the beneficiary 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 treatment
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 beneficiary can return to his or her
home environment. Limited, short-term, intermittent, inpatient respite
services are also available to the family/caregiver of the hospice
patient 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
Sec. 418.204. A minimum of 8 hours of nursing care, or nursing and
aide care, must be furnished on a particular day to qualify for the
continuous home care rate (Sec. 418.302(e)(4)).
Hospices are expected to comply with all civil rights laws,
including the provision of auxiliary aids and services to ensure
effective communication with patients and patient care representatives
with disabilities consistent with section 504 of the Rehabilitation Act
of 1973 and the Americans with Disabilities Act, 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 https://www.hhs.gov/civil-rights.
B. History of the Medicare Hospice Benefit
Before the creation of the Medicare hospice benefit, hospice
programs were originally operated by volunteers who cared for the
dying. During the early development stages of the Medicare hospice
benefit, hospice advocates were clear that they wanted a Medicare
benefit that provided all-inclusive care for terminally-ill
individuals, provided pain relief and symptom management, and offered
the opportunity to die with dignity in the comfort of one's home rather
than in an institutional setting.\1\ As stated in the August 22, 1983
proposed rule titled ``Medicare Program; Hospice Care'' (48 FR 38146),
``the hospice experience in the United States has placed emphasis on
home care. It offers physician services, specialized nursing services,
and other forms of care in the home to enable the terminally ill
individual to remain at home in the company of family and friends as
long as possible.'' The concept of a beneficiary ``electing'' the
hospice benefit and being certified as terminally ill were two key
components of the legislation responsible for the creation of the
Medicare Hospice Benefit (section 122 of the Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA), (Pub. L. 97-248)). Section 122 of
TEFRA created the Medicare Hospice benefit, which was implemented on
November 1, 1983. Under sections 1812(d) and 1861(dd) of the Act, we
provide coverage of hospice care for terminally ill Medicare
beneficiaries who elect to receive care from a Medicare-certified
hospice. Our regulations at Sec. 418.54(c) stipulate that the
comprehensive hospice assessment must identify the beneficiary's
physical, psychosocial, emotional, and spiritual needs related to the
terminal illness and related conditions, and address those needs in
order to promote the beneficiary's well-being, comfort, and dignity
throughout the dying process. The comprehensive assessment must take
into consideration the following factors: 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; imminence of death; and severity of
symptoms (Sec. 418.54(c)). The Medicare hospice benefit requires the
hospice to cover all reasonable and necessary palliative care related
to the terminal prognosis, as described in the beneficiary's plan of
care. The December 16, 1983 Hospice final rule (48 FR 56008) requires
hospices to cover care for interventions to manage pain and symptoms.
Additionally, the hospice Conditions of Participation (CoPs) at Sec.
418.56(c) require that the hospice must provide all reasonable and
necessary services for the palliation and management of the terminal
illness, related conditions, and interventions to manage pain and
symptoms. Therapy and interventions must be assessed and managed in
terms of providing palliation and comfort without undue symptom burden
for the hospice patient or family.\2\ In the December 16, 1983 Hospice
final rule (48 FR 56010), regarding what is related versus
[[Page 52147]]
unrelated to the terminal illness, we stated: ``. . . we believe that
the unique physical condition of each terminally ill individual makes
it necessary for these decisions to be made on a case by case basis. It
is our general view that hospices are required to provide virtually all
the care that is needed by terminally ill patients.'' Therefore, unless
there is clear evidence that a condition is unrelated to the terminal
prognosis, all conditions are considered to be related to the terminal
prognosis and the responsibility of the hospice to address and treat.
---------------------------------------------------------------------------
\1\ Connor, Stephen. (2007). Development of Hospice and
Palliative Care in the United States. OMEGA. 56(1), p. 89-99.
\2\ Paolini, DO, Charlotte. (2001). Symptoms Management at End
of Life. JAOA. 101(10). p. 609-615.
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As stated in the December 16, 1983 Hospice final rule, the
fundamental premise upon which the hospice benefit was designed was the
``revocation'' of traditional curative care and the ``election'' of
hospice care for end-of-life symptom management and maximization of
quality of life (48 FR 56008). After electing hospice care, the
beneficiary typically returns to the home from an institutionalized
setting or remains in the home, to be surrounded by family and friends,
and to prepare emotionally and spiritually, if requested, for death
while receiving expert symptom management and other supportive
services. Election of hospice care also requires waiving the right to
Medicare payment for curative treatment for the terminal prognosis, and
instead receiving palliative care to manage pain or other symptoms.
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, Medicare
beneficiaries can elect hospice care for two 90-day periods and an
unlimited number of subsequent 60-day periods; however, at the
beginning of each period, a physician must certify that the beneficiary
has a life expectancy of 6 months or less if the terminal illness runs
its normal course.
C. Services Covered by the Medicare Hospice Benefit
One requirement for coverage under the Medicare Hospice benefit is
that hospice services must be reasonable and necessary for the
palliation and management of the terminal illness and related
conditions. Section 1861(dd)(1) of the Act establishes the services
that are to be rendered by a Medicare certified hospice program. These
covered services include: Nursing care; physical therapy; occupational
therapy; speech-language pathology therapy; medical social services;
home health aide services (now called hospice aide services); physician
services; homemaker services; medical supplies (including drugs and
biologicals); medical appliances; counseling services (including
dietary counseling); short-term inpatient care in a hospital, nursing
facility, or hospice inpatient facility (including both respite care
and procedures necessary for pain control and acute or chronic symptom
management); continuous home care during periods of crisis, and only as
necessary to maintain the terminally ill individual at home; and any
other item or service which is specified in the plan of care and for
which payment may otherwise be made under Medicare, in accordance with
Title XVIII of the Act.
Section 1814(a)(7)(B) of the Act requires that a written plan for
providing hospice care to a beneficiary who is a hospice patient be
established before care is provided by, or under arrangements made by,
that hospice program and that the written plan be periodically reviewed
by the beneficiary's attending physician (if any), the hospice medical
director, and an interdisciplinary group (described in section
1861(dd)(2)(B) of the Act). The services offered under the Medicare
hospice benefit must be available to beneficiaries as needed, 24 hours
a day, 7 days a week (section 1861(dd)(2)(A)(i) of the Act). Upon the
implementation of the hospice benefit, Congress expected hospices to
continue to use volunteer services, though these services are not
reimbursed by Medicare (see section 1861(dd)(2)(E) of the Act and 48 FR
38149). As stated in the August 22, 1983 Hospice proposed rule, the
hospice interdisciplinary group should comprise paid hospice employees
as well as hospice volunteers (48 FR 38149). This expectation supports
the hospice philosophy of holistic, comprehensive, compassionate, end-
of-life care.
Before the Medicare hospice benefit was established, Congress
requested a demonstration project to test the feasibility of covering
hospice care under Medicare. The National Hospice Study was initiated
in 1980 through a grant sponsored by the Robert Wood Johnson and John
A. Hartford Foundations and the Centers for Medicare & Medicaid
Services (CMS) (then, the Health Care Financing Administration (HCFA)).
The demonstration project was conducted between October 1980 and March
1983. The project summarized the hospice care philosophy and principles
as the following:
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 Medicare hospice
benefit. The identified hospice services were incorporated into the
service requirements under the Medicare hospice benefit. Importantly,
in the August 22, 1983 Hospice proposed rule, we stated ``the hospice
benefit and the resulting Medicare reimbursement is not intended to
diminish the voluntary spirit of hospices'' (48 FR 38149).
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 Medicare program. Part 418, subpart
G, provides for a per diem payment in one of four prospectively-
determined rate categories of hospice care (Routine Home Care (RHC),
Continuous Home Care (CHC), inpatient respite care, and general
inpatient care), based on each day a qualified Medicare beneficiary is
under hospice care (once the individual has elected). This per diem
payment is to include all of the hospice services needed to manage the
beneficiary's care, as required by section 1861(dd)(1) of the Act.
There has been little change in the hospice payment structure since the
benefit's inception. The per diem rate based on level of care was
established in 1983, and this payment structure remains today with some
adjustments, as noted below:
1. Omnibus Budget Reconciliation Act of 1989
Section 6005(a) of the Omnibus Budget Reconciliation Act of 1989
(Pub. L. 101-239) amended section 1814(i)(1)(C) of the Act and provided
for the following two changes in the methodology concerning updating
the daily payment rates: (1) Effective January 1, 1990, the daily
payment rates for RHC and other services included in
[[Page 52148]]
hospice care were increased to equal 120 percent of the rates in effect
on September 30, 1989; and (2) the daily payment rate for RHC and other
services included in hospice care for fiscal years (FYs) beginning on
or after October 1, 1990, were the payment rates in effect during the
previous Federal FY increased by the hospital market basket percentage
increase.
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 August 8, 1997 FY 1998 Hospice Wage Index final rule (62 FR
42860), we implemented a new methodology for calculating the hospice
wage index based on the recommendations of a negotiated rulemaking
committee. The original hospice wage index was based on 1981 Bureau of
Labor Statistics hospital data and had not been updated since 1983. In
1994, because of disparity in wages from one geographical location to
another, the Hospice Wage Index Negotiated Rulemaking Committee was
formed to negotiate a new wage index methodology that could be accepted
by the industry and the government. This Committee was composed of
representatives from national hospice associations; rural, urban, large
and small hospices, and multi-site hospices; consumer groups; and a
government representative. The Committee decided that in updating the
hospice wage index, aggregate Medicare payments to hospices would
remain budget neutral to payments calculated using the 1983 wage index,
to cushion the impact of using a new wage index methodology. To
implement this policy, a Budget Neutrality Adjustment Factor (BNAF) was
computed and applied annually to the pre-floor, pre-reclassified
hospital wage index when deriving the hospice wage index, subject to a
wage index floor.
4. FY 2010 Hospice Wage Index Final Rule
Inpatient hospital pre-floor and pre-reclassified wage index
values, as described in the August 8, 1997 Hospice Wage Index final
rule, are subject to either a budget neutrality adjustment or
application of the wage index floor. Wage index values of 0.8 or
greater are adjusted by the BNAF. Starting in FY 2010, a 7-year phase-
out of the BNAF began (FY 2010 Hospice Wage Index final rule, (74 FR
39384, August 6, 2009)), with a 10 percent reduction in FY 2010, an
additional 15 percent reduction for a total of 25 percent in FY 2011,
an additional 15 percent reduction for a total 40 percent reduction in
FY 2012, an additional 15 percent reduction for a total of 55 percent
in FY 2013, and an additional 15 percent reduction for a total 70
percent reduction in FY 2014. The phase-out continued with an
additional 15 percent reduction for a total reduction of 85 percent in
FY 2015, an additional, and final, 15 percent reduction for complete
elimination in FY 2016. We note that the BNAF was an adjustment which
increased the hospice wage index value. Therefore, the BNAF phase-out
reduced the amount of the BNAF increase applied to the hospice wage
index value. It was not a reduction in the hospice wage index value
itself or in the hospice payment rates.
5. The Affordable Care Act
Starting with FY 2013 (and in subsequent FYs), the market basket
percentage update under the hospice payment system referenced in
sections 1814(i)(1)(C)(ii)(VII) and 1814(i)(1)(C)(iii) of the Act is
subject to annual reductions related to changes in economy-wide
productivity, as specified in section 1814(i)(1)(C)(iv) of the Act. In
FY 2013 through FY 2019, the market basket percentage update under the
hospice payment system will be reduced by an additional 0.3 percentage
point (although for FY 2014 to FY 2019, the potential 0.3 percentage
point reduction is subject to suspension under conditions specified in
section 1814(i)(1)(C)(v) of the Act).
In addition, sections 1814(i)(5)(A) through (C) of the Act, as
added by section 3132(a) of the Affordable Care Act, require hospices
to begin submitting quality data, based on measures to be specified by
the Secretary of the Department of Health and Human Services (the
Secretary), for FY 2014 and subsequent FYs. Beginning in FY 2014,
hospices which fail to report quality data will have their market
basket update reduced by 2 percentage points.
Section 1814(a)(7)(D)(i) of the Act, as added by section 3132(b)(2)
of the Affordable Care Act, requires, effective January 1, 2011, that a
hospice physician or nurse practitioner have a face-to-face encounter
with the beneficiary to determine continued eligibility of the
beneficiary's hospice care prior to the 180th-day recertification and
each subsequent recertification, and to attest that such visit took
place. When implementing this provision, we finalized in the CY 2011
Home Health Prospective Payment System final rule (75 FR 70435) that
the 180th-day recertification and subsequent recertifications would
correspond to the beneficiary's third or subsequent benefit periods.
Further, section 1814(i)(6) of the Act, as added by section
3132(a)(1)(B) of the Affordable Care Act, authorizes the Secretary to
collect additional data and information determined appropriate to
revise payments for hospice care and other purposes. The types of data
and information suggested in the Affordable Care Act could capture
accurate resource utilization, which could be collected on claims, cost
reports, and possibly other mechanisms, as the Secretary determined to
be appropriate. The data collected could be used to revise the
methodology for determining the payment rates for RHC and other
services included in hospice care, no earlier than October 1, 2013, as
described in section 1814(i)(6)(D) of the Act. In addition, we were
required to consult with hospice programs and the Medicare Payment
Advisory Commission (MedPAC) regarding additional data collection and
payment revision options.
6. FY 2012 Hospice Wage Index Final Rule
When the Medicare Hospice benefit was implemented, Congress
included an aggregate cap on hospice payments, which limits the total
aggregate payments any individual hospice can receive in a year.
Congress stipulated that a ``cap amount'' be computed each year. The
cap amount was set at $6,500 per beneficiary when first enacted in 1983
and has been adjusted annually by the change in the medical care
expenditure category of the consumer price index for urban consumers
from March 1984 to March of the cap year (section 1814(i)(2)(B) of the
Act). The cap year was defined as the period from November 1st to
October 31st. In the August 4, 2011 FY 2012 Hospice Wage Index final
rule (76 FR 47308 through 47314) for the 2012 cap year and
[[Page 52149]]
subsequent cap years, we announced that subsequently, the hospice
aggregate cap would be calculated using the patient-by-patient
proportional methodology. We allowed existing hospices the option of
having their cap calculated via the original streamlined methodology.
As of FY 2012, new hospices have their cap determinations calculated
using the patient-by-patient proportional methodology. The patient-by-
patient proportional methodology and the streamlined methodology are
two different methodologies for counting beneficiaries when calculating
the hospice aggregate cap. A detailed explanation of these methods is
found in the August 4, 2011 FY 2012 Hospice Wage Index final rule (76
FR 47308 through 47314). If a hospice's total Medicare reimbursement
for the cap year exceeds the hospice aggregate cap, then the hospice
must repay the excess back to Medicare.
7. FY 2015 Hospice Wage Index and Payment Rate Update Final Rule
When electing hospice, a beneficiary waives Medicare coverage for
any care for the terminal illness and related conditions except for
services provided by the designated hospice and attending physician.
The FY 2015 Hospice Wage Index and Payment Rate Update final rule (79
FR 50452) finalized a requirement that requires the Notice of Election
(NOE) be filed within 5 calendar days after the effective date of
hospice election. If the NOE is filed beyond this 5-day period, hospice
providers are liable for the services furnished during the days from
the effective date of hospice election to the date of NOE filing (79 FR
50474). Similar to the NOE, the claims processing system must be
notified of a beneficiary's discharge from hospice or hospice benefit
revocation. This update to the beneficiary's status allows claims from
non-hospice providers to be processed and paid. Late filing of the NOE
can result in inaccurate benefit period data and leaves Medicare
vulnerable to paying non-hospice claims related to the terminal illness
and related conditions and beneficiaries possibly liable for any cost-
sharing associated costs. Upon live discharge or revocation, the
beneficiary immediately resumes the Medicare coverage that had been
waived when he or she elected hospice. The FY 2015 Hospice Wage Index
and Payment Rate Update final rule also finalized a requirement that
requires hospices to file a notice of termination/revocation within 5
calendar days of a beneficiary's live discharge or revocation, unless
the hospices have already filed a final claim. This requirement helps
to protect beneficiaries from delays in accessing needed care (Sec.
418.26(e)).
A hospice ``attending physician'' is described by the statutory and
regulatory definitions as a medical doctor, osteopath, or nurse
practitioner whom the beneficiary 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 person's designated attending physician
and a third of hospice patients had multiple providers submit Part B
claims as the ``attending physician,'' using a claim modifier. The FY
2015 Hospice Wage Index and Payment Rate Update final rule finalized a
requirement that the election form include the beneficiary's choice of
attending physician and that the beneficiary provide the hospice with a
signed document when he or she chooses to change attending physicians
(79 FR 50479).
Hospice providers are required to begin using a Hospice Experience
of Care Survey for informal caregivers of hospice patients surveyed in
2015. The FY 2015 Hospice Wage Index and Payment Rate Update final rule
provided background and a description of the development of the Hospice
Experience of Care Survey, including the model of survey
implementation, the survey respondents, eligibility criteria for the
sample, and the languages in which the survey is offered. The FY 2015
Hospice Rate Update final rule also set out participation requirements
for CY 2015 and discussed vendor oversight activities and the
reconsideration and appeals process for entities that failed to win CMS
approval as vendors (79 FR 50496).
Finally, the FY 2015 Hospice Wage Index and Payment Rate Update
final rule required providers to complete their aggregate cap
determination not sooner than 3 months after the end of the cap year,
and not later than 5 months after, and remit any overpayments. Those
hospices that fail to timely submit their aggregate cap determinations
will have their payments suspended until the determination is completed
and received by the Medicare Administrative Contractor (MAC) (79 FR
50503).
8. IMPACT Act of 2014
The Improving Medicare Post-Acute Care Transformation Act of 2014
(Pub. L. 113-185) (IMPACT Act) became law on October 6, 2014. Section
3(a) of the IMPACT Act mandated that all Medicare certified hospices be
surveyed every 3 years beginning April 6, 2015 and ending September 30,
2025. In addition, section 3(c) of the IMPACT Act requires medical
review of hospice cases involving beneficiaries receiving more than 180
days care in select hospices that show a preponderance of such
patients; section 3(d) of the IMPACT Act contains a new provision
mandating that the cap amount for accounting years that end after
September 30, 2016, and before October 1, 2025 be updated by the
hospice payment update rather than using the consumer price index for
urban consumers (CPI-U) for medical care expenditures.
9. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule
In the FY 2016 Hospice Rate Update final rule, we created two
different payment rates for RHC that resulted in a higher base payment
rate for the first 60 days of hospice care and a reduced base payment
rate for all subsequent days of hospice care (80 FR 47172). We also
created a Service Intensity Add-on (SIA) payment payable for services
during the last 7 days of the beneficiary's life, equal to the CHC
hourly payment rate multiplied by the amount of direct patient care
provided by a registered nurse (RN) or social worker that occurs during
the last 7 days (80 FR 47177).
In addition to the hospice payment reform changes discussed, the FY
2016 Hospice Wage Index and Payment 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 is updated by the hospice payment update percentage rather than
using the CPI-U. This was applied to the 2016 cap year, starting on
November 1, 2015 and ending on October 31, 2016. In addition, we
finalized a provision to align the cap accounting year for both the
inpatient cap and the hospice aggregate cap with the FY, for FY 2017
and later (80 FR 47186). This allows for the timely implementation of
the IMPACT Act changes while better aligning the cap accounting year
with the timeframe described in the IMPACT Act.
Finally, the FY 2016 Hospice Wage Index and Payment Rate Update
final rule clarified that hospices must report all diagnoses of the
beneficiary on the hospice claim as a part of the ongoing data
collection efforts for possible future hospice payment refinements.
Reporting of all diagnoses on the hospice claim aligns with current
coding guidelines as
[[Page 52150]]
well as admission requirements for hospice certifications (80 FR
47142).
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 benefit utilization. The number of Medicare beneficiaries
receiving hospice services has grown from 513,000 in FY 2000 to nearly
1.4 million in FY 2015. Similarly, Medicare hospice expenditures have
risen from $2.8 billion in FY 2000 to an estimated $15.5 billion in FY
2015.\3\ Under the economic assumptions from the 2017 Mid-Session
Review,\4\ our Office of the Actuary (OACT) projects that hospice
expenditures are expected to continue to increase, by approximately 7
percent annually, reflecting an increase in the number of Medicare
beneficiaries, more beneficiary awareness of the Medicare Hospice
Benefit for end-of-life care, and a growing preference for care
provided in home and community-based settings.
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\3\ FY2000 figures from MedPAC analysis of the denominator file,
the Medicare Beneficiary Database, and the 100 percent hospice
claims standard analytic file from CMS (https://www.medpac.gov/documents/reports/chapter-11-hospice-services-(march-2012-
report).pdf?sfvrsn=4). FY 2015 hospice claims data from the Chronic
Conditions Data Warehouse (CCW), accessed on June 20, 2016.
\4\ ``Mid-Session Review: Budget of the US Government.'' Office
of Management and Budget. July 15, 2016. https://www.whitehouse.gov/sites/default/files/omb/budget/fy2017/assets/17msr.pdf.
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There have also been changes in the diagnosis patterns among
Medicare hospice enrollees. Specifically, as described in Table 2,
there have been notable increases between 2002 and 2015 in
neurologically-based diagnoses, including various dementia and
Alzheimer's diagnoses. Additionally, there had been significant
increases in the use of non-specific, symptom-classified diagnoses,
such as ``debility'' and ``adult failure to thrive.'' In FY 2013,
``debility'' and ``adult failure to thrive'' were the first and sixth
most common hospice claims-reported diagnoses, respectively, accounting
for approximately 14 percent of all diagnoses. Effective October 1,
2014, hospice claims are returned to the provider if ``debility'' and
``adult failure to thrive'' are coded as the principal hospice
diagnosis as well as other ICD-9-CM (and as of October 1, 2015, ICD-10-
CM) codes that are not permissible as principal diagnosis codes per
ICD-9-CM (or ICD-10-CM) coding guidelines. In the FY 2015 Hospice Wage
Index and Payment Rate Update final rule (79 FR 50452), we reminded the
hospice industry that this policy would go into effect and claims would
start to be returned to the provider effective October 1, 2014. As a
result of this, there has been a shift in coding patterns on hospice
claims. For FY 2015, the most common hospice principal diagnoses were
Alzheimer's disease, Congestive Heart Failure, Lung Cancer, Chronic
Airway Obstruction, and Senile Dementia which constituted approximately
35 percent of all claims-reported principal diagnosis codes reported in
FY 2015. In Table 2 we have updated the information initially presented
in the FY 2017 proposed rule (81 FR 25504-06).
Table 2--The Top Twenty Principal Hospice Diagnoses, FY 2002, FY 2007, FY 2013, FY 2015
----------------------------------------------------------------------------------------------------------------
Reported principal
Rank ICD-9 diagnosis Count Percentage
----------------------------------------------------------------------------------------------------------------
Year: FY 2002
----------------------------------------------------------------------------------------------------------------
1............................. 162.9 Lung Cancer............... 73,769 11
2............................. 428.0 Congestive Heart Failure.. 45,951 7
3............................. 799.3 Debility Unspecified...... 36,999 6
4............................. 496 COPD...................... 35,197 5
5............................. 331.0 Alzheimer's Disease....... 28,787 4
6............................. 436 CVA/Stroke................ 26,897 4
7............................. 185 Prostate Cancer........... 20,262 3
8............................. 783.7 Adult Failure To Thrive... 18,304 3
9............................. 174.9 Breast Cancer............. 17,812 3
10............................ 290.0 Senile Dementia, Uncomp... 16,999 3
11............................ 153.0 Colon Cancer.............. 16,379 2
12............................ 157.9 Pancreatic Cancer......... 15,427 2
13............................ 294.8 Organic Brain Synd Nec.... 10,394 2
14............................ 429.9 Heart Disease Unspecified. 10,332 2
15............................ 154.0 Rectosigmoid Colon Cancer. 8,956 1
16............................ 332.0 Parkinson's Disease....... 8,865 1
17............................ 586 Renal Failure Unspecified. 8,764 1
18............................ 585 Chronic Renal Failure (End 8,599 1
2005).
19............................ 183.0 Ovarian Cancer............ 7,432 1
20............................ 188.9 Bladder Cancer............ 6,916 1
----------------------------------------------------------------------------------------------------------------
Year: FY 2007
----------------------------------------------------------------------------------------------------------------
1............................. 799.3 Debility Unspecified...... 90,150 9
2............................. 162.9 Lung Cancer............... 86,954 8
3............................. 428.0 Congestive Heart Failure.. 77,836 7
4............................. 496 COPD...................... 60,815 6
5............................. 783.7 Adult Failure To Thrive... 58,303 6
6............................. 331.0 Alzheimer's Disease....... 58,200 6
7............................. 290.0 Senile Dementia Uncomp.... 37,667 4
8............................. 436 CVA/Stroke................ 31,800 3
9............................. 429.9 Heart Disease Unspecified. 22,170 2
10............................ 185 Prostate Cancer........... 22,086 2
11............................ 174.9 Breast Cancer............. 20,378 2
12............................ 157.9 Pancreas Unspecified...... 19,082 2
13............................ 153.9 Colon Cancer.............. 19,080 2
[[Page 52151]]
14............................ 294.8 Organic Brain Syndrome NEC 17,697 2
15............................ 332.0 Parkinson's Disease....... 16,524 2
16............................ 294.10 Dementia In Other Diseases 15,777 2
w/o Behav. Dist.
17............................ 586 Renal Failure Unspecified. 12,188 1
18............................ 585.6 End Stage Renal Disease... 11,196 1
19............................ 188.9 Bladder Cancer............ 8,806 1
20............................ 183.0 Ovarian Cancer............ 8,434 1
----------------------------------------------------------------------------------------------------------------
Year: FY 2013
----------------------------------------------------------------------------------------------------------------
1............................. 799.3 Debility Unspecified...... 127,415 9
2............................. 428.0 Congestive Heart Failure.. 96,171 7
3............................. 162.9 Lung Cancer............... 91,598 6
4............................. 496 COPD..................... 82,184 6
5............................. 331.0 Alzheimer's Disease....... 79,626 6
6............................. 783.7 Adult Failure to Thrive... 71,122 5
7............................. 290.0 Senile Dementia, Uncomp... 60,579 4
8............................. 429.9 Heart Disease Unspecified. 36,914 3
9............................. 436 CVA/Stroke................ 34,459 2
10............................ 294.10 Dementia In Other Diseases 30,963 2
w/o Behavioral Dist.
11............................ 332.0 Parkinson's Disease....... 25,396 2
12............................ 153.9 Colon Cancer.............. 23,228 2
13............................ 294.20 Dementia Unspecified w/o 23,224 2
Behavioral Dist.
14............................ 174.9 Breast Cancer............. 23,059 2
15............................ 157.9 Pancreatic Cancer......... 22,341 2
16............................ 185 Prostate Cancer........... 21,769 2
17............................ 585.6 End-Stage Renal Disease... 19,309 1
18............................ 518.81 Acute Respiratory Failure. 15,965 1
19............................ 294.8 Other Persistent Mental 14,372 1
Dis.-classified elsewhere.
20............................ 294.11 Dementia In Other Diseases 13,687 1
w/Behavioral Dist.
----------------------------------------------------------------------------------------------------------------
Year: FY 2015
----------------------------------------------------------------------------------------------------------------
1............................. 331.0 Alzheimer's disease....... 196,705 13
2............................. 428.0 Congestive heart failure, 115,111 8
unspecified.
3............................. 162.9 Lung Cancer............... 88,404 6
4............................. 496 COPD...................... 80,655 6
5............................. 331.2 Senile degeneration of 46,843 3
brain.
6............................. 332.0 Parkinson's Disease....... 34,957 2
7............................. 429.9 Heart disease, unspecified 31,906 2
8............................. 436 CVA/Stroke................ 29,172 2
9............................. 437.0 Cerebral atherosclerosis.. 26,887 2
10............................ 174.9 Breast Cancer............. 23,969 2
11............................ 153.9 Colon Cancer.............. 23,844 2
12............................ 185 Prostate Cancer........... 23,293 2
13............................ 157.9 Pancreatic Cancer......... 23,127 2
14............................ 585.6 End stage renal disease... 22,990 2
15............................ 491.21 Obstructive chronic 21,493 1
bronchitis with (acute)
exacerbation.
16............................ 518.81 Acute respiratory failure. 20,214 1
17............................ 429.2 Cardiovascular disease, 16,937 1
unspecified.
18............................ 434.91 Cerebral artery 15,841 1
occlusion, unspecified
with cerebral infarction.
19............................ 414.00 Coronary atherosclerosis 15,689 1
of unspecified type of
vessel.
20............................ 188.9 Bladder Cancer............ 11,648 1
----------------------------------------------------------------------------------------------------------------
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 the Chronic Conditions Data Warehouse (CCW), accessed on
February 14 and February 20, 2013. FY 2013 hospice claims data from the CCW, accessed on June 26, 2014, and FY
2015 hospice claims data from the CCW, accessed on June 20, 2016.
While there has been a shift in the reporting of the principal
diagnosis as a result of diagnosis clarifications, a significant
proportion of hospice claims (49 percent) in FY 2014 only reported a
single principal diagnosis, which may not fully explain the
characteristics of Medicare beneficiaries who are approaching the end
of life. To address this pattern of single diagnosis reporting, the FY
2015 Hospice Wage Index and Payment Rate Update final rule (79 FR
50498) reiterated ICD-9-CM coding guidelines for the reporting of the
principal and additional diagnoses on the hospice claim. We reminded
providers to report all diagnoses on the hospice claim for the terminal
illness and related conditions, including those that affect the care
and clinical management for the beneficiary. Additionally, in the FY
2016 Hospice Wage Index and Payment Rate Update final rule (80 FR
47201), we provided further clarification regarding diagnosis reporting
on hospice claims. We clarified that hospices will report all
[[Page 52152]]
diagnoses identified in the initial and comprehensive assessments on
hospice claims, whether related or unrelated to the terminal prognosis
of the individual, effective October 1, 2015. Analysis of FY 2015
hospice claims show that only 37 percent of hospice claims include a
single, principal diagnosis, with 63 percent submitting at least two
diagnoses and 46 percent including at least three.
F. Use of Health Information Technology
The Department of Health and Human Services (HHS) believes that the
use of certified health IT by hospices can help providers improve
internal care delivery practices and advance the interoperable exchange
of health information across care partners to improve communication and
care coordination. HHS has a number of initiatives designed to
encourage and support the adoption of health information technology and
promote nationwide health information exchange to improve health care.
The Office of the National Coordinator for Health Information
Technology (ONC) leads these efforts in collaboration with other
agencies, including CMS and the Office of the Assistant Secretary for
Planning and Evaluation (ASPE). In 2015, ONC released a document
entitled ``Connecting Health and Care for the Nation: A Shared
Nationwide Interoperability Roadmap'' (available at: https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdf), which includes a near-
term focus on actions that will enable a majority of individuals and
providers across the care continuum to send, receive, find and use a
common set of electronic clinical information at the nationwide level
by the end of 2017. The 2015 Edition Health IT Certification Criteria
(2015 Edition) builds on past rulemakings to facilitate greater
interoperability for several clinical health information purposes and
enables health information exchange through new and enhanced
certification criteria, standards, and implementation specifications.
The 2015 Edition also focuses on the establishment of an interoperable
nationwide health information infrastructure. More information on the
2015 Edition Final Rule is available at: https://www.healthit.gov/policy-researchers-implementers/2015-edition-final-rule
III. Provisions of the Proposed Regulations
The proposed rule, titled ``Medicare Program; FY 2017 Hospice
Payment Rate Update'' (81 FR 25497 through 25538), was published in the
Federal Register on April 28, 2016, with a comment period that ended on
June 20, 2016. In that proposed rule, we proposed to update the hospice
wage index, payment rates, and cap amount for fiscal year (FY) 2017. In
addition, the proposed rule proposed changes to the hospice quality
reporting program, including new quality measures. The proposed rule
also solicited feedback on an enhanced data collection instrument and
described plans to publicly display quality measures and other hospice
data beginning in the middle of 2017. Finally, the proposed rule
included information regarding the Medicare Care Choices Model (MCCM).
