Readers who want more information about the development of the survey, originally called the Hospice Experience of Care Survey, may refer to 79 FR 50452 and 78 FR 48261. Thus, we will publicly report claims data for care delivered in Q4 2019 and Q3 2020 onward, but we will not publicly report claims data for care delivered Q1 and Q2 of 2020. It will assess patients in real-time, based on interactions with the patient. American Journal of Hospice & Palliative Care, 30(6): 601-616. doi: 10.1177/1049909112468222. Therefore, in response to public comment, we are revising our methodology for calculating overhead benefits attributable to each level of care. The HCI is a single measure comprising ten indicators calculated from Medicare claims data. We are interested in exploring patient preferences for symptom management, addressing patient spiritual and psychosocial needs, and medication management in outcomes of care in development of quality measures. In the March 27, 2020 CMS Guidance Memo, we granted an exception to the HH QRP reporting requirements under the HH QRP exceptions and extension requirements for Quarter 4 (Q4) 2019 (October 1, 2019 through December 31, 2019), Q1 2020 (January 1, 2020 through March 30, 2020), and Q2 2020 (April 1, 2020 through June 30, 2020). Some comments expressed concern about the public's ability to be aware of and find the seven HIS measure scores in the Provider Data Catalogue. We will continue to take all concerns, comments, and suggestions into consideration for future development and expansion of our health equity quality measurement efforts. 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). The FY 2020 Hospice Wage Index and Payment Rate Update final rule (84 FR 38484) finalized the proposal to migrate to a new internet Quality Improvement and Evaluation System (iQIES) that will enable us to make real-time upgrades. County Name CBSA Urban/Rural . Using the same FY 2020 data, we apply the FY 2022 wage index and the current labor share values to simulate FY 2022 payments. We also revised and refined how the HCI will be publicly displayed on Care Compare in response to family caregiver input. Under the final rule, the hospices would see a 2.0 percent increase ($480 million) in their payments for FY 2022 relative to FY 2021. All Rights Reserved (or such other date of publication of CPT). Thus, 42 CFR 418.306(b)(2) has been revised to follow the CAA of 2021 updates for the survey agencies. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. The commenter stated that these labor market challenges will have an impact on the labor shares, which will not necessarily be reflected when the cost report data used is 2 years old. We previously finalized the participation requirements for the CAHPS Hospice Survey, (84 FR 38484). We reiterated that the signature on the addendum is only acknowledgement of receipt and not a tacit indication of agreement with its contents, and that we expect the hospice to inform the beneficiary of the purpose of the addendum and rationale for the signature. Information defining the last three days has been included in the HIS Manuals since 2017. Several commenters suggested that CMS adjust the thresholds for specific services, such as gaps in skilled nursing visits, and phase in the thresholds over time. We outline our proposed trimming methodology using CHC as an example. A summary of these comments and our responses to those comments appear below: Comment: One commenter expressed concern that hospices in Montgomery County, Maryland are at a long-term competitive disadvantage due to what they refer to as a Medicare hospice Federal payment inequity involving CBSAs specifically when Metropolitan Divisions are present. Additionally, in the event that a beneficiary (or representative) does not request the addendum, we expect hospices to document, in some fashion, that an addendum has been discussed with the patient (or representative) at the time of election, similar to how other patient and family discussions are documented in the hospice's clinical record. MedPAC. Background and Description of the CAHPS Hospice Survey, b. Overview of the CAHPS Hospice Survey Measures, d. Public Reporting of CAHPS Hospice Survey Results, e. Volume-Based Exemption for CAHPS Hospice Survey Data Collection and Reporting Requirements, f. Newness Exemption for CAHPS Hospice Survey Data Collection and Public Reporting Requirements, h. Proposal to Add CAHPS Hospice Survey Star Ratings to Public Reporting, 9. We then trim the data for each level of care separately to remove outliers. (2013). A summary of these comment and our responses to those comment appear below: Comment: Several commenters requested 6-month minimum notice prior to the transition of hospice to the iQIES system. Response: We appreciate commenters' interest in having the HCI reflect how prepared hospices are to provide key services to patients. For both claims and OASIS-based measures, the quarters used in our analysis were the most recently available data that exclude the same quarters (Q1 and Q2) as that are relevant from the COVID-19 PHE exception, and thus take seasonality into consideration. We believe these cost centers (Physician Administrative Services and Nursing Administration) are labor-intensive and vary with the local labor market and, thus, we believe contract labor costs for these services should be included in the labor shares for each level of care. CMS is working to make the HQRP and CMSs other quality reporting programs more transparent to consumers and providers, enabling them to make better choices as well as promoting provider accountability around health equity. Simulation means a training and assessment technique that mimics the reality of the homecare environment, including environmental distractions and constraints that evoke or replicate substantial aspects of the real world in a fully interactive fashion, in order to teach and assess proficiency in performing skills, and to promote decision making and critical thinking. Response: We do not believe that making these clarifications retroactive or delaying the effective date is necessary. National implementation of the CAHPS Hospice Survey commenced January 1, 2015, as stated in the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79 FR 50452). Response: We recognize that claims data do not include all the disciplines involved in the delivery of hospice care, such as the frequency and length of chaplain visits. This contract is currently held by the National Quality Forum (NQF). In response to this solicitation, CMS received public comments highlighting the potential limitations of a single concept claims-based measure. Now that we reached that milestone, we need to recognize that there is a need to focus on assessing the 7 HIS measures to each patient at admission, which is what the HIS Comprehensive Assessment Measure addresses. 