Response: We appreciate the commenters' recommendations; however, these comments are outside the scope of the proposed rule. Regions Counties FFY2023 As a claims-based measure, the HVLDL measure would not impose any new requirements for the collection of information. 20-01 consistent with our longstanding policy of adopting OMB delineation updates, we note that specific wage index updates would not be necessary for FY 2022 as a result of adopting these OMB updates. Some commenters requested that LPNs count for the measure, in addition to RNs. As discussed earlier, the HIS V3.00 PRA Submission, CMS-10390 (OMB control number: 0938-1153), finalized the proposal to replace the HVWDII measure pair with a re-specified version called HVLDL, which is a single measure based on Medicare claims. As discussed previously, we are finalizing our proposal to publicly report the HCI and HVLDL using 2 years, which is 8 quarters of Medicare claims data. Therefore, we proposed to exclude providers that reported costs greater than zero on Worksheet A-3, column 7, line 25 (Inpatient CareContracted) for IRC and Worksheet A-4, column 7, line 25 (Inpatient CareContracted) for GIP. Specifications for the HCI Indicators Selected, (1). The following sections provide the results of our testing for OASIS and claims and explain how we used the results to inform a proposal for accommodating excepted data in public reporting. Journal of Hospice & Palliative Nursing: December 2018Volume 20Issue 6p 507. Hospital claims-based measures are also updated annually. Performance or improvement on a measure does not result in better patient outcomes; 3. Response: We recognize the commenters' concerns and agree that it is appropriate for the hospice to document only on the addendum itself the reason that an addendum is un-signed. The 'Hospice Rates' links contain the standardized Medicare payment amount for each hospice level of care. The third column shows the effect of using the FY 2022 updated wage index data. The Future of Hospice and Medicare Advantage Organizations Hospice providers will be increasingly impacted by the growth of Medicare Advantage Organizations and their evolving ability to offer hospice benefits to patients. With just one click, patients can find information that is easy to understand about doctors, hospitals, nursing homes, and other health care services instead of searching through multiple tools. Indicator Four: Late Live Discharges, (5). The Public Inspection page Obtaining the required signatures on the election statement has been a longstanding regulatory requirement (84 FR 38484); however, we did acknowledge in the proposed rule that there may be time constraints and/or circumstances that would prevent a beneficiary from signing and returning the addendum to the hospice by a specified deadline. 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. One commenter also expressed a desire to include permanent telehealth provisions in the QRP, as that would help improve rural healthcare access. MedPAC, in descriptive analyses of hospices exceeding the Medicare annual payment cap, noted that if some hospices have rates of discharging patients alive that are substantially higher than most other hospices it raises concerns that some hospices may be pursuing business models that seek out patients likely to have long stays who may not meet the hospice eligibility criteria. As discussed in the FY 2016 Hospice Wage Index and 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. Data Collection and Reporting During a Public Health Emergency, (1). In addition, this rule finalizes changes to the Hospice Conditions of Participation (CoPs) and Hospice Quality Reporting Program (HQRP). This means that hospice providers must furnish the addendum to the beneficiary or representative on or before the third day after the date of the request. Section 3(f) of Executive Order 12866 defines a significant regulatory action as an action that is likely to result in a rule: (1) Having an annual effect on the economy of $100 million or more in any 1 year, or adversely and materially affecting a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or state, local or tribal governments or communities (also referred to as economically significant); (2) creating a serious inconsistency or otherwise interfering with an action taken or planned by another agency; (3) materially altering the budgetary impacts of entitlement grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raising novel legal or policy issues arising out of legal mandates, the President's priorities, or the principles set forth in the Executive Order. Similar to other CAHPS programs, we proposed that the cut-points used to determine the stars be constructed using statistical clustering procedures that minimize the score differences within a star category and maximize the differences across star categories. We were also interested in feedback regarding whether including facility-level quality measure results stratified by social risk factors and social determinants of health (and relevant proxies, such as dual eligibility for Medicare and Medicaid, and race) in confidential feedback reports could allow facilities to identify gaps in the quality of care they provide. Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. When implementing this provision, the Centers for Medicare & Medicaid Services (CMS) finalized in the FY 2011 Hospice Wage Index final rule (75 FR 70435) that the 180th day recertification and subsequent recertifications would correspond to the beneficiary's third or subsequent benefit periods. Applications are available at the, Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. L. 113-185). Response: We appreciate MedPAC's comments; however, we are required by law to update the hospice cap amount from the preceding year by the hospice payment update percentage, in accordance with section 1814(i)(2)(B)(ii) of the Act. 202-690-6145. Both the use of the pseudo-patient and targeted aide training align requirements between these two providers, home health and hospice, affording the opportunity for efficiency in implementation for many agencies that are Medicare certified to provide both services. The proposed labor shares reflect the skilled care (including the number of visits) provided under the hospice per diem payment rates for each level of care. 48. 