We received approximately 56 public comments on the proposed rule,
including comments from MedPAC, hospice agencies, national provider
associations, patient organizations, nurses, and advocacy groups.
In this final rule, we provide a summary of each proposed
provision, a summary of the public comments received and our responses
to them, and the policies we are finalizing for the FY 2017 Hospice
Payment Rate Update. Comments related to the paperwork burden are
addressed in the ``Collection of Information Requirements'' section in
this final rule. Comments related to the impact analysis are addressed
in the ``Economic Analyses'' section in this final rule.
A. Monitoring for Potential Impacts--Affordable Care Act Hospice Reform
In the FY 2017 Hospice Wage Index and Rate Update proposed rule (81
FR 25497), we provided a summary of analysis conducted on pre-hospice
spending, non-hospice spending, live discharge rates, and skilled
visits in the last days of life. In addition, we also provided a
summary of our plans to monitor for impacts of hospice payment reform.
We will continue to monitor the impact of future payment and policy
changes and will provide the industry with periodic updates on our
analysis in future rulemaking and/or announcements on the Hospice
Center Web page at: https://www.cms.gov/Center/Provider-Type/Hospice-Center.html.
We received several comments on the analysis and CMS's plans for
future monitoring efforts with regards to hospice payment reform
outlined in the proposed rule, which are summarized below.
Comment: A few commenters expressed concerns regarding whether pre-
hospice spending is an appropriate standard for comparison for post-
hospice spending for any diagnosis, including dementia. The commenters
noted the illness trajectory of dementia is marked by a slow,
progressive decline, differs from the illness trajectories of other
hospice appropriate diagnoses, and results in care needs increasing and
extending over longer periods of time. In turn, it may require higher
spending. The commenters asked us to recognize the overall care needs
of patients with dementia and other progressive neurological
conditions, and the costs associated with these patients and their
caregivers. Additionally, several commenters highlighted the challenges
of and intensive resources required for short-stay patients, noting
that the current payment system may not address the unique needs of
that population.
Several commenters suggested that CMS consider payment refinements
that help to incentivize appropriate timing on enrollment for hospice.
Additional commenters noted their concern regarding a potential case-
mix payment system for hospice, as the commenters believe that the
hospice benefit differs from all other Medicare payment systems, as it
is designed to account for the patient's full scope of Medicare needs.
With regards to non-hospice spending during a hospice election,
several commenters suggested that CMS take action to educate other
Medicare provider types in order to increase understanding of benefits
coverage and claims processing after a beneficiary has elected hospice.
Several commenters also suggested that CMS investigate options for
preventing other Medicare providers from billing without checking the
Common Working File and notifying the hospice for a determination as to
whether or not the care is related to the terminal prognosis. Several
commenters requested that a greater level of specificity for Part D
data be supplied to hospice providers, such that they can track where
the billing issues originate and begin to address them. The commenters
suggested that a coordinated system would help address the non-hospice
spending.
With regards to hospice live discharge rates, a few commenters
noted concerns about the difference between two types of live
discharges: A patient-initiated discharge or revocation versus a
hospice-initiated discharge. The commenters suggested that analysis of
live discharge rates should exclude the patient-initiated discharges or
revocations. Commenters suggested that for hospice-initiated
discharges, the reasons for such discharges should be reported so that
hospice providers can
[[Page 52153]]
make adjustments in their admission and discharge practices.
With regards to skilled visits during the last days of life, the
number of visits by RNs and social workers is anticipated to increase
during the last 7 days of a beneficiary's life as a result of the
service intensity add[hyphen]on payment, implemented on January 1,
2016. A few commenters stated that hospices take their cues from
patients and families, who should always have the option to decline a
visit. As such, decisions regarding visits made by the patient and
family ought to be considered and/or reflected in the data.
Finally, most commenters supported our planned analysis to monitor
the impact of hospice payment reform and would like to use the
monitoring results to target program integrity efforts to those
aberrant individual providers.
Although the analysis and monitoring efforts described in the
proposed rule did not relate to the timely filing requirement for the
hospice Notice of Election (NOE), nevertheless a few commenters
expressed concern about the timely filing requirement and lost revenue
due to data entry errors that cannot be immediately corrected.
Commenters encouraged CMS to continue to explore the possibility of
transmitting NOEs through Electronic Data Interchange rather than
through direct data entry and recommended that, in the meantime, when
the hospice files the NOE in good faith within the 5-day requirement,
but the MAC does not accept the NOE within 5 days, the payment for
hospice services should be allowed back to the date of election, once
the MAC has accepted the NOE.
Response: We appreciate these comments on the ongoing analysis
presented and will continue to monitor hospice trends and
vulnerabilities within the hospice benefit while also investigating
means by which we can educate the larger provider community regarding
appropriate billing practices. Additionally, we continue to explore
options and strategies for addressing and responding to concerning
behavior in the provider community. We will also consider these
suggestions in any potential future policy and payment refinements.
With regards to the comments received regarding the NOE timely
filing requirement, we recognize that inadvertent NOE errors, such as
transposed numbers or incorrect admission dates, will not trigger the
NOE to return to the hospice for correction. The hospice must wait
until the incorrect information is fully processed by Medicare systems
before they can correct it, and this could cause the NOE to be late. We
strongly encourage hospices to have quality assurance measures in place
regarding the accuracy of the NOE information to mitigate any potential
untimely NOEs. Our expectation is that the information provided on the
hospice NOE is accurate and free of transcribing errors. To aid in
reducing the impact of these situations on hospices, CMS is currently
conducting an analysis that aims to redesign the hospice benefit period
data in our systems.
B. FY 2017 Hospice Wage Index and Rate Update
1. FY 2017 Hospice Wage Index
a. Background
The hospice wage index is used to adjust payment rates for hospice
agencies under the Medicare program to reflect local differences in
area wage levels, based on the location where services are furnished.
The hospice wage index utilizes the wage adjustment factors used by the
Secretary for purposes of section 1886(d)(3)(E) of the Act for hospital
wage adjustments. Our regulations at Sec. 418.306(c) require each
labor market to be established using the most current hospital wage
data available, including any changes made by the Office of Management
and Budget (OMB) to the Metropolitan Statistical Areas (MSAs)
definitions.
We use the previous FY's hospital wage index data to calculate the
hospice wage index values. For FY 2017, the hospice wage index will be
based on the FY 2016 pre-floor, pre-reclassified hospital 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 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 (June 6,
2003). This bulletin announced revised definitions for MSAs and the
creation of micropolitan statistical areas and combined statistical
areas. The bulletin is available online at https://www.whitehouse.gov/omb/bulletins/b03-04.html. 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, on
which to base the calculation of the hospice wage index. In the FY 2010
Hospice Wage Index final rule (74 FR 39386), we 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, Hinesville-Fort Stewart, Georgia.
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 Puerto Rico. However, our policy of
imputing a rural pre-floor, pre-reclassified hospital wage index value
based on the pre-floor, pre-reclassified hospital wage index (or
indices) of CBSAs contiguous to a rural area without a hospital from
which hospital wage data could be derived does not recognize the unique
circumstances of Puerto Rico. In this final rule, for FY 2017, we will
continue to use the most recent pre-floor, pre-reclassified hospital
wage index value available for Puerto Rico, which is 0.4047.
As described in the August 8, 1997 Hospice Wage Index final rule
(62 FR 42860), the pre-floor and pre-reclassified hospital wage index
is used as the raw wage index for the hospice benefit. These raw wage
index values are then subject to application of the hospice floor to
compute the hospice wage index used to determine payments to hospices.
Pre-floor, pre-reclassified hospital wage index values below 0.8 are
adjusted by a 15 percent increase subject to a maximum wage index value
of 0.8. For example, if County A has a pre-floor, pre-reclassified
hospital wage index value of 0.3994, we would multiply 0.3994 by 1.15,
which equals 0.4593. Since 0.4593 is not greater than 0.8, then County
A's hospice wage index would be 0.4593. In another example, if County B
has a pre-floor,
[[Page 52154]]
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.
b. FY 2016 Implementation of New Labor Market Delineations
OMB has published subsequent bulletins regarding CBSA changes. On
February 28, 2013, OMB issued OMB Bulletin No. 13-01, announcing
revisions to the delineation of MSAs, Micropolitan Statistical Areas,
and Combined Statistical Areas, and guidance on uses of the delineation
in these areas. A copy of this bulletin is available online at: https://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-01.pdf.
This bulletin states that it ``provides the delineations of all
Metropolitan Statistical Areas, Metropolitan Divisions, Micropolitan
Statistical Areas, Combined Statistical Areas, and New England City and
Town Areas in the United States and Puerto Rico based on the standards
published on June 28, 2010, in the Federal Register (75 FR 37246
through 37252) and Census Bureau data.'' In the FY 2016 Hospice Wage
Index final rule (80 FR 47178), we adopted the OMB's new area
delineations using a 1-year transition. In the FY 2016 Hospice Wage
Index and Payment Rate Update final rule (80 FR 47178), we stated that
beginning October 1, 2016, the wage index for all hospice payments
would be fully based on the new OMB delineations.
A summary of the comments we received regarding the wage index and
our responses to those comments appears below.
Comment: Several commenters noted their support for the full
adoption of the new labor market delineations.
Response: We appreciate the comments in support of the CBSA
delineations finalized in last year's FY 2016 Hospice Wage Index and
Payment Rate Update final rule (80 FR 47142).
Comment: One commenter disagreed with fully basing hospice
geographic area wage adjustments on the new OMB delineations. The
commenter was particularly concerned with the New York City CBSA and
the fact that the CBSA contains counties from New Jersey.
Response: In the FY 2016 Hospice Wage Index and Rate Update final
rule (80 FR 47178), we stated that a 1-year transition policy would
apply to the FY 2016 payment rates and that, beginning in FY 2017,
hospice payments would be fully-based on the new OMB delineations. In
addition, we believe that the OMB's CBSA designations reflect the most
recent available geographic classifications and are a reasonable and
appropriate method of defining geographic areas for the purposes of
wage adjusting the hospice payment rates. We do not see any compelling
reason to deviate from the OMB designations.
Comment: A commenter was concerned with the continued use of the
pre-floor, pre-reclassified hospital wage index to adjust the hospice
payment rates, because this causes continuing volatility of the hospice
wage index from one year to the next. The commenter believes that this
volatility is often based on inaccurate or incomplete hospital cost
report data.
Response: We believe that annual changes in the wage index reflect
real variations in costs of providing care in various geographic
locations. The wage index values are based on data submitted on the
inpatient hospital cost reports. We utilize efficient means to ensure
and review the accuracy of the hospital cost report data and resulting
wage index. The hospice wage index is derived from the pre-floor, pre-
reclassified wage index, which is calculated based on cost report data
from hospitals paid under the Inpatient Prospective Payment System
(IPPS). All IPPS hospitals must complete the wage index survey
(Worksheet S-3, Parts II and III) as part of their Medicare cost
reports. Cost reports will be rejected if Worksheet S-3 is not
completed. In addition, our Medicare contractors perform desk reviews
on all hospitals' Worksheet S-3 wage data, and we run edits on the wage
data to further ensure the accuracy and validity of the wage data. We
believe that our review processes result in an accurate reflection of
the applicable wages for the areas given.
In addition, we believe that finalizing our proposal to adopt a
hospice wage index standardization factor will provide a safeguard to
the Medicare program as well as to hospices because it will mitigate
fluctuations in the wage index by ensuring that wage index updates and
revisions are implemented in a budget neutral manner.
Comment: A commenter was concerned with the lack of parity between
different health care sectors, each of which utilizes some form of a
hospital wage index, that experience differing wage index values for
specific geographic areas. The commenter also stated that hospital
reclassifications create labor market distortions in areas in which
hospice costs are not reclassified.
Response: Several post-acute care payment systems utilize the pre-
floor, pre-reclassified hospital wage index as the basis for their wage
indexes (for example, the Home Health Prospective Payment System (HH
PPS), the Skilled Nursing Facility Prospective Payment System (SNF PPS)
and the Inpatient Rehabilitation Facility Prospective Payment System
(IRF PPS)). The statutes that govern hospice payment do not provide any
discretion to permit a mechanism for allowing hospices to seek
geographic reclassification. The reclassification provision is found in
section 1886(d)(10) of the Act. Section 1886(d)(10)(C)(i) of the Act
states, ``The Board shall consider the application of any subsection
(d) hospital requesting that the Secretary change the hospital's
geographic classification . . .'' This provision is only applicable to
hospitals, as defined at section 1886(d) of the Act. In addition, we do
not believe that using hospital reclassification data would be
appropriate as these data are specific to the requesting hospitals and
the data may or may not apply to a given hospice in a given instance.
Comment: One commenter requested that CMS modify the wage index so
that the area wage index applicable to any hospice that is located in
an urban area of a state may not be less than the area wage index
applicable to hospices located in rural areas in that State.
Response: Section 4410(a) of the Balanced Budget Act of 1997 (Pub.
L. 105-33) provides that the area wage index applicable to any hospital
that is located in an urban area of a state may not be less than the
area wage index applicable to hospitals located in rural areas in that
state. This rural floor provision is specific to hospitals. Because the
hospital rural floor applies only to hospitals, and not to hospices, we
continue to believe the use of the previous year's pre-floor and pre-
reclassified hospital wage index results in the most appropriate
adjustment to the labor portion of the hospice payment rates. This
position is longstanding and consistent with other Medicare payment
systems (SNF PPS, IRF PPS, HH PPS, etc.).
Comment: A commenter requested that CMS explore a wholesale
revision and reform of the hospice wage index.
Response: We are exploring other methodologies for future reform of
the Medicare wage index. CMS' ``Report to Congress: Plan to Reform the
Medicare Wage Index'' was submitted by the Secretary on April 11, 2012
and is available on our Wage Index Reform Web page at: https://
www.cms.gov/Medicare/Medicare-Fee-for-Service-
[[Page 52155]]
Payment/AcuteInpatientPPS/Wage-Index-Reform.html.
Final Action: After considering the comments received in response
to the proposed rule and for the reasons discussed above, we are
finalizing our proposal to use the pre-floor, pre-reclassified hospital
inpatient wage index as the wage adjustment to the labor portion of the
hospice rates. For FY 2017, the updated wage data are for hospital cost
reporting periods beginning on or after October 1, 2011 and before
October 1, 2012 (FY 2012 cost report data).
The wage index applicable for FY 2017 is available on the CMS Web
site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/. As of FY 2012, the wage index values applicable for
the upcoming fiscal year and subsequent fiscal years are no longer
published in the Federal Register (77 FR 44242). The hospice wage index
for FY 2017 will be effective October 1, 2016 through September 30,
2017.
2. 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 inpatient hospital market basket index
set out under section 1886(b)(3)(B)(iii) of the Act, minus 1 percentage
point. Payment rates for FYs since 2002 have been updated according to
section 1814(i)(1)(C)(ii)(VII) of the Act, which states that the update
to the payment rates for subsequent FYs must be the inpatient market
basket percentage 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: https://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 hospice payment
update percentage for FY 2017 is based on the estimated inpatient
hospital market basket update of 2.7 percent (based on IHS Global
Insight, Inc.'s second quarter 2016 forecast with historical data
through the first quarter of 2016). Due to the requirements at sections
1886(b)(3)(B)(xi)(II) and 1814(i)(1)(C)(v) of the Act, the estimated
inpatient hospital market basket update for FY 2017 of 2.7 percent must
be reduced by a MFP adjustment as mandated by Affordable Care Act
(currently estimated to be 0.3 percentage point for FY 2017). The
estimated inpatient hospital market basket update for FY 2017 is
reduced further by 0.3 percentage point, as mandated by the Affordable
Care Act. In effect, the hospice payment update percentage for FY 2017
is 2.1 percent.
Currently, the labor portion of the hospice payment rates is as
follows: For RHC, 68.71 percent; for CHC, 68.71 percent; for General
Inpatient Care, 64.01 percent; and for Respite Care, 54.13 percent. The
non-labor portion is equal to 100 percent minus the labor portion for
each level of care. Therefore, the non-labor portion of the payment
rates is as follows: For RHC, 31.29 percent; for CHC, 31.29 percent;
for General Inpatient Care, 35.99 percent; and for Respite Care, 45.87
percent.
A summary of the comments we received regarding the payment rates
and our responses to those comments appear below.
Comment: Several commenters noted their support of the hospice
payment update percentage.
Response: We appreciate the comments in support of the hospice
payment update percentage.
Comment: One commenter suggested the CMS eliminate the hospice
payment update percentage to hospice payments for FY 2017, as the
commenter maintains that payment adequacy for hospice providers is
generally positive. Other commenters noted that the proposed hospice
payment update percentage is not sufficient to keep pace with rising
costs of providing hospice care and suggested that CMS revisit the
proposed hospice payment update percentage for potential increase.
Response: The payment update percentage to the hospice rates is
required by statute, as previously described in detail in this section,
and we do not have regulatory authority to alter the payment update.
Final Action: We are implementing the hospice payment update
percentage as discussed in the proposed rule. Based on IHS Global
Insight, Inc.'s updated forecast, the hospice payment update percentage
for FY 2017 will be 2.1 percent for hospices that submit the required
quality data and 0.1 percent for hospices that do not submit the
required quality data.
3. FY 2017 Hospice Payment Rates
There are four payment categories that are distinguished by the
location and intensity of the services provided. The base payments are
adjusted for geographic differences in wages by multiplying the labor
share, which varies by category, of each base rate by the applicable
hospice wage index. A hospice is paid the RHC rate for each day the
beneficiary is enrolled in hospice, unless the hospice provides
continuous home care, IRC, or general inpatient care. CHC is provided
during a period of patient crisis to maintain the person at home; IRC
is short-term care to allow the usual caregiver to rest and be relieved
from caregiving; and General Inpatient Care (GIP) is to treat symptoms
that cannot be managed in another setting.
As discussed in the FY 2016 Hospice Wage Index and Payment Rate
Update final rule (80 FR 47172), we implemented two different RHC
payment rates, one RHC rate for the first 60 days and a second RHC rate
for days 61 and beyond. In addition, in the final rule, we adopted a
Service Intensity Add-on (SIA) payment, when direct patient care is
provided by a RN or social worker during the last 7 days of the
beneficiary's life. The SIA payment is equal to the CHC hourly rate
multiplied by the hours of nursing or social work provided (up to 4
hours total) that occurred on the day of service. In order to maintain
budget neutrality, as required under section 1814(i)(6)(D)(ii) of the
Act, the new RHC rates were adjusted by a SIA budget neutrality factor.
As discussed in the FY 2016 Hospice Wage Index and Payment Rate
Update final rule (80 FR 47177), we will continue to make the SIA
payments budget neutral through an annual determination of the SIA
budget neutrality factor (SBNF), which will then be applied to the RHC
payment
[[Page 52156]]
rates. The SBNF will be calculated for each FY using the most current
and complete FY utilization data available at the time of rulemaking.
For FY 2017, the budget neutrality adjustment that applies to days 1
through 60 is calculated to be 1.0000. The budget neutrality adjustment
that applies to days 61 and beyond is calculated to be 0.9999.
For FY 2017, we are applying a wage index standardization factor to
the FY 2017 hospice payment rates in order to ensure overall budget
neutrality when updating the hospice wage index with more recent
hospital wage data. Wage index standardization factors are applied in
other payment settings such as under home health Prospective Payment
System (PPS), IRF PPS, and SNF PPS. Applying a wage index
standardization factor to hospice payments will eliminate the aggregate
effect of annual variations in hospital wage data. We believe that
adopting a hospice wage index standardization factor will provide a
safeguard to the Medicare program as well as to hospices because it
will mitigate fluctuations in the wage index by ensuring that wage
index updates and revisions are implemented in a budget neutral manner.
To calculate the wage index standardization factor, we simulated total
payments using the FY 2017 hospice wage index and compared it to our
simulation of total payments using the FY 2016 hospice wage index. By
dividing payments for each level of care using the FY 2017 wage index
by payments for each level of care using the FY 2016 wage index, we
obtain a wage index standardization factor for each level of care (RHC
days 1-60, RHC days 61+, CHC, IRC, and GIP).
Lastly, the hospice payment rates for hospices that submit the
required quality data will be increased by the full FY 2017 hospice
payment update percentage of 2.1 percent as discussed in section
III.C.3 of this final rule. The FY 2017 RHC rates are shown in Table
11. The FY 2017 payment rates for CHC, IRC, and GIP are shown in Table
12.
Table 11--FY 2017 Hospice RHC Payment Rates
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2017
Wage index hospice
Code Description FY 2016 SBNF standardization payment FY 2017
payment rates factor update payment rates
percentage
--------------------------------------------------------------------------------------------------------------------------------------------------------
651.................................. Routine Home Care (days 1-60).. $186.84 x 1.0000 x 0.9989 x 1.021 $190.55
651.................................. Routine Home Care (days 61+)... 146.83 x 0.9999 x 0.9995 x 1.021 149.82
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 12--FY 2017 Hospice CHC, IRC, and GIP Payment Rates
----------------------------------------------------------------------------------------------------------------
FY 2017
Wage index hospice
Code Description FY 2016 standardization payment FY 2017
payment rates factor update payment rates
percentage
----------------------------------------------------------------------------------------------------------------
652...................... Continuous Home $944.79 x 1.0000 x 1.021 $964.63
Care.
Full Rate = 24
hours of care..
$40.19 = FY 2017
hourly rate..
655...................... Inpatient Respite 167.45 x 1.0000 x 1.021 170.97
Care.
656...................... General Inpatient 720.11 x 0.9996 x 1.021 734.94
Care.
----------------------------------------------------------------------------------------------------------------
Sections 1814(i)(5)(A) through (C) of the Act require that hospices
begin submitting quality data, based on measures to be specified by the
Secretary. In the FY 2012 Hospice Wage Index final rule (76 FR 47320
through 47324), we implemented a Hospice Quality Reporting Program
(HQRP), as required by section 3004 of the Affordable Care Act.
Hospices were required to begin collecting quality data in October
2012, and submit that quality data in 2013. Section 1814(i)(5)(A)(i) of
the Act requires that beginning with FY 2014 and 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. The FY 2017 rates for
hospices that do not submit the required quality data will be updated
by the FY 2017 hospice payment update percentage of 2.1 percent minus 2
percentage points. These rates are shown in Tables 13 and 14.
Table 13--FY 2017 Hospice RHC Payment Rates for Hospices That DO NOT Submit the Required Quality Data
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2017
hospice
Wage index payment
Code Description FY 2016 SBNF standardization update of 2.1% FY 2017
payment rates factor minus 2 payment rates
percentage
points = 0.1%
--------------------------------------------------------------------------------------------------------------------------------------------------------
651.................................. Routine Home Care (days 1-60).. $186.84 x 1.0000 x 0.9989 x 1.001 $186.82
651.................................. Routine Home Care (days 61+)... 146.83 x 0.9999 x 0.9995 x 1.001 146.89
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 52157]]
Table 14--FY 2017 Hospice CHC, IRC, and GIP Payment Rates for Hospices That DO NOT Submit the Required Quality
Data
----------------------------------------------------------------------------------------------------------------
FY 2017
hospice
Wage index payment
Code Description FY 2016 standardization update of 2.1% FY 2017
payment rates factor minus 2 payment rates
percentage
points = 0.1%
----------------------------------------------------------------------------------------------------------------
652...................... Continuous Home $944.79 x 1.0000 x 1.001 $945.73
Care.
Full Rate = 24
hours of care..
$39.41 = FY 2017
hourly rate..
655...................... Inpatient Respite 167.45 x 1.0000 x 1.001 167.62
Care.
656...................... General Inpatient 720.11 x 0.9996 x 1.001 720.54
Care.
----------------------------------------------------------------------------------------------------------------
A summary of the comments we received regarding the payment rates
and our responses to those comments appear below.
Comment: A commenter asked if the application of the
standardization factor is premature or is it part of the continued
progression of hospice reimbursement from hybrid fee-for-service/health
maintenance organization to a full case-mix or value-based purchasing
(VBP) system.
Response: We believe that applying a wage index standardization
factor to the hospice rates is appropriate. The application of the
standardization factor will mitigate any potential effects due to the
annual variations in hospital wage data. Moreover, this approach
creates a level of protection for the Medicare program as well as to
hospices, as it minimizes the impacts of any fluctuations in the wage
index.
Comment: Several commenters requested that the SIA Payment
eligibility requirements be modified to include additional hospice
services, including visits from licensed practical nurses (LPNs), music
therapists, and other professionals providing care during the last 7
days of life. In addition, several commenters requested that data be
collected in order to determine if the SIA Payment increased the number
of visits during beneficiaries' most intensive time of need for skilled
care (specifically, the last 7 days of life).
Response: CMS finalized the SIA payment policy in the FY 2016
Hospice Wage Index and Payment Update final rule (80 FR 47141) and we
did not solicit comments on a proposal to modify these policy
parameters in the FY 2017 Hospice Wage Index and Payment Rate update
proposed rule (81 FR 25498). However, we will continue to consider and
monitor for potential refinements to this policy, including current
monitoring efforts that were described in the FY 2017 Hospice Wage
Index and Payment Rate Update proposed rule (81 FR 25498) in response
to these policy changes, and we will take these comments into account
as we continue to do so.
Comment: One commenter noted that there have been issues with the
technical implementation of the SIA payment such that payment
adjustments are not occurring as originally intended.
Response: While the technical implementations issues with regards
to SIA payments have been minimal, we appreciate this comment and are
working diligently with appropriate stakeholders to expedite the
appropriate system remediation to ensure accurate payment to providers.
Comment: One commenter expressed concern that the RHC rate payment
amount for Days 61 and beyond may lead to payment inadequacy for
patients with long lengths of stay. One commenter noted that the
episode gap required by the two RHC rates policy implemented for FY
2016 could have a negative impact on those hospices that accept
patients via transfers. Moreover, the commenter noted that CMS should
consider payment adjustments if a patient is transferred from one
hospice to another, particularly at or near day 61 of a hospice
episode.
Response: We appreciate the comments and the concern for
appropriate payment for long stay beneficiaries as well as transfer
patients. The creation of the two RHC rates (one for days 1-60 and a
another for days 61 and beyond) was finalized in the FY 2016 Hospice
Wage Index and Payment Rate Update final rule (80 FR 47141), and we did
not propose any changes for FY 2017 nor did we solicit comments on any
future changes. In response to public comments, we stated in the FY
2016 Hospice Wage Index and Payment Rate Update final rule that
allowing for a higher payment for a new hospice election (or in
transfer situations) without a gap in hospice care of greater than 60
days goes against our intent to mitigate the incentive to discharge and
readmit patients (or transfer patients) at or around day 60 for the
purposes of obtaining a higher payment (80 FR 47168). With regards to
the commenter's concern regarding reimbursement for long lengths of
stay, we refer the commenter to the FY 2016 Hospice Wage Index and
Payment Rate Update final rule (80 FR 47142), where we discuss the
rationale for the creation of a higher RHC rate for days 1-60 and a
lower rate for days 61 and beyond. In that final rule, we noted that
hospice stays manifest in a `U-Shaped' pattern (that is, the intensity
of services provided is higher both at admission and near death and,
conversely, is relatively lower during the middle period of the hospice
episode). Since hospice care is most profitable during the long, low-
cost middle portions of an episode, longer episodes have very
profitable, long middle segments (80 FR 47161). Therefore, in order to
better align hospice payments with service intensity during a hospice
episode of care, we implemented a higher RHC rate for days 1-60 and a
lower rate for days 61 and beyond, effective January 1, 2016. We also
implemented a service intensity add-on (SIA) payment policy that
reimburses hospices for visits performed during the last 7 days of a
beneficiary's life (in addition to RHC per diem payments), also
effective January 1, 2016. We will continue to monitor for and consider
potential refinements to these policies as appropriate.
Comment: A commenter noted that Medicaid agencies have encountered
challenges in the implementation of the payment changes due to hospice
reform.
Response: We appreciate this comment and are working diligently
with appropriate stakeholders and State Agencies to facilitate
effective implementation of hospice payment reform.
Final Action: We are implementing the updates to hospice payment
rates as discussed in the proposed rule.
[[Page 52158]]
4. Hospice Cap Amount for FY 2017
As discussed in the FY 2016 Hospice Wage Index and Payment Rate
Update final rule (80 FR 47183), we implemented changes mandated by the
Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT
Act). Specifically, for accounting years that end after September 30,
2016 and before October 1, 2025, the hospice cap is updated by the
hospice payment update percentage rather than using the consumer price
index for urban consumers (CPI-U). As required by section
1814(i)(2)(B)(ii) of the Act, the hospice cap amount for the 2016 cap
year, starting on November 1, 2015 and ending on October 31, 2016, is
equal to the 2015 cap amount ($27,382.63) updated by the FY 2016
hospice payment update percentage of 1.6 percent. As such, the 2016 cap
amount is $27,820.75.
In the FY 2016 Hospice Wage Index and Payment Rate Update final
rule (80 FR 47142), we finalized aligning the cap accounting year with
the federal FY beginning in 2017. Therefore, the 2017 cap year will
start on October 1, 2016 and end on September 30, 2017. Table 26 in the
FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR
47185) outlines the timeframes for counting beneficiaries and payments
during the 2017 transition year. The hospice cap amount for the 2017
cap year will be $28,404.99, which is equal to the 2016 cap amount
($27,820.75) updated by the FY 2017 hospice payment update percentage
of 2.1 percent.
A summary of public comments and our responses to comments on the
hospice cap are summarized below:
Comment: One commenter expressed concerns that the methodology used
to calculate the hospice cap creates an incentive for rural hospices to
inflate their utilization of the GIP level of care, as some rural
hospices may do this to gain higher reimbursement by placing patients
at the GIP level of care that may not qualify for that level of care.
Response: The hospice aggregate cap is calculated based on total
reimbursement across all levels of care. In addition, the hospice
inpatient cap limits total payments to the hospice for inpatient care
(general or respite). Total payments are subject to a limitation that
total inpatient care days for Medicare patients does not exceed 20
percent of the total days for which patients had elected hospice care.
We urge providers to adhere to appropriate guidelines with respect to
the hospice levels of care. We note that in a March 2016 Office of
Inspector General (OIG) report, OIG found that hospices billed one-
third of GIP stays inappropriately, costing Medicare $268 million in
2012. According to the report, ``hospices commonly billed for GIP when
the beneficiary did not have uncontrolled pain or unmanaged symptoms.''
(https://oig.hhs.gov/oei/reports/oei-02-10-00491.asp) As such, we will
continue to monitor the use of the various levels of care in order to
identify any aberrant or problematic behavior.
Final Action: We are implementing the changes to the hospice cap
amount as discussed in the proposed rule.
C. Proposed Updates to the Hospice Quality Reporting Program (HQRP)
1. Background and Statutory Authority
Section 3004(c) of the Affordable Care Act amended section
1814(i)(5) of the Act to authorize a quality reporting program for
hospices. Section 1814(i)(5)(A)(i) of the Act requires that beginning
with FY 2014 and each subsequent FY, the Secretary shall reduce the
market basket update by 2 percentage points for any hospice that does
not comply with the quality data submission requirements for that FY.
Depending on the amount of the annual update for a particular year, a
reduction of 2 percentage points could result in the annual market
basket update being less than 0 percent for a FY and may result in
payment rates that are less than payment rates for the preceding FY.