47. The hospice benefit is a comprehensive package of services offering palliative care support to terminally ill Minnesota Health Care Programs (MHCP) members and their families. The CAHPS Hospice Survey measures was re-endorsed by NQF on November 20, 2020. In Paperwork Reduction Act package (PRA), CMS-10390 (OMB control number: 0938-1153), we provided the HVLDL specifications and also proposed to replace the HVWDII measure pair with the HVLDL. HOPE will include key items from the HIS and demographics like gender and race. This two-stage approach allows for calculation of stable cut-points that reflect the full range of hospice performance. Additionally, as the plan of care should identify the conditions or symptoms that the hospice determines to be unrelated, this information should be readily accessible to the hospice in order to allow for the timely completion of the addendum. Beginning with fiscal year 2024 and subsequent fiscal years, the reduction increases to 4 percentage points. The HIS Comprehensive Assessment Measure's all or none criterion requires hospices to perform all seven care processes in order to receive credit. documents in the last year, 19 In addition, we finalized a policy to use the current year's pre-floor, pre-reclassified hospital inpatient wage index as the wage adjustment to the labor portion of the hospice rates. NQF 3235 does not require NQF's endorsements of the previous components to remain valid. If we were to provide preview data a year in advance, the publicly reported data would be too old to be a meaningful reflection of the hospice's performance. HQRP Compliance requires understanding three timeframes for both HIS and CAHPS. We count discharges as any claim with a discharge status code other than 30 (which is defined as Still Patient). As displayed in Table 14, the number of providers who met the public reporting threshold for the HIS Comprehensive Assessment Measure decreases by 236 (or by 5.2 percentage points) when reporting three versus four quarters of data. We discuss the impact to the OASIS and claims here, and discuss to the HH CAHPS further in section III.G. While the commenter commended CMS for using hospice-specific data, they were also concerned about the accuracy of the data submitted by providers. [3] We proposed that hospice star ratings for each measure be assigned based on where the hospice-level measure score falls within these cut-points. Azar, A. M. (2020 March 15). In the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR 47142), CMS finalized two different payment rates for RHC: A higher per diem base payment rate for the first 60 days of hospice care and a reduced per diem base payment rate for subsequent days of hospice care. They note that other star ratings use a 0-100 linear-scaled score. GIP is provided to ensure that any new or worsening symptoms are intensively addressed so that the beneficiary can return to his or her home and continue to receive routine home care. For example, for the Home Health QRP, we finalized the Potentially Preventable 30-Day Post-Discharge Readmission Measure in the CY 2017 Home Health QRP Rule (81 FR 76770 through 76775) for reporting with three consecutive years of claims data beginning with the CY 2018 Home Health QRP. Final Decision: In summary, in response to public comments, we are adopting the revised hospice labor shares calculated as we proposed with a slight modification to the methodology to derive the overhead benefit calculations as described previously. Response: Our analyses of existing CAHPS Hospice Survey data demonstrate that hospices with high scores would overwhelmingly receive 4 and 5 stars. Also included in the compensation costs for each level of care, as discussed in the FY 2022 Hospice proposed rule (86 FR 19718) and below, is a proportion overhead salaries and benefits. The primary HOPE items used to calculate this measure include Pain Screening, Pain Active Problem, and Patient Desired Tolerance Level for Symptoms or Patient Preferences for Symptom Management. Further, the commenters stated that these changes should be instituted to ensure greater accuracy of the data being used to establish labor shares for GIP and IRC. The COVID-19 PHE Exception applied to Q1 and Q2 of 2020. This information was also posted in the document Common Questions HQRP Claims-Based Measures_Feb.2021 located in the Downloads section of the Hospice Item Set web page at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Item-Set-HIS. We plan to provide opportunities for interaction with stakeholders to discuss our plans and methodology and to receive feedback prior to the start of star ratings display. CMS is working to further the mission to improve the quality of healthcare for hospice beneficiaries through measurement, transparency and public reporting of data. Although this a smaller sample of providers than used for the other proposed labor shares for RHC (2,919 providers) and CHC (1,240 providers), we believe this is a technical improvement to the current labor shares that were primarily based on skilled nursing facility costs from the early 1980s. Direct patient