Summary: Due Date: June 29, 2015

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NHPCO Talking Points FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements Proposed Rule Published in the Federal Register on May 5, 2015 Summary: On April 30,

1 NHPCO Talking Points FY 2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements Proposed Rule Published in the Federal Register on May 5, 2015 Summary: On April 30, 2015, CMS posted the FY2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements proposed rule to the public inspection page of the Federal Register. (CMS-1629-P) Since that time, NHPCO s Regulatory Committee and Relatedness Workgroup have analyzed the proposals, other NHPCO committees have reviewed and discussed the proposed rule and NHPCO has held two well-attended listening sessions with providers to discuss the proposed rule and hear concerns and questions from providers. The talking points below are NHPCO s response to the proposed rule and will inform the process for development of the NHPCO comment letter, due to CMS no later than June 29, Overall, NHPCO applauds CMS for moving toward the proposed two-tiered payment system, along with the proposed service intensity add-on. However, significant infrastructure and procedural implementation challenges remain unresolved. Therefore, NHPCO strongly recommends a comprehensive and time-limited test or dry run of the new payment system, both within the Medicare and Medicaid systems, before it is applied to the hospice community. NHPCO encourages members to submit their own comments on the proposed rule expressing their views and questions regarding the proposed rule, using the submission guidelines below. Due Date: June 29, 2015 Address To: Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1629-P P.O. Box 8010 Baltimore, MD King Street, Suite 100 Alexandria, VA

2 Submit: 1. Electronically: Follow the Submit a Comment instructions for proposed rule CMS-1629-P. 2. Regular mail: Use the address above. NHPCO Talking Points 1. Hospice Payment Reform Research and Analyses The rule outlines the research and analyses CMS has conducted pursuant to the Affordable Care Act ( ACA ) requirement to undertake hospice payment reform. In particular, CMS details their identification of non-hospice Medicare spending on hospitalizations, drugs, DME and diagnostic services for beneficiaries during a hospice election. CMS expresses concern about unbundling of the hospice benefit, and that many of these expenses were for items and services that were related to the terminal prognosis and should have been covered by the hospice. CMS also identified high rates of live discharges among some hospices and expresses concern that hospices may be admitting individuals who do not meet eligibility criteria. NHPCO Recommendations: NHPCO shares CMS s concern about any in appropriate unbundling of the hospice benefit and has undertaken efforts to help providers identify and cover all items and services that are related to the terminal prognosis, and to ensure that beneficiaries understand the scope and structure of the hospice benefit. However, hospices cannot prevent or control all non-hospice spending for beneficiaries enrolled in hospice: o CMS needs to develop systems to provide all Medicare providers with more timely access to information about a beneficiary s hospice election, and the need to coordinate with the hospice regarding any care provided to that beneficiary o CMS should undertake education of hospitals, physicians and other providers so that they better understand the coverage of services for beneficiaries enrolled in hospice under the Medicare hospice benefit. o CMS should establish systems in claims processing so that other providers are immediately aware of the patient s hospice election and are guided to communication with the hospice provider and appropriate billing. 2 NHPCO Talking Points on FY2016 Hospice Wage Index Proposed Rule, June 2015

3 2. Establishment of a Two Tiered Routine Home Care Rate In response to the ACA requirement to implement revisions to the methodology for determining hospice payment rates, CMS is proposing to establish a twotiered model for Routine Home Care ( RHC ) days. Hospices would be paid one rate for the first 60 days of hospice care and a lower rate for subsequent days in hospice care. The count of days would follow the patient, whether they remained in the same hospice or changed hospices, unless there was a 60 day lapse in hospice enrollment. If the patient re-enrolled in hospice after a 60 day or greater gap, the patient would be eligible for the higher rate for another 60 days. NHPCO is supportive of the proposal for a two tiered payment rate for RHC and believes that payment of a higher rate during the first 60 days of care reflects the service intensity identified by CMS and its contractors in claims data. It s unclear in the proposed rule whether hospices will simply bill a routine home care day and CMS will determine the count of days for the patient and pay at the appropriate rate, or if hospices will be responsible for determining the patient day count and billing at the correct rate. Regardless of who is responsible for determining the day count for patient billing, access to timely and accurate data regarding the day count is essential. A number of factors make this challenging, and we have serious concerns about the ability of CMS, the state Medicaid offices or hospices to make the necessary system changes, and undertake the education and training to be ready to implement the new billing system by October 1 st. If a hospice is delayed in filing a Notice of Termination/Revocation ( NOTR ), the days that a beneficiary was served by a previous program may not be visible for purposes of determining the day count and the appropriate billing rate. How will CMS address this concern? Regardless of who is responsible for determining the day count, if payments made to the hospice are later found to have been at the wrong rate because of missing or inaccurate information on the day count, what will be the process for reconciliation and recoupment, and over what time period might this occur? If access to a timely and accurate day count, and a fair and speedy reconciliation process, isn t available, it will have serious implications for a hospice s budgeting and planning process. How will the new two tiered rate system be applied to patients in hospice on the effective date? Will it be implemented only for patients admitted on or after the effective date, with current patients continuing to be billed at current rates until they die or are discharged? Will hospices have to 3 NHPCO Talking Points on FY2016 Hospice Wage Index Proposed Rule, June 2015

