FutureFocus September 5, 2018 Paradigm Shift For Hospice Begins

Lisa Remington

In this week’s FutureFocus, we discuss the paradigm shift for hospice provders. There are a number of key trends impacting the future of hospice providers. Our analysis and insight will help the industry have a better understanding of how this change is taking place, how it shifts the industry and why it is important for all providers to understand the paradigm shift. A reminder: when there are major shifts to one healthcare provider, it means it also can impact your organization.

Lisa Remington, President, Remington Health Strategy Group

By: Lisa Remington, President Remington Health Strategy Group

A number of key trends are impacting the future of hospice providers.

  • Principal diagnoses are changing.
  • Expenditures are expected to increase by 8% annually.
  • Expanded role of physician assistants …. now has a “twist.”
  • A Meaningful Measures Initiative has been established.

How are these key trends impacting the future of Medicare hospice providers? And…..other providers.

New Diagnoses Patterns for Hospice

The number of Medicare beneficiaries receiving hospice services has grown from 513,000 in FY 2000 to nearly 1.5 million in FY 2017. Similarly, Medicare hospice expenditures rose from $2.8 billion in FY 2000 to approximately $17.7 billion in FY 2017.

The CMS Office of the Actuary (OACT) projects that hospice expenditures are expected to continue to increase, by approximately 8 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. While in 2002, lung cancer was the top principal diagnosis, neurologically based diagnoses have topped the list for the past 5 years. (Table 1)

Table 1—The Top Ten Principal Hospice Diagnoses, FY 2017

Hospice Diagnoses FY 2017


















Hospice Diagnoses Patterns Create Expanded Referrals Sources

It is important for hospice organizations to have a clear strategy when it comes to how their organizations align and impact quality, cost and patient-centered care.

Organizations should re-examine their current list of referrals. For example, is your organization partnering with pulmonologists for COPD patients? What about home health agencies caring for COPD patients? Did you know that one of the ambulatory quality measures for ACOs is COPD?

ACO #9—Prevention Quality Indicator (PQI): Ambulatory Care Sensitive Conditions: Admissions for Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults

Hospital admissions for COPD or asthma are a Prevention Quality Indicator of interest to comprehensive health care delivery systems including ACOs. COPD or Asthma can often be controlled in an outpatient setting. Evidence suggests that these hospital admissions could have been avoided through high quality outpatient care, or the condition would have been less severe if treated early and appropriately. Proper outpatient treatment and adherence to care may reduce the rate of occurrence for this event, and thus of hospital admissions.

Aligning Clinical Services Lines to Primary Diagnoses Patterns

To help stakeholders understand the value of your partnership, it may be time to re-package your programs. For example, a heart failure program, or a COPD program. This can also help specialists know they have a partner that have specific solutions to a particular disease.

Hospice Meaningful Measures Initiatives: What you Really Need to Know

In the final rule of Medicare Program; FY 2019 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements were a list of the meaningful measures initiatives.

The Meaningful Measures Initiative is aimed at identifying the highest priority areas for quality measurement and quality improvement in order to assess the core quality of care issues that are most vital to advancing our work to improve patient outcomes.

The initiative represents a new approach to quality measures that fosters operational efficiencies, and it will reduce costs, including collection and reporting burden, while producing quality measurement that is more focused on meaningful outcomes.

The Meaningful Measures Framework has the following objectives:

  • Address high-impact measure areas that safeguard public health;
  • Patient-centered and meaningful to patients;
  • Outcome-based where possible;
  • Fulfill each program’s statutory requirements;
  • Minimize the level of burden for health care providers (for example, through a preference for EHR-based measures where possible, such as electronic clinical quality measures;
  • Significant opportunity for improvement;
  • Address measure needs for population-based payment through alternative payment models; and
  • Align across programs and/or with other payers.

In order to achieve these objectives, 19 Meaningful Measures areas are mapped to six overarching quality priorities as shown in the Table 2 below.

TABLE 2—Quality Priority & Meaningful Measures

1. Making Care Safer by Reducing Harm Caused in the Delivery of Care

  • Healthcare-Associated Infections.
  • Preventable Healthcare Harm.