Any reduction based on failure to comply with the reporting
requirements, as required by section 1814(i)(5)(B) of the Act, would
apply only for the particular 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, including the endorsement of quality measures, with the
Secretary under section 1890(a) of the Act. This contract is currently
held by the National Quality Forum (NQF). However, section
1814(i)(5)(D)(ii) of the Act provides that in the case of a specified
area or medical topic determined appropriate by the Secretary for which
a feasible and practical measure has not been endorsed by the
consensus-based entity, the Secretary may specify measures that are not
so endorsed as long as due consideration is given to measures that have
been endorsed or adopted by a consensus-based organization identified
by the Secretary. Our paramount concern is the successful development
of an HQRP that promotes the delivery of high quality healthcare
services. We seek to adopt measures for the HQRP that promote person-
centered, high quality, and safe care. Our measure selection activities
for the HQRP take into consideration input from the Measure
Applications Partnership (MAP), convened by the NQF, as part of the
established CMS pre-rulemaking process required under section 1890A of
the Act. The MAP is a public-private partnership comprised of multi-
stakeholder groups convened by the NQF for the primary purpose of
providing input to CMS on the selection of certain categories of
quality and efficiency measures, as required by section 1890A(a)(3) of
the Act. By February 1st of each year, the NQF must provide that input
to CMS. Input from the MAP is located at https://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx.
We also take into account national priorities, such as those
established by the National Priorities Partnership at (https://www.qualityforum.org/npp/), the HHS Strategic Plan (https://www.hhs.gov/secretary/about/priorities/priorities.html), the National Strategy for
Quality Improvement in Healthcare, (https://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm) and the CMS Quality Strategy
(https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html). To
the extent practicable, we have sought to adopt measures endorsed by
member organizations of the National Consensus Project (NCP),
recommended by multi-stakeholder organizations, and developed with the
input of providers, purchasers and/or payers, and other stakeholders.
3. Policy for Retention of HQRP Measures Adopted for Previous Payment
Determinations
For the purpose of streamlining the rulemaking process, we
finalized our policy in the FY 2016 Hospice Wage Index final rule (80
FR 47187) that when we adopt measures for the HQRP beginning with a
payment
[[Page 52159]]
determination year, these measures would automatically be adopted for
all subsequent years' payment determinations, unless we proposed to
remove, suspend, or replace the measures. Quality measures would be
considered for removal by CMS for reasons including, but not limited
to:
Measure performance among hospices was so high and
unvarying that meaningful distinction in improvements in performance
could no longer be made;
Performance or improvement on a measure did not result in
better patient outcomes;
A measure did not align with current clinical guidelines
or practice;
A more broadly applicable measure (across settings,
populations, or conditions) for the particular topic was available;
A measure that was more proximal in time to desired
patient outcomes for the particular topic was available;
A measure that was more strongly associated with desired
patient outcomes for the particular topic was available; or
Collection or public reporting of a measure led to
negative unintended consequences.
For any such removal, the public would be given an opportunity to
comment through the annual rulemaking process. However, if there were
reason to believe continued collection of a measure raised potential
safety concerns, we would take immediate action to remove the measure
from the HQRP and not wait for the annual rulemaking cycle. The
measures would be promptly removed, and we would immediately notify
hospices and the public of such a decision through the usual CMS HQRP
communication channels, including postings and announcements on the CMS
HQRP Web site, Medicare Learning Network (MLN) eNews communications,
national provider association calls, and announcements on Open Door
Forums and Special Open Door Forums. In such instances, the removal of
a measure would be formally announced in the next annual rulemaking
cycle.
To further streamline the rulemaking process, we proposed to codify
that if measures we are using in the HQRP have non-substantive changes
in their specifications change as part of their NQF endorsement
process, we would continue to utilize the measure with their new
endorsed status in the HQRP. As mentioned previously, quality measures
selected for the HQRP must be endorsed by the NQF unless they meet the
statutory criteria for exception under section 1814(i)(5)(D)(ii) of the
Act. The NQF is a voluntary consensus standard-setting organization
with a diverse representation of consumer, purchaser, provider,
academic, clinical, and other healthcare stakeholder organizations. The
NQF was established to standardize healthcare quality measurement and
reporting through its consensus measure development process (https://www.qualityforum.org/About_NQF/Mission_and_Vision.aspx). The NQF
undertakes review of: (a) New quality measures and national consensus
standards for measuring and publicly reporting on performance, (b)
regular maintenance processes for endorsed quality measures, (c)
measures with time-limited endorsement for consideration of full
endorsement, and (d) ad hoc review of endorsed quality measures,
practices, consensus standards, or events with adequate justification
to substantiate the review. Through NQF's measure maintenance process,
NQF-endorsed measures are sometimes updated to incorporate changes that
we believe do not substantially change the nature of the measure.
Examples of such changes could be updated diagnosis or procedure codes,
changes to exclusions to a particular patient/consumer population, or
definitions. We believe these types of maintenance changes are distinct
from more substantive changes to measures. Additionally, since the NQF
endorsement and measure maintenance process is one that ensures
transparency, public input, and discussion among representatives across
the healthcare enterprise,\5\ we believe that the NQF measure
endorsement and maintenance process itself is transparent,
scientifically rigorous, and provides opportunity for public input.
Thus, we proposed to codify at Sec. 418.312 that if the NQF makes only
non-substantive changes to specifications for HQRP measures in the
NQF's re-endorsement process, we would continue to utilize the measure
in its new endorsed status. If NQF-endorsed specifications change and
we do not adopt those changes, then we would propose the measure as an
application. An application of a NQF-endorsed quality measure is
utilized in instances when CMS has identified a need to use a NQF-
endorsed measure in a QRP but need to use it with one or more
modifications to the quality measure's specifications. These
modifications pertain to, but are not limited to, one or more of the
following aspects of a NQF-endorsed quality measure: (a) Numerator, (b)
denominator, (c) setting, (d) look-back period, (e) calculation period,
(f) risk adjustment, and (g) revisions to data elements used to collect
the data required for the measure, etc. CMS may adopt a quality measure
for the HQRP under section 1814(i)(5)(D)(ii) of the Act, which states,
``In the case of a specified area or medical topic determined
appropriate by the Secretary for which a feasible and practical measure
has not been endorsed by [the NQF], the Secretary may specify a measure
that is not so endorsed as long as due consideration is given to
measures that have been endorsed or adopted by a consensus organization
identified by the Secretary.'' Reasons for not adopting changes in
measure specifications to a measure may include any of the
aforementioned criteria in this section, including that the new
specification does not align with clinical guidelines or practice or
that the new specification leads to negative unintended consequences.
Finally, we will continue to use rulemaking to adopt substantive
updates made by the NQF to the endorsed measures we have adopted for
the HQRP. We continue to make these determinations about what
constitutes a substantive versus non-substantive change on a measure-
by-measure basis. A change would be deemed substantive if the intent of
the measure changes, the facility/setting changes, the data sources
changes, the level of analysis changes, and/or the measure is removed.
We will continue to provide updates about changes to measure
specifications as a result of NQF endorsement or maintenance processes
through the normal CMS HQRP communication channels, including postings
and announcements on the CMS HQRP Web site, MLN eNews communications,
national provider association calls, and announcements on Open Door
Forums and Special Open Door Forums.
---------------------------------------------------------------------------
\5\ ``NQF: How Endorsement Happens--National Quality Forum.''
2010. 26 Jan. 2016 https://www.qualityforum.org/Measuring_Performance/ABCs/How_Endorsement_Happens.aspx.
---------------------------------------------------------------------------
Comment: CMS received two comments on our proposal to codify that
if measures used in the HQRP undergo non-substantive changes as part of
their NQF re-endorsement process, we would utilize the measure with
their new endorsed status without going through a new notice-and-
comment rulemaking process. One commenter supported the proposal to
codify this policy. Another commenter was concerned that CMS's plan to
adopt non-substantive change(s) approved through the NQF re-endorsement
process without a notice-and-comment rulemaking process does not allow
providers and vendors the
[[Page 52160]]
opportunity to provide input on changes to measure specifications.
Additionally, the commenter also had concerns that adopting non-
substantive changes to measures outside of the rulemaking process would
limit the ability for hospices and vendors to make necessary changes to
data collection systems to implement non-substantive updates to
measures.
Response: We thank commenters for their support of this proposal,
and for their concerns raised. We agree that the opportunity for the
public to provide input on all changes to measure specifications (both
substantive and non-substantive) is vital to the measure development,
endorsement, and maintenance process. We also agree with the commenter
that vendors and the hospice community need ample time to implement
changes to measure specifications, especially those that would warrant
updates to Hospice Item Set (HIS) items or technical specifications. We
would like to reassure commenters that, as stated in this rule, we will
still propose substantive changes to measure through rulemaking. With
regard to non-substantive measure changes that could occur as a result
of the measure maintenance and re-endorsement process, we would like to
clarify that the NQF processes for endorsement and maintenance of
measures includes review by an expert Standing Committee, public and
Member comment periods, Member voting, consideration by the Consensus
Standards Approval Committee (CSAC), endorsement by the Board of
Directors, and a 30-day appeals period. The NQF endorsement and
maintenance (re-endorsement) process allows ample opportunity for NQF
member and public input, during the measure development, endorsement
and maintenance phases. We encourage hospices to participate in these
NQF comment periods to offer their insights about potential impacts of
changes to measures and measure specifications. We believe that in
instances of non-substantive changes to measure specifications,
maximizing the use of NQF opportunities for public input allows us to
efficiently and expediently adopt non-substantive, but important
changes to measures. Regarding the commenter's concern about whether
this policy will allow providers ample time to implement and adopt non-
substantive changes, we would like to point out that when non-
substantive changes put forth by the NQF are adopted, we are not
required to immediately implement those changes on the date of re-
endorsement by NQF. Once a non-substantive change is endorsed by NQF,
we will consider the time necessary for providers and vendors to
implement the change. If newly endorsed non-substantive changes require
updates to data collection mechanisms (for example, updates to HIS
specifications) or associated training materials, we will allow ample
time for providers and vendors to prepare and implement such changes.
As noted in the rule, we will communicate the endorsement of non-
substantive changes, decisions about whether to adopt non-substantive
changes, and timeline for implementation of non-substantive changes
through regular HQRP communication channels. Additionally, CMS welcomes
comment on any non-substantive changes adopted under this mechanism
through the appropriate sub-regulatory communication channels,
including but not limited to: NQF public comment periods held as part
of endorsement processes, feedback from providers on the Hospice
Quality HelpDesk, and feedback from the provider community on ODFs and
SODFs. CMS will make such comments and their responses available to the
public under the appropriate sub-regulatory communication channels.
Finally, we would like to note that this policy is consistent with
similar policies in other QRPs.
Comment: We received a few comments on our previously finalized
policy for measure retention. These commenters encouraged CMS's
continued consideration of whether previously adopted quality measures
are appropriate for retention in the HQRP. Commenters encouraged CMS to
eliminate measures that are no longer considered to effectively measure
quality.
Response: We thank commenters for their suggestions surrounding
measure retention and removal. We agree that any quality measures
proposed and retained in the HQRP should continue to provide meaningful
data to providers and consumers on quality of care. We regularly
conduct measure testing activities according to NQF guidelines and the
Blueprint for the CMS Measures Management System Version 12.0 (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-120.pdf) to ensure that measures
continue to demonstrate scientific acceptability (including reliability
and validity) and meet the goals of the HQRP, which include
distinguishing performance among hospices and contributing to better
patient outcomes. As outlined in this section of the rule, we will
propose a measure for removal if meaningful distinctions in quality of
care can no longer be made from the measure due to high and unvarying
performance.
Final Action: After consideration of the comments, we are codifying
our policy that once a quality measure is adopted, it be retained for
use in the subsequent fiscal year payment determinations until
otherwise stated, as proposed.
4. Previously Adopted Quality Measures for FY 2017 and FY 2018 Payment
Determination
As stated in the CY 2013 HH PPS final rule (77 FR 67068 through
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, tested, and
implemented a hospice patient-level item set, the HIS. Hospices are
required to submit a HIS-Admission record and a HIS-Discharge record
for each patient admission to hospice since July 1, 2014. In developing
the standardized HIS, we considered comments offered in response to the
CY 2013 HH PPS proposed rule (77 FR 41548 through 41573). In the FY
2014 Hospice Wage Index final rule (78 FR 48257), and in compliance
with section 1814(i)(5)(C) of the Act, we finalized the specific
collection of data items that support the following 6 NQF-endorsed
measures and 1 modified measure for hospice:
NQF #1617 Patients Treated with an Opioid who are Given a
Bowel Regimen,
NQF #1634 Pain Screening,
NQF #1637 Pain Assessment,
NQF #1638 Dyspnea Treatment,
NQF #1639 Dyspnea Screening,
NQF #1641 Treatment Preferences,
NQF #1647 Beliefs/Values Addressed (if desired by the
patient) (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 July 1, 2014 (78 FR 48258). To meet the quality reporting
requirements for hospices for the FY 2016 payment determination and
each subsequent year, we require regular and ongoing
[[Page 52161]]
electronic submission of the HIS data for each patient admission to
hospice after July 1, 2014, regardless of payer or patient age (78 FR
48234 through 48258). We finalized a requirement in the FY 2014 Hospice
Wage Index final rule (78 FR 48258) that hospice providers collect data
on all patients to ensure that all patients regardless of payer or
patient age are receiving the same care and that provider metrics
measure performance across the spectrum of patients.
Hospices are required to complete and submit a HIS-Admission and a
HIS-Discharge record for each patient admission. Hospices failing to
report quality data via the HIS for patient admissions occurring in
2016 will have their market basket update reduced by 2 percentage
points in FY 2018 (beginning in October 1, 2017). In the FY 2015
Hospice Wage Index final rule (79 FR 50485 through 50487), we finalized
the proposal to codify the HIS submission requirement at Sec. 418.312.
The System of Record (SOR) Notice titled ``Hospice Item Set (HIS)
System,'' SOR number 09-70-0548, was published in the Federal Register
on April 8, 2014 (79 FR 19341).
Table 15--Previously Finalized Quality Measures Affecting the FY 2017 Payment Determination and Subsequent Year
--------------------------------------------------------------------------------------------------------------------------------------------------------
Data submission
Quality measure NQF ID# Type Submission method deadlines
--------------------------------------------------------------------------------------------------------------------------------------------------------
Treatment Preferences................. 1641 Process Measure..................... Hospice Item Set.................... Within 30 days of
Beliefs/Values Addressed.............. 1647 patient admission or
discharge (Event Date).
Pain Screening........................ 1634
Pain Assessment....................... 1637
Dyspnea Screening..................... 1639
Dyspnea Treatment..................... 1638
Patients Treated with an Opioid who 1617
are Given a Bowel Regimen.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Comment: CMS received a comment regarding the retirement of the
seven day length of stay (LOS) exclusion for six of the care process
measures currently implemented in the HQRP. This commenter expressed
concern that in eliminating the LOS exclusion, provider behavior may
shift towards focusing on completing the HIS requirements and
compliance at the expense of addressing the needs and preferences of
imminently dying patients. Additionally, this commenter recommended
that CMS reconsider eliminating the LOS exclusion or risk adjust for
hospices with an excessive number of short-stay patients for patients.
Response: We appreciate the commenters' input on the retirement of
the LOS exclusion specification for six of the quality measures
currently implemented in the HQRP. Developing and adopting measures
that are meaningful and do not lead to negative unintended consequences
for patients or providers is important to us. At the time the measures
were developed, technical experts recommended that short patient stays
be excluded from those measures' denominators for assessing quality of
care in hospices. However, no national data regarding the implications
of the LOS exclusion was available to the Technical Expert Panel (TEP)
at that time. CMS's contractor analyzed data from the HIS to examine
the implications of the LOS exclusion on hospices' denominator size and
quality measure (QM) scores. Additionally, this analysis examined the
timing of when hospices perform the care processes assessed in the
quality measures. These analyses were conducted using HIS-Admission and
HIS-Discharge records for stays in July 1, 2014 through March 31, 2015.
The results of these analyses demonstrated that the denominator sizes
for the HQRP QMs are largely impacted by the current 7-day LOS
exclusion used to calculate the QMs. Excluding stays with LOS less than
7 days prevents some hospices from being included in QM score
calculations because they do not have any qualifying patient stays.
Therefore, removing the LOS exclusion criteria will increase the number
of patients included in the measures, and thus the number of hospices
that are included in the QM calculation. The impact of the LOS
exclusions on the distribution of hospices' scores is generally small
for all of the QMs. In addition, these analyses revealed that the care
processes targeted by the QMs are performed on the day of, or within
one day of, admission for the vast majority of patient stays. For
example, among patient admissions for which a pain screening was
administered, approximately 92 percent of screenings occurred on the
day of admission and close to 99 percent occurred within 1 day of
admission. This suggested that including stays of less than 7 days in
QM calculations (that is, removing the QM LOS exclusion) could be
appropriate and would not create a burden on hospices. In response to
these results, the individual QMs were submitted by the measures'
stewards to the NQF Palliative Care and End of Life Project for re-
endorsement in February 2016 and received preliminary approval. In sum,
6 of the 7 current HIS measures that were adopted in the FY 2014
Hospice Wage Index final rule excluded beneficiaries with a LOS of <7
days from the denominator. However, since these measures were adopted
in the HQRP, they have undergone their endorsement maintenance with the
NQF. As part of the maintenance endorsement, the LOS exclusion for the
6 HIS measures was proposed for removal. NQF has indicated initial
support for the removal of the LOS exclusion, and pending NQF
maintenance endorsement of the previously adopted measures, we
anticipate that the entire set of the 7 HIS measures will no longer
exclude any patients with LOS <7 days in future public reporting and
use in the HQRP. We appreciate the commenters' recommendation to risk
adjust these measures and will consider this recommendation for future
measure development efforts.
Comment: CMS received one comment requesting additional items or
response options on the HIS V1.00.0 to capture instances where data
regarding preferences or other care processes captured on the HIS are
not available for non-verbal patients admitted to hospice who do not
have a formal caregiver or responsible party available.
Response: We thank the commenter for their comment. For additional
information on how to respond to current HIS items when the patient is
nonverbal and/or a caregiver is unavailable, we refer readers to the
HIS Manual V1.02 available on the Hospice
[[Page 52162]]
Item Set portion of the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html. Specifically, we refer
readers to the HIS Manual Section F Item-Specific Tips, which specifies
roles of responsible parties for patients unable to self-report. The
HIS Manual states that the ``Responsible party'' refers to the legally
responsible or authorized individual, such as the Health Care Power of
Attorney or legal guardian. In the rare cases where there is no legal
guardian or power of attorney identified, the hospice should use state
law guidance to identify the appropriate surrogate decision-maker.
Other items that require patient or caregiver input, such as the pain
assessment items, can be completed for nonverbal patients using the
nonverbal assessment processes described in the HIS Manual.
5. Proposed Removal of Previously Adopted Measures
As mentioned in section III.C.3, a measure that is adopted and
implemented in the HQRP will be adopted for all subsequent years,
unless the measure is proposed for removal, suspension, or replacement
by CMS. Policies and criteria for removing a measure include those
mentioned in section III.C.3 of this proposed rule. CMS is not
proposing to remove any of the current HQRP measures at this time. Any
future proposals regarding removal, suspension, or replacement of
measures will be proposed in this section of future rules.
6. Proposed New Quality Measures for FY 2019 Payment Determinations and
Subsequent Years and Concepts Under Consideration for Future Years
a. Background and Considerations in Developing New Quality Measures for
the HQRP
As noted in section III.C.2 of this proposed rule, CMS's paramount
concern is to develop quality measures that promote care that is
person-centered, high quality, and safe. In identifying priority areas
for future measure enhancement and development, CMS takes into
consideration input from numerous stakeholders, including the MAP, the
MedPAC, Technical Expert Panels (TEP), and national priorities, such as
those established by the National Priorities Partnership, the HHS
Strategic Plan, the National Strategy for Quality Improvement in
Healthcare, and the CMS Quality Strategy. In addition, CMS takes into
consideration vital feedback and input from research published by our
payment reform contractor, as well as important observations and
recommendations contained in the Institute of Medicine (IOM) report,
titled ``Dying in America,'' released in September 2014.\6\ Finally,
the current HQRP measure set is also an important consideration for
future measure development areas; future measure development areas
should complement the current HQRP measure set, which includes HIS
measures and Consumer Assessment of Healthcare Providers and Systems
(CAHPS[supreg]) Hospice Survey measures.
---------------------------------------------------------------------------
\6\ IOM (Institute of Medicine). 2014. Dying in America:
Improving quality and honoring individual preferences near the end
of life. Washington, DC: The National Academies Press.
---------------------------------------------------------------------------
As stated in the FY 2016 Hospice Wage Index final rule (80 FR
47188), based on input from stakeholders, CMS identified several high
priority areas for future measure development, including: A patient
reported pain outcome measure; claims-based measures focused on care
practices patterns, including skilled visits in the last days of life;
responsiveness of the hospice to patient and family care needs; and
hospice team communication and care coordination. Of the aforementioned
measure areas, CMS has pursued measure development for two quality
measures: Hospice Visits when Death is Imminent Measure Pair, and
Hospice and Palliative Care Composite Process Measure-Comprehensive
Assessment at Admission. These measures were included in CMS' List of
Measures under Consideration (MUC) list for 2015 and discussed at the
MAP meeting on December 14 and 15, 2015. All materials related to the
MUC list and the MAP's recommendations for each measure can be found on
the National Quality Forum Web site, MAP Post-Acute Care/Long-Term Care
Workgroup Web page at: https://www.qualityforum.org/ProjectMaterials.aspx?projectID=75370. The MAP supported the direction
of each proposed measure.
Comment: Many comments were received about the HQRP quality
measures and concepts under consideration for future years. Overall,
commenters were supportive of CMS's efforts to develop a more robust
quality reporting program that includes development of two new quality
measures, the Hospice Visits when Death is Imminent Measure Pair, and
Hospice and Palliative Care Composite Process Measure-Comprehensive
Assessment at Admission. In addition to the two measures we proposed,
regarding measure development in future years, commenters urged CMS to
focus on meaningful quality measures and encouraged CMS to move towards
the development of outcome measures. Several commenters noted the
complexities associated with developing outcomes measures. These
commenters also recommended that CMS conduct regular measure testing
activities to ensure that all measures currently implemented in the
HQRP are relevant and meaningful to providers and consumers. Finally,
some commenters recommended the development of future measures of
hospice live discharge rates. Commenters believe that such measures
could contribute to quality information and hospice performance.
Response: We appreciate the commenters' input and recommendations
for future measure development areas for the HQRP. We plan to continue
developing the HQRP to respond to the measure gaps identified by the
MAP and others, and align measure development with the National Quality
Strategy and the CMS Quality Strategy. We will take these comments into
consideration in developing and implementing measures for future
inclusion in the HQRP. We would like to assure commenters that we are
pursuing opportunities related to the development of live-discharge
measures through environmental scans, public engagement, and
participation in special topic panels. We would also like to assure
commenters that for all measures implemented in the HQRP, we regularly
conduct measure testing activities according to the Blueprint for the
CMS Measures Management System Version 12.0 (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-120.pdf). This ensures that measures continue to
demonstrate scientific acceptability (including reliability and
validity) and meet the goals of the HQRP, which include distinguishing
performance among hospices and contributing to better patient outcomes.
If measure testing activities reveal that a measure meets one of the
conditions for removal that is listed in the proposed rule (measure
performance among hospices high and unvarying, performance or
improvement in a measure does not result in better patient outcomes,
etc.), the measure will be considered for removal from the HQRP to
avoid unintended consequences and to ensure that providers' data
collection efforts are meaningful and are contributing to quality of
care. Finally, we would like to assure commenters that we continue to
explore opportunities to pursue
[[Page 52163]]
hospice outcome measures, and we appreciate the commenters' support for
such development efforts.
b. New Quality Measures for the FY 2019 Payment Determination and
Subsequent Years
We proposed two new quality measures for the HRQP for the FY 2019
payment determination and subsequent years: Hospice Visits when Death
is Imminent Measure Pair, and Hospice and Palliative Care Composite
Process Measure-Comprehensive Assessment at Admission.
(1) Proposed Quality Measure 1: Hospice Visits When Death Is Imminent
Measure Pair
Measure Background. This measure set addresses whether a hospice
patient and their caregivers' needs were addressed by the hospice staff
during the last days of life. This measure is specified as a set of 2
measures. Measure 1 assesses the percentage of patients receiving at
least 1 visit from registered nurses, physicians, nurse practitioners,
or physician assistants in the last 3 days of life. Measure 2 assesses
the percentage of patients receiving at least 2 visits from medical
social workers, chaplains or spiritual counselors, licensed practical
nurses, or hospice aides in the last 7 days of life. Measure 1
addresses case management and clinical care, while Measure 2 gives
providers the flexibility to provide individualized care that is in
line with the patient, family, and caregiver's preferences and goals
for care and contributing to the overall well-being of the individual
and others important in their life.
Measure Importance. The last week of life is typically the period
in the terminal illness trajectory with the highest symptom burden.
Particularly during the last few days before death, patients experience
myriad physical and emotional symptoms, necessitating close care and
attention from the integrated hospice team. Hospice responsiveness
during times of patient and caregiver need is an important aspect of
care for hospice consumers. In addition, clinician visits to patients
at the end of life have been demonstrated to be associated with
improved outcomes such as decreased risk of hospitalization, emergency
room visits, hospital deaths, decreased distress for caregivers, and
higher satisfaction with care.
Several organizations and panels have identified care of the
imminently dying patient as an important domain of palliative and
hospice care and established guidelines and recommendations related to
this high priority aspect of healthcare that affects a large number of
people. The NQF 2006 report A Framework for Preferred Practices for
Palliative Care Quality \7\ and the NCP Clinical Practice Guidelines
for Quality Palliative Care \8\ recommend that signs and symptoms of
impending death are recognized, communicated and educated, and care
appropriate for the phase of illness is provided. The American College
of Physicians Clinical Practice Guidelines \9\ recommend that
clinicians regularly assess pain, dyspnea, and depression for patients
with serious illness at the end of life. These measures address this
high priority area by assessing hospice staff visits to patients and
caregivers during the final days of life when patients and caregivers
typically experience higher symptom and caregiving burdens, and
therefore a higher need for care.
---------------------------------------------------------------------------
\7\ National Quality Forum. A National Framework and Preferred
Practices for Palliative and Hospice Care Quality. 2006; Available
from: https://www.qualityforum.org/publications/2006/12/A_National_Framework_and_Preferred_Practices_for_Palliative_and_Hospice_Care_Quality.aspx.
\8\ National Consensus Project, Clinical Practice Guidelines for
Quality Palliative Care. 3rd edition. 2013, National Consensus
Project: Pittsburgh, PA.
\9\ Qaseem, A., 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 American College of
Physicians. Annals of Internal Medicine, 2008. 148(2): p. 141-146.
---------------------------------------------------------------------------
Measure Impact. The literature shows that health care providers'
practice is responsive to quality measuring and reporting.\10\ CMS
feels this research, while not specific to hospices, reasonably
predicts the effect of measures on hospice provider behavior.
Collecting information about hospice staff visits for measuring quality
of care, in addition to the requirement of reporting visits from some
disciplines on hospice claims, will encourage hospices to visit
patients and caregivers and provide services that will address their
care needs and improve quality of life during the patients' last days
of life.
---------------------------------------------------------------------------
\10\ Werner, R., E. Stuart, and D. Polsky, Public reporting
drove quality gains at nursing homes. Health Affairs, 2010. 29(9):
p. 1706-1713.
---------------------------------------------------------------------------
Performance Gap. The 2014 Abt Medicare Hospice Payment Reform
Report indicated that 28.9 percent of Routine Home Care hospice
patients did not receive a skilled visit on the last day of life.\11\
The Report defines a `skilled visit' as a visit from a nurse, social
worker, or therapist. This percentage could be, in part, a result of
rapid decline and unexpected death. The report revealed variation in
receipt of visits at the end of life related to multiple factors.
Patients who died on a weekday rather than a weekend, patients with a
very short length of stay (5 days or less), and patients aged 84 and
younger were more likely to receive a skilled visit in the last 2 days
of life. Smaller hospices and hospices in operation for 5 years or less
were slightly less likely to provide a visit at the end of life. States
with the lowest rates of no visits in the last days of life were some
of the more rural states (ND, WI, TN, KS, VT), whereas states with the
highest rates of no visits were more urban (NJ, MA, OR, WA, MN).
---------------------------------------------------------------------------
\11\ Plotzke, M., et al., Medicare Hospice Payment Reform:
Analyses to Support Payment Reform. May 2014, Abt Associates Inc.
Prepared for Centers for Medicare and Medicaid Services: Cambridge,
MA.
---------------------------------------------------------------------------
Existing Measures. This quality measure set will fill a gap by
addressing hospice care provided at the end of life. No current HQRP
measures address care beyond the hospice initial and comprehensive
assessment period, nor do any current HQRP measures relate to the
assessment of hospice staff visits to patients and caregivers in the
last week of life.
Stakeholder Support. A TEP convened by our measure development
contractor, RTI International, on May 7 and 8, 2015, provided input on
the measure concept. The TEP agreed that hospice visits when death is
imminent is an important concept to measure and supported data
collection using the HIS. A second TEP was convened October 19 and 21,
2015, to provide input on the technical specifications of this quality
measure pair. The TEP supported development of a measure set rather
than a single measure, using different timeframes to measure the
different types of care provided, and limiting the measures to patients
receiving routine home care. The NQF MAP met on December 14 and 15,
2015, and provided input to CMS. The MAP encouraged continued
development of the Hospice Visits when Death is Imminent Measure Pair
in the HQRP. More information about the MAP's recommendations for this
measure is available at https://www.qualityforum.org/ProjectMaterials.aspx?projectID=75370. While this measure is not
currently NQF endorsed, we recognize that the NQF endorsement process
is an important part of measure development and plan to submit this
measure pair for NQF endorsement.
Form, Manner, and Timing of Data Collection and Submission. Data
for this measure would be collected via the existing data collection
mechanism, the HIS. CMS has proposed that 4 new items be added to the
HIS-Discharge record to collect the necessary data elements for this
measure. CMS expects that data collection for this quality
[[Page 52164]]
measure via the 4 new HIS items would begin no earlier than April 1,
2017. Thus, under current CMS timelines, hospice providers would begin
data collection for this measure for patient admissions and discharges
occurring after April 1, 2017. Prior to the release of the new HIS data
items, CMS will provide education and training to hospice providers to
ensure all providers have adequate information and guidance to collect
and submit data on this measure to CMS.
Since the data collection mechanism is the HIS, providers would
collect and submit data using the same processes that are outlined in
sections III.C.7c through III.C.7e of this rule. In brief, processes in
section III.C.7c through III.C.7e specify that data for the measure
would be submitted to the Quality Improvement and Evaluation System
(QIES) Assessment Submission and Processing (ASAP) system, in
compliance with the timeliness criterion and threshold set out in
sections III.C.7c through III.C.7e.
For more information on the specifications and data elements for
the measure set, Hospice Visits when Death is Imminent, we refer
readers to the HQRP Specifications for the Hospice Item Set-based
Quality Measures document, available on the ``Current Measures''
portion of the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html. In addition, to facilitate the reporting of HIS
data as it relates to the implementation of the new measure, we
submitted a request for approval to OMB for the Hospice Item Set
version 2.00.0 under the Paperwork Reduction Act (PRA) process. The new
HIS data items that would collect this measure data are also available
for public viewing in the PRA package available at: https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
We received multiple comments pertaining to the Hospice Visits when
Death is Imminent Measure Pair. The following is a summary of the
comments we received on this topic and our responses:
Comment: We received many comments in support of our proposal to
implement the Hospice Visits when Death is Imminent Measure Pair.
Commenters emphasized the importance of visits at the end of life, and
stated that this measure pair would provide a valuable measure of
quality. Commenters also stated that they expect this measure will
improve quality of life during patients' final days and that this
measure could be useful to patients, families, and the Medicare
program. One commenter said that hospice nurses are often aware when
death is imminent because they are skilled at recognizing the final
stages of a terminal condition, and that most individuals and families
are aided and reassured by visits from some disciplines at the end of
life.