4 determine the day count for all patients currently on service and begin billing at the appropriate rate after the implementation date? 3. Service Intensity Add-On Payment As part of their effort to address what they believe is a misalignment between resource use and associated Medicare payments, and in order to enhance patient care by promoting more skilled visits at the end of life, when patients and families typically have more intensive needs, CMS has proposed to make a Service Intensity Add-On ( SIA ) payment for patients receiving certain skilled visits during the last week of life. CMS has stated that they would calculate and make the appropriate SIA payment based on a retrospective review, after a patient s death, of hospice claims for the last 7 days of the patient s life. Under this proposal, to qualify for SIA payments the day must be billed at the RHC rate, the patient must have received direct patient care on one or more of those days provided by a RN or a social worker (as defined in the hospice regulations), and the service must not have been provided in a skilled nursing facility ( SNF ) or nursing facility ( NF ). The SIA payment would be equal to the Continuous Home Care hourly rate, multiplied by the amount of direct patient care provided by an RN or social worker for up to a total of 4 hours per day. This SIA payment would be in addition to the RHC rate. CMS would annually establish a SIA payment budget neutrality adjustment factor ( SBNF ) that would be applied to adjust the RHC rate based on the level of SIA payments made, in order to maintain budget neutrality. NHPCO supports CMS s proposal to make SIA payments available for hospices making skilled visits to patients during the last week of life. The need for skilled direct patient care and support is often greater at this time, so hospice costs are higher. NHPCO strongly objects to CMS s proposal to not allow SIA payments for beneficiaries who reside in SNFs or NFs. Regardless of any concerns CMS may have about payments for hospice patients residing in nursing homes, the needs of patients dying in these settings are just as acute as other patients, and they are no less deserving of more intensive services during their last week of life. o SNFs and NFs are not able to provide these services. SNFs and NFs typically have only one, if any, RN on staff, and those nurses are often present for only one shift per day and are fully subscribed in overseeing the entire nursing home population. Nursing facilities don t typically have a social worker on site, so the facilities would 4 NHPCO Talking Points on FY2016 Hospice Wage Index Proposed Rule, June 2015

5 not be providing the needed level of skilled support to families when a resident is at the end of life. o The Medicare conditions of participation for both hospices and nursing facilities require them to provide the same level of services to patients, regardless of setting, so paying hospices to provide a service in one setting but not another raises concerns about regulatory compliance as well as discriminatory patient care. NHPCO supports the identification of RNs and social workers as appropriate disciplines for the SIA payment. RNs because of their training and expertise in assessment, which is required at greater frequency as the patient nears the end of life, and social workers for providing a skilled level of support for the patient and family. In order to maintain budget neutrality, CMS proposes to establish an SIA Budget Neutrality Factor, based on SIA payment amounts, which would be used to adjust routine home care rates in future years. However, the timeframes for the SBNF aren t clear. Would there be a two year lag between the data and its application to the RHC? 4. Alignment of the Inpatient and Aggregate Cap Accounting Year with the Federal Fiscal Year Currently the accounting year for the inpatient and aggregate cap is November 1 to October 31. CMS proposes to align the cap accounting year for both the inpatient and aggregate cap with the federal fiscal year for FYs 2017 and later, in order to eliminate timeframe complexities associated with counting payments and beneficiaries differently from the federal fiscal year, and help hospices avoid mistakes in calculating their aggregate cap. We support this alignment as we believe it will help eliminate confusion and misunderstandings. CMS should ensure that there is information available on the transition to the new accounting year time frames. 5. Updates to the Hospice Quality Reporting Program a. HQRP Quality Measures and Concepts Under Consideration for Future Years CMS has identified several high priority concept areas for future measure development: 5 NHPCO Talking Points on FY2016 Hospice Wage Index Proposed Rule, June 2015