2. Strengthen Person and Family Engagement as Partners in Their Care

  • Care is Personalized and Aligned with Patient’s Goals.
  • End of Life Care according to Preferences.
  • Patient’s Experience of Care.
  • Patient Reported Functional Outcomes.

3. Promote Effective Communication and Coordination of Care

  • Medication Management.
  • Admissions and Readmissions to Hospitals.
  • Transfer of Health Information and Interoperability.

4. Promote Effective Prevention and Treatment of Chronic Disease

  • Preventive Care.
  • Management of Chronic Conditions.
  • Prevention, Treatment, and Management of Mental Health.
  • Prevention and Treatment of Opioid and Substance Use Disorders.
  • Risk Adjusted Mortality.

5. Work with Communities to Promote Best Practices of Healthy Living

  • Equity of Care.
  • Community Engagement.

6. Make Care Affordable

  • Appropriate Use of Healthcare.
  • Patient-focused Episode of Care.
  • Risk Adjusted Total Cost of Care

By including Meaningful Measures into the programs, it will address the following cross-cutting measure criteria:

  • Eliminating disparities;
  • Tracking measurable outcomes and impact;
  • Safeguarding public health;
  • Achieving cost savings;
  • Improving access for rural communities; and
  • Reducing burden.

The Meaningful Measures Initiative will improve outcomes for patients, their families, and health care providers while reducing burden and costs for clinicians and providers as well as promoting operational efficiencies.

Make no mistake. These measures have purpose internally for your organization, but also externally to better align with the financial and quality measures of other providers across the healthcare delivery system. For example: Promote Effective Prevention and Treatment of Chronic Disease  and Strengthen Person and Family Engagement as Partners in Their Care are domains found in Medicaid initiatives. We are at the tip of the iceberg aligning provider to provider and provider to payor.

Changes to Physician Assistant Hospice Responsibilities

By: Ronald M. Schwartz, Contributing Writer, The Remington Report

As published in the August 6 Federal Register, under final regulations hospices will see a 1.8 percent ($340 million) increase in their payments for FY 2019. The 1.8 percent hospice payment update percentage for FY 2019 is based on a 2.9 percent inpatient hospital market basket update, reduced by a 0.8 percentage point multifactor productivity adjustment and reduced by a 0.3 percentage point adjustment required by law.

Hospices that fail to meet quality reporting requirements receive a 2.0 percentage point reduction to their payments.

The hospice payment system includes a statutory aggregate cap, which limits the overall payments made to a hospice annually. The cap amount for FY 2019 will be $29,205.44 (2018 cap amount of $28,689.04 increased by 1.8 percent).

The Centers for Medicare & Medicaid Services (CMS) rule also makes conforming regulations text changes to recognize physician assistants as designated hospice attending physicians effective January 1, 2019. Finally, the rule includes changes to the Hospice Quality Reporting Program. Except for the changes regarding physician assistants, these regulations are effective on October 1, 2018.

“NHPCO supports the statutory change allowing physician assistants to serve as hospice attending physicians and to allow for the billing of reasonable and necessary services provided by PAs to Medicare beneficiaries,” said Edo Banach, president and CEO of National Hospice and Palliative Care Organization. “We also look forward to working with CMS on quality measures that reinforce the value and quality of patient care.”

Limits Placed on New Responsibilities of Physician Assistants

Section 51006 of the Bipartisan Budget Act of 2018 (BBA) amended Medicare law such that, effective January 1, 2019, physician assistants are recognized as attending physicians for Medicare hospice beneficiaries. This statutory change expands the definition of a hospice attending physician to include physician assistants in addition to physicians and nurse practitioners.

This section would permit physician assistants to serve as the attending physician, which allows them to manage and separately bill for hospice care. Finally, this section would clarify that, as with nurse practitioners, physician assistants cannot certify or recertify hospice care for individuals.

“The BBA of 2018 did not make changes to allow PAs to certify terminal illness or perform the face-to-face encounter for Medicare beneficiaries,” the rule states.

Also, CMS notes, the states’ scope of practice governance may not permit a PA to serve as a hospice beneficiary’s attending physician. As stated in the final rule, “hospice providers are responsible for reviewing the state hospice licensure requirements and scope of practice regulations for PAs to ensure that PAs are allowed to serve as a hospice patient’s attending physician in accordance with state law and make staffing decisions accordingly.”