care is furnished by a registered nurse (RN) or social worker (SW) that day. CAHPS Hospice Survey Participation Requirements for the FY 2023 APU and Subsequent Years, a. Section 1861(dd)(1) of the Act establishes the services that are to be rendered by a Medicare-certified hospice program. Section III.A of this final rule includes a summary of comments from the public, including hospice providers as well as patients and advocates, regarding the presented analysis in the FY 2022 hospice proposed rule on hospice utilization, spending patterns and non-hospice spending during a hospice election. Specifically, we compared submission rates in Q4 2019 to average rates in other quarters to assess the extent to which HHAs had taken advantage of the exception, and thus the extent to which data and measure scores might be affected. We appreciate the comments provided regarding the analysis presented in the proposed rule. While comments were overwhelmingly supportive, we did not receive any comments that would support burden changes. documents in the last year, by the National Oceanic and Atmospheric Administration Some commenters suggested that the measure should allow for two visits occurring on the same day to meet the measure qualifications, as visits on the same day could address different patient needs, representing meaningful care on the part of the hospice. The hospice CoPs at 418.52(a)(1) require that in advance of receiving care, patients are informed about their rights, and hospices must provide the patient (or representative) with verbal and written notice of the patient's rights and responsibilities in a language and manner the patient understands. Similarly, this same right should be afforded hospices under the Star Rating system through a clear portrayal Star Rating of performance to consumers and the public that reflects how most respondents scored the hospice, not how the hospice fares compared to all other hospices. One commenter also suggested that star ratings calculations be made available to hospices before they are publicly reported. Several commenters opposed removing the seven HIS process measures, at least prior to implementation of HOPE. CMS releases new federal hospice rates for federal fiscal year 2022 The Centers for Medicare & Medicaid Services (CMS) released new federal hospice rates for federal fiscal year 2022 . As stated in the FY 2019 Hospice Wage Index and Rate Update final rule (83 FR 38622), we launched the Meaningful Measures initiative (which identifies high priority areas for quality measurement and improvement) to improve outcomes for patients, their families, and providers while also reducing burden on clinicians and providers. Live discharges occur when the patient discharge status code on a hospice claim does not equal a code from the following list: 30, 40, 41, 42, 50, 51. The Reporting Year (HIS)/Data Collection Year (CAHPS). (7) Collection or public reporting of a measure leads to negative unintended consequences other than patient harm. The calculation of the last three days remain unchanged from the last three days documented in Section O of the HIS V2.00 that was used to calculate the HVWDII. MedPAC. They stated that social workers and counselors provide direct patient care along with nurses and hospice aides in both routine home care and general inpatient care. In particular, we will continue to host HQRP Forums to allow hospices and other interested parties to engage with us on the latest updates and ask questions on the development of HOPE and related quality measures. Services furnished voluntarily by physicians are not reimbursable. Like HIS, our goal is to report as much of the most recent CAHPS Hospice Survey data as possible, to display data for as many hospices as possible, and to maintain the reliability of the data. that agencies use to create their documents. Thus, it is important that hospices ensure the completeness and correctness of their claims prior to the claims snapshot.. in recent years noted that the HIS Comprehensive Assessment Measure differentiates the hospice's overall ability to address care processes better than the seven individual HIS process measures. Response: We appreciate the commenter's concern. For each hospice that reviews the rule, the estimated cost is $274.18 (2.4 hour $114.24). They noted the implementation of a new assessment instrument would be burdensome on both providers and EMR vendors. Finally, the NQF Measures Application Partnership (MAP) met on January 11, 2021 and provided input to CMS. Other comments also suggested that data already provided in PEPPER reports should not be included in HCI or that CMS should share the indicators in the PEPPER reports rather than implement the HCI quality measure to provide hospices the opportunity to implement continuous quality improvement activities. We proposed that only the overall Star Rating be publicly reported and that hospices must have a minimum of 75 completed surveys in order to be assigned a Star Rating. Comment: Several commenters requested that CMS communicate widely and display prominently notices and information about the increase in the penalty for failure to comply with HQRP requirements. (5) The availability of a measure that is more proximal in time to desired patient outcomes for the particular topic. Refinements to repricing: For CY 2022, CMS will reprice the CY 2017-2019 historical hospice . National implementation of the CAHPS Hospice Survey commenced January 1, 2015 as stated in the FY 2015 Hospice Wage Index and Payment Rate Update final rule (79 FR 50452). 