7. Comment: We received a comment that we are making many updates in this rule and the resources for them are significant, especially during the COVID-19 Public Health Emergency (PHE). The specifications for Indicator Eight, Skilled Nurse Care Minutes per RHC Day, are as follows: Our regulations at 418.100(c)(2) require that [n]ursing services, physician services, and drugs and biologicals . Sections 1812(d), 1813(a)(4), 1814(a)(7), 1814(i), and 1861(dd) of the Act, and the regulations in 42 CFR part 418, establish eligibility requirements, payment standards and procedures; define covered services; and delineate the conditions a hospice must meet to be approved for participation in the Medicare program. For example, the higher labor share for CHC compared to RHC reflects the higher number of visits per day provided with CHC relative to RHC. To support new measure development, our contractor convened TEP meetings in 2020 to provide feedback on several measure concepts. We will consider other star ratings as applicable. Methodology for Calculating Compensation Costs, a. In contrast, HOPE is a patient assessment instrument, designed to capture patient and family care needs in real-time during patient interactions throughout the patient's hospice stay, with the flexibility to accommodate patients with varying clinical needs. For IRC, we proposed to multiply this ratio by total other patient care costs for IRC (Worksheet A-3, column 7, lines 38 through 46). In this way, it provides consumers viewing data on Care Compare with a streamlined way to assess the extent to which a hospice follows care processes. 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 each scenario, we calculated the reportability as the percent of hospices meeting the 20-case minimum for public reporting (the public reporting threshold). If regulations impose administrative costs on private entities, such as the time needed to read and interpret this rule, we should estimate the cost associated with regulatory review. On March 13, 2020, the President declared a national state of emergency under the Stafford Act, effective March 1, 2020, allowing the Secretary to invoke section 1135(b) of the Act (42 U.S.C. We would use those data to calculate and publicly report the claims-based measures for the CY2022 reporting period. We acknowledge that this assumption may understate or overstate the costs of reviewing this rule. Using fewer quarters of more up-to-date data requires that: (1) A sufficient percentage of HHAs would still likely have enough OASIS data to report quality measures (reportability); and (2) using fewer quarters of data to calculate measures would likely produce similar measure scores for HHAs, and thus not unfairly represent the quality of care HHAs provided during the period reported in a given refresh (reliability). This policy will apply beginning with FY 2024 annual payment update (APU). The publicly-reported version of HCI on Care Compare will only include the final HCI score, and not the component indicators. 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. We sought public comment on the technical correction to the regulation at 418.312(b) effective October 1, 2021. (vi) The availability of a measure that is more strongly associated with desired patient outcomes for the particular topic. Instead, they included all these days on line 23 and 33 of Worksheet S-1 but failed to report contracted days on line 40 and 41 of Worksheet S-1. Accessed June 13, 2021. Comment: Another specific concern raised by commenters was that the cost reports should be amended to allow for a greater breakdown of costs for contracted vs. hospice-administered inpatient services. In that same final rule, we discussed that we will issue public notice, through rulemaking, of measures under consideration for removal, suspension, or replacement. We also conducted a stability analysis by comparing index scores calculated for the same hospice using claims from Federal FY 2017 and 2019. This could include collecting information on race, ethnicity, and certain SDOH, including preferred language, interpreter services, health literacy, transportation and social isolation. As such, HCI scores are consistent with CAHPS Hospice caregiver ratings, supporting the index as a valid measurement of hospice care. We believe that by measuring whether hospices actually provided CHC and GIP, the HCI will recognize the extent to which hospices both kept patients at home and recognized the need for inpatient care when necessary. We want hospices to be successful with meeting the HQRP requirements. This indicator helps the HCI to capture patients' receipt of skilled nursing visits and direct patient care, which is an important aspect of hospice care. regulatory information on FederalRegister.gov with the objective of Testing also yielded correlation coefficients above 0.9, indicating a high degree of agreement between hospices' HIS Comprehensive Assessment Measure scores when using 3 or 4 quarters of data. We found that hospices currently underutilize HQRP measures to inform their quality improvement, mainly because of gaps in relevant quality information within the HQRP measure set. Many commenters emphasized the need to engage providers to share information and for CMS to seek feedback when developing quality measures. The utilization and application of these waivers pushed us to consider whether permanent changes would be beneficial to patients, providers, and professionals. Omnibus Budget Reconciliation Act of 1989, 8. 