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On April 27, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1675-P) that would update fiscal year (FY) 2018 Medicare payment rates and the wage index for hospices serving Medicare beneficiaries and releases Request for Information within the proposed rule.

Summary

This proposed rule would update the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2018. This rule also solicits comments regarding the source(s) of clinical information for certifying terminal illness and proposes changes to the Hospice Quality Reporting Program (Hospice QRP), including proposing new quality measures utilizing data collected in the Hospice CAHPS Survey.  The proposed rule also discusses new quality measure concepts under consideration for future years, solicits feedback on an enhanced data collection instrument, and describes plans to publicly display quality measure data via the Hospice Compare website in 2017.   

Background

This rule proposes updates to the hospice payment rates for fiscal year (FY) 2018, as required under section 1814(i) of the Social Security Act (the Act).  This proposed rule also specifies public reporting measures derived from the CAHPS® Hospice Survey, and provides an update on the Hospice QRP consistent with the requirements of section 1814(i)(5) of the Act, as added by section 3004(c) of the Affordable Care Act.  In accordance with section 1814(i)(5)(A) of the Act, starting in FY 2014, hospices that fail to meet quality reporting requirements receive a 2.0 percentage point reduction to their payments. 

Request for Information

In addition to the proposed rule, CMS is releasing a Request for Information to welcome feedback on positive solutions to better achieve transparency, flexibility, program simplification and innovation. This will inform the discussion on future regulatory action related to hospices.

CMS would like to start a national conversation about improving the health care delivery system, how Medicare can contribute to making the delivery system less bureaucratic and complex, and how we can reduce burden for clinicians, providers and patients in a way that increases quality of care and decreases costs –thereby making the health care system more effective, simple, and accessible while maintaining program integrity and preventing fraud. 

CMS is soliciting ideas for regulatory, sub-regulatory, policy, practice and procedural changes to better accomplish these goals. Ideas could include recommendations regarding payment system re-design; elimination or streamlining of reporting; monitoring and documentation requirements; operational flexibility; and feedback mechanisms and data sharing that would enhance patient care, support the doctor-patient relationship in care delivery, and facilitate patient-centered care within hospices. Ideas could also include recommendations regarding when and how CMS issues regulations and policies and how CMS can simplify rules and policies for beneficiaries, clinicians, providers and suppliers.

In responding to the RFI, CMS should be provided with clear and concise proposals that include data and specific examples. If the proposals involve novel legal questions, analysis regarding CMS’ authority is welcome. CMS will not respond to RFI comment submissions in the final rule, but rather will actively consider all input in developing future regulatory proposals or future sub-regulatory guidance. 

Proposed Rule Details

Routine Annual Rate Setting Changes 

Section 411(d) of the Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10) (MACRA) amends section 1814(i) of the Social Security Act to set the market basket percentage increase at 1 percent for hospices in FY 2018. As such, hospices would generally see a 1.0 percent ($180 million) increase in their payments for FY 2018.

The hospice payment system includes a statutory aggregate cap. The aggregate cap limits the overall payments made to a hospice annually. As mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (Pub. L. 113-185) (IMPACT Act), the cap amount for accounting years that end after September 30, 2016 and before October 1, 2025 must be updated by the hospice payment update percentage, rather than the Consumer Price Index (CPI). Therefore, the cap amount for FY 2018 will be $28,689.04 (2017 cap amount of $28,404.99 increased by 1 percent).

Discussion and Solicitation of Comments Regarding Sources of Clinical Information for Certifying Terminal Illness

This rule also solicits comments on a clarifying regulations text change that identifies the source of the required clinical information used to certify a life expectancy of six months or less as the referring physician’s and/or the acute/post-acute care facility’s medical record. Our longstanding expectation is that the referring physician/acute/post-acute care facility’s clinical documentation serves as the basis of the certification of terminal illness. Additionally, we are soliciting comments regarding the use of clinical documentation from an in-person visit from the hospice medical director or the hospice physician member of the interdisciplinary group to support the certification of terminal illness and whether such documentation is needed to augment the clinical information from the referring physician/facility’s medical records.

Hospice CAHPS® Experience of Care Survey

The Hospice CAHPS® Survey is a component of the Hospice Quality Reporting Program. This proposed rule outlines requirements for the Hospice CAHPS Survey for the FY 2020, FY 2021, and FY 2022 annual payment updates.  In addition, the rule proposes to adopt two global CAHPS Hospice Survey measures and six composite CAHPS Hospice Survey-based measures, which would be based on data submitted on the survey. The rule also proposes how these measures would be calculated based on the survey data. More information about the survey can be obtained at the survey website, www.hospicecahpssurvey.org.

Hospice CAHPS® is important for the hospice community because the results of the survey will allow comparisons among hospices nationally. Once it is publicly reported, CMS believes the data will help beneficiaries and their families to select a hospice program.  CMS also believes public reporting of survey results will encourage hospices to improve quality.

Quality Measure Concepts Under Consideration for Future Years

Although CMS is not proposing any new measures based on the Hospice Item Set in this proposed rule, we discuss and solicit public feedback on two measure concepts under consideration for future years. Those measure concepts are: 1) potentially avoidable hospice care transitions, and 2) access to levels of hospice care. Both measure concepts would be claims-based measures; these two measure concepts are under development, and details regarding measure definitions, specifications, and timeline for implementation will be communicated in future rulemaking.

New Data Collection Mechanisms Under Consideration: Hospice Evaluation & Assessment Reporting Tool (HEART)  

CMS is considering enhancing the current Hospice Item Set data collection instrument to be more in line with other post-acute care settings.  This revised data collection instrument, HEART, would be a patient assessment tool, rather than the current chart abstraction tool.  By integrating a core standard data set into an assessment tool, hospices could use such a data set as the foundation for valid and reliable information for patient assessment, care planning, and service delivery.  This would enable greater accuracy in quality reporting; decrease provider burden; help surveyors ensure hospices are meeting Conditions of Participation and providing high quality patient care; and, in the future, inform payment refinement efforts.

Public Reporting 

CMS expects to begin public reporting via a Hospice Compare Site in CY 2017 to help customers make informed choices.  In this proposed rule, CMS discusses details of public reporting including measures eligible for public reporting and opportunities for providers to preview their quality measure data prior to public reporting. CMS proposes that public display of the Hospice CAHPS Survey data would begin during CY 2018.

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