52. Indicator One: Continuous Home Care (CHC) or General Inpatient (GIP) Provided, (2). Denominator: The total number of elections with the hospice, excluding hospice elections where the patient elected hospice for less than 30 days within a reporting period. There exist some geographic areas where there were no hospitals, and thus, no hospital wage data on which to base the calculation of the hospice wage index. For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services amends 42 CFR chapter IV as set forth below. Some commenters requested that CMS expand billing codes for telehealth visits and recognize telehealth services within the HCI. Finally, we proposed conforming regulations text changes at 418.24(c) in alignment with subregulatory guidance indicating that hospices have 3 days, rather than 72 hours to meet the requirement when a patient requests the addendum during the course of a hospice election. CMS is finalizing the use of the pseudo-patient for hospice aide competency training. Comment: One commenter stated that many of the hospice cost reports filed in 2018 failed to report contracted GIP days and contracted IRC care days on Worksheet S-1. They also requested clarification on the logistics of the reporting processin particular, when specifications would be available. Response: Similar to other CMS CAHPS star ratings, we propose that the cut-points used to determine CAHPS Hospice Survey stars be constructed using statistical clustering procedures that minimize the score differences within a star category and maximize the differences across star categories. We sought public comment on the technical correction to the regulation at 418.312(b) effective October 1, 2021. (8) The costs associated with a measure outweigh the benefit of its continued use in the program. Response: We appreciate the commenter's concern regarding labor hours provided by type of facility. If, in the judgment of the hospice interdisciplinary team, which includes the hospice physician, the patient's symptoms cannot be effectively managed at home, then the patient is eligible for general inpatient care (GIP), a more medically intense level of care. Registered Nurses Did Not Always Visit Medicare Beneficiaries Homes at Least Once Every 14 Days to Assess the Quality of Care and Services Provided by Hospice Aides. An unusually high rate of live discharges could indicate that a hospice provider is not meeting the needs of patients and families or is admitting patients who do not meet the eligibility criteria., Our live discharge indicators included in the HCI, like MedPAC's, comprise discharges for all reasons. We stated that hospices can develop processes (including how to document such requests from non-hospice providers and Medicare contractors) to address circumstances in which the non-hospice provider or Medicare contractor requests the addendum, and the beneficiary or representative does not (86 FR 19725). More information about this is detailed in the section entitled: Proposal for Public Reporting CAHPS-based measures with Fewer than Standard Numbers of Quarters Due to the COVID-19 PHE Exemptions. Its removal would not only leave HQRP without this important admission quality of care measure but also result in HQRP having only two claims-based measures, HCI and HVLDL, and the CAHPS Hospice Survey. This rule rebases the hospice labor shares and clarifies certain aspects of the hospice election statement addendum requirements. On April 6, 2020, we published an interim final rule Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (85 FR 19230). Response: We thank the commenters for their views, but as noted, this provision is required by section 407(b) of the CAA and does not permit any discretion on the part of the Secretary to implement it. We also shared the measure concept publicly and solicited stakeholder feedback, which we considered before finalizing the measure specifications. Because the indicators comprising the HCI differ in data source from the HIS Comprehensive Measure, the HCI and the HIS Comprehensive Measure can together provide a meaningful and efficient way to inform patients and family caregivers while supporting their selection of hospice care providers. We believe that updating the data in January 2022 by more than a year relative to the October 2020 freeze data can assist the public by providing more relevant quality data and allow CMS to display more recent HHA performance. Response: We thank the commenter and will take this into consideration as information for Care Compare is developed. There are four payment categories that are distinguished by the location and intensity of the hospice services provided. Since we limited our sample for IRC and GIP compensation cost weights to those hospices providing inpatient services in their facility, we conducted sensitivity analysis to test for the representative of this sample by reweighting compensation cost weights using data from the universe of freestanding providers that reported either IRC or GIP total costs. Comment: Another specific concern stated by the commenters was that the determination of the labor share for GIP and IRC is based on Worksheet A-3 and A-4; however, any hospices reporting costs on line 25 (contracted services) were not included in the sample used for setting the labor share. We note that based on comments received during the CMS-1984-14; OMB NO. At the same time, we want to report measures scores to the public for as many hospices as possible, including small hospices. Limited, short-term, intermittent, inpatient respite care (IRC) is also available because of the absence or need for relief of the family or other caregivers. have brought to light the potential role hospices could play in medical aid in dying (MAID) where such practices have been legalized in certain states, we wish to remind hospices that The Assisted Suicide Funding Restriction Act of 1997 (Pub. The hospice must note the reason the addendum was not furnished to the patient and the addendum would become part of the patient's medical record if the hospice has completed it at the time of discharge, revocation, or death. A few commenters stated that if data from the hospice cost report is to be used for calculating the labor component by level of care, revisions to the cost report should be proposed to address current inconsistent, but acceptable, reporting practices.
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