24. Proposal To Modify HH QRP Public Reporting To Address CMS' Guidance To Except Data During the COVID-19 PHE Beginning January 2022 Through July 2024, 4. We will resume public reporting by displaying 3 quarters of post-exemption data, plus five quarters of pre-exemption data. Comment: We received several comments with a request for CMS to consider quarterly as opposed to annual reporting of claims-based measures to best support continuous quality improvement activities. Therefore, we have identified a need for a new quality measure to address this gap and reflect care delivery processes during the hospice stay using available data without increasing data collection burden. Centers for Medicare & Medicaid Services. We encourage hospices to use this website at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Reporting-Training-Training-and-Education-Library. This means that we will no longer report HVWDII with patient stays and will start publicly reporting HVLDL no earlier than May 2022. To comply with CMS' quality reporting requirements for CAHPS, hospices are required to collect data monthly using the CAHPS Hospice Survey. In the FY 2021 Hospice Wage Index and Payment Rate Update final rule, we stated that most often we would expect the addendum would be in a hard copy format the beneficiary or representative can keep for his or her own records, similar to how hospices are required by the hospice CoPs at 418.52(a)(1) to provide the individual a copy of the notice of patient rights and responsibilities (85 FR 47091). (v) The availability of a measure that is more proximal in time to desired patient outcomes for the particular topic. Part 418, subpart G, provides for a per diem payment based on one of four prospectively-determined rate categories of hospice care (routine home care (RHC), CHC, IRC, and GIP), based on each day a qualified Medicare beneficiary is under hospice care (once the individual has elected). Therefore, we proposed to clarify in regulation that the date furnished must be within the required timeframe (that is, 3 or 5 days of the beneficiary or representative request, depending on when such request was made), rather than the signature date. Section 1871(b)(2)(C) of the Act and 5 U.S.C. Index Earned Point Criterion: Hospices earn a point towards the HCI if their individual hospice score for Type 2 burdensome transitions falls below the 90th percentile ranking among hospices nationally. Only official editions of the 42 U.S.C. The guidelines were developed by the National Consensus Project for Quality Palliative Care, comprising 16 national organizations with extensive expertise in and experience with palliative care and hospice, and were published by the National Coalition for Hospice and Palliative Care. An analysis of the 8 quarters of data from Q1 2018 through Q4 2019 (publicly reported in November 2020) shows there were 5,041 active hospices. o2+XXH3H3'@ cM We will work with colleagues to provide information on Care Compare that alerts users the composition of the data. Since FY 2014, hospices that fail to report quality data have their market basket percentage increase reduced by 2 percentage points. On August 31, 2020, we added correcting language to the FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements; Correcting Amendment (85 FR 53679) hereafter referred to as the FY 2021 HQRP Correcting Amendment. As discussed in the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR 47183), we implemented changes mandated by the IMPACT Act of 2014 (Pub. Other commenters requested that this measure recognize visits offered during CHC or GIP care. For these analyses, we exclude claims from hospices with 19 or fewer discharges[14] 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. This document has been published in the Federal Register. For each hospice, we sum together all skilled nursing minutes provided on RHC days that occur on a Saturday or Sunday and divide by the sum of all skilled nursing minutes provided on all RHC days. Response: We appreciate commenters' concerns that hospice providers continue to recognize and address the unique circumstances of hospice patients. Section III.E makes permanent selected regulatory blanket waivers that were issued to Medicare-participating hospice agencies during the COVID-19 PHE. Our testing results indicate we can achieve these positive impacts while maintaining high standards for reportability and reliability. The 7 HIS measures credited hospices when any of these measures were performed regardless of the individual patient. Analysis for each year was based on the FY calendar. Variability analyses confirmed that HCI demonstrates sufficient ability to differentiate hospices. They suggested that the display of star ratings be delayed because CMS needs to provide additional opportunities for providers to learn about and comment on the details of the methodology. Response: We appreciate the commenter's concern and the request for additional research in this area. February 26, 2020. https://www.medscape.com/viewarticle/925769#vp_1. They stated that some hospices use Worksheets A-1, A-2, A-3, and A-4 to report all or most of these costs whereas others use lines 10 and lines 14 and report costs as overhead costs. In order to finalize this proposal in time to release the required preview report related to the refresh, which we release 3 months prior to any given refresh (October 2021), we need the rule containing this proposal to finalize by October 2021. It is necessary for the hospice to document that the addendum was discussed and whether or not it was requested, in order to prevent potential claims denials related to any absence of an addendum (or addendum updates) in the medical record. Our information gathering activities included soliciting feedback from hospice stakeholders such as providers and family caregivers; seeking input from hospice and quality experts through a Technical Expert Panel (TEP); interviews with hospice quality experts; considering public comments received in response to previous solicitations on claims-based hospice quality initiatives; and a review of quality measurement recommendations offered by the HHS Office of Inspector General (OIG), MedPAC, and the peer-reviewed literature. Additionally, the distribution of HCI scores aligns with caregivers' perceptions of hospice quality. This indicates that scores estimated using 3 quarters of data continue to capture provider-level differences and that admission-level scores remain consistent within hospices. 