Response: We thank the commenters for their support of the Hospice
Visits when Death is Imminent Measure Pair in the HQRP. We agree that
visits at the end of life are an important component of hospice care
and that this measure can help to drive holistic, patient centered
quality improvement. We believe that this information will be useful to
consumers, providers, and payers.
Comment: Some commenters questioned whether the Hospice Visits when
Death is Imminent Measure Pair would foster better quality for hospice
care patients and requested evidence-based research showing the link
between hospice visits and quality. One commenter emphasized the
important role that hospices play in helping prepare patients and
caregivers for the end of life, and stated that if hospices provide
high quality preparation, then patients and families may need fewer
visits at the end of life. The commenter stated that a focus on visits
at the end of life may take focus away from empowering patients and
caregivers. One commenter stated that, as a process measure, this
measure pair does not adequately reflect high quality care, and urged
CMS to conduct further testing of the measure. One commenter cautioned
that, while sociodemographic differences in receipt of visits may
appear to indicate differences in quality, one must also take into
consideration possible differences in religious beliefs and cultural
values that may affect desire for visits. One commenter noted that
these measures alone might not be representative of the quality of care
that hospice beneficiaries and their families receive.
Response: We thank the commenters for their feedback. We are
committed to the ensuring that all quality measures implemented in the
HQRP meet the goals of the program, which include distinguishing
performance among hospices and contributing to better patient outcomes.
We believe that provision of hospice visits at the end of life is
an important component of high quality hospice care for most patients.
The last week of life is typically the period in the terminal illness
trajectory with the highest symptom burden and the literature supports
hospice visits when death is imminent as a high priority in end-of-life
care. Clinician visits to patients at the end of life have been
demonstrated to be associated with improved outcomes such as decreased
risk of hospitalization, emergency room visits, and hospital death; and
higher satisfaction with care.\12\ \13\ \14\ Measurements of visits at
the end of life are already used in the literature as quality
indicators for end of life or hospice care.\15\ \16\ \17\ Studies
focusing on the expectations of patients and families also demonstrate
the importance of care and attention from the hospice team in the days
leading up to death. Caregivers of dying patients agree overwhelmingly
with the importance of preparation at the end of life. Hospice
assistance, ranging from legal to logistical to emotional, is paramount
in preparing hospice patients and their families for imminent
death.\18\ Bereaved family members and friends from a variety of
settings identified the provision of physical comfort and emotional
support to dying patients and their families as fundamental aspects of
high-quality care.\19\
---------------------------------------------------------------------------
\12\ Seow, H., Barbera, L., Howell, D., & Dy, S. M. (2010).
Using more end-of-life homecare services is associated with using
fewer acute care services: a population-based cohort study. Med
Care, 48(2), 118-124. doi:10.1097/MLR.0b013e3181c162ef.
\13\ Almaawiy, U., Pond, G. R., Sussman, J., Brazil, K., & Seow,
H. (2014). Are family physician visits and continuity of care
associated with acute care use at end-of-life? A population-based
cohort study of homecare cancer patients. Palliat Med, 28(2), 176-
183. doi:10.1177/0269216313493125.
\14\ Pivodic, L., Harding, R., Calanzani, N., McCrone, P., Hall,
S., Deliens, L. & Gomes, B. (2015). Home care by general
practitioners for cancer patients in the last 3 months of life: An
epidemiological study of quality and associated factors. Palliat
Med. doi:10.1177/0269216315589213.
\15\ Barbera, L., Seow, H., Sutradhar, R., Chu, A., Burge, F.,
Fassbender, K., . . . Potapov, A. (2015). Quality Indicators of End-
of-Life Care in Patients With Cancer: What Rate Is Right? J Oncol
Pract, 11(3), e279-287. doi:10.1200/jop.2015.004416.
\16\ Gandhi, S. O. (2012). Differences between non-profit and
for-profit hospices: patient selection and quality. Int J Health
Care Finance Econ, 12(2), 107-127. doi:10.1007/s10754-012-9109-y.
\17\ Lorenz, K. A., Ettner, S. L., Rosenfeld, K. E., Carlisle,
D. M., Leake, B., & Asch, S. M. (2002). Cash and compassion: profit
status and the delivery of hospice services. J Palliat Med, 5(4),
507-514. doi:10.1089/109662102760269742.
\18\ Steinhauser, K. E., Christakis, N. A., Clipp, E. C.,
McNeilly, M., McIntyre, L., & Tulsky, J. A. (2000). Factors
considered important at the end of life by patients, family,
physicians, and other care providers. Jama, 284(19), 2476-2482.
\19\ Steinhauser, K. E., Christakis, N. A., Clipp, E. C.,
McNeilly, M., McIntyre, L., & Tulsky, J. A. (2000). Factors
considered important at the end of life by patients, family,
physicians, and other care providers. Jama, 284(19), 2476-2482.
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The literature shows that health care providers' practices are
responsive to
[[Page 52165]]
quality measurement and reporting.\20\ We believe that this research,
while not specific to hospices, reasonably predicts the effect of
measures on hospice provider behavior. Collecting information about
hospice staff visits for measuring quality of care, in addition to the
requirement of reporting visits from some disciplines on hospice
claims, will encourage hospices to visit patients and caregivers and
provide services that will address their care needs and improve quality
of life during the patients' last days of life. While we agree that a
greater number of visits does not always indicate higher quality care,
based on the published literature and expert input, we believe that
most patients benefit from some visits near the end of life. For this
reason, this measure set is specified to measure receipt of at least 1
clinician visit (Measure 1) and at least 2 visits from other staff
(Measure 2), rather than measuring the total number of visits. A TEP
held in October 19 and 21, 2015, by our contractor agreed that a
measure of patients receiving at least a minimum number of visits would
be a better indicator of quality than a measure of the total number of
visits provided.
---------------------------------------------------------------------------
\20\ Werner, R., E. Stuart, and D. Polsky, Public reporting
drove quality gains at nursing homes. Health Affairs, 2010. 29(9):
p. 1706-1713.
---------------------------------------------------------------------------
We agree with the commenter that this measure pair alone may not
provide a full representation of the quality of care that hospices
provide. The previously finalized measures in the HQRP address care
processes at admission, and the Hospice CAHPS survey examines caregiver
experience retrospectively. This measure pair fills an important gap in
the HQRP by providing a measure of quality of care provided near the
time of death, and it is intended to be interpreted along with the
other measures in the HQRP to reflect quality of care provided by
hospices across several domains of care that are important to patients
and other stakeholders. CMS also plans to analyze the relationship
between this quality measure pair and other quality measures to support
the validity of this measure pair (that is, the measure reflects true
quality of care).
Comment: One commenter expressed concern that the results of the
Hospice Visits when Death is Imminent Measure Pair may be
mischaracterized once they are publicly reported, if appropriate
disclaimers are absent from the information provided. Another commenter
requested that CMS remind measure users that patients/families have the
right to decline services and that those declinations should not be
considered an ``under-service'' by the hospice provider.
Response: We thank the commenters for their feedback regarding
interpreting these measures. We agree that it is important to educate
both providers and consumers on how to use and interpret these quality
measures. Prior to public reporting of this measure, we will provide
resources through the Hospice Compare Web site to aid consumers in
interpreting the quality metrics reported there. CMS has carefully
considered usability by consumers throughout the measure development
process. The measure specifications take into account usability
feedback from a TEP, caregiver workgroup, and clinical user panel. We
recognize that some patients may decline services and that rapid and
unanticipated patient declines do occur; thus, a score of 100% is not
the expectation for this measure pair.
Comment: Some commenters stated that it is not always known when a
patient's death is imminent. One commenter stated that there is not
always an opportunity for hospices to provide the visits specified in
this measure set if a patient experiences a rapid and unanticipated
decline.
Response: We understand that it is not always possible to
accurately predict time of death. However, the last week of life is
typically the period in the terminal illness trajectory with the
highest symptom burden, especially during the last few days before
death. We recognize that rapid and unanticipated patient declines do
occur; thus, a score of 100 percent is not the expectation for this
measure pair. We do expect that hospices delivering high quality care
will be responsive to the patient and caregiver needs that arise during
the last days of a patient's life. In order to address performance gaps
in this measure, providers may be motivated to proactively assess
symptom burden, resulting in improved symptom management and higher
quality of life during the final days.
Comment: We received some comments related to the structure of the
Hospice Visits when Death is Imminent Measure Pair and intent of each
measure. Some comments indicated that commenters might have
misinterpreted the intent of this measure pair. For example, one
commenter stated that adoption of this measure pair would in fact
create three visit metrics, and another commenter referenced the
calculation of a composite measure for visits at the end of life. Some
commenters interpreted the specifications as not including visits
addressing spiritual or psychosocial suffering in the 3 days before
death.
Some commenters requested clarification of the calculation of each
of these measures and of the disciplines included in each. One
commenter recommended that Measure 1 and Measure 2 be combined into one
measure in order to streamline data collection. One commenter requested
that RN visits be included in both Measure 1 and Measure 2 since some
interventions to manage symptoms may only be provided by an RN.
Response: We wish to clarify the intent of this measure pair. The
Hospice Visits when Death is Imminent Measure Pair will be calculated
and reported as two separate measures. These measures are intended to
be interpreted as a set. For more information on the specifications and
data elements for the measure set, Hospice Visits when Death is
Imminent Measure Pair, we refer readers to the HQRP Specifications for
the Hospice Item Set-based Quality Measures document, available on the
``Current Measures'' portion of the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/CurrentMeasures.html.
The two measures are intended to capture distinct aspects of
hospice care at the end of life. The inclusion of registered nurses,
physicians, nurse practitioners, and physician assistants in Measure 1
is intended to capture the range of clinical disciplines that might
visit a patient, depending on patient and hospice preferences, and uses
a 3-day timeframe to reflect the active dying phase. The inclusion of
medical social workers, chaplains or spiritual counselors, licensed
practical nurses, and hospice aides in Measure 2 is intended to allow
for flexible and individualized care in line with patient, family, and
caregiver preferences. The 7-day time frame covers both the active
dying phase and the transition period before, and thus could also
capture important visits related to preparation for active dying. To
clarify, the 7-day time frame is inclusive of the 3 days prior to
death. Data collection is conducted at the discipline level in order to
provide us with sufficient information to conduct reliability and
validity testing and possible future measure refinement.
Comment: We received some comments regarding the types of visits
included in the Hospice Visits when Death is Imminent Measure Pair.
Some commenters requested that all visits on the date of death be
included in the measures, including postmortem visits, as this is an
important service that hospices provide. One commenter
[[Page 52166]]
recommended that a new, separate measure could look at postmortem
visits. Some commenters requested that phone calls or videoconferencing
be included in the measures. One commenter stated that phone calls may
be an especially important form of contact in rural areas. A few
commenters requested clarification of the definition of a visit counted
for quality purposes, and one inquired what visit duration is expected.
Response: We thank the commenters for their feedback regarding the
types of visits included in this measure pair. We agree that post
mortem and bereavement visits are an important service for hospices to
provide. However, we believe that these services are outside the scope
of this quality measure pair, which focusses specifically on visits
when death is imminent. These visits provided shortly prior to death
are intended to address the increased symptom burden many patients
experience when death is imminent and provide an opportunity for
proactive assessment and communication.
We recognize that some providers use phone calls to supplement care
provided in person and that these calls can be helpful in facilitating
ongoing care and communication. However, in agreement with a TEP and
based on the available evidence, we consider these calls as a
supplement to, and not a replacement for, in-person care, particularly
when death is imminent. For this reason, phone calls are not included
in the definition of a visit for this measure pair. Prior to
implementation of the HIS V2.00.0, we will provide hospices with
guidance and training materials, including an updated version of the
HIS Manual. These training materials will further clarify the types of
visits included in this measure pair and other item coding information.
Comment: We received many comments regarding the disciplines
included in each of the Hospice Visits when Death is Imminent measures.
One commenter stated that this measure pair recognizes the value of the
core interdisciplinary team members and maintains a holistic approach
to care. Many commenters supported the inclusion of chaplains or
spiritual counselors and aides in Measure 2, as they play an important
role in the interdisciplinary team. Some commenters encouraged CMS to
conduct further research on the types of visits provided at the end of
life and present a clear rationale for inclusion or exclusion from this
measure. One commenter recommended that both measures be amended to
include any member of the hospice's interdisciplinary team.
Many commenters requested that visits from volunteers be included
in Measure 2. The commenters pointed out that the use of volunteers is
a Medicare requirement for hospices, and that volunteers play an
important role in the delivery of hospice care. One commenter indicated
that it might be burdensome to report data on volunteer visits, but
that inclusion of volunteers would be valuable. A couple of commenters
requested that visits from music therapists or massage therapists be
included in Measure 2.
Several commenters noted that although physician assistant (PA)
visits are included in this quality measure pair, this discipline is
not identified by CMS as a core or non-core service of a hospice
provider. Some of these commenters requested that PA visits be removed
from the measure in order to align with the Conditions of Participation
and Medicare payment practices. Some of these commenters supported the
inclusion of PAs and recommended that their role be clarified. One
commenter stated that since the use of PAs is limited, inclusion of PA
visits would negatively skew the data.
One commenter noted that a Licensed Practicing Nurse's (LPN) scope
of practice varies from state to state, and asked that CMS consider
removing LPN visits from the measure to make the measure more uniform
nation-wide. One commenter expressed appreciation for the inclusion of
LPNs and stated that the discipline is frequently used.
Some commenters requested that bereavement coordinator or
bereavement counselor visits be included in this measure pair. One
commenter requested clarification of whether a visit from a provider
contracted but not employed by a hospice program would be considered a
visit under this measure pair.
Response: We thank the commenters for their support of the
disciplines included in this measure, including chaplains or spiritual
counselors and aides. This measure pair is designed to allow hospices
flexibility to determine the most appropriate discipline or disciplines
to visit a patient. The inclusion of registered nurses, physicians,
nurse practitioners, and physician assistants in Measure 1 is intended
to capture the range of clinical disciplines that might visit a
patient, depending on patient and family preferences and emerging care
needs in the last days of life. Similarly, the inclusion of medical
social workers, chaplains or spiritual counselors, licensed practical
nurses, and hospice aides in Measure 2 is intended to allow for
flexible and individualized care in line with patient, family, and
caregiver preferences. This measure is not intended to require visits
from any given discipline, but aims to allow flexibility in the types
of visits provided. The Hospice Conditions of Participation state that
the interdisciplinary group must include, but is not limited to, a
doctor of medicine or osteopathy, a registered nurse, a social worker,
and a pastoral or other counselor. Visits from all of these disciplines
are included in this measure pair, as well as from some additional
disciplines. We have carefully researched the topic of which
disciplines to include in this measure pair, including an environmental
scan, pilot test of this measure in summer 2015, TEP discussions on May
7 and 8, 2015, and October 19 and 21, 2015, and input from our Clinical
Users Panel and Caregiver Workgroup.
Regarding volunteer visits, we agree that volunteers play an
important role in high quality hospice care and that their visits are
important to patients and families. Visits from volunteers were
included in an early version of this measure, which pilot tested for
feasibility in summer 2015. Many of the hospices included in the pilot
had trouble reporting data on visits from volunteers because the
records of volunteer visits were often stored in a separate system and
were frequently delayed. The data was unreliable, and hospices reported
significant reporting burden. This topic was discussed with the TEP,
held October 19 and 21, 2015. After reviewing the results from the
pilot test and thoroughly discussing the issues, the TEP members did
not support including visits from volunteers in this measure pair. For
the same reasons, the TEP advised against including complementary and
alternative therapists such as music or massage therapists in this
measure pair, though they do provide important services.
Regarding physician assistant visits, although Medicare does not
provide separate payments for visits from physician assistants, these
services would be covered under the hospice per diem. Additionally,
this measure is an all-payer measure and some states and other programs
may authorize physician assistants to provide hospice care under
separate payments. This measure pair is separate from payment and
should focus on services provided by hospices and not be restricted by
the terms of payment by Medicare. Therefore, the inclusion of physician
assistants in the
[[Page 52167]]
measure specifications provides the flexibility for hospices that may
have physician assistants to count these clinical visits as part of
Measure 1. We wish to clarify that the absence of physician assistant
visits will not negatively skew the data reported in this measure.
Visits from physician assistants are one of the options included in
Measure 1, but patients will also be included in the numerator of the
measure if they receive a visit from a registered nurse, physician, or
nurse practitioner.
We thank the commenters for their feedback regarding the inclusion
of LPNs in Measure 2. Members of our TEP agreed that LPNs provide an
important service in hospice care that is distinct from the role of
RNs. For this reason, we have included visits from LPNs in Measure 2 of
this measure pair.
We appreciate the commenters' recommendations to include
bereavement coordinators, and agree that visits from these disciplines
are important for many patients and families. However, we believe that
bereavement services are outside the scope of this quality measure
pair, which focusses specifically on visits, which may address the
increased symptom burden many patients experience when death is
imminent, and provide an opportunity for proactive assessment and
communication.
Regarding contracted hospice staff, we clarify that visits from
contracted staff may be included in this measure pair. As defined in
the HIS Manual V1.02, hospice staff members may include volunteers,
contractors, and affiliates.
Comment: Some commenters recommended changes to the Hospice Visits
when Death is Imminent Measure Pair to further align the two measures.
A few commenters suggested that both Measure 1 and Measure 2 be
measured over a 7-day timeframe in order to improve consistency between
the measures and simplify data collection for providers. A few
commenters recommended that CMS consider altering Measure 2 such that
it includes in the numerator patients who receive one visit from
medical social workers, chaplains or spiritual counselors, licensed
practical nurses or hospice aides in the final seven days of life.
Response: We thank the commenters for their feedback on the
specifications of the two measures in this measure pair. As currently
specified, Measure 1 uses a 3-day timeframe and Measure 2 uses a 7-day
timeframe. A TEP meeting held October 19 and 21, 2015, provided input
on the timeframes. The TEP indicated that the 3-day timeframe would be
reflective of the active dying phase, and that it would be appropriate
to measure clinical visits provided during the active dying phase. The
7-day time frame covers both the active dying phase and the transition
period before, and thus could also capture important visits related to
preparation for active dying. An analysis of Medicare claims indicates
that most routine home care patients (94 percent) receive at least one
skilled visit from a nurse, social worker, therapist or physician in
the last four days of life.\21\ Because of this, there may be a ceiling
effect for these quality measures using a longer time frame.
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\21\ Plotzke, M. C., T.J.; Axelrod, Elizabeth; Hunt, Meaghan;
Muma, Allison; Gozalo, Pedro; Teno, Joan. (2015). Medicare Hospice
Payment Reform: Analysis of How the Medicare Hospice Benefit is
Used. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/December-2015-Technical-Report.pdf.
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The current specification of Measure 2 limits the numerator to
patients who receive at least two visits from those disciplines in the
final 7 days of life. Using two visits rather than one may also serve
to reduce the expected ceiling effect that is likely to result from
grouping multiple disciplines together in Measure 2.
Comment: Many commenters pointed out that, in keeping with the
individualized and patient-centered focus of hospice care, patients and
families have the option of declining visits from hospice providers if
they deem them unnecessary or unwanted. Commenters indicated that
patients and caregivers might decline a visit for various reasons:
Desire for privacy at the end of life, adequate preparation for the end
of life such that additional visits are not necessary, or patient is
receiving receipt of similar services from outside of the hospice
provider. Some commenters recommended that revisions be made to the HIS
Discharge form to allow a hospice to indicate that a patient or family
was offered a visit included in either Measure 1 or Measure 2, but
refused or deferred the visit. Some commenters recommended that
patients who refuse an offered visit be included in the measure
numerator, while others recommended that these patients be excluded
from the measure pair, and a few recommended that the measures be risk
adjusted to reflect patient refusal of services.
Some commenters cautioned that this measure pair could result in an
unintended consequence: Hospices might provide unnecessary or unwanted
visits, thus undermining patient and family preferences and choice. One
commenter cautioned that specifying when particular staff must visit
would undermine the flexibility hospices have in customizing the plan
of care. Some commenters pointed out that, by respecting the wishes of
some patients to receive fewer visits, a hospice might have lower
scores on this measure pair but that it would not reflect an issue with
quality of care.
Response: We thank the commenter for their feedback about patients
and families that may refuse a visit at the end of life. In a pilot
study conducted by our measure development contractor, hospices
reported that information on visit refusal is available, but is
burdensome for hospices to report. In addition, fewer than 4 percent of
patients in the pilot study refused a visit from a given discipline,
and no patients refused all visits offered. By including multiple
disciplines in each measure, the Hospice Visits when Death is Imminent
Measure Pair is designed to allow hospices flexibility to determine the
most appropriate discipline or disciplines to visit a patient, and to
consider patient and family preferences. A TEP held by our measure
development contractor did not expect that there would be wide
variation in the rate of visit refusal across hospices. The TEP
determined that the burden of data collection would outweigh the
benefit of excluding patients who refuse visits. For these reasons, we
determined not to require hospices to report data on visit refusals.
Hospices may wish to track visit refusals internally for quality
improvement purposes. This measure pair will be tested for reliability
and validity prior to public reporting. We recognize that some patients
may decline services and that rapid and unanticipated patient declines
do occur; thus, the expectation is not for hospices to score 100
percent on this measure pair. We will take these comments into account
during future measure development.
Comment: Some commenters recommended using risk adjustment or
exclusions to account for patient characteristics in the Hospice Visits
when Death is Imminent Measure Pair. Some commenters stated that
patients with shorter lengths of stay will likely receive different
visits than patients with longer lengths of stay. Commenters requested
that CMS examine any differences, and some requested that the Hospice
Visits when Death is Imminent Measure Pair be risk adjusted or
stratified for length of stay in hospice. Another commenter requested
that case mix adjustment be used in the calculation of this measure
pair.
[[Page 52168]]
One commenter recommended that patients with a length of stay
shorter than 5 days be excluded from Measure 2. This is the length of
time allowed by Hospice Conditions of Participation requirements for
the comprehensive assessments to be completed, and the commenter
expects that some patients might not receive two visits from a medical
social worker, chaplain or spiritual counselor, licensed practical
nurse, or hospice aide before Day 5. Another commenter recommended that
patients with a length of stay of three days or fewer be excluded from
Measure 1 if the only visit received is the initial nursing assessment.
The commenter expressed concern that for such short lengths of stay,
the measure would function as an indicator of compliance rather than of
quality.
Finally, one commenter requested clarification of whether this
measure pair would be applied across all levels of care.
Response: We thank the commenters for their feedback. As currently
specified, this measure set is not risk adjusted. A TEP convened by our
measure development contractor discussed possible risk adjustment of
this measure pair, including risk adjustment by diagnosis or length of
stay. The TEP determined that diagnosis may not reliably predict
symptom burden at the end of life and therefore may not reliably
predict need for visits. The TEP members determined that it might be
important to take length of stay into account in measure calculations.
We will continue to consider this feedback, and will examine measure
performance, including the potential need for risk adjustment in the
future.
As currently specified, Measure 1 does not include a length of stay
exclusion, while Measure 2 excludes patients with a length of stay less
than or equal to one day (that is, admitted and discharged on the same
day). The rationale for excluding patients with a very short length of
stay from Measure 2 is that Measure 2 requires two visits from select
hospice staff, and it may be difficult or possibly inappropriate to
provide more than one such visit for patients receiving only one day of
hospice care. We do not exclude these patients from Measure 1 because
Measure 1 specifies at least one clinician visit, and it is reasonable
to expect that a hospice would provide at least one such visit, even
for patients with a very short length of stay. It is acceptable if this
visit is the initial nursing assessment visit. One of the goals of this
measure pair is to increase prospective assessment of patient needs and
timely management of symptoms prior to death, and this can be
accomplished during the initial nursing assessment visit as well as
other types of visits provided in the final days to patients with
longer length of stay. We do not intend to increase burden on providers
or patients by requiring specific types of visits to meet the goals of
this measure. Patients with short lengths of stay are expected to have
high symptom burden throughout their short stay and can benefit from
hospice visits. For these reasons, patients with short lengths of stay
are included in this measure.
This measure pair currently includes only patients who received
routine home care. It does not include patients who received general
inpatient care, respite care, or continuous home care during the
measure timeframes. Routine home care patients for whom the hospice
receives a service intensity add-on payment are included in this
measure, as this payment is an add-on to the routine home care rate.
Comment: Some commenters encouraged CMS to obtain NQF endorsement
prior to proposing new measures. One commenter expressed appreciation
that this measure development process has included input from the
Measure Applications Partnership (MAP).
Response: We appreciate the commenters' input and support of the
NQF endorsement process. Our paramount concern is the successful
development of a HQRP that promotes the delivery of high quality
healthcare services. We seek to adopt measures for the HQRP that
promote patient-centered and high quality care. Our measure selection
activities for the HQRP take into consideration input from the MAP,
convened by the NQF, as part of the established CMS pre-rulemaking
process required under section 1890A of the Act. The NQF MAP met on
December 14th and 15th, 2015 and encouraged continued development of
this measure pair. Additionally, while this measure is not currently
NQF-endorsed, we recognize that the NQF endorsement process is an
important part of measure development and plan to submit this measure
for NQF endorsement. This quality measure will fill a gap by addressing
quality of hospice care at the end of life. Furthermore, no current
NQF-endorsed measures address hospice care when death is imminent, and
this measure is a first step towards that goal. CMS is establishing the
timeline for seeking NQF endorsement for this quality measure and will
communicate this timeline to the public in future rulemaking cycles.
Comment: One commenter asked whether CMS would correlate the
Hospice Visits when Death is Imminent Measure Pair with the Hospice
CAHPS results. Another commenter recommended that CMS compare outcomes
as measured by the HIS care processes and the CAHPS survey with the
data collected on visits at the end of life to guide refinement of this
measure pair.
Response: We plan to conduct reliability and validity testing of
this measure pair as part of ongoing measure maintenance and refinement
and to prepare for NQF endorsement. As part of those efforts, we will
examine the correlations of the paired measures with other quality
measures calculated from the HIS and possibly from the CAHPS.
Comment: Some commenters indicated that data collection for the
Hospice Visits when Death is Imminent Measure Pair would be burdensome
for providers, and potentially duplicative of the information about
visits reported in Medicare claims. One commenter requested that claims
data be used to calculate this measure pair in order to reduce provider
burden of data collection. Another commenter encouraged CMS to
establish a claims code for spiritual counselor/chaplain visits so that
their visits can be reviewed for reimbursement and quality
considerations. One commenter indicated that this measure pair would be
calculated using claims data.
Response: We wish to clarify the data source for this measure pair.
This measure will be calculated using data from the HIS V2.00.0, and
will not be a claims-based measure. This HIS-based measure pair will
expand upon information that would be available in Medicare hospice
claims. The HIS includes data for all hospice patients, regardless of
payment source, while claims data capture only Medicare Fee-for-service
beneficiaries. Therefore, the use of assessment data allows the measure
to be inclusive of all patients regardless of payer. Medicare claims
capture visits from certain disciplines, including skilled nursing,
medical social services, aides, physical therapy, occupational therapy,
and speech therapy--language pathology. HIS items will capture hospice
visits by members of additional disciplines that are not included in
the Medicare hospice claims (for example, chaplains). Finally, visit
information on the HIS can be assessed and reported in a timelier
manner than Medicare claims, providing hospices with opportunities to
review and improve care.
Comment: Some commenters requested that sufficient time be given
[[Page 52169]]
prior to measure implementation of the Hospice Visits when Death is
Imminent Measure Pair to ensure time for software vendors to develop
new processes, and hospices to upgrade their EMR systems, train staff,
and conduct testing. One commenter recommended that CMS delay
initiation of data collection for this measure pair until October 1,
2016. One commenter encouraged CMS to solicit feedback from the hospice
industry and software vendors to determine whether necessary updates
can be made by April 1, 2017. Other commenters recommended a period of
data collection on the proposed measures prior to implementation of the
measures.
Response: We appreciate the commenters' feedback regarding the
timeline for implementation and public reporting of this measure pair.
We would like to clarify the implementation date proposed in this rule;
data used for calculation of this measure pair will be collected via
the HIS V2.00.0. The HIS V2.00.0 is undergoing review as part of a PRA
package under OMB number 0938-1153 and will be implemented April 1,
2017. This measure pair is proposed for the FY 2019 payment
determination and subsequent years. The HIS V2.00.0 is currently
available for review by software vendors and hospice providers. Some of
the activities that are necessary prior to implementation can be done
concurrently. For example, hospice education and training in the new
items and data abstraction can be conducted at the same time as vendor
development of software. As stated in section III.C.7.c, providers may
also use the Hospice Abstraction Reporting Tool (HART) software, which
is free to download and use. HART provides an alternative option for
hospice providers to collect and maintain facility, patient, and HIS
Record information for subsequent submission to the QIES ASAP system.
We agree it is critical to establish the reliability and validity of
the quality measures prior to public reporting. We plan to conduct data
analysis to demonstrate the ability of the quality measures to
distinguish the quality of services provided. More detail on public
display is provided in section III.C.11 of this rule.
Comment: Some commenters drew connections between the Hospice
Visits when Death is Imminent Measure Pair and the Service Intensity
Add-on payment. Some commenters recommended delaying implementation of
this measure pair until the impact of the SIA payment is better
understood. One commenter recommended that CMS use the data obtained
for Measure 2 to update the payment of the SIA payment to include
visits by licensed practical nurses and other disciplines. One
commenter stated that CMS should align financial payment and quality
measures.
Response: We thank the commenters for their feedback regarding the
Hospice Visits when Death is Imminent Measure Pair and the SIA. CMS
adopted SIA payments to address the observed misalignment between
resource use and associated Medicare payments and to improve patient
care through the promotion of skilled visits at end of life with
minimal claims processing systems changes. While it may be good for
payment and quality to align when possible, this measure pair is a
measure of quality, not of practice driven by reimbursement structure.
We will take into consideration using measure data for further
refinement of the SIA.
Final Action: After consideration of the comments, we are
finalizing our proposal to implement the Hospice Visits when Death is
Imminent Measure Pair effective April 1, 2017. Data will be collected
starting on such date, and will, if not reported, affect payments for
FY 2019.
(2) Proposed Quality Measure 2: Hospice and Palliative Care Composite
Process Measure--Comprehensive Assessment at Admission
Measure Background. The Hospice and Palliative Care Composite
Process Measure--Comprehensive Assessment at Admission is a composite
measure that assesses whether a comprehensive patient assessment is
completed at hospice admission by evaluating the number of individual
care processes completed upon admission for each hospice patient stay.
A composite measure, as defined by the NQF, is a combination of two or
more component measures, each of which individually reflects quality of
care, fashioned into a single performance measure with a single
score.\22\ For more information on composite measure definitions,
guiding principles, and measure evaluation criteria, we refer readers
to the NQF Composite Performance Measure Evaluation Guidance
Publication available at https://www.qualityforum.org/Publications/2013/04/Composite_Performance_Measure_Evaluation_Guidance.aspx. A total
of 7 individual care processes will be captured in this composite
measure, which include the 6 NQF-endorsed quality measures and 1
modified NQF-endorsed quality measure currently implemented in the
HQRP. Thus, the Hospice and Palliative Care Composite Process quality
measure will use the current HQRP quality measures as its components.
These individual component measures address care processes around
hospice admission that are clinically recommended or required in the
hospice CoPs.\23\ This measure calculates the percentage of patients
who received all care processes at admission. To calculate this
measure, the individual components of the composite measure are
assessed separately for each patient and then aggregated into one score
for each hospice.
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\22\ National Quality Forum. (2013). Composite Performance
Measure Evaluation Guidance: National Quality Forum.
\23\ Medicare and Medicaid Programs: Hospice Conditions of
Participation, Part 418 subpart 54. Centers for Medicare and
Medicaid Services, June 5, 2008.
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Measure Importance. This composite quality measure for
comprehensive assessment at admission addresses high priority aspects
of quality hospice care as identified by both leading hospice
stakeholders and beneficiaries receiving hospice services. The NCP for
Quality Palliative Care Clinical Practice Guidelines for Quality
Palliative Care established 8 core palliative care domains, and this
composite measure captures 4 of those domains.\24\ The 4 domains
captured by this composite measure are the Structure and Process of
Care Domain; the Physical Aspects of Care Domain; the Spiritual,
Religious, and Existential Aspects of Care Domain, and the Ethical and
Legal Aspects of Care Domain. The NCP guidelines placed equal weight on
both the physical and psychosocial domains, emphasizing a comprehensive
approach to patient care. For more information on the NCP domains for
palliative care, refer to https://www.nationalconsensusproject.org/guidelines_download2.aspx. In addition, the Medicare Hospice CoPs
require that hospice comprehensive assessments identify patients'
physical, psychosocial, emotional, and spiritual needs and address them
to promote the hospice patient's comfort throughout the end-of-life
process. Furthermore, the person-centered, family, and caregiver
perspective align with the domains identified by the CoPs and NCP, as
patients and their families/caregivers also place value on physical
symptom management and spiritual/psychosocial care as important factors
at the end of
[[Page 52170]]
life.25 26 A composite measure serves to ensure all hospice
patients receive a comprehensive assessment for both physical and
psychosocial needs at admission.
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\24\ The National Consensus Project for Quality Palliative Care
Clinical Practice Guidelines for Quality Palliative Care 3rd edition
2013.
\25\ Singer PA, Martin DK, Kelner M. Quality End-of-Life Care:
Patients' Perspectives. JAMA. 1999;281(2):163-168. doi:10.1001/
jama.281.2.163.
\26\ Steinhauser KE, Christakis NA, Clipp EC, McNeilly M,
McIntyre L, Tulsky JA. Factors Considered Important at the End of
Life by Patients, Family, Physicians, and Other Care Providers.
JAMA. 2000;284(19):2476-2482. doi:10.1001/jama.284.19.2476.
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Measure Impact. The literature indicates that health care
providers' practice is responsive to quality measures reported.\27\ CMS
feels this research, while not specific to hospices, reasonably
predicts the effect of measures on hospice provider behavior.
Collecting information about the total number of care processes
conducted for each patient will incentivize hospices to conduct all
desirable care processes for each patient and provide services that
will address their care needs and improve quality during the time he or
she is receiving hospice care. Additionally, creating a composite
quality measure for comprehensive assessment at admission will provide
consumers and providers with a single measure regarding the overall
quality and completeness of assessment of patient needs at hospice
admission, which can then be used to meaningfully and easily compare
quality across hospice providers and increase transparency.
---------------------------------------------------------------------------
\27\ Werner, R., E. Stuart, and D. Polsky, Public reporting
drove quality gains at nursing homes. Health Affairs, 2010. 29(9):
p. 1706-1713.
---------------------------------------------------------------------------
Performance Gap. Analyses conducted by our measure development
contractor, RTI International, show that hospice performance scores on
the current 7 HQRP measures are high (a score of 90 percent or higher
on most measures); however, these analyses also revealed that, on
average, a much lower percentage of patient stays in a hospice had
documentation that all of these desirable care processes were completed
at admission. Thus, by assessing hospices' performance of comprehensive
assessment, the composite measure sets a higher standard of care for
hospices and reveals a larger performance gap. A similar effect has
been shown in the literature where facilities are achieving more than
90 percent compliance with individual measures, but compliance numbers
decrease when multiple measures are combined as one.28 29
The performance gap identified by the composite measure creates
opportunities for quality improvement and may motivate providers to
conduct a greater number of high priority care processes for as many
patients as possible upon admission to hospice.
---------------------------------------------------------------------------
\28\ Nolan, T., & Berwick, D. M. (2006). All-or-none measurement
raises the bar on performance. JAMA [H.W. Wilson--GS], 295(10),
1168.
\29\ Agency for Healthcare Research and Quality. (2004).
National Healthcare Quality Report.
---------------------------------------------------------------------------
Existing Measures. The Family Evaluation of Hospice Care (FEHC),
NQF #0208, is a precursor of the Hospice CAHPS[supreg]. The surveys
cover some similar domains. However, a major difference between them is
the detailed requirements for survey administration of the
CAHPS[supreg] Hospice Survey, which allow for comparison of hospice
programs, The Hospice CAHPS[supreg] survey quality measure is not yet
endorsed by NQF. CMS has recently submitted the CAHPS[supreg] Hospice
Survey (experience of care) measure (NQF #2651) to be considered for
endorsement under the Palliative and End-of-Life Care Project 2015-
2016. For more information regarding this project and the measure
submitted, we refer readers to https://www.qualityforum.org/ProjectMeasures.aspx?projectID=80663. In addition, we refer readers to
section III.C.9 of this rule for more information on the Hospice
CAHPS[supreg] survey and associated quality measures. The
CAHPS[supreg]-based quality measures submitted to NQF include patient
and caregiver experience of care outcome measures and CMS plans to
propose these measures as part of the HQRP measure set in future
rulemaking cycles. A key difference between the FEHC, Hospice
CAHPS[supreg] and the Hospice and Palliative Care Composite Process
Measure is that the FEHC and Hospice CAHPS[supreg] focus on the
consumer's perspective of their health agency and experience, whereas
the Hospice and Palliative Care Composite Process Measure focuses on
the clinical care processes that are actually delivered by the hospice
to each patient.
Stakeholder Support. A TEP convened by our measure development
contractor, RTI International, on December 2, 2015, provided input on
this measure concept. The TEP unanimously agreed that a comprehensive
hospice composite measure is an important measure and supported data
collection using the HIS. The NQF MAP met on December 14th and 15th,
2015 and provided input to CMS. In their final recommendation, the MAP
encouraged continued development of the Hospice and Palliative Care
Composite Process Measure--Comprehensive Assessment at Admission
measure. More information about the MAP's recommendations for this
measure is available at https://www.qualityforum.org/ProjectMaterials.aspx?projectID=75370.
While this measure is not currently NQF-endorsed, we recognize that
the NQF endorsement process is an important part of measure development
and plan to submit this measure for NQF endorsement. As noted, this
quality measure will fill a gap by holding hospices to a higher
standard of care and will motivate providers to conduct a greater
number of high priority care processes for as many beneficiaries as
possible upon admission as hospice patients. Furthermore, no current
NQF-endorsed measures address the completion of a comprehensive care
assessment at hospice admission.
Form, Manner, and Timing of Data Collection and Submission. The
data source for this measure will be currently implemented HIS items
that are currently used in the calculation of the 7 component measures.
These items and quality measure algorithms for the 7 component measures
can be found in the HQRP Specifications for the Hospice Item Set-based
Quality Measures document, which is available in the ``Downloads''
section of the ``Current Measures'' portion of the CMS HQRP Web site:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-QualityReporting/Current-Measures.html. Since the
proposed measure is a composite measure whose components are currently
adopted HQRP measures, no new data collection will be required; data
for the composite measure will come from existing items from the
existing 7 HQRP component measures. CMS proposes to begin calculating
this measure using existing data items, beginning April 1, 2017; this
means patient admissions occurring after April 1, 2017 would be
included in the composite measure calculation.
Since the composite measure components are existing HIS data items,
providers are already collecting the data needed to calculate the
composite measure. Data collection will continue in accordance with
processes outlined in sections III.C.7c through III.C.7e of this rule.
For more information on the specifications and data elements for
the measure, Hospice and Palliative Care Composite Process Measure-
Comprehensive Assessment at Admission, we refer readers to the https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html document,
available on the ``Current Measures''
[[Page 52171]]
portion of the CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html.
We received multiple comments pertaining to the Hospice and
Palliative Care Composite Process Measure. The following is a summary
of the comments we received on this topic and our responses.
Comment: CMS received many comments in support of the proposed
Hospice and Palliative Care Composite Process Measure--Comprehensive
Assessment at Admission quality measure. Commenters appreciated that
the measure demonstrates greater variation in hospice performance than
the individual component measures, and that it can be used to
differentiate performance across hospices. Commenters also appreciated
that CMS's measure selection activities for the HQRP take into
consideration input from stakeholders such as the Measure Applications
Partnership (MAP). Several commenters were supportive of CMS's approach
to quality measure development in the HQRP, specifically, the use of
Technical Expert Panels (TEP) to obtain expert and other stakeholder
input.
Response: We thank commenters for their support of the proposed
Hospice and Palliative Care Composite Process Measure--Comprehensive
Assessment at Admission quality measure, herein after referred to as
the `Composite QM'.
Comment: Many comments were received regarding the retirement of
the seven day length of stay exclusion for six of the care process
measures that comprise the Composite QM. Commenters' primary concern
focused on the impact of removing this exclusion on provider behavior;
specifically, commenters suggested that eliminating the LOS exclusion
may inappropriately incentivize providers to focus on completion and
compliance with the HIS requirements at the expense of addressing the
needs and preferences of imminently dying patients. Commenters noted
that upon admission for imminently dying patients, a comprehensive
assessment is not in the interest of patients and caregivers, nor may
it be feasible for hospices to deliver because the focus is on
appropriately directed to other priorities. One commenter stated that
the level and intensity of hospices services are different for patients
with short LOS and that the items captured in this measure are not
reflective of quality of care for patients imminently dying. Finally,
one commenter indicated that this measure might complicate data
collection efforts and processes already in place at hospices, noting
that different members of the interdisciplinary team often complete
different sections of the HIS at different times. This commenter
believed that hospices would therefore need to establish new data
collection processes when addressing urgent patient/family needs should
be the priority. In response to these concerns, commenters requested
that provisions be made to account for patients with short LOS and
suggested alternative approaches to do so. Namely, commenters
recommended that CMS risk adjust or stratify for patients with a 2-day
or less, 3-day or less, or 5-day or less LOS, while other comments
recommended that CMS maintain the current 7-day LOS exclusion. Another
commenter recommended that a new measure be created to capture data for
short LOS patients, rather than including them in this measure.
Commenters requested clarification on why the measure was not created
with risk adjustment in its current specifications.
Response: We appreciate the commenters' input on the Composite QM
LOS exclusion specifications. Developing and adopting measures that
benefit patient outcomes and do not lead to negative unintended
consequences of the utmost importance to CMS. We would like to take
this opportunity to respond to commenters' concerns about the impact of
retiring the LOS exclusion, first by describing the history of the LOS
exclusion and the reason for retiring it from the individual measures.
As many commenters noted, 6 of the 7 component quality measure (QMs)
exclude patient stays that are less than 7 days from the measure
denominator. At the time the measures were developed, no national data
regarding the implications of the LOS exclusion was available at that
time, and technical experts recommended that short patient stays be
excluded from those measures' denominators for assessing quality of
care. Since the implementation of the HIS, we have performed
descriptive analyses to examine the implications of the LOS exclusion
on hospices' denominator size and QM scores. Additionally, this
analysis also examined the timing of when hospices perform the care
processes assessed in the quality measures. The results of these
analyses demonstrated that the denominator sizes for the HQRP QMs are
largely impacted by the current 7 day LOS exclusion used to calculate
the QMs. Excluding stays with LOS less than 7 days result in many
hospices not having sufficient denominator size to allow for public
display of their quality scores. Although the LOS exclusion has a
sizable impact on the number of hospices eligible to have their data
publicly displayed, the impact of the LOS exclusions on the
distribution of hospices' scores is generally small for all of the QMs.
Therefore, removing the LOS exclusion criteria will increase the number
of hospices eligible for public reporting while having a minimal impact
on the QM scores. In addition, these analyses revealed that the care
processes targeted by the QMs are performed on the day of or within one
day of admission for the vast majority of patient stays. For example,
among patient admissions for which a pain screening was administered,
approximately 92 percent of screenings occurred on the day of admission
and close to 99 percent occurred within 1 day of admission. This
suggests that including stays of less than 7 days in QM calculations
(that is, removing the QM LOS exclusion) may be appropriate and would
not create a burden on hospices. In response to these results, the
measure developer and steward submitted the individual QMs to the NQF
Palliative Care and End of Life Project for re-endorsement in February
2016 without the LOS exclusion. Because of the anticipated removal of
the LOS exclusion for the current HQRP measures (component measures for
this Composite QM), this Composite QM was proposed without the LOS
exclusion in order to be consistent with the individual measure
components. Our contractor convened a TEP in December 2015 to inform
the development of the Composite QM. The TEP, presented with the
results of the LOS analysis, strongly recommended that the Composite QM
maintain the same measure specifications as the individual measures.
Additionally, this TEP considered the creation of a separate measure
specifically for short LOS patients, as recommended by a commenter, but
ultimately agreed that such a measure would not capture comprehensive
care for short LOS patients as the current proposed measure would.
Furthermore, we remind commenters that because the Composite QM is
based on the 7 current HIS measures that are already endorsed by NQF,
risk adjustment for the Composite QM will be consistent with any risk
adjustment created and applied for the individual measures. Any
additional risk adjustment applied to the individual measures will
first be developed and tested for in coordination with the NQF prior to
[[Page 52172]]
implementation. We will keep the commenters' recommendations and
concerns regarding short LOS in mind for future development efforts and
data analysis.
Comment: CMS received comments regarding the contribution of this
measure to quality of care. While commenters did not object to the
development and implementation of this measure, many were concerned
whether this measure is truly reflective of comprehensive care at
admission and whether it will provide patients and families with
meaningful information.
Response: We appreciate the commenters' concern regarding the
impact and relevance of the Composite QM. We are committed to the
ensuring that all quality measures implemented in the HQRP meet the
goals of the HQRP, which include distinguishing performance among
hospices and improving patient outcomes. We regularly conduct measure
testing and evaluation activities to ensure that measures continue to
demonstrate improvements in-patient care. We would like to convey to
commenters that a primary motivation in developing the Composite QM is
to provide interpretable and meaningful information to consumers. We
believe that, above and beyond information provided by the individual
component QMs, the Composite QM accomplishes this by providing
consumers with a single measure regarding the overall quality and
completeness of assessment of patient needs at hospice admission, which
can then be used to compare quality across hospice providers and
increase transparency, while also accessing information about hospice
performance on each of the individual measures that comprise the
Composite QM. As also noted in this rule, the Composite QM demonstrates
greater variation in hospice performance than individual measures.
Hospice performance scores on the current 7 HQRP measures are high (a
score of 90 percent or higher on most measures); however, on average, a
much lower percentage of patient stays in a hospice had documentation
that all 7 of these care processes were completed at admission.
Additionally, we would like to reiterate that the Composite QM for
comprehensive assessment at admission addresses high priority aspects
of comprehensive quality hospice care as identified by both leading
hospice stakeholders and beneficiaries receiving hospice services, all
of which emphasize attention to physical, psychosocial, emotional, and
spiritual needs of patients.
Comment: CMS received a few comments recommending that CMS attain
NQF endorsement of the Composite QM prior to implementation.
Response: We appreciate the commenters' input and support of the
NQF endorsement process. Our paramount concern is the successful
development of a HQRP that promotes the delivery of high quality
healthcare services. We seek to adopt measures for the HQRP that
promote patient-centered and high quality care. Our measure selection
activities for the HQRP take into consideration input from the Measure
Applications Partnership (MAP), convened by the NQF, as part of the
established CMS pre-rulemaking process required under section 1890A of
the Act. The NQF MAP met on December 14th and 15th, 2015 and encouraged
continued development of this measure. Additionally, while this measure
is not currently NQF-endorsed, we recognize that the NQF endorsement
process is an important part of measure development and plan to submit
this measure for NQF endorsement. This quality measure will fill a gap
by holding hospices to a higher standard of care and will motivate
providers to conduct a greater number of high priority care processes
for as many beneficiaries as possible upon admission as hospice
patients--a unique contribution to hospices. Furthermore, no current
NQF-endorsed measures address the completion of a comprehensive care
assessment at hospice admission, and this measure is a first step
towards that goal. We are establishing the timeline for seeking NQF
endorsement for this quality measure and will communicate this timeline
to the public in future rulemaking cycles.
Comment: CMS received one comment requesting clarification on the
logic behind including NQF #1617 Patients Treated with an Opioid Who
Are Given a Bowel Regimen measure as a component measure of the
proposed Composite QM. This commenter indicated that the NQF #1617
measure does not collect data representative of comprehensive care on
the first day of admission and, therefore, does not serve this measure
well as a component.
Response: We would like to clarify that the Composite QM is not
designed to focus on care processes completed on the first day of
admission; rather, this measure is intended to capture all
comprehensive assessment activities around the time of hospice
admission. This timeframe is in line with guidelines identified the
Medicare Hospice Conditions of Participation (CoPs).\30\ The Medicare
CoPs mandate that an initial assessment be completed within 48 hours
after the election of hospice care and that a comprehensive assessment
be completed no later than 5 calendar days after the election of
hospice care is in accordance with Sec. 418.24. Therefore, by
collecting data beyond the first day of admission, this measure aligns
with the practices recommended by the CoPs and with national guidelines
and clinical recommendations. The Medicare CoPs require that both the
hospice initial and comprehensive assessments identify patients'
physical needs and address them to promote the hospice patients' well-
being and comfort throughout the dying process. Additionally, the
Quality Palliative Care Clinical Practice Guidelines \31\ produced by
the National Consensus Project (NCP) established eight core palliative
care domains, one of which emphasizes the assessment and management of
pain and/or other physical symptoms. This measure captures care
processes related to bowel management and opioid use. Most patients
prescribed opioids to manage pain or other symptoms develop some degree
of constipation after opioid initiation or dose increases. Reducing
opioid-induced constipation can reduce patient discomfort and improve
quality of life. Properly assessing and managing symptoms related to
bowel management are critical components of the comprehensive
assessment. Therefore, by including the NQF #1617 measure in this
comprehensive assessment, we address high priority aspects of quality
hospice care as identified by leading hospice stakeholders.
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\30\ Medicare and Medicaid Programs: Hospice Conditions of
Participation, Part 418 subpart 54. Centers for Medicare and
Medicaid Services (2008).
\31\ Clinical Practice Guidelines for Quality Palliative Care.
National Consensus Project for Quality Palliative Care (2013).
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Comment: CMS received one comment recommending that the title of
this measure, specifically the term ``at admission'', be clarified or
replaced. The commenter believed that the use of the phrase ``at
admission'' was misleading since it seemed to imply that the measure
captures care processes completed on the day of admission. Since the
composite measure in fact captures care processes completed during the
initial and/or comprehensive assessment (which, per CoP requirements,
must be completed within 2 and 5 days from admission, respectively),
the commenter believed the title of the measure could be misleading
since care processes that are components of the measure may be
completed beyond the day of admission.
[[Page 52173]]
Response: We would like to thank this commenter for their
recommendation. We would like to clarify that this measure title was
developed based on the CoP requirement for the comprehensive
assessment. While it is true that the CoPs require the first
comprehensive assessment to be completed within 5 days of admission,
the CoPs also require hospices to update the comprehensive assessment
as frequently as the condition of the patient requires, but no less
frequently than every 15 days. Thus, we used the phrase Comprehensive
Assessment ``at Admission'' to denote that this measure and the data it
captures refers to care processes delivered during the first
comprehensive assessment completed upon admission to hospice and not
any subsequent comprehensive assessment updates.
Comment: CMS received a few comments regarding the measure
specifications of the Composite QM. Commenters requested clarification
on the composite measure score calculation, construction, and
components.
Response: The Composite QM is a composite measure that assesses
whether a comprehensive patient assessment is completed at hospice
admission by evaluating whether seven critical individual care
processes were completed upon admission for each hospice patient stay.
A composite measure, as defined by the NQF, is a combination of two or
more component measures, each of which individually reflects quality of
care, into a single performance measure with a single score. For more
information on composite measure definitions, guiding principles, and
measure evaluation criteria, we refer readers to the NQF Composite
Performance Measure Evaluation Guidance Publication available at
https://www.qualityforum.org/Publications/2013/04/Composite_Performance_Measure_Evaluation_Guidance.aspx. A total of 7
individual care processes will be captured in this Composite QM, which
include the 6 NQF endorsed quality measures and 1 modified NQF endorsed
quality measure currently implemented in the HQRP. This Composite QM
calculates the percentage of patients who received all applicable care
processes at admission. For additional details on the draft Composite
QM specifications, we refer readers to the HQRP Specifications for HIS-
Based QM document, available on the ``Current Measures'' portion of the
CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/HospiceQuality-Reporting/CurrentMeasures.html. This measure, therefore, reflects the variation
in hospices' performance on all 7 quality measures for each patient at
admission. We will continue the development and analyses of the
Composite QM. Potential refinement to the measure specifications will
be communicated with the public via HQRP communication channels,
including postings and announcements on the CMS HQRP Web site, MLN
eNews communications, national provider association calls, and
announcements on Open Door Forums and Special Open Door Forums.
Comment: CMS received a few comments recommending that CMS be
mindful of public awareness of differences between process and outcome
measures when creating a composite measure. Two commenters stated that
although this measure concept is valuable and consistent with existing
clinical guidelines, knowledge about differences in hospice measure
types is minimal among the public. The commenter noted that the public
might not be able to understand the relationship of hospice performance
on the Composite QM to quality of care delivery at the hospice.
Additionally, two commenters recommended that to aid consumer
understanding of information from the Composite QM, CMS should
supplement this data with information from the hospice CAHPS survey.
Response: We appreciate the commenters' feedback on public
usability of the Composite QM. We would like to highlight that one
primary motivation for creating this Composite QM was to provide
interpretable and meaningful information to consumers. We believe the
Composite QM may be easier for consumers to understand because it
provides the public with a single metric regarding care processes at
admission as compared to the individual component QMs. As such, QM
scores can be easily used to compare quality across providers and make
informed decisions. We are committed to providing all users with the
necessary information to understand the intent and application of
measures in the HQRP. As with other measures, we will conduct measure
testing and reportability analysis to determine if the Composite QM is
appropriate for public reporting. Should we determine the Composite QM
is appropriate for public reporting, we would take necessary steps to
ensure that any data publicly reported is meaningful and understandable
by the public. Such steps may include usability testing and cognitive
interviewing. We also plan to make hospice CAHPS quality measures
publicly available to consumers.
Final Action: After consideration of the comments, we are
finalizing our proposal to implement the Hospice and Palliative Care
Composite Process Measure--Comprehensive Assessment at Admission
effective April 1, 2017.
Table 16--Proposed Quality Measures and Data Collection Period Affecting the FY 2019 Payment Determination and Subsequent Years
--------------------------------------------------------------------------------------------------------------------------------------------------------
Data
Quality measure NQF ID No. Type Submission method collection to
begin
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hospice Visits when Death is Imminent TBD...................... Process Measure................... Hospice Item Set.................. 04/01/2017
Hospice and Palliative Care Composite TBD......................
Process Measure.
--------------------------------------------------------------------------------------------------------------------------------------------------------
7. Form, Manner, and Timing of Quality Data Submission
a. Background
Section 1814(i)(5)(C) of the Act requires that each hospice submit
data to the Secretary on quality measures specified by the Secretary.
Such data must be submitted in a form and manner, and at a time
specified by the Secretary. Section 1814(i)(5)(A)(i) of the Act
requires that beginning with the FY 2014 and for each subsequent FY,
the Secretary shall reduce the market basket update by 2 percentage
points for any hospice that does not comply with the quality data
submission requirements for that FY.
b. Previously Finalized Policy for New Facilities To Begin Submitting
Quality Data
In the FY 2015 Hospice Wage Index final rule (79 FR 50488), we
finalized a policy stating that any hospice that receives its CMS
Certification Number (CCN) (also known as the Medicare Provider Number)
notification letter
[[Page 52174]]
dated on or after November 1 of the preceding year involved is excluded
from any payment penalty for quality reporting purposes for the
following FY. This requirement was codified at Sec. 418.312.
In the FY 2016 Hospice Wage Index final rule (80 FR 47189), we
further clarified and finalized our policy for the timing of new
providers to begin reporting data to CMS. The clarified policy
finalized in the FY 2016 Hospice Wage Index final rule (80 FR 47189)
distinguished between when new hospice providers are required to begin
submitting HIS data and when providers will be subject to the potential
2 percentage point annual payment update (APU) reduction for failure to
comply with HQRP requirements. In summary, the policy finalized in the
FY 2016 Hospice Wage Index final rule (80 FR 47189 through 47190)
clarified that providers must begin submitting HIS data on the date
listed in the letterhead of the CCN Notification letter received from
CMS but will be subject to the APU reduction based on whether the CCN
Notification letter was dated before or after November 1 of the
reporting year involved. Thus, beginning with the FY 2018 payment
determination and for each subsequent payment determination, we
finalized our policy that a new hospice be responsible for HQRP quality
data submission beginning on the date of the CCN notification letter;
we retained our prior policy that hospices not be subject to the APU
reduction if the CCN notification letter was dated after November 1 of
the year involved. For example, if a provider receives their CCN
notification letter and the date in the letterhead is November 5, 2016,
that provider will begin submitting HIS data for patient admissions
occurring after November 5, 2016. However, since the CCN notification
letter was dated after November 1st, they would not be evaluated for,
or subject to any payment penalties for, the relevant FY APU update
(which in this instance is the FY 2018 APU, which is associated with
patient admissions occurring 1/1/16-12/31/16).
This policy allows CMS to receive HIS data on all patient
admissions on or after the date a hospice receives their CCN
notification letter, while at the same time allowing hospices
flexibility and time to establish the necessary accounts for data
submission before they are subject to the potential APU reduction for a
given reporting year. Currently, new hospices may experience a lag
between Medicare certification and receipt of their actual CCN Number.
Since hospices cannot submit data to the QIES ASAP system without a
valid CCN Number, CMS proposed that new hospices begin collecting HIS
quality data beginning on the date noted on the CCN notification
letter. We believe this policy will provide sufficient time for new
hospices to establish appropriate collection and reporting mechanisms
to submit the required quality data to CMS. Requiring quality data
reporting beginning on the date listed in the letterhead of the CCN
notification letter aligns CMS policy for requirements for new
providers with the functionality of the HIS data submission system
(QIES ASAP).
c. Previously Finalized Data Submission Mechanism, Collection
Timelines, and Submission Deadlines for the FY 2017 Payment
Determination
In the FY 2015 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 after July 1, 2014. For each HQRP program
year, we require that hospices submit data on each of the adopted
measures in accordance with the reporting requirements specified in
sections III.C.7c through III.C.7e of that rule for the designated
reporting period. This requirement applies to previously finalized and
adopted measures, as well as new measures proposed through the
rulemaking process. Electronic submission is required for all HIS
records. Although electronic submission of HIS records is required,
hospices do not need to have an electronic medical record to complete
or submit HIS data. In the FY 2014 Hospice Wage Index final rule (78 FR
48258), we finalized a provision requiring that providers can use
either the Hospice Abstraction Reporting Tool (HART) (which is free to
download and use) or vendor-designed software to complete HIS records.
HART provides an alternative option for hospice providers to collect
and maintain facility, patient, and HIS Record information for
subsequent submission to the QIES ASAP system. Once HIS records are
complete, electronic HIS files must be submitted to CMS via the QIES
ASAP system. Electronic data submission via the QIES ASAP system is
required for all HIS submissions; there are no other data submission
methods available. Hospices have 30 days from a patient admission or
discharge to submit the appropriate HIS record for that patient through
the QIES ASAP system. CMS will continue to make HIS completion and
submission software available to hospices at no cost. We provided
details on data collection and submission timing under the downloads
section of the HIS Web site on the CMS.gov Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html.
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 site, Open Door Forums,
announcements in the CMS MLN Connects Provider e-News (E-News), and
provider training.
d. Previously Finalized 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 for 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 is the date on which the completed record is
submitted and accepted by the QIES ASAP system. In the FY 2016 Hospice
Wage Index final rule (80 FR 47191), CMS finalized our policy that
beginning with the FY 2018 payment determination 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 must 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.
[[Page 52175]]
For HIS-Discharge records, the submission date must 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 of submission 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 to
establish a robust quality reporting program and ensure the scientific
reliability of the data received.
In the FY 2016 Hospice Wage Index final rule (80 FR 47191), CMS
also clarified the difference between the completion deadlines and the
submission deadlines. Current sub-regulatory guidance produced by CMS
(for example, HIS Manual, HIS trainings) states that the completion
deadlines for HIS records are 14 days from the Event Date for HIS-
Admission records and 7 days from the Event Date for HIS-Discharge
records. Completion deadlines continue to reflect CMS guidance only;
these guidelines are not statutorily specified and are not designated
through regulation. These guidelines are intended to offer clear
direction to hospice agencies in regards to the timely completion of
HIS-Admission and HIS-Discharge records. The completion deadlines
define only the latest possible date on which a hospice should complete
each HIS record. This guidance is meant to better align HIS completion
processes with clinical workflow processes; however, hospices may
develop alternative internal policies to complete HIS records. Although
it is at the discretion of the hospice to develop internal policies for
completing HIS records, CMS continues to recommend that providers
complete and attempt to submit HIS records early, prior to the
previously finalized submission deadline of 30 days, beginning in FY
2018. Completing and attempting to submit records early allows
providers ample time to address any technical issues encountered in the
QIES ASAP submission process, such as correcting fatal error messages.
Completing and attempting to submit records early will ensure that
providers are able to comply with the 30 day submission deadline. HQRP
guidance documents, including the CMS HQRP Web site, HIS Manual, HIS
trainings, Frequently Asked Questions, and Fact Sheets, continue to
offer the most up-to-date CMS guidance to assist providers in the
successful completion and submission of HIS records. Availability of
updated guidance will be communicated to providers through the usual
CMS HQRP communication channels, including postings and announcements
on the CMS HQRP Web site, MLN eNews communications, national provider
association calls, and announcements on Open Door Forums and Special
Open Door Forums.
e. Previously Finalized HQRP Data Submission and Compliance Thresholds
for the FY 2018 Payment Determination and Subsequent Years
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. In the FY 2016 Hospice
Wage Index final rule (80 FR 47192), CMS finalized the timeliness
criteria for submission of HIS-Admission and HIS-Discharge records. The
finalized timeliness criteria was 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.
Last year, we finalized our policy (80 FR 47191 through 47192) that
beginning with the FY 2018 payment determination and subsequent FY
payment determinations, all HIS records would have to be submitted
within 30 days of the event date, which is the patient's admission date
or discharge date. In conjunction with this requirement, we also
finalized our policy (80 FR 47192) to establish an incremental
threshold for compliance over a 3-year period. To be compliant for the
FY 2018 APU determination, hospices must 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. The timeliness threshold is set
at 80 percent for the FY 2019 APU determination and at 90 percent for
the FY 2020 APU determination 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 compliance
rate of 90 percent or more.
To summarize, in the FY 2016 Hospice Wage Index final rule (80 FR
47193), we finalized our policy to implement the timeliness threshold
requirement beginning with all HIS admission and discharge records that
occur after January 1, 2016, in accordance with the following schedule.
Beginning January 1, 2016 to December 31, 2016, hospices
must submit at least 70 percent of all required HIS records 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 2018.
Beginning January 1, 2017 to December 31, 2017, hospices
must submit at least 80 percent of all required HIS records 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 January 1, 2018 to December 31, 2018, hospices
must submit at least 90 percent of all required HIS records 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.
Timely submission of data is necessary to accurately analyze
quality measure data received by providers. To support the feasibility
of a hospice to achieve the compliance thresholds, CMS's measure
development contractor conducted some preliminary analyses of Quarter 3
and Quarter 4 HIS data from 2014. According to this analysis, the vast
majority of hospices (92 percent) would have met the compliance
thresholds at 70 percent. Moreover, 88 percent and 78 percent of
hospices would have met the compliance thresholds at 80 percent and 90
percent, respectively. CMS believes this analysis is further evidence
that the compliance thresholds are reasonable and achievable by hospice
providers.