1. 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)). Comment: A few commenters stated that providers should be protected against substantial payment reductions due to dramatic reductions in wage index values from one year to the next. These covered services include: Nursing care; physical therapy; occupational therapy; speech-language pathology therapy; medical social services; home health aide services (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. We proposed to use the CAR scenario for the last of the refreshes affecting OASIS-based measures, which will occur in January 2022. We are revising the regulations text at 418.306(b)(2) under a good cause waiver of proposed rulemaking as this change was noted in the proposed rule and is a statutory requirement of the CAA of 2021. It will be published in the Federal Register on August 4, 2021. Response: We are currently conducting an experiment to test a new version of the survey, including the web mode of administration which may have an impact on response rates and the number of survey completes. We measure whether a live discharge occurs during the first 7 days of hospice by looking at a patient's lifetime length of stay in Start Printed Page 42560hospice. Closing the Health Equity Gap in the Hospice Quality Reporting Program Request for Information (RFI). However, in its comment, MedPAC concluded that the aggregate level of payments could be reduced and would still be sufficient to cover hospice providers' costs and preserve beneficiaries' access to care. Therefore, MedPAC recommended a zero percent update for FY 2022 for all hospice providers. As illustrated in Table 25, the combined effects of all the proposals vary by specific types of providers and by location. However, we will consider this comment when requesting any future revisions to the Level 1 edits applied to the hospice cost report. We intend to submit additional claims-based measures for future consideration and solicit public comment. See Payment procedures for hospice care, Title 42, Chapter IV, Subchapter B, Part 418, 418.302. https://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5#se42.3.418_1302. 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. Thus, inpatient services on line 25 are not captured. Family caregiver perspectives on symptoms and treatments for patients dying from complications of cystic fibrosis. Direct patient care is furnished by a registered nurse (RN) or social worker (SW) that day. Given the timing of the COVID-19 PHE onset, we determined that we would use any data that was submitted for Q4 2019. Thus, the reportability of the actual data used is likely to be better than this simulation. Additionally, the rule finalizes the addition of the claims-based Hospice Visits in the Last Days of Life (HVLDL) measure for public reporting, which supports patient empowerment and transparency of hospice performance. Response: The star rating approach proposed for CAHPS Hospice Survey measures is similar to what has been used for Medicare Advantage and Part D plan measures and Hospital CAHPS measures successfully for many years. The AMA does not directly or indirectly practice medicine or dispense medical services. Public Health Emergency. Any potential health equity data collection or measure reporting within a CMS program that might result from public comments received in response to this solicitation would be addressed through a separate notice-and-comment rulemaking in the future. 37. Testing also yielded correlation coefficients above 0.85, indicating a high degree of agreement between HH measure scores when using the CAR scenario or the SPR scenario. However, we will remain open to reconsidering the frequency of reporting claims across all PAC settings in the future, should data after implementation indicate that such change is warranted. The FY 2022 hospice payment impacts appear in Table 25. We ordinarily publish a notice of proposed rulemaking in the Federal Register and invite public comment on the proposed rule before the provisions of the rule are finalized, either as proposed or as amended in response to public comments, and take effect, in accordance with the Administrative Procedure Act (APA) (Pub. A summary of the comments we received regarding HCI and our responses to those comments appear below: Comment: Several commenters expressed the importance of HCI for beneficiary and families that will give them information about care processes and add value to the available information about hospices that identifies aberrant practice when comparing hospices. within a FY. Identification of the beneficiary's terminal illness and related conditions; 5. The size exemption is only valid for the year on the size exemption request form. This will allow us to maximize the number of hospices that will have CAHPS scores displayed on Care Compare, protect the reliability of the data, and report as much of the most recent data as possible.
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