The current reports available to providers in the Certification and
Survey Provider Enhanced Reports (CASPER) system do allow providers to
track the number of HIS records that are submitted within the 30 day
submission timeframe. Currently, submitting an HIS record past the 30
day submission timeframe results in a non-fatal (warning) error. In
April 2015, CMS made available 3 new Hospice Reports in CASPER, which
include reports that can list HIS Record Errors by Field by Provider
and HIS records with a specific error number. CMS is working on
expanding this functionality of CASPER reports to include a timeliness
compliance threshold report that
[[Page 52176]]
providers could run to determine their preliminary compliance with the
timeliness compliance requirement. CMS expects these reports to be
available by late fall of 2016.
In the FY 2016 Hospice Wage Index final rule (80 FR 47192 through
47193), CMS provided clarification regarding the methodology used in
calculating the 70 percent/80 percent/90 percent compliance thresholds.
In general, HIS records submitted for patient admissions and discharges
occurring during the reporting period (January 1st to December 31st of
the reporting year involved) will be included in the denominator for
the compliance threshold calculation. The numerator of the compliance
threshold calculation would include any records from the denominator
that were submitted within the 30 day submission deadline. In the FY
2016 Hospice Wage Index final rule (80 FR 47192), CMS also stated we
would make allowances in the calculation methodology for two
circumstances. First, the calculation methodology will be adjusted
following the applicable reporting period for records for which a
hospice is granted an extension or exemption by CMS. Second,
adjustments will be made for instances of modification/inactivation
requests (Item A0050. Type of Record = 2 or 3). Additional helpful
resources regarding the timeliness compliance threshold for HIS
submissions can be found under the downloads section of the Hospice
Item Set Web site at CMS.gov at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html. Lastly, as further details of the data
submission and compliance threshold are determined by CMS, we
anticipate communicating these details through the regular CMS HQRP
communication channels, including postings and announcements on the CMS
HQRP Web site, MLN eNews communications, national provider association
calls, and announcements on Open Door Forums and Special Open Door
Forums.
Comment: A few commenters commented on our previously finalized
policies for form, manner, and timing of data collection. One commenter
raised concern about the ability of hospices to comply with the
incremental 70 percent/80 percent/90 percent timeliness compliance
threshold in cases of natural disasters. Specifically, the commenter
was concerned that in the case of protracted natural disasters (for
example, Hurricane Sandy), hospice organizations may not be able to
email CMS within the 30-day timeframe to request an extension or
exemption as appropriate, and that, in turn, failure to submit a timely
request for extension or exemption may put a hospice at risk of non-
compliance with the timeliness threshold. Another commenter stated they
believed the process for HIS data collection and submission, which
relies heavily on chart abstraction, was error-ridden and outdated. The
commenter encouraged CMS to automate data collection and submission
processes via electronic submission of HIS data.
Response: We thank the commenters for their comments on our
previously finalized policies for form, manner, and timing of data
collection. Regarding the first commenter's concern about ability to
submit a timely extension or exemption request to maintain compliance
with the 70/80/90 timeliness compliance thresholds in the case of
extended natural disasters, CMS refers readers to our previously
finalized policies for extensions and exemptions, addressed in section
III.C.8 of this rule. As noted in section III.C.8, in instances of
extraordinary circumstances (like widespread natural disasters), we may
grant an extension/exemption to hospices that have not requested them,
which may include instances where hospices are unable to make the
request within the 30-day timeframe due to extenuating circumstances.
Regarding the second commenter's request for electronic data collection
and submission processes for the HIS, we would like to clarify that, as
noted in section III.C.7.c of this rule, electronic submission of HIS
records is already required; no other data submission methods are
available. Hospices are required to submit all HIS records through the
QIES ASAP system. We also provide electronic software to hospices free
of charge that allows hospices to complete HIS records electronically;
alternatively, hospices may choose to use vendor-designed software to
complete HIS records. As noted by the commenter, we believe this
electronic process of data completion and submission minimizes burden
on providers and helps ensure data quality through the HIS record
validation process. We refer readers to section III.C.7.c for more
information on mechanisms of data submission for the HIS.
f. New Data Collection and Submission Mechanisms Under Consideration
for Future Years
CMS has made great progress in implementing the objectives set
forth in the quality reporting and data collection activities required
by sections 3004 of the Affordable Care Act. To date, CMS has
established the HQRP, which includes 7 NQF-endorsed quality measures
that are collected via the HIS. As stated in this rule, data on these
measures are expected to be publicly reported sometime in 2017.
Additionally, CMS has also implemented the Hospice CAHPS[supreg] as
part of the HQRP to gather important input on patient experience of
care in hospice. Over the past several years, CMS has conducted data
collection and analysis on hospice utilization and trends to help
reform the hospice payment system. In the FY 2016 Hospice Wage Index
final rule, we finalized payment reform measures, including changes to
the RHC payment rate and the implementation of a Service Intensity Add-
On (SIA) payment, effective January 1st, 2016. As part of payment
reform and ongoing program integrity efforts, we will continue ongoing
monitoring of utilization trends for any future refinements.
To facilitate continued progress towards the requirements set forth
in section 3004 of the Affordable Care Act, CMS is considering
developing a new data collection mechanism for use by hospices. This
new data collection mechanism would be a hospice patient assessment
instrument, which would serve 2 primary objectives concordant with the
Affordable Care Act legislation: (1) To provide the quality data
necessary for HQRP requirements and the current function of the HIS;
and (2) provide additional clinical data that could inform future
payment refinements.
CMS believes that the development of a hospice patient assessment
tool could offer several benefits over the current mechanisms of data
collection for quality and payment purposes, which include the
submission of HIS data and the submission of claims data. For future
payment refinements, a hospice patient assessment tool would allow CMS
to gather more detailed clinical information, beyond the patient
diagnosis and comorbidities that are currently reported on hospice
claims. As stated in the FY 2016 Hospice Wage Index final rule (80 FR
47203), detailed patient characteristics are necessary to determine
whether a case mix payment system could be achieved. A hospice patient
assessment tool would allow CMS to capture information on symptom
burden, functional status, and patient, family, and caregiver
preferences, all of which will inform future payment refinements.
While systematic assessment is vital throughout the continuum of
care, including palliative and end-of-life care, documentation
confirming completion
[[Page 52177]]
of systematic assessment in hospice settings is often inadequate or
absent.\32\ The value of the introduction of structured approaches via
a clinical assessment is well established, as it enables a more
comprehensive and consistent way of identifying and meeting patient
needs.\33\
---------------------------------------------------------------------------
\32\ McMillan, S., Small, B., & Haley, W. (2011). Improving
Hospice Outcomes through Systematic Assessment: A Clinical Trial.
Cancer Nursing, 34(2), 89-97.
\33\ Bourbonnais, F.F., Perreault, A., & Bouvette, M. (2004).
Introduction of a pain and symptom assessment tool in the clinical
setting--lessons learned. Journal of Nursing Management, 12(3), 194-
200.
---------------------------------------------------------------------------
Moreover, symptoms are the leading reason that people seek medical
care in the first place and frequently serve as the basis for
establishing a diagnosis. Measures of physical function and disease
burden have been used to identify older adults at high-risk for excess
health care utilization, disability, or mortality.\34\ Currently, data
collected on claims includes line-item visits by discipline, General
Inpatient Care (GIP) visit reporting to hospice patients in skilled
nursing facilities or hospitals, post-mortem visits, injectable and
non-injectable drugs and infusion pumps. Industry representatives have
communicated to CMS that required claims information is not
sufficiently comprehensive to accurately reflect the provision and the
cost of hospice care.
---------------------------------------------------------------------------
\34\ Sha, M., Callahan, C., Counsell, S., Westmoreland, G.,
Stump, T., Kroenke, K. (2005). Physical symptoms as a predictor of
health care use and mortality among older adults. 118, 301-306.
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For quality data collection, a hospice patient assessment
instrument would support the goals of the HQRP as new quality measures
are developed and adopted. Since the current quality data collection
tool (HIS) is a chart abstraction tool, not a hospice patient
assessment instrument, CMS is limited in the types of data that can be
collected via the HIS. Instead of retrospective data collection
elements, a hospice patient assessment tool would include data elements
designed to be collected concurrent with provision of care. As such,
CMS believes a hospice patient assessment tool would allow for more
robust data collection that could inform development of new quality
measures that are meaningful to hospice patients, their families and
caregivers, and other stakeholders.
Finally, a hospice patient assessment tool that provides clinical
data that is used for both payment and quality purposes would align the
hospice benefit with other care settings that use similar approaches,
such as nursing homes, inpatient rehabilitation facilities, and home
health agencies which submit data via the MDS 3.0, IRF-PAI, and OASIS,
respectively.
CMS envisions the hospice patient assessment tool itself as an
expanded HIS. The hospice patient assessment tool would include current
HIS items, as well as additional clinical items that could be used for
payment refinement purposes or to develop new quality measures. The
hospice patient assessment tool would not replace existing requirements
set forth in the Medicare Hospice CoPs (such as the initial nursing and
comprehensive assessment), but would be designed to complement data
that are collected as part of normal clinical care. If such a patient
assessment were adopted, the new data collection effort would replace
the current HIS, but would not replace other HQRP data collection
efforts (that is, the Hospice CAHPS[supreg] survey), nor would it
replace regular submission of claims data. CMS envisions that patient
assessment data would be collected upon a patient's admission to and
discharge from any Medicare-certified hospice provider; additional
interim data collection efforts are also possible. Should CMS develop
and implement a hospice patient assessment tool, CMS would provide
several training opportunities to ensure providers are able to comply
with any new requirements.
CMS is not proposing a hospice patient assessment tool at this
time; we are still in the early stages of development of an assessment
tool to determine if it would be feasible to implement under the
Medicare Hospice Benefit. In the development of such a hospice patient
assessment tool, CMS will continue to receive stakeholder input from
MedPAC and ongoing input from the provider community, Medicare
beneficiaries, and technical experts. It is of the utmost importance to
CMS to develop a hospice patient assessment tool that is scientifically
rigorous and clinically appropriate, thus we believe that continued and
transparent involvement of stakeholders is critical. Additionally, it
is of the utmost importance to CMS to minimize data collection burden
on providers; in the development of any hospice patient assessment
tool, CMS will ensure that patient assessment data items are not
duplicative or overly burdensome to providers, patients, caregivers, or
their families.
We received multiple comments pertaining to a potential hospice
patient assessment tool to collect quality, clinical and other data
with the ability to be used to inform future payment refinement
efforts. The following is a summary of the comments we received on this
topic and our responses.
Comment: CMS received many comments about the potential new data
collection mechanism--a comprehensive, standardized hospice patient
assessment instrument--under consideration for future years. Overall,
the vast majority of commenters were supportive of CMS's efforts to
develop a patient assessment tool. Commenters believed that a patient
assessment tool capturing information on symptom burden, functional
status, and patient, family, and caregiver preferences has the
potential to more accurately inform future payment refinements and
quality measure development based on the needs of the populations
served. Commenters noted that the development of a patient assessment
tool would be an integral step in improving care management and
coordination across settings, providing standardized data on the
services that patients and families receive to better understand the
complex patient characteristics. One of the commenters, MedPAC,
supported the development of a patient assessment instrument, noting
its potential value in capturing more meaningful quality data, as well
as providing more detailed clinical information that might be useful
for payment policy.
Commenters offered several suggestions for CMS to consider in
moving forward with the development of a patient assessment tool.
Suggestions focused on two main themes: (1) Considerations for the
content of any patient assessment tool (2) considerations for the
process used by CMS to develop and test a patient assessment tool.
Beyond these two themes, commenters also listed other considerations,
including cross-setting considerations (experience with other
assessment tools and relationship to the IMPACT Act), burden and costs,
use for future payment refinements, and general concerns.
Regarding considerations for the content of a patient assessment
tool, overall, commenters emphasized the unique nature and care goals
of hospice, urging CMS to bear in mind these complexities in the
development of a patient assessment. Specifically, commenters stated
that the patient assessment tool should reflect the holistic nature of
hospice care delivery to the patient and their loved ones and should
include physical, psychosocial, and spiritual components. Commenters
also noted that the unit of care in hospice is the patient and family,
and that the initial and ongoing assessment, as well as care planning
and
[[Page 52178]]
interventions, address the holistic care needs of both the patient and
family. Commenters urged CMS not to limit the focus of a patient
assessment tool to the clinical, ``head-to-toe'' nursing assessment,
since care plans in hospice are often ``more personal than medical''
with emphasis on the patient's family and environment. Similarly,
commenters pointed out the interdisciplinary nature of hospice, and
recommended that any patient assessment tool include information from
the entire hospice team. In consideration of all of these factors,
commenters ultimately urged CMS to develop data elements that are
relevant and meaningful to hospice practice.
In addition to comments about the nature and goals of hospice care,
several commenters also had specific content suggestions for CMS to
consider in the development of a patient assessment tool:
Several commenters recommended that the assessment tool
recognize the patient's right to refuse or defer offered services and
the importance of an individualized plan of care.
Several commenters recommended that the assessment tool
accommodate care delivered in various settings, including nursing
homes, assisted living facilities, hospitals, hospice facilities, and
the patient's home.
Several commenters recommended that the assessment tool
allow for modified assessment of patients who are imminently dying to
facilitate a focus on the urgent and immediate needs of the patient and
family. Commenters noted that for imminently dying patients, the focus
is the management of symptoms and the family's emotions, not
necessarily a detailed medical history and physical assessment of the
patient.
Several commenters noted that the assessment tool should
preserve the integrity of the hospice philosophy by allowing hospice
interdisciplinary team members to individualize assessments and care
based on their best clinical judgment. Additionally, commenters
recommended that CMS not place overly restrictive limits on members of
the interdisciplinary team that are permitted to complete the
assessment tool. Commenters recommended that CMS allow several
disciplines to contribute patient information and goals on the
assessment, noting that this was a limitation of other assessment
tools.
One commenter recommended that CMS collect assessment data
beyond the admission and discharge time points discussed in the
proposed rule (81 FR 25528). The commenter noted the importance of
measuring care throughout the entire stay, not just at admission and
discharge.
Commenters recommended that any outcome measure derived
from the assessment be risk-adjusted.
A couple of commenters suggested that any ``Reason for
Discharge'' item(s) on the assessment tool differentiate the reason
behind any live discharges (for example, revoked vs. moved out of
service area).
One commenter recommended CMS consider the International
Classification of Function (ICF), in the development of a patient
assessment tool. The commenter noted that the ICF provides a scientific
basis for understanding health and health-related states as well as
outcomes, related to both physical as well as social determinants, and
could be a way to determine appropriate outcomes more quickly. Finally,
the commenter noted that the ICF is already integrated into the ICD-10
and ICD-11 taxonomy internationally.
Another commenter recommended that CMS align any new
hospice assessment tool with the National Consensus Project for Quality
Palliative Care Clinical Practice Guidelines for Quality Palliative
Care.
Commenters had several suggestions regarding the process for
development of any patient assessment tool. The majority of comments on
the process for assessment tool development focused on systematically
and comprehensively gathering input from hospice providers and other
stakeholders with respect to what is appropriate and relevant to
include in the assessment tool. Commenters offered specific suggestions
of ways to involve the provider community, including CMS-convened
technical expert panels (TEP) that include representation from
hospices, physicians, and other members of the hospice
Interdisciplinary Team (IDT). In addition to TEPs, one commenter
suggested that CMS consider extending opportunities for input beyond
TEPs and employ widespread processes for gathering provider input.
Commenters also had suggestions for testing and refinement of a patient
assessment tool. Commenters recommended piloting the tool with a wide
variety of hospices, to ensure that the assessment tool is tested with
variation in hospice size, rurality, state regulatory environments, and
organization type (that is, hospital based, freestanding, those with
inpatient facilities vs. those who contract for inpatient care, etc.).
Commenters recommended a pilot testing process that is thorough and
includes a dry-run period or phased-in implementation approach.
Finally, commenters encouraged CMS to provide thorough and ongoing
education and support for hospices as the patient assessment tool is
implemented. Commenters specifically requested that educational
materials include clear definitions of patient assessment items and
data collection procedures.
Several commenters also discussed their experience with assessment
tools in other care settings (for example, the OASIS in home health and
the MDS in nursing homes). Some commenters expressed concerns about
potential overreliance on existing assessment instrument items citing
the difference in care goals between hospice and other post-acute care
settings. These commenters emphasized the importance of creating an
assessment tool tailored to the unique needs of hospice. On the other
hand, commenters also urged CMS to create an assessment tool that is
aligned and consistent with other assessment tools to facilitate care
coordination and planning across the care continuum.
A few commenters offered considerations on potential burden and
costs of a new assessment instrument. Commenters urged CMS to pursue
efforts that would limit administrative burden, reduce redundancy, and
ensure the use of definitions consistent with other assessment tools.
Commenters noted that the assessment would likely be completed by
different staff than those who are currently completing the HIS-
Admission and HIS-Discharge records and that the assessment would
likely be more time-intensive than the current HIS. Commenters urged
CMS to consider increased costs to providers and to take into
consideration the time and resources necessary to complete the
assessment.
One commenter suggested that CMS--as appropriate--consider
harmonizing measures from the IMPACT Act. The commenter noted that such
harmonization would facilitate communication among providers and to
measure the care of patient populations across setting measures. With
respect to use of the patient assessment for future payment
refinements, a few commenters noted the importance of rigorous testing
of assessment items for inter-rater reliability and validity.
Beyond the support and suggestions offered, some commenters did
raise concerns about a patient assessment tool. Commenters cautioned
against a patient assessment tool that would lead to ``checklist''
assessments and undue restrictions on patient eligibility and the
freedom to employ clinical judgment. Finally, one commenter had
concerns about the flexibility of electronic medical record systems to
capture
[[Page 52179]]
assessment items in a structured and minimally burdensome manner.
Response: First, we thank the commenters for their support of the
development of a patient assessment tool. We agree that development of
a patient assessment tool is a critical next step in refining quality
data collection efforts and to inform future refinements to the hospice
payment system. Second, we greatly appreciate the thoughtful input and
recommendations from the hospice community. We believe the initial
input from our stakeholders regarding the content and process for
development of a patient assessment tool is aligned with our vision and
guiding principles for moving forward with developing this new data
collection mechanism. We would like to assure the provider community
that we wholeheartedly agree with commenters regarding the unique
nature of hospice care, and we intended to keep the hospice philosophy
as the foundation of the patient assessment tool. We seek to develop an
assessment tool that reflects the distinctive aspects of hospice care,
including the palliative, rather than curative, focus of hospice care.
We agree with the points raised by commenters about the overall focus
of an assessment tool and aims to develop a tool that addresses the
holistic nature of hospice, incorporating important medical,
psychosocial, spiritual, and other aspects of care that are important
for patients and their caregivers. We also appreciate commenters'
specific suggestions regarding the content of a patient assessment tool
including the need for a flexible assessment, which would incorporate
input from various members of the IDT and accommodate circumstances
unique to hospice such as care of the imminently dying and patient/
caregivers' right to decline services or treatment.
With respect to commenters' suggestions about the process for
development of a patient assessment tool, we would again like to thank
the hospice community for their detailed input and careful
consideration. Again, we would like to assure the provider community
that it is our intent to use a development process that is transparent
and includes multiple opportunities for stakeholder input. Feedback
from the provider community is vital to the development of a patient
assessment tool that is meaningful and not unduly burdensome on
providers. As noted by commenters and discussed in this rule, CMS plans
to hold TEPs to inform the development, testing, and refinement of the
patient assessment. CMS also plans to provide other opportunities for
stakeholders to provide input through venues such as special open door
forums and other regular HQRP communication channels. We are committed
to a development process that will ensure rigorous and iterative
testing of the patient assessment tool in hospices with varying
organizational characteristics, patient populations, settings of care
delivery, and levels of care. We recognize the emphasis that we will
need to place on thorough testing and analysis of items for reliability
and validity, particularly for purposes of any future payment
refinements. Finally, we agree that ongoing training and education will
be vital, and we will ensure access to regular HQRP education and
outreach outlets, such as training webinars, manuals and access to
various Helpdesks.
We also appreciate commenters' suggestions on cross-setting
harmonization and for sharing their experience with assessment tools in
other care settings. We would like to assure commenters that we
recognize the unique nature of hospice care; it is not our intent to
develop an assessment tool that inappropriately relies on items from
existing tools, such as the Minimum Data Set (MDS) and Outcome and
Information Assessment Information Set (OASIS). We will work diligently
with the provider community to gather information on current assessment
practices in hospice and to ensure that a hospice assessment tool would
capture the goals of hospice care and be complementary to current
clinical practice. Regarding the commenters' suggestion to harmonize
assessment items and resulting quality measure with the IMPACT Act
quality measures, we appreciate the commenter's suggestion and will
take it under consideration for future measure and assessment
development.
Finally, with respect to concerns raised by commenters about costs
and administrative burden, as stated in the rule, it is our goal to
minimize data collection burden on providers and ensure that patient
assessment items are not duplicative or overly burdensome to providers,
patients, or their families. We believe that regular, ongoing input
from the provider community will aide in the development of an
assessment that is not overly burdensome. We expect that development of
the patient assessment will take into account the ongoing movement
toward use of certified EHRs and other interoperable health IT across
all patient settings. We expect that our consultations with providers
and with technical experts including health IT experts will include
assessing and taking advantage of opportunities to develop and deploy
the instrument in a way that integrates with hospice work flows and
with the potential of health IT to help providers improve care,
communication and coordination across the interdisciplinary care team
while reducing burden on clinicians and other care team members by
streamlining data collection and management. In addition, any patient
assessment tool would be submitted to OMB as required by the Paperwork
Reduction Act, the purpose of which is to ensure that Federally-
sponsored data collection efforts pose no undue burden on the public.
We appreciate the input from the public regarding the development
of a patient assessment tool for hospice. We will continue to inform
our stakeholders on any progress and proposals regarding the patient
assessment tool through future rulemaking cycles.
8. HQRP Submission Exemption and Extension Requirements for the FY 2017
Payment Determination and Subsequent Years
In the FY 2015 Hospice Wage Index final rule (79 FR 50488), we
finalized our proposal to allow hospices to request, and for CMS to
grant, exemptions/extensions for the reporting of required HIS quality
data when there are extraordinary circumstances beyond the control of
the provider. When an extension/exemption 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/
exemption of the requirement to submit quality data for a specified
time period. In the event that a hospice requests an extension/
exemption for quality reporting purposes, the hospice would submit a
written request to CMS. In general, exemptions 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 exemptions or
extension for quality reporting purposes, the hospice must request an
exemption 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
HospiceQRPReconsiderations@cms.hhs.gov. Exception or extension requests
sent to CMS through any other channel will not be considered valid. The
request for an exemption or extension must contain all of the finalized
requirements as outlined on our Web site at https://www.cms.gov/
Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-
[[Page 52180]]
Quality-Reporting/Extensions-and-Exemption-Requests.html.
If a hospice is granted an exemption or extension, timeframes for
which an exemption or extension is granted will be applied to the new
timeliness requirement so such hospices are not penalized. If a hospice
is granted an exemption, we will not require that the hospice submit
any quality data for a given period of time. By contrast, 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 these quality data.
This process does not preclude us from granting extensions/
exemptions 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/exemption 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/
exemption to hospices in a region or locale, we will communicate this
decision through routine CMS HQRP communication channels, including
postings and announcements on the CMS HQRP Web site, MLN eNews
communications, national provider association calls, and announcements
on Open Door Forums and Special Open Door Forums.
9. Hospice CAHPS[supreg] Participation Requirements for the 2019 APU
and 2020 APU
National Implementation of the Hospice CAHPS[supreg] Survey started
January 1, 2015 as stated in the FY 2015 Hospice Wage Index and Payment
Rate Update final rule (79 FR 50452). The CAHPS[supreg] 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. Readers who want
more information are referred 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[supreg] Hospice Survey is the first national hospice
experience of care survey that includes standard survey administration
protocols that allow for fair comparisons across hospices. Consistent
with many other CMS CAHPS[supreg] 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 the United States, in order to help
patients, family, friends, and caregivers choose the right hospice
program.
The goals of the CAHPS[supreg] Hospice Survey are to:
Produce comparable data on hospice 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.
Hold hospice care providers accountable by informing the
public about the providers' quality of care.
Details regarding CAHPS[supreg] Hospice Survey national
implementation, and survey administration as well as participation
requirements, exemptions from the survey requirement, hospice patient
and caregiver eligibility criteria, fielding schedules, sampling
requirements, and the languages in which is questionnaire, are
available on the CAHPS[supreg] Web site, www.HospiceCAHPSsurvey.org and
in the Quality Assurance Guidelines (QAG) manual, which is also on the
same site and is available for download. Measures from the survey will
be submitted to the NQF for endorsement.
b. Participation Requirements To Meet Quality Reporting Requirements
for the FY 2019 APU
To meet participation requirements for the FY 2019 APU, hospices
must collect survey data on an ongoing monthly basis from January 2017
through December 2017 (inclusive). Data submission deadlines for the
2019 APU can be found in Table 17. The data must be submitted by the
deadlines listed in Table 17 by the hospice's authorized approved CMS
vendor.
Hospices provide lists of the patients who died under their care to
form the sample for the Hospice CAHPS[supreg] Survey. We emphasize the
importance of hospices providing complete and accurate information to
their vendors in a timely manner. Hospices must contract with an
approved Hospice CAHPS[supreg] Survey vendor to conduct the survey on
their behalf. The hospice is responsible for making sure their vendor
meets all data submission deadlines. Vendor failure to submit data on
time will be the responsibility of the hospice.
Table 17--CAHPS[supreg] Hospice Survey Data Submission Dates FY 2018
APU, FY 2019 APU, and FY 2020 APU
------------------------------------------------------------------------
Sample months (that is, month of death) Quarterly data submission
\1\ deadlines \2\
------------------------------------------------------------------------
FY 2018 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.
------------------------------------------------------------------------
FY 2019 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.
------------------------------------------------------------------------
FY 2020 APU
------------------------------------------------------------------------
January-March 2018 (Q1)................... August 8, 2018.
[[Page 52181]]
April-June 2018 (Q2)...................... November 14, 2018.
July-September 2018 (Q3).................. February 13, 2019.
October-December 2018 (Q4)................ May 8, 2019.
------------------------------------------------------------------------
1 Data collection for each sample month initiates 2 months following the
month of patient death (for example, in April for deaths occurring in
January).
2 Data submission deadlines are the second Wednesday of the submission
months, which are Augst, November, February, and May.
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[supreg] 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[supreg] Hospice Survey
Web site https://www.hospiceCAHPSsurvey.org. Hospices that want to claim
the size exemption 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
2019 APU is August 10, 2017.
CMS proposed that hospices that received their CCN after January 1,
2017 are exempted from the FY 2019 APU Hospice CAHPS[supreg]
requirements due to newness. This exemption will be determined by CMS.
The exemption is for 1 year only.
c. Participation Requirements To Meet Quality Reporting Requirements
for the FY 2020 APU
To meet participation requirements for the FY 2020 APU, hospices
must collect survey data on an ongoing monthly basis from January 2018
through December 2018 (inclusive). Data submission deadlines for the
2020 APU can be found in Table 17. The data must be submitted by the
deadlines in Table 17 by the hospice's authorized approved CMS vendor.
Hospices that have fewer than 50 survey-eligible decedents/
caregivers in the period from January 1, 2017 through December 31, 2017
are exempt from CAHPS[supreg] Hospice Survey data collection and
reporting requirements for the FY 2020 payment determination. To
qualify, hospices must submit an exemption request form. This form will
be available in first quarter 2018 on the CAHPS[supreg] Hospice Survey
Web site https://www.hospiceCAHPSsurvey.org. Hospices that want to claim
the size exemption are required to submit to CMS their total unique
patient count for the period of January 1, 2017 through December 31,
2017. The due date for submitting the exemption request form for the FY
2020 APU is August 10, 2018.
CMS proposed that hospices that received their CCN after January 1,
2018 are exempted from the FY 2020 APU Hospice CAHPS[supreg]
requirements due to newness. This exemption will be determined by CMS.
The exemption is for 1 year only.
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 for 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 final rule, we added the CAHPS[supreg] 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.
To meet the HQRP requirements for the FY 2020 payment
determination, hospices would collect survey data on a monthly basis
for the months of January 1, 2018 through December 31, 2018 to qualify
for the full APU.
e. Hospice CAHPS[supreg] Reconsiderations and Appeals Process
Hospices are required to monitor their respective Hospice
CAHPS[supreg] Survey vendors to ensure that vendors submit their data
on time. The hospice CAHPS[supreg] data warehouse provides reports to
vendors and hospices, including reports on the status of their data
submissions. Details about the reports and emails received after data
submission should be referred to the Quality Assurance Guidelines
Manual. If a hospice does not know how to retrieve their reports, or
lacks access to the reports, they should contact Hospice CAHPS[supreg]
Technical Assistance at hospiceCAHPSsurvey@hcqis.org or call them at 1-
844 -472 -4621. Additional information can be found on page 113 of the
Hospice CAHPS[supreg] Quality Assurance Guidelines manual Version 2.0
which is available on the Hospice CAHPS[supreg] Web site,
www.hospicecahpssurvey.org.
In the FY 2017 payment determination and subsequent years,
reporting compliance is determined by successfully fulfilling both the
Hospice CAHPS[supreg] Survey requirements and the HIS data submission
requirements. Providers would use the same process for submitting a
reconsideration request that are outlined in section III.C.10 of this
rule.
We received multiple comments pertaining to the Hospice
CAHPS[supreg] Survey. The following is a summary of the comments we
received on this topic and our responses.
Comment: One commenter expressed concern about the length of the
survey and described it as a tool that is 36 pages in length and
fraught with arduous stipulations of its delivery. In addition, the
commenter stated that it would be very difficult for CMS to monitor
compliance with how hospices are portraying the survey and described
the survey as cumbersome for bereaved families to complete.
Response: The Hospice CAHPS Survey consists of a total of 47
[[Page 52182]]
questions, some of which are only asked when the patient received
services in a specific setting. The Hospice CAHPS Survey has fewer
questions than NHPCO's well-known Family Evaluation of Hospice Care
(FEHC) survey, which has 54 items. We offer a 36-page document on the
CAHPS Survey Web site that contains survey materials
(www.hospicecahpssurvey.org). The document packages three copies of the
questionnaire, each set up for a different optical scanning program.
This is offered for the convenience of the survey vendors. Vendors will
use only one of these versions. In addition, the file includes some
sample letters for vendors' use. We have implemented detailed
specifications for the survey vendors to follow. This ensures
standardization of survey administration procedures across vendors.
Standardization is important for accurate data quality and to ensure
that the data from different vendors is comparable for public
reporting. While it is true that we have no way to monitor the way
hospices are portraying the survey, we offer guidelines in the Quality
Assurance Guidelines manual on the survey Web site
(www.hospicecahpssurvey.org). We rely on the professionalism of the
providers to cooperate with the survey's requirements.
The commenter also states that the survey is burdensome for
bereaved families to complete. We thank the commenters for their
comments; we have not received complaints from respondents regarding
the survey being burdensome. Responses are voluntary and at the
discretion of the person receiving the survey. If they find the survey
too burdensome, they simply do not need to respond.
Comment: A few commenters stated that it is unclear whether public
reporting will use only the eligible HIS quality measures or will also
use the Hospice CAHPS results. Commenters claim that the inclusion of
Hospice CAHPS results is essential if Hospice Compare is to provide a
meaningful reflection of hospice care quality.
Response: We thank the commenters for their comments. We are
currently building the infrastructure for the new Hospice Compare site
and are evaluating the best method to include both the Hospice Item Set
measures and the results of the Hospice CAHPS Survey.
Comment: One commenter made the point that, for smaller hospices,
Hospice CAHPS data is likely to be more vulnerable to variations
numerator size and variability than comparable data for larger
hospices.
Response: We agree that smaller hospices may be subject to greater
variability than large ones. We plan to report an eight-quarter rolling
average for Hospice CAHPS public reporting. For the initial report, we
may include fewer quarters, but we will build up to eight quarters and
continue on an ongoing basis. These plans are intended to
counterbalance concerns about variability of the data while at the same
time including as many hospices as possible on the Compare site.
Comment: One commenter recommended that CMS conduct analysis to
determine how CAHPS results are affected by survey eligibility
requirements and response rates. Specifically, they express concern
about the relationship between Hospice CAHPS data and the data that
would be obtained if survey eligibility rules were modified.
Response: We thank the commenter for their comments. When a sample
is taken, it is a random sample to represent the care of all eligible
hospice patients. We do exclude patients who have been in hospice care
for fewer than 48 hours since their caregivers do not have enough
experience to evaluate the care provided by the hospice. We intend to
conduct a variety of special and ongoing analyses of Hospice CAHPS
data, as well as other related data available to the agency, including
analyses of how non-responders differ from responders to determine if
we need to control for non-response bias. Generally, the adjustment is
already completed for differences in the mix of patients across
providers also controls for any non-response bias. We will, however,
continue to monitor how eligibility requirements and response rates
impact the character of the data reported and whether changes in
requirements need to be made.
Comment: A few commenters commented that hospices not included in
public reporting might be disadvantaged.
Response: As mentioned previously, we are aware that hospices might
want to be included in the Hospice Compare Web site. We are increasing
the number of quarters included in the rolling average that will be
reported on the public reporting site. The goal of this process is to
make it possible for a larger proportion of hospices to be included on
the site, while at the same time limiting the variability of the
results for smaller hospices.
Comment: One commenter requested that CMS use two individual
questions from the survey, the hospice rating item and the
``willingness to recommend'' item, on the Hospice Compare Web site.
Response: We plan to include both the hospice rating question and
the willingness to recommend question as part of the Hospice CAHPS data
reported on Hospice Compare.
Final Action: After consideration of comments, we are finalizing
our proposals that hospices that receive their CCN after January 1,
2017 for the FY 2019 APU and January 1, 2018 for the FY 2020 APU are
exempted from the Hospice CAHPS[supreg] requirements due to newness.
10. HQRP Reconsideration and Appeals Procedures for the FY 2017 Payment
Determination and Subsequent Years
In the FY 2015 Hospice Wage Index 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.
We clarified 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
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Reconsideration-Requests.html.
Electronic email sent to HospiceQRPReconsiderations@cms.hhs.gov is the
only form of submission that will be accepted. Any reconsideration
requests received through any other channel including the United States
Postal Service or phone will not be considered as a valid
reconsideration request. We codified this process at Sec. 418.312(h).
In addition, we codified at Sec. 418.306(b)(2) that beginning with FY
2014 and each subsequent FY, the Secretary shall reduce the market
basket update by 2 percentage points for any hospice that does not
comply with the quality data submission requirements for that FY and
solicited comments on all of the proposals and the associated
regulations text at Sec. 418.312 and in Sec. 418.306 in section VI.
Official instructions regarding the payment reduction reconsideration
process can be located under the Regulations and Guidance,
Transmittals, 2015 Transmittals Web site at https://www.cms.gov/
Regulations-and-Guidance/Guidance/Transmittals/2015-Transmittals-Items/
[[Page 52183]]
R52QRI.html?DLPage=1&DLEntries=10&DLSort=4&DLSortDir=descending.
In the past, only hospices found to be non-compliant with the
reporting requirements set forth for a given payment determination
received a notification from CMS of this finding along with
instructions for requesting reconsideration in the form of a United
States Postal Service (USPS) letter. In the FY 2016 Hospice Wage Index
final rule (80 FR 47198), we stated that we would use the QIES CASPER
reporting system as an additional mechanism to communicate to hospices
regarding their compliance with the reporting requirements for the
given reporting cycle. We will implement this additional communication
mechanism via the QIES CASPER timeliness compliance reports referenced
in section III.C.7e of this final rule. As stated in section III.C.7e
of the rule, these QIES CASPER reports will be automated reports that
hospices will be able to generate at any point in time to determine
their preliminary compliance with HQRP requirements, specifically, the
timeliness compliance threshold for the HIS. We believe the QIES CASPER
timeliness compliance reports meet CMS's intent of developing a method
to communicate as quickly, efficiently, and broadly as possible with
hospices regarding their preliminary compliance with reporting
requirements. We will continue to send notification of noncompliance
via delivery of a letter via the United States Postal Service.
Requesting access to the CMS systems is performed in 2 steps. Details
are provided on the QIES Technical Support Office Web site at https://www.qtso.com/hospice.html. Providers may access the CMS QIES Hospice
Users Guides and Training by going to the QIES Technical Support Office
Web site and selecting Hospice and then selecting the CASPER Reporting
Users Guide at https://www.qtso.com/hospicetrain.html. Additional
information about how to access the QIES CASPER reports will be
provided prior to the availability of these new reports.
We proposed to disseminate communications regarding the
availability of hospice compliance reports in CASPER files through CMS
HQRP communication channels, including postings and announcements on
the CMS HQRP Web site, MLN eNews communications, national provider
association calls, and announcements on Open Door Forums and Special
Open Door Forums. We further proposed to publish a list of hospices who
successfully meet the reporting requirements for the applicable payment
determination on the CMS HQRP Web site https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/. We proposed updating the list after
reconsideration requests are processed on an annual basis. We clarified
that the published list of compliant hospices on the CMS HQRP Web site
would include limited organizational data, such as the name and
location of the hospice. Finalizing the list of compliant providers for
any given year is most appropriately done after the final determination
of compliance is made. It is our intent for the published list of
compliant hospices to be as complete and accurate as possible, giving
recognition to all providers who were compliant with HQRP requirements
for that year. Finalizing the list after requests for reconsideration
are reviewed and a final determination of compliance is made allows for
a more complete and accurate listing of compliant providers than
developing any such list prior to reconsideration. Developing the list
after the final determination of compliance has been made allows
providers whose initial determination of noncompliance was reversed to
be included in the list of compliant hospices for that year. We believe
that finalizing the list of compliant hospices annually after the
reconsideration period will provide the most accurate listing of
hospices compliant with HQRP requirements.
11. 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. Such procedures shall ensure that a
hospice program has the opportunity to review the data that is to be
made public for the hospice program prior to such data being made
public. The Secretary shall report quality measures that relate to
hospice care provided by hospice programs on the CMS Web site.
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 transparent 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 7 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 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 1 or 2 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) was not used for assessing validity and reliability
of the quality measures. We analyzed data collected by hospices during
Quarter 4 (Q4) CY 2014 and Q1 through Q3 CY 2015. Preliminary analyses
of HIS data show that all 7 quality measures that can be calculated
using HIS data are eligible for public reporting (NQF #1634, NQF #1637,
NQF #1639, NQF #1638, NQF #1641, modified NQF #1647, NQF #1617). Based
on analyses conducted to establish reportability of the measures, 71
percent through 90 percent of all hospices would be able to participate
in public reporting, depending on the measure. For additional details
regarding analysis, we refer readers to the Measure Testing Executive
Summary document available on the ``Current Measures'' section of the
CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html. Although analyses show that many hospices perform well
on the 7 measures from the HIS measure set, the measures still show
variation, especially among hospices with suboptimal performance,
indicating that these measures are still meaningful for comparing
quality of care across hospice providers. In addition to conducting
quantitative analysis to establish scientific acceptability of the HIS
measures, CMS's measure development contractor conducted interviews
with family and caregivers of hospice patients. The purpose of these
interviews was to determine what information patients and caregivers
would find useful in selecting hospices, as well as gathering input
about patient and caregiver experience with hospice
[[Page 52184]]
care. Results from these interviews indicate that all 7 HIS quality
measures provide consumers with useful information. Interview
participants stated that quality measure data would be especially
helpful in identifying poor quality outliers that inform beneficiaries,
families, caregivers, and other hospice stakeholders.
To inform which of the HIS measures are eligible for public
reporting, CMS's measure development contractor, RTI International,
examined the distribution of hospice-level denominator size for each
quality measure to assess whether the denominator size is large enough
to generate the statistically reliable scores necessary for public
reporting. This goal of this analysis is to establish the minimum
denominator size for public reporting, which is referred to as
``reportability'' analysis. Reportability analysis is necessary since
small denominators may not yield statistically meaningful QM scores.
Thus, for other quality reporting programs, such as Nursing Home
Compare,\35\ CMS sets a minimum denominator size for public reporting,
as well as the data selection period necessary to generate the minimum
denominator size. Reportability analysis showed that calculating and
publicly displaying measures based on 12 months of data would allow for
sufficient measure denominator size. Having ample denominator size
ensures that quality measure scores that are publicly reported are
reliable and stable; a minimum sample size of 20 stays is commonly
applied to assessment-based quality measures in other reporting
programs. The 12-month data selection period produced significantly
larger mean and median sample sizes among hospices, which will generate
more reliable quality measure scores. Additionally, our analysis
revealed that when applying a minimum sample size of 20 stays, using
rolling 12 months of data to create QMs would only exclude about 10
percent through 29 percent of hospices from public reporting, depending
on the measure. For more information on analyses conducted to determine
minimum denominator size and data selection period, we refer readers to
the Reportability Analysis Section of the Measure Testing Executive
Summary, available on the ``Current Measures'' portion of the CMS HQRP
Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html.
---------------------------------------------------------------------------
\35\ ``CMS Nursing Home Quality Initiative--Centers for Medicare
. . .'' 2011. 25 Jan. 2016 https://www.cms.gov/nursinghomequalityinits/45_nhqimds30trainingmaterials.asp.
---------------------------------------------------------------------------
Based on reportability analysis and input from other stakeholders,
we have determined that all 7 HIS measures are eligible for public
reporting. Thus, we plan to publicly report all 7 HIS measures on a CMS
Compare Web site for hospice agencies. For more details on each of the
7 measures, including information on measure background, justification,
measure specifications, and measure calculation algorithms, we refer
readers to the HQRP QM User's Manual, which is available on the
downloads portion of the Current Measures CMS HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html. Individual
scores for each of the 7 HIS measure scores would be reported on a new
publicly available CMS Hospice Compare Web site. Current reportability
analysis indicates that a minimum denominator size of 20 based on 12
rolling months of data would be sufficient for public reporting of all
HIS quality measures. Under this methodology, hospices with a quality
measure denominator size of smaller than 20 patient stays would not
have the quality measure score publicly displayed since a quality
measure score on the basis of small denominator size may not be
reliable. We will continue to monitor quality measure performance and
reportability and will adjust public reporting methodology in the
future if needed.
Reportability analysis is typically conducted on a measure-by-
measure basis. We would like to clarify that any new measure adopted as
part of the HQRP will undergo reportability analysis to determine: (1)
If the measure is eligible for public reporting; and (2) the data
selection period and minimum denominator size for the measure. Results
of reportability analyses conducted for new measures will be
communicated through future rulemaking.
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. We are currently
developing the infrastructure for public reporting and will provide
hospices an opportunity to review their quality measure data prior to
publicly reporting information about the quality of care provided by
Medicare-certified hospice agencies throughout the nation. These
quality measure data reports or ``preview reports'' will be made
available in the CASPER system prior to public reporting and will offer
providers the opportunity to review their quality measure data prior to
public reporting on the CMS Compare Web site for hospice agencies.
Under this process, providers would have the opportunity to review and
correct data they submit on all measures that are derived from the
Hospice Item Set. Reports would contain the provider's performance on
each measure calculated based on HIS submission to the QIES ASAP
system. The data from the HIS submissions would be populated into
reports with all data that have been submitted by the provider. CMS
will post preview reports with sufficient time for providers to be able
to submit, review data, make corrections to the data, and view their
data. Providers are encouraged to regularly evaluate their performance
in an effort to ensure the most accurate information regarding their
agency is reflected.
We also plan to make available additional provider-level feedback
reports, which are separate from public reporting and will be for
provider viewing only, for the purposes of internal provider quality
improvement. As is common in other quality reporting programs, quality
reports would contain feedback on facility-level performance on quality
metrics, as well as benchmarks and thresholds. For the CY 2015
Reporting Cycle, several new quality reporting provider participation
reports were made available in CASPER. Providers can access a detailed
list and description of each of the 12 reports currently available to
hospices on the QIES Web site, under the Training & Education
Selections, CASPER Reporting Users Guide at https://www.qtso.com/hospicetrain.html. We anticipate that providers would use the quality
reports as part of their Quality Assessment and Performance Improvement
(QAPI) efforts.
Furthermore, to meet the requirement for making such data public,
we are developing a CMS Hospice Compare Web site, which will provide
valuable information regarding the quality of care provided by
Medicare-certified hospice agencies throughout the nation. Consumers
would be able to search for all Medicare approved hospice providers
that serve their city or zip code (which would include the quality
measures and CAHPS[supreg] Hospice Survey results) and then find the
agencies offering the types of services they need, along with provider
quality information. Based on the efforts necessary to build the
infrastructure for public reporting, we anticipate that public
reporting of the eligible HIS quality measures on the CMS Compare Web
site for hospice
[[Page 52185]]
agencies will begin sometime in the spring/summer of CY 2017. To help
providers prepare for public reporting, we will offer opportunities for
stakeholder engagement and education prior to the rollout of a Hospice
Compare site. We will offer outreach opportunities for providers
through the MLN eNews, Open Door Forums and Special Open Door Forums;
we will also post additional educational materials regarding public
reporting on the CMS HQRP Web site. Finally, we will offer training to
all hospice providers on the systems and processes for reviewing their
data prior to public reporting; availability of trainings will be
communicated through the regular CMS HQRP communication channels,
including postings and announcements on the CMS HQRP Web site, MLN
eNews communications, national provider association calls, and
announcements on Open Door Forums and Special Open Door Forums.
Like other CMS Compare Web sites, the Hospice Compare Web site
will, in time, feature a quality rating system that gives each hospice
a rating of between 1 and 5 stars. Hospices will have prepublication
access to their own agency's quality data, which enables each agency to
know how it is performing before public posting of data on the Hospice
Compare Web site. Public comments regarding how the rating system would
determine a hospice's star rating and the methods used for
calculations, as well as a proposed timeline for implementation will be
announced via regular CMS HQRP communication channels, including
postings and announcements on the CMS HQRP Web site, MLN eNews
communications, provider association calls, and announcements on Open
Door Forums and Special Open Door Forums. We will announce the timeline
for development and implementation of the star rating system in future
rulemaking.
Lastly, as part of our ongoing efforts to make healthcare more
transparent, affordable, and accountable for all hospice stakeholders,
the HQRP is prepared to post hospice data on a public data set, the
Data.Medicare.gov Web site, and directory located at https://data.medicare.gov. This site includes the official datasets used on the
Medicare.gov Compare Web sites provided by CMS. In addition, this data
will serve as a helpful resource regarding information on Medicare-
certified hospice agencies throughout the nation. In an effort to move
toward public reporting of hospice data, we will initially post
demographic data of hospice agencies that have been registered with
Medicare. This list will include high-level demographic data for each
agency including, provider name, address, phone numbers, ownership
type, CMS Certification Number (CCN), profit status, and date of
original CMS certification. The posting of this new hospice data
directory occurred on June 14, 2016. Information can be located at
https://data.medicare.gov/data/hospice-directory. Additional details
regarding hospice datasets will be announced via regular CMS HQRP
communication channels, including postings and announcements on the CMS
HQRP Web site, MLN eNews communications, national provider association
calls, and announcements on Open Door Forums and Special Open Door
Forums. In addition, we have provided the list of CASPER/ASPEN and
Regional Office coordinators in the event the Medicare-certified agency
is either not listed in the database or the characteristics/
administrative data (name, address, phone number, services, or type of
ownership) are incorrect or have changed. To continue to meet Medicare
enrollment requirements, all Medicare providers are required to report
changes to their information in their enrollment application as
outlined in the Provider-Supplier Enrollment Fact Sheet Series located
at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedEnroll_InstProv_FactSheet_ICN903783.pdf.
Comment: CMS received several comments that were supportive of
public reporting of hospice quality measures. Commenters noted that
they were in favor of CMS's efforts to publicly report hospice quality
data to support the timely and transparent reporting of HQRP data. One
commenter shared that public reporting of valid and reliable quality
data demonstrates value, underpins compliance, and provides structure
for hospice care. Several commenters did have suggestions,
recommendations, and concerns about specific aspects of the public
display of hospice quality measure data. These specific comments are
summarized below.
Response: We appreciate the commenters' support of public reporting
of hospice quality measures. We address commenters' specific concerns
with respect to public reporting reports below.
Comment: CMS received a few comments expressing concerns that many
hospice providers have high scores on the current HIS measures and some
Hospice CAHPS measures. The potential lack of variation in scores for
these measures may make differentiating between hospice providers'
performance challenging for consumers. Given the limited range of
scores, commenters thought that presenting data as rankings or
percentiles may present results in a way that does not provide valuable
information to consumers. One commenter suggested that CMS consider
risk-adjusting quality measures reported on the Compare Web site.
Response: We agree that all publicly reported data should be
presented in a manner that is meaningful and understandable to the
general public. We will take steps and use recognized practices to
ensure that any publicly reported data is displayed in an appropriate
and meaningful manner. We are developing the format and content for
public display of quality measure data on the Hospice Compare site. We
appreciate the commenters input on how to most meaningfully display
quality measure data and will take these suggestions into consideration
as we finalize the format of public reporting (that is, whether to
report scores or the percentiles for each quality measure (QM)).
Regarding commenters' concerns about the lack of variation in
current HIS measure scores, the overall distribution and variability of
the seven currently adopted HIS QMs is an indicator that most hospices
are providing the required and recommended care to the majority of the
patients around hospice admission, demonstrating overall high quality
of care. However, the seven measures demonstrate room for improvement.
Analysis conducted by our measure development contractor demonstrates
that a low percentage of hospices have perfect scores for most measures
and a small percentage of hospices have very low scores. We believe
this is valuable and important information to communicate to consumers
as well as to providers to motivate quality improvement. Additionally,
we are working on the specific format for publicly reporting these 7
QMs and will take commenters' suggestions into consideration. We agree
that given the skewed distribution, presenting hospice scores in
formats like percentiles may provide misleading information. Presenting
hospices' quality scores may provide information that is more
straightforward for consumers and providers. Finally, input that we
have received from hospice caregivers will also inform our strategy for
public reporting of quality measure data. Our measure development
contractor interviewed hospice caregivers about public display of
quality data and what
[[Page 52186]]
types of data would be most meaningful to consumers. In these
interviews, respondents supported the continued data collection and
reporting of the individual HIS measures, noting that information on
the individual measures is valuable to consumers. Respondents also
noted that although overall performance on the 7 HIS measures is high,
public display of these scores would still be meaningful as a way to
identify low-performing hospices.
With respect to the commenter's suggestion to risk adjust quality
measures reported on the Hospice Compare Web site, we would like to
point out that both the current HIS measure set (NQF #1634, NQF #1637,
NQF #1639, NQF #1638, NQF #1617, NQF #1641 and NQF #1647) and Hospice
CAHPS quality measures are currently under review by the National
Quality Forum (NQF) for maintenance endorsement and endorsement,
respectively. NQF criteria for review and endorsement includes
consideration of risk adjustment. As stated in section III.C.3 of this
rule, it is CMS's intent to implement endorsed quality measures, using
the specifications as endorsed by the NQF.
Comment: A few commenters suggested that CMS provide quarterly
benchmark data to hospices for at least 1 year in advance of publicly
reporting the data. Commenters believed the benchmark data would
demonstrate to individual hospices how they perform compared to all
hospices on the existing measures and allow opportunity for improvement
prior to the onset of public reporting. One commenter shared that
hospices have found stable benchmark scores for comparison to be far
more useful for setting goals and tracking performance improvement.
Response: We appreciate the commenters' suggestion to provide
quarterly benchmark data. As we previously stated, we plan to make
available additional provider-level feedback reports prior to public
reporting; these reports will help hospices with their quality
assessment and performance improvement efforts. As is common in other
quality reporting programs, these reports would provide feedback on
facility-level performance on quality metrics, as well as national
benchmarks. Additionally, national means of the HIS quality measures,
based on Q4 2014 through Q3 2015 HIS data, are reported in the Hospice
Quality Reporting Program: Executive Summary of Measure Testing and
Validation, available on the ``Current Measures'' portion of the CMS
HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html.
Comment: One commenter urged CMS to not only showcase quality
measures from HIS and Hospice CAHPS, but also demonstrate the scope and
level of services provided by different hospice programs. The commenter
stated that while hospices are required to be able to provide certain
services, patient and family access to these services varies,
especially for the non-clinical services. In addition, this commenter
stated that there is variation in how well hospices meet the
requirements. Moreover, the commenter stated that and a lack of
enforcement allowed lower quality programs to minimally comply with
requirements, if at all. For example, many hospice programs send
mailings to families on bereavement; while this technically meets the
bereavement requirements under the benefit; other hospices offer and
provide robust, individualized bereavement support. The commenter
thought that it would be important for consumers to have information
about these services to help them select a hospice.
Response: We appreciate the commenter's recommendation to report
quality metrics and hospice information beyond HIS and Hospice CAHPS
measures. We recognize that information regarding the scope and level
services provided would be valuable to consumers and hospice providers;
however, we note that such information may not be readily available to
us through billing records or other reporting mechanisms, and we are
cognizant of the burden additional reporting could place on providers.
We will take this recommendation into consideration as we move forward
with the development for future HQRP measures.
Comment: The majority of commenters supported the minimum
denominator size for public reporting. Although commenters were
generally supportive of this requirement, some commenters had concerns
about the possible negative impact on small hospices for which quality
information is not included in public reporting due to not meeting the
minimum denominator size. Commenters noted that hospices who do not
meet the threshold of 20 stays for the HIS-based QMs or the size
exemption for Hospice CAHPS[supreg] Survey, which is less than 50-
survey eligible patients in the previous year, would not be included in
all or part of public reporting. Commenters raised concerns that a lack
of displayed data on Hospice Compare may disadvantage these smaller
providers. Commenters believed that consumers using Hospice Compare to
search for a provider might disregard hospices that do not have some or
all of their data displayed due to size issues, and that, in turn,
consumers may be more likely to seriously consider only those hospices
for which quality information is presented. One commenter expressed
concerns that there are some important statistical considerations, in
addition to denominator size, that should be addressed in creating a
means for public display of hospice quality data. Specifically, the
commenter noted that a small denominator that meets the minimum
denominator size is more sensitive to fluctuations in the numerator
than a large denominator. Smaller hospices are likely to have smaller
denominators and are more vulnerable to numerator size and variability
than larger hospices. The commenters suggested that CMS create a means
to counterbalance the potential negative consequences for those
hospices for which quality information is not included in public
reporting.
Response: We thank the commenters for their support of our
recommendation to set a minimum denominator size for public reporting.
We appreciate commenters sharing concerns regarding the possible
negative impact on small hospices. To establish the minimum denominator
size, we examined the national hospice-level denominator size for the
HIS quality measures. The determination of the minimum denominator size
balanced the necessity of yielding statistically meaningful QM scores
and the goal of allowing as many hospices to have their quality measure
scores publicly displayed as possible. To be consistent with other
quality reporting programs' public reporting policies, we set a minimum
denominator size for public reporting of quality measures, as well as
the data selection period necessary to generate the minimum denominator
size. The minimum denominator size is determined based on a hospice's
patient stays over a 12-month period. Analysis conducted by RTI
International shows that only about 10 percent of hospices would not
have accumulated 20 patient stays to have any HIS quality measure
publicly displayed. RTI's analysis also shows that quality measures
calculated based on 12 months of data are stable and robust against
fluctuation. These results were summarized in the Measure Testing
Executive Summary document referenced in this section of the rule and
posted on the ``Current Measures'' portion of the CMS HQRP Web site:
[[Page 52187]]
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Current-Measures.html. On the
Hospice Compare Web site, CMS plans to indicate in some manner (for
example, through a footnote or some other statement) instances where
data is not displayed due to denominator size issues. We believe this
will minimize any potential negative impact on small providers and
signal to consumers that in such instances, the lack of data is a
result of the hospice having too few admissions to allow for reporting
of a valid quality measure, and is not in and of itself an indicator of
hospice quality. Finally, we will take the commenters suggestion
regarding creating a means to counterbalance the potential negative
consequences for small hospices as we move forward with the development
and launch of Hospice Compare.
Comment: CMS received several comments regarding data sources that
would be included in the launch of Hospice Compare. Overall, commenters
offered two main considerations. First, commenters brought up concerns
about the limitations of HIS data for consumer decision-making. Second,
commenters requested clarification from and encouraged CMS to include
Hospice CAHPS data in the launch of Hospice Compare. Regarding the
first concern, commenters noted that HIS data alone might provide
inadequate information to aid in consumer decision-making. Commenters
noted that all HIS measures are process of care measures and, as such,
do not address important issues such as whether the patient/family was
treated with respect or felt supported by the hospice team. They
strongly recommended that the Hospice CAHPS results be reported along
with HIS measures to provide consumers with the most meaningful and
comprehensive picture of quality of care. Finally, commenters
encouraged CMS to provide appropriate disclaimers about the hospice
quality data and information, outlining the limitations of the data and
its utility.
Response: We appreciate the commenters' feedback on public
reporting of HIS and Hospice CAHPS data. We agree with commenters that
HIS and Hospice CAHPS data are complementary and, together, provide a
more meaningful and comprehensive view of quality of care provided by
hospices. As noted in section III.C.9 of this rule, we plan to include
both HIS and Hospice CAHPS data in the launch of Hospice Compare.
Reporting both data sources will address commenters' concerns and
mirrors the approach for public reporting used in other CMS Compare
sites. We will communicate additional plans for the public reporting of
hospice quality data through the usual CMS HQRP communication channels,
including postings and announcements on the CMS HQRP Web site, MLN
eNews communications, national provider association calls, and
announcements on Open Door Forums and Special Open Door Forums.
Comment: A few commenters expressed concerns that consumers will
not understand the difference between a process measure and an outcome
measure and be able to draw conclusions about the experience of hospice
care from just the composite process measure. One commenter shared that
CMS needs to provide education and resources to help the public
understand what the measures mean.
Response: We agree that any publicly reported data should be
presented in a manner that is meaningful and understandable by the
public. We intend to take steps and use recognized practices to ensure
that any publicly reported data is displayed in an appropriate and
meaningful manner. We intend to work with our Web site development
contractor to ensure that the Hospice Compare site has been tested for
usability, readability, and navigation, and that consumers and
stakeholders are continuously involved and have opportunities for input
throughout the development process. We will write in plain language,
with awareness of variations in health and general literacy, and
solicit input from key stakeholders and technical experts in the
development of the presentation of publicly available quality data.
Comment: CMS received a few comments regarding concerns about the
publicly reported HIS measures because they are constructed using HIS
data that is self-reported by hospice providers. Commenters had
concerns about the validity of this data and encouraged CMS to
determine methods to monitor the veracity of the data being submitted.
Commenters noted that the launch of Hospice Compare might create
perverse incentives for hospices to submit false data to avoid
unfavorable scores being publicly reported on the Compare Web site.
Response: We acknowledge commenters' concerns regarding the
validity of self-reported HIS measures. Publicly reported quality
measure data relies on the submission of valid and reliable data at the
patient level. Our measure development contractor conducts ongoing
testing and validation of the quality measure data to identify data
irregularities and trends. We will consider additional validation
processes for future rulemaking cycles.
Comment: CMS received a few comments expressing providers' desire
to review data prior to publication. One commenter inquired about the
process for correcting data errors.
Response: We appreciate the commenters' interest in reviewing data
prior to public reporting. We would like to take this opportunity to
clarify the processes available to providers for reviewing and making
changes to HIS data, and for previewing QM scores prior to public
display. First, as outlined in the HIS Manual, providers have the
opportunity to make corrections to HIS data through HIS record
modification and inactivation processes. HIS record modifications and
inactivations are available if a provider finds an error in HIS data
that has been submitted and accepted by the QIES ASAP system. Further
details on processes for modifications and inactivations are available
in Chapter 3 of the HIS Manual, available on the HIS portion of the CMS
HQRP Web site: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html. It is vital for providers to correct any errors in HIS
data to ensure information in the QIES ASAP system accurately reflects
the patient's hospice record and HIS-related care processes delivered
to the patient; this initial corrections process for errors in HIS data
helps ensure QM scores and any publicly displayed data are accurate.
In addition to modification and inactivation processes available in
QIES ASAP, as we previously stated, we are currently developing the
infrastructure to provide hospices with the opportunity to view their
quality measure data via CASPER provider-level feedback reports. These
internal provider-level feedback reports will provide hospices an
initial opportunity to review QM score data in CASPER. Provider-level
feedback reports are confidential and separate from the public
reporting processes. The purpose of provider-level feedback reports is
to provide hospices with QM score data that can be used at the
individual facility level and for internal quality improvement. We are
planning for release of the QM provider-level feedback reports sometime
in December of 2016. Availability of the new CASPER QM reports will be
communicated to providers through the usual CMS HQRP communication
channels, including postings and announcements on the CMS HQRP Web
site, MLN eNews communications,
[[Page 52188]]
national provider association calls, and announcements on Open Door
Forums and Special Open Door Forums.
Finally, we will ensure providers have the opportunity to preview
QM score data to be displayed on Hospice Compare, prior to public
posting of the data. Prior to public reporting, quality measure data
``preview'' reports will be made available in CASPER system. Hospices
will have a 30-day preview period prior to public display during which
they can preview the performance information on their measures that
will be made public. The ``preview'' reports will be made available
using the Certification and Survey Provider Enhanced Reporting (CASPER)
System because hospices are familiar with this system. In line with
other PAC QRPs, hospices will have 30 days to review this information,
beginning from the date on which they can access the preview report.
Corrections to the underlying data would not be permitted during this
time; however, hospices would be able to ask for a correction to their
measure calculations during the 30-day preview period. If we determine
that the measure, as it is displayed in the preview report, contains a
calculation error, we would suppress the data on the public reporting
Web site, recalculate the measure and publish the corrected rate at the
time of the next scheduled public display date. This process is
consistent with informal processes used in the Hospital IQR and other
PAC programs. Technical details for how and when providers may contest
their measure calculations, as well as the process for submitting a
suppression request will be conveyed through the usual CMS HQRP
communication channels.
Comment: CMS received a comment in support of the initiative to
make available additional provider-level feedback reports in the CASPER
reporting system. The commenter requested CMS consider additional
reports to display quality metric scores that would be available 2 days
after HIS records are submitted and accepted by the QIES ASAP system.
Response: We appreciate the commenter's support of the initiative
to provide additional provider-level feedback reports in CASPER. We
agree that providing timely feedback to hospice providers is a critical
step in the process of quality improvement since providers need data
about their performance to inform QAPI and other performance
improvement efforts. We will continue to refine the provider-level
feedback reports to make timely data available to providers within the
CASPER system.
Comment: One commenter expressed concerns regarding consumers
leaving anonymous negative comments or grievances on the Hospice
Compare Web site. The commenter noted that there is no manner for the
hospice to respond to or rebut negative comments or grievances.
Response: We would like to thank the commenters for taking the time
to convey their concerns regarding consumers leaving anonymous negative
comments or grievances on the Hospice Compare Web site. Consumers will
only be able to search for hospice providers and review quality data;
they will not be able to post comments or grievances on the CMS Hospice
Compare Web site.
Comment: Though commenters were generally supportive of public
reporting of quality data, several commenters expressed concerns over
the methodology for the star rating system to be used in the future as
part of the Hospice Compare Web site. One commenter urged CMS to be
conservative and cautious about the use of star ratings when applied to
Hospice CAHPS data because patient and family experience with care data
is typically positively skewed. A few commenters cautioned CMS against
evaluating hospice providers along a bell curve rather than on a
grading scale when developing star ratings for hospice providers. They
shared that the use of a bell curve creates confusion for consumers and
may misrepresent the quality of the care provided by hospices.
Commenters encouraged CMS to develop a star-rating methodology that
incorporates both HIS and Hospice CAHPS data. A few commenters
suggested that CMS provide sufficient time for stakeholders to review
the star ratings model. One commenter voiced concerns about star-rating
methodologies used in other care settings and recommended CMS take into
consideration lessons learned about unintended consequences when
developing the hospice star rating system. One commenter recommended
that CMS take a criterion approach to constructing the CMS Hospice
Compare Web site and determining the methodology to be used for
calculating star ratings. Another commenter stated that any star rating
system developed should reflect care provided by the entire
interdisciplinary team and should be risk adjusted to account for
individualized care, short lengths of stay and patient right to refuse
care.
Response: We appreciate the thorough and detailed input on the
development of a Hospice Compare Web site and the future development of
a star rating system for hospices. We would like to assure commenters
that it is of paramount concern to develop a star rating methodology
that is valid, is reliable, and presents quality data that is
meaningful to stakeholders. As with the development of star methodology
in other care programs, we will allow continued opportunities for the
provider community and other stakeholders to comment on and provide
input to the proposed rating system. In addition to regular HQRP
communication channels, we will solicit input from the public regarding
star methodology through special listening sessions, invitation to
submit comments via a Help Desk mailbox, Open Door Forums, a Technical
Expert Panel, and other opportunities. Additionally, we will benefit
from lessons learned from the development and implementation of star
ratings in other QRPs to help guide the hospice star rating initiative.
D. The Medicare Care Choices Model
We want to remind the provider community that the Medicare Care
Choices Model (MCCM) is testing a new option for Medicare beneficiaries
with certain advanced diseases to receive hospice-like support services
from MCCM hospices while receiving care from other Medicare providers
for their terminal condition. This 5 year model is being tested to
encourage greater and earlier use of the Medicare and Medicaid hospice
benefit to determine whether it can improve the quality of life and
care received by Medicare beneficiaries, increase beneficiary, family,
and caregiver satisfaction, and reduce Medicare or Medicaid
expenditures. Participation in the model is limited to Medicare and
dual eligible beneficiaries with advanced cancers, chronic obstructive
pulmonary disease, congestive heart failure, and Human Immunodeficiency
Virus/Acquired Immune Deficiency Syndrome who qualify for the Medicare
or Medicaid hospice benefit and meet the eligibility requirements of
the model. The model includes more than 130 hospices from 39 states
across the country and is projected to serve 100,000 beneficiaries by
2020. The first cohort of MCCM participating hospices began providing
services under the model in January 2016, and the second cohort will
begin to provide services under the model in January 2018. The last
patient will be accepted into the model 6 months before the December
31, 2020 model end date.
For more information, see the MCCM Web site: https://innovation.cms.gov/initiatives/Medicare-Care-Choices/.
[[Page 52189]]
IV. Collection of Information Requirements
Under the Paperwork Reduction Act of 1995, we are required to
provide 60-day notice in the Federal Register and solicit public
comment before a collection of information requirement is submitted to
the Office of Management and Budget (OMB) for review and approval. To
fairly evaluate whether an information collection should be approved by
OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995
requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency.
The accuracy of our estimate of the information collection
burden.
The quality, utility, and clarity of the information to be
collected.
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
We solicited public comment on each of the following information
collection requirements (ICRs).
A. Information Collection Requirements
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, manner, and at a time specified
by the Secretary. In the FY 2014 Hospice Wage Index final rule (78 FR
48257), and in compliance with section 1814(i)(5)(C) of the Act, we
finalized the specific collection of data items that support the
following six NQF-endorsed measures and one modified measure for
hospice:
NQF #1617 Patients Treated with an Opioid who are Given a
Bowel Regimen,
NQF #1634 Pain Screening,
NQF #1637 Pain Assessment,
NQF #1638 Dyspnea Treatment,
NQF #1639 Dyspnea Screening,
NQF #1641 Treatment Preferences,
NQF #1647 Beliefs/Values Addressed (if desired by the
patient) (modified).
Data for the aforementioned 7 measures is collected via the HIS.
Data collection for the 7 NQF-endorsed measures via the HIS V1.00.0 was
approved by the Office of Management and Budget April 3, 2014 (OMB
control number 0938-1153--Hospice Quality Reporting Program). As
outlined in this final rule, we continue data collection for these 7
NQF-endorsed measures.
In this final rule, we finalized the implementation of two new
measures. The first measure is the Hospice and Palliative Care
Composite Process Measure--Comprehensive Assessment at Admission. Seven
individual care processes will be captured in this composite measure,
which includes the six NQF-endorsed quality measures and one modified
NQF-endorsed quality measure currently implemented in the HQRP. Thus,
the Hospice and Palliative Care Composite Process quality measure will
use the current HQRP quality measures as its components. The data
source for this measure will be currently implemented HIS items that
are currently used in the calculation of the 7 component measures.
Since the measure is a composite measure created from components, which
are currently adopted HQRP measures, no new data collection will be
required; data for the composite measure will come from existing items
from the existing 7 HQRP component measures. CMS will begin calculating
this measure using existing data items, beginning April 1, 2017; this
means patient admissions occurring on or after April 1, 2017 will be
included in the composite measure calculation.
The second measure is the Hospice Visits when Death is Imminent
Measure Pair. Data for this measure will be collected via the existing
data collection mechanism, the HIS. Four new items will be added to the
HIS-Discharge record to collect the necessary data elements for this
measure. CMS expects that data collection for this quality measure via
the 4 new HIS items will begin no earlier than April 1, 2017. Thus,
under current CMS timelines, hospice providers will begin data
collection for this measure for patient admissions and discharges
occurring on or after April 1, 2017.
The HIS V2.00.0 will fulfill the data collection requirements for
the 7 currently adopted NQF measures and the 2 new measures. The HIS
V2.00.0 contains:
All items from the HIS V1.00.0, which are necessary to
calculate the 7 adopted NQF measures (and thus the composite measure),
plus the HIS V1.00.0 administrative items necessary for patient
identification and record matching,
One new item for measure refinement of the existing
measure NQF #1637 Pain Assessment,
New items to collect data for the Hospice Visits when
Death is Imminent measure pair,
New administrative items for patient record matching and
future public reporting of hospice quality data.
Hospice providers will submit an HIS-Admission and an HIS-Discharge
for each patient admission. Using HIS data for assessments submitted
October 1, 2014 through September 30, 2015, we have estimated that
there will be approximately 1,248,419 discharges across all hospices
per year and, therefore, we would expect that there should be 1,248,419
Hospice Item Sets (consisting of one admission and one discharge
assessment per patient) submitted across all hospices yearly. Over a
three-year period, we expect 3,745,257 Hospice Item Sets across all
hospices. There were 4,259 certified hospices in the U.S. as of January
2016; \36\ we estimate that each individual hospice will submit on
average 293 Hospice Item Sets annually, which is approximately 24
Hospice Items Sets per month or 879 Hospice Item Sets over 3 years.
---------------------------------------------------------------------------
\36\ Quality Improvement and Evaluation System (QIES) List of
Hospice Providers, January 2016.
---------------------------------------------------------------------------
The Hospice Item Set consists of an admission assessment and a
discharge assessment. As noted above, we estimate that there will be
1,248,419 hospice admissions across all hospices per year. Therefore,
we expect there to be 2,496,838 Hospice Item Set assessment submissions
(admission and discharge assessments counted separately) submitted
across all hospices annually, which is 208,070 across all hospices
monthly, or 7,490,514 across all hospices over three years. We further
estimate that there will be 586 Hospice Item Set submissions by each
hospice annually, which is approximately 49 submissions monthly or
1,759 submissions over three years.
For the Admission Hospice Item Set, we estimate that it will take
14 minutes of time by a clinician, such as a Registered Nurse, at an
hourly wage of $67.10 \37\ to abstract data for Admission Hospice Item
Set. This would cost the facility approximately $15.66 for each
admission assessment. We further estimate that it will take 5 minutes
of time by clerical or administrative staff person, such as a medical
data entry clerk or medical secretary, at an hourly wage of $32.24 \38\
to upload the Hospice Item Set data into the CMS system. This would
cost each facility approximately $2.69 per assessment. For the
Discharge Hospice Item Set, we estimate that it
[[Page 52190]]
will take 9 minutes of time by a clinician, such as a nurse, at an
hourly wage of $67.10 to abstract data for Discharge Hospice Item Set.
This would cost the facility approximately $10.07. We further estimate
that it will take 5 minutes of time by clerical or administrative
staff, such as a medical data entry clerk or medical secretary, at an
hourly wage of $32.24 to upload data into the CMS system. This would
cost each facility approximately $2.69. The estimated cost for each
full Hospice Item Set submission (admission assessment and discharge
assessment) is $31.10.
---------------------------------------------------------------------------
\37\ The adjusted hourly wage of $67.10 per hour for a
Registered Nurse was obtained using the mean hourly wage from the
U.S. Bureau of Labor Statistics, $33.55. This mean hourly wage is
adjusted by a factor of 100 percent to include fringe benefits. See
https://www.bls.gov/oes/current/oes291141.htm.
\38\ The adjusted hourly wage of $32.24 per hour for a Medical
Secretary was obtained using the mean hourly wage from the U.S.
Bureau of Labor Statistics, $16.12. This mean hourly wage is
adjusted by a factor of 100 percent to include fringe benefits. See
https://www.bls.gov/oes/current/oes436013.htm.
---------------------------------------------------------------------------
We estimate that the total nursing time required for completion of
both the admission and discharge assessments is 23 minutes at a rate of
$67.10 per hour. The cost across all hospices for the nursing/clinical
time required to complete both the admission and discharge Hospice Item
Sets is estimated to be $32,111,417 annually, or $96,334,252 over 3
years, and the cost to each individual hospice is estimated to be
$7,539.66 annually, or $22,618.98 over 3 years. The estimated time
burden to hospices for a medical data entry clerk to complete the
admission and discharge Hospice Item Set assessments is 10 minutes at a
rate of $32.24 per hour. The cost for completion of the both the
admission and discharge Hospice Item Sets by a medical data entry clerk
is estimated to be $6,708,171 across all hospices annually, or
$20,124,514 across all hospices over 3 years, and $1,575.06 to each
hospice annually, or $4,725.17 to each hospice over 3 years.
The total combined time burden for completion of the Admission and
Discharge Hospice Item Sets is estimated to be 33 minutes. The total
cost across all hospices is estimated to be $38,819,589 annually or
$116,458,766 over 3 years. For each individual hospice, this cost is
estimated to be $9,114.72 annually or $27,344.16 over 3 years. See
Table 18 for breakdown of burden and cost by assessment form.
Table 18--Summary of Burden Hours and Costs
--------------------------------------------------------------------------------------------------------------------------------------------------------
OMB Number of Burden per Total annual Hourly labor cost Total cost
Regulation section(s) Control No. respondents Number of responses response (hours) burden (hours) of reporting ($) ($)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hospice Item Set Admission 0938-1153 4,259 1,248,419 per year. 0.233 clinician 395,333 hours..... Clinician at $22,900,166
Assessment. hours; 0.083 $67.10 per hour;
clerical hours. Clerical staff at
$32.24 per hour.
Hospice Item Set Discharge 0938-1153 4,259 1,248,419 per year. 0.150 clinician 291,298 hours..... Clinician at 15,919,423
Assessment. hours; 0.083 $67.10 per hour;
clerical hours. Clerical staff at
$32.24 per hour.
3-year Total.................... 0938-1153 4,259 7,490,514.......... 0.55 hours........ 2,059,891 hours... Clinician at 116,458,766
$67.10 per hour;
Clerical staff at
$32.24 per hour.
--------------------------------------------------------------------------------------------------------------------------------------------------------
C. Submission of PRA-Related Comments
We have submitted a copy of this final rule to OMB for its review
of the rule's information collection and recordkeeping requirements.
These requirements are not effective until they have been approved by
the OMB.
To obtain copies of the supporting statement and any related forms
for the collections discussed above, please visit CMS's Web site at
https://www.cms.gov/RegulationsandGuidance/Legislation/PaperworkReductionActof1995/PRAListing.html, or call the Reports
Clearance Office at 410-786-1326.
We invited public comments on these potential information
collection requirements. If you wish to comment, please submit your
comments electronically as specified in the ADDRESSES section of this
final rule and identify the rule (CMS-1652-F) the ICR's CFR citation,
CMS ID number, and OMB control number.
Public Comments Received for PRA Package (CMS Form Number--CMS-R-245)
Comment: CMS received one supportive comment indicating that the
additional data sought by CMS for the calculation of the Hospice Visits
when Death is Imminent Measure Pair does not represent a significant
burden on providers and may result in useful information. Other
commenters stated that CMS's burden estimates underestimate the costs
of completing the HIS. One commenter stated that the typical admission
assessment time is 45 minutes to 1 hour, and that staff travel can
significantly increase costs. Another commenter stated that the costs
of training and operational processes to support valid data abstraction
should be included in the burden estimate.
Response: We thank the commenters for their feedback regarding the
burden of the HIS V2.00.0, and the support of the new items used to
collect data for the Hospice Visits when Death is Imminent Measure
Pair. Regarding the cost estimates for the HIS Admission form, the HIS
is a set of data elements that can be used to calculate 7 NQF endorsed
quality measures and 2 new measures adopted in this rule. The HIS is
not a patient assessment that would be directly administered to the
patient and/or family or caregivers during the initial assessment or
comprehensive assessment visit. Since the HIS is not intended to
replace the initial/comprehensive assessment, the PRA burden estimates,
by definition, do not include the time spent assessing the patient. HIS
PRA burden estimates are intended to reflect only the time needed to
complete HIS items, independent of clinical time spent assessing the
patient. Similarly, PRA burden estimates include the Annualized Cost to
the Federal Government related to the HIS V2.00.0 for provider
training, preparation of HIS V2.00.0 manuals and materials, receipt and
storage of data, data analysis, and upkeep of data submission software.
In order to mitigate costs of operational processes, providers may use
the Hospice Abstraction Reporting Tool (HART) software, which is free
to download and use, to collect and maintain facility, patient, and HIS
Record information for subsequent submission to the QIES
[[Page 52191]]
ASAP system. Burden estimates for completing the HIS data items were
based on the HIS V1.00.0 and HIS V2.00.0 pilot tests. We recognize
additional activities and efforts will be required to implement and use
the HIS V2.00.0 as part of the quality reporting program. We agree that
it is important for hospices to learn about and understand the new HIS,
and we plan to provide hospices with training resources to facilitate
implementation of the HIS.
Comment: One commenter stated that the addition of new items to the
HIS Discharge record will require vendor software development and
testing, hospice implementation, education and training, and internal
validation. The commenter stated that the target implementation date of
April 1, 2017 may not provide adequate time for implementation.
Response: We appreciate the commenter's feedback regarding the
timeline for implementation and of the HIS V2.00.0. The HIS V2.00.0 is
undergoing review as part of a PRA package under OMB number 0938-1153
and will be implemented April 1, 2017. We believe the April 1, 2017
implementation date will allow sufficient time for providers to update
their clinical documentation systems and train staff on new HIS items.
The timeline for implementation of the HIS V2.00.0 is consistent with
the timeline from prior years when the HIS V1.00.0 was implemented. We
expect training and implementation activities to take considerably less
time for the HIS V2.00.0 compared to the HIS V1.00.0 since the HIS
V2.00.0 can capitalize on existing infrastructures used by stakeholders
for the HIS V1.00.0 and contains only 17 new item components (compared
to the 60 item components that were implemented in the HIS V1.00.0).
Moreover, we encourage providers to begin preparations for HIS V2.00.0
implementation as soon as possible. The HIS V2.00.0 is currently
available for review by software vendors and hospice providers. Some of
the activities that are necessary prior to implementation can be done
concurrently. For example, hospice education and training on the new
items and data abstraction can be conducted at the same time as vendor
development of software.
We are aware of the effort hospices and vendors will have to make
to prepare for implementation of the HIS. The HIS pilot showed that
implementing the HIS is feasible and that hospices are most likely
already collecting the information needed to complete the HIS data
items. A draft version of the HIS technical data specifications was
posted on the CMS Web site on May 19, 2016. Thus, vendors have been
provided with more than adequate time to develop products for their
clients. We expect vendors to begin reviewing the draft technical data
specifications as soon as they are posted. We encourage vendors to
submit questions and comments to the HIS technical email box:
HospiceTechnicalIssues@cms.hhs.gov. Software vendors should not be
waiting for final technical data specifications to be posted to begin
development of their own products. Therefore, we believe that vendors
have been provided with adequate time and resources to meet the April
1, 2017 implementation date of the HIS. For providers that currently
use a vendor-designed software to complete HIS records, if a provider
has concerns about the timeliness of release of HIS V2.00.0 items in
vendor-designed software, CMS reminds providers that alternative means
of completing HIS records (HART software) are available to all
providers free of charge. Although electronic submission of HIS records
is required, hospices do not need to have an electronic medical record
to complete or submit HIS data. In the FY 2014 Hospice Wage Index,
final rule (78 FR 48258) we finalized that to complete HIS records
providers can use either the HART software, which is free to download
and use, or vendor-designed software. HART provides an alternative
option for hospice providers to collect and maintain facility, patient,
and HIS Record information for subsequent submission to the QIES ASAP
system. Once HIS records are complete, electronic HIS files must be
submitted to CMS via the QIES ASAP system. Electronic data submission
via the QIES ASAP system is required for all HIS submissions; there are
no other data submission methods available. Hospices have 30 days from
a patient admission or discharge to submit the appropriate HIS record
for that patient through the QIES ASAP system. We will continue to make
HIS completion and submission software available to hospices at no
cost. We provided details on data collection and submission timing
under the downloads section of the HIS Web page on the CMS.gov Web site
at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS.html.
Comment: One commenter stated that although the burden associated
with the HIS assessment may not be unduly burdensome, the collective
burden of various reporting requirements makes a large fiscal impact on
hospices.
Response: We thank the commenters for taking the time to convey
their concerns about the burden and cost of data collection for the
HQRP and other regulatory requirements. We attempted to reduce the
regulatory burden of our quality reporting programs to the greatest
extent possible. The estimated burden for completing the HIS V2.00.0
can be viewed here: (https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html).
Specifically, CMS estimates 19 minutes per response for the Admission
HIS and 14 minutes per response for the Discharge HIS. Details
regarding the estimate can be found at https://cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html.
Comments concerning the accuracy of the time estimate(s) or suggestions
for improving the HIS can be directed to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850. With respect to the commenter's concern about
additional expenses incurred as part of quality reporting, any
additional costs incurred as part of quality reporting programs should
be reported on the cost reports. Cost report data may be considered in
future payment reform.
Comment: One commenter stated that the addition of the J0905 Pain
Active Problem item to the HIS V2.00.0 would be burdensome to hospice
providers since it requires an update to the Admission HIS
documentation and the item will not be used in calculation of the Pain
Assessment measure. The commenter suggested adding the item when a
Patient Reported Outcome Pain Measure is implemented or when a Hospice
Patient Assessment Instrument is developed.
Response: We thank the commenter for their comments regarding the
new item J0905, Pain Active problem. CMS would like to clarify our
reasoning and intent behind the addition of the J0905 Pain Active
Problem item. Since the HIS V1.00.0 was implemented on July 1, 2014,
CMS has received an overwhelming amount of feedback from the provider
community regarding the items in Section J: Pain of the HIS V1.00.0
(J0900. Pain Screening and J0910. Comprehensive Pain Assessment). These
items correspond to the National Quality Forum (NQF) #1634 Pain
Screening quality measure and the NQF #1637 Pain Assessment quality
measure, respectively. NQF #1634 calculates the percentage of
[[Page 52192]]
patients who were screened for pain within two days of admission.
Patients who screen positive for pain are included in the denominator
for NQF #1637, which measures the percentage of patients who screened
positive for pain who received a comprehensive pain assessment within 1
day.
Under current specifications for NQF #1634 and NQF #1637, if a
patient is not in pain at the time of the first screening, that patient
is not included in the denominator for NQF #1637--even if pain is an
active problem for the patient. As such, if a patient is not in current
pain at the time of the first pain screening, HIS V1.00.0 skip patterns
direct providers to skip Item J0910, the comprehensive pain assessment
item. RTI received feedback from the provider community that the
measure specifications and associated skip pattern between J0900 and
J0910 do not align with clinical practice, as clinicians will often
complete a comprehensive pain assessment for patients when pain is an
active problem but the patient is not in pain at the time of the
screening. Providers further noted that some vendor-designed software
built HIS skip patterns into clinical documentation systems and the
skip pattern between J0900 and J0910 was thus restricting the ability
of clinicians to document comprehensive assessments that were conducted
per clinical best practice but not required for the purposes of the HIS
pain quality measures. Due to these factors, CMS has received feedback
from the provider community to consider changing items in the pain
section to align HIS pain items with current clinical practice.
Thus, directly in response to feedback from providers, CMS added
the J0905 Pain Active Problem item to the HIS V2.00.0. We believe this
addition will actually reduce burden on providers since it is better
aligned with current clinical practice. The addition of J0905 also
better aligns items in the pain section with items in Section J:
Respiratory Status. CMS plans to analyze data from J0905 to inform
future potential refinements to the NQF-endorsed pain quality measures.
ICR-related comments are due October 4, 2016.
V. Economic Analyses
A. Regulatory Impact Analysis
1. Introduction
We have examined the impacts of this final 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 final 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 final
rule was also reviewed by OMB.
2. Statement of Need
This final rule meets the requirements of our regulations at Sec.
418.306(c), which requires annual issuance, in the Federal Register, of
the hospice wage index based on the most current available CMS hospital
wage data, including any changes to the definitions of Core-Based
Statistical Areas (CBSAs), or previously used Metropolitan Statistical
Areas (MSAs). This final rule will also update payment rates for each
of the categories of hospice care described in Sec. 418.302(b) for FY
2017 as required under section 1814(i)(1)(C)(ii)(VII) of the Act. The
payment rate updates are subject to changes in economy-wide
productivity as specified in section 1886(b)(3)(B)(xi)(II) of the Act.
In addition, the payment rate updates may be reduced by an additional
0.3 percentage point (although for FY 2014 to FY 2019, the potential
0.3 percentage point reduction is subject to suspension under
conditions specified in section 1814(i)(1)(C)(v) of the Act). In 2010,
the Congress amended section 1814(i)(6) of the Act with section 3132(a)
of the Affordable Care Act. The amendment authorized the Secretary to
revise the methodology for determining the payment rates for routine
home care and other services included in hospice care, no earlier than
October 1, 2013. In the FY 2016 Hospice Wage Index and Rate Update
final rule (80 FR 47164), we finalized the creation of two different
payment rates for RHC that resulted in a higher base payment rate for
the first 60 days of hospice care and a reduced base payment rate for
days 61 and over of hospice and created a SIA payment, in addition to
the per diem rate for the RHC level of care, equal to the CHC hourly
payment rate multiplied by the amount of direct patient care provided
by an RN or social worker that occurs during the last 7 days of a
beneficiary's life, if certain criteria are met. Finally, section 3004
of the Affordable Care Act amended the Act to authorize a quality
reporting program for hospices, and this rule discusses changes in the
requirements for the hospice quality reporting program in accordance
with section 1814(i)(5) of the Act.
3. Overall Impacts
We estimate that the aggregate impact of this final rule will be an
increase of $350 million in payments to hospices, resulting from the
hospice payment update percentage of 2.1 percent. The impact analysis
of this final rule represents the projected effects of the changes in
hospice payments from FY 2016 to FY 2017. Using the most recent data
available at the time of rulemaking, in this case FY 2015 hospice
claims data, we apply the current FY 2016 wage index and labor-related
share values to the level of care per diem payments and SIA payments
for each day of hospice care to simulate FY 2016 payments. Then, using
the same FY 2015 data, we apply the FY 2017 wage index and labor-
related share values to simulate FY 2017 payments. Certain events may
limit the scope or accuracy of our impact analysis, because such an
analysis is susceptible to forecasting errors due to other changes in
the forecasted impact time period. The nature of the Medicare program
is such that the changes may interact, and the complexity of the
interaction of these changes could make it difficult to predict
accurately the full scope of the impact upon hospices.
4. Detailed Economic Analysis
The FY 2017 hospice payment impacts appear in Table 19. We tabulate
the resulting payments according to the classifications in Table 19
(for example, facility type, geographic region, facility ownership),
and compare the difference between current and proposed payments to
determine the overall impact.
[[Page 52193]]
The first column shows the breakdown of all hospices by urban or
rural status, census region, hospital-based or freestanding status,
size, and type of ownership, and hospice base. The second column shows
the number of hospices in each of the categories in the first column.
The third column shows the effect of the annual update to the wage
index. This represents the effect of using the FY 2017 hospice wage
index. The aggregate impact of this change is zero percent, due to the
hospice wage index standardization factor. However, there are
distributional effects of the FY 2017 hospice wage index.
The fourth column shows the effect of the hospice payment update
percentage for FY 2017. The 2.1 percent hospice payment update
percentage for FY 2017 is based on an estimated 2.7 percent inpatient
hospital market basket update, reduced by a 0.3 percentage point
productivity adjustment and by a 0.3 percentage point adjustment
mandated by the Affordable Care Act, and is constant for all providers.
The fifth column shows the effect of all the changes on FY 2017
hospice payments. It is projected that aggregate payments will increase
by 2.1 percent, assuming hospices do not change their service and
billing practices in response.
As illustrated in Table 19, the combined effects of all the
proposals vary by specific types of providers and by location. For
example, due to the changes in this rule, the estimated impacts on FY
2017 payments range from a 1.1 percent increase for hospices providing
care in the rural West North Central region to a 2.8 percent increase
for hospices providing care in the rural Pacific region.
Table 19--Projected Impact to Hospices for FY 2017
----------------------------------------------------------------------------------------------------------------
Proposed
Number of Updated wage hospice FY 2017 total
providers data (%) payment change (%)
update (%)
(1) (2) (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
All Hospices.................................... 4,177 0.0 2.1 2.1
Urban Hospices.................................. 3,179 0.0 2.1 2.1
Rural Hospices.................................. 998 -0.1 2.1 2.0
Urban Hospices--New England..................... 138 0.4 2.1 2.5
Urban Hospices--Middle Atlantic................. 252 0.2 2.1 2.3
Urban Hospices--South Atlantic.................. 422 -0.1 2.1 2.0
Urban Hospices--East North Central.............. 399 -0.1 2.1 2.0
Urban Hospices--East South Central.............. 162 -0.1 2.1 2.0
Urban Hospices--West North Central.............. 220 -0.5 2.1 1.6
Urban Hospices--West South Central.............. 616 -0.2 2.1 1.9
Urban Hospices--Mountain........................ 313 -0.3 2.1 1.8
Urban Hospices--Pacific......................... 618 0.6 2.1 2.7
Urban Hospices--Outlying........................ 39 -0.7 2.1 1.4
Rural Hospices--New England..................... 23 -0.4 2.1 1.7
Rural Hospices--Middle Atlantic................. 42 -0.2 2.1 1.9
Rural Hospices--South Atlantic.................. 136 0.2 2.1 2.3
Rural Hospices--East North Central.............. 141 0.1 2.1 2.2
Rural Hospices--East South Central.............. 129 -0.1 2.1 2.0
Rural Hospices--West North Central.............. 186 -1.0 2.1 1.1
Rural Hospices--West South Central.............. 184 -0.1 2.1 2.0
Rural Hospices--Mountain........................ 107 -0.2 2.1 1.9
Rural Hospices--Pacific......................... 47 0.7 2.1 2.8
Rural Hospices--Outlying........................ 3 -0.2 2.1 1.9
0-3,499 RHC Days (Small)........................ 912 0.0 2.1 2.1
3,500-19,999 RHC Days (Medium).................. 2,004 0.0 2.1 2.1
20,000+ RHC Days (Large)........................ 1,261 0.0 2.1 2.1
Non-Profit Ownership............................ 1,071 0.1 2.1 2.2
For Profit Ownership............................ 2,553 -0.1 2.1 2.0
Govt Ownership.................................. 160 0.5 2.1 2.6
Other Ownership................................. 393 -0.1 2.1 2.0
Freestanding Facility Type...................... 3,184 0.0 2.1 2.1
HHA/Facility-Based Facility Type................ 993 0.2 2.1 2.3
----------------------------------------------------------------------------------------------------------------
Source: FY 2015 hospice claims data from the Standard Analytic Files for CY 2014 (as of June 30, 2015) and CY
2015 (as of March 31, 2016).
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.
5. Alternatives Considered
Since the hospice payment update percentage is determined based on
statutory requirements, we did not consider not updating hospice
payment rates by the payment update percentage. The 2.1 percent hospice
payment update percentage for FY 2017 is based on a 2.7 percent
inpatient hospital market basket update for FY 2017, reduced by a 0.3
percentage point productivity adjustment and by an
[[Page 52194]]
additional 0.3 percentage point. Payment rates since FY 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 years must
be the market basket percentage for that FY. Section 3401(g) of the
Affordable Care Act also mandates that, starting with FY 2013 (and in
subsequent years), 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. In addition, section
3401(g) of the Affordable Care Act 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).
We considered not adopting a hospice wage index standardization
factor. However, as discussed in section III.C.1 of this final rule, we
believe that adopting a hospice wage index standardization factor would
provide a safeguard to the Medicare program, as well as to hospices,
because it will mitigate changes in overall hospice expenditures due to
annual fluctuations in the hospital wage data from year-to-year by
ensuring that hospice wage index updates and revisions are implemented
in a budget neutral manner. We estimate that if the hospice wage index
standardization factor is not finalized, total payments in a given year
would increase or decrease by as much as 0.3 percent or $50 million.
6. Accounting Statement
As required by OMB Circular A-4 (available at https://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in Table 20, we have
prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this final rule. Table
20 provides our best estimate of the possible changes in Medicare
payments under the hospice benefit as a result of the policies in this
final rule. This estimate is based on the data for 4,177 hospices in
our impact analysis file, which was constructed using FY 2015 claims
available as of March 31, 2016. All expenditures are classified as
transfers to hospices.
Table 20--Accounting Statement: Classification of Estimated Transfers,
From FY 2016 to FY 2017
[in $Millions]
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
FY 2017 Hospice Wage Index and Payment Rate Update
------------------------------------------------------------------------
Annualized Monetized Transfers.......... $350 *
From Whom to Whom? Federal Government to Medicare
Hospices.
------------------------------------------------------------------------
* The net increase of $350 million in transfer payments is a result of
the 2.1 percent hospice payment update percentage compared to payments
in FY 2016.
7. Conclusion
We estimate that aggregate payments to hospices in FY 2017 would
increase by $350 million, or 2.1 percent, compared to payments in FY
2016. We estimate that in FY 2017, hospices in urban and rural areas
would experience, on average, a 2.1 percent and a 2.0 percent increase,
respectively, in estimated payments compared to FY 2016. Hospices
providing services in the urban Pacific and rural Pacific regions would
experience the largest estimated increases in payments of 2.7 percent
and 2.8 percent, respectively. Hospices serving patients in rural areas
in the West North Central region would experience the lowest estimated
increase of 1.1 percent in FY 2017 payments.
B. 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.
The effect of the final FY 2017 hospice payment update percentage
results in an overall increase in estimated hospice payments of 2.1
percent, or $350 million. Therefore, the Secretary has determined that
this final 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 final rule only
affects hospices. Therefore, the Secretary has determined that this
final rule will not have a significant impact on the operations of a
substantial number of small rural hospitals.
C. 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 2016, that
threshold is approximately $146 million. This final rule is not
anticipated to have an effect on State, local, or tribal governments,
in the aggregate, or on the private sector of $146 million or more.
VI. Federalism Analysis
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 final rule under these criteria of
Executive Order 13132, and have determined that it will not impose
substantial direct costs on state or local governments.
Dated: July 18, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
Dated: July 25, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2016-18221 Filed 7-29-16; 4:15 pm]
BILLING CODE 4120-01-P