6 Patient reported pain outcome measure that incorporates patient and/or proxy report regarding pain management; Claims-based measures focused on care practice patterns including skilled visits in the last days of life, burdensome transitions of care for patients in and out of the hospice benefit, and rates of live discharges from hospice; Responsiveness of hospice to patient and family care needs; Hospice team communication and care coordination. While the identified measure areas do focus on important areas of hospice care, claims do not have sufficient information to inform performance measures that truly reflect hospice practice and that could be used to improve quality of care. Performance measures should guide and promote the quality of direct care received by hospice patients and families. Performance measures should not be implemented in order to discourage or correct or undesirable organizational practices. Currently hospice claims cannot adequately inform quality of care and should not be used as the basis for performance measures for hospice. NHPCO requests that CMS establish a code that would allow reporting of visits by chaplains and other spiritual counselors. Allowing these visits to be identified and tracked, and in so doing acknowledging their important role in providing hospice care, will serve as a first step toward enhancing the usability of claims as a data source for performance measures. In addition, in the development of quality measures, CMS should be mindful of provider burden in measure implementation and usable/meaningful measures for which there is evidence of a link to quality. b. Proposed Policy for New Facilities to Begin Submitting Quality Data CMS proposes that new hospices begin submitting quality data on the date they receive their Certification Number (CCN). NHPCO supports the requirement and believes that it will be a clear start date for new providers. 6 NHPCO Talking Points on FY2016 Hospice Wage Index Proposed Rule, June 2015

7 c. Proposed HQRP Data Submission and Compliance Thresholds for the FY2018 Payment Determination and Subsequent Years CMS has proposed a compliance goal of 90% compliance for meeting the submission deadline for HIS admission and discharge records. The penalty for non-compliance is a 2% reduction in the market basest increase in subsequent years. The compliance threshold will be phased in incrementally over a period of three years as follows: a % good, below 70% - 2% penalty b % threshold, below 80% - 2% penalty c % threshold, below 90% - 2% penalty NHPCO supports the establishment of data submission and compliance thresholds for FY2018 payment determinations and for subsequent years. Hospice providers have asked for compliance thresholds and it will be very helpful to have them established. d. Public Display of other Hospice Information CMS anticipates that provider level quality reports will begin to be available sometime in CY CMS anticipates that providers would use the quality reports as part of their Quality Assessment and Performance Improvement (QAPI) efforts. NHPCO supports provider level quality reports in CY2015 as a way for hospices to have additional information on their own data and as a way to inform QAPI efforts. 6. Diagnosis Reporting on Hospice Claims In the proposed rule, CMS is clarifying that hospices should report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual, and that ICD-10 Coding Guidelines state that diagnoses should be reported that develop subsequently, coexist, or affect the treatment of the individual. In the proposed rule, CMS indicates that there is anecdotal evidence that some hospices are inappropriately unbundling the hospice benefit and telling other 7 NHPCO Talking Points on FY2016 Hospice Wage Index Proposed Rule, June 2015

8 providers to bill Medicare for services as unrelated and receive reimbursement from Medicare Parts A, B or D. In this section CMS also addresses the issue of related to the terminal condition and states that comorbidities, including longstanding, preexisting, chronic, stable and controlled conditions and disease states, are included in the bundle of hospice services. NHPCO is concerned that hospice providers often do not know, and are not in control of, whether or how other providers bill, and for what services. We encourage CMS to establish systems in claims processing so that other providers are immediately aware of the patient s hospice election and are guided to appropriate billing. It s unclear whether hospices will be expected to indicate on the claim which diagnoses they have determined are related vs. unrelated to the patient s terminal prognosis. We request that a mechanism be developed, such as a modifier, which enables the hospice to distinguish between related and unrelated diagnoses on the claim form. NHPCO requests clarification regarding the scope of diagnoses a hospice is expected to identify. o With so many patients in hospice for a week or less, hospices are managing actively dying patients and often have limited information about the patient s medical history other than their terminal diagnosis, and this information often isn t relevant to the patient s palliative care needs during their final days of life. o If the hospice learns of additional diagnoses after submitting claims, are they expected to update the claims? For many patients with a short stay in hospice, there will be only one claim. Why is CMS requesting all diagnoses on the claim form, and how do they plan to use this information? Providers have concerns that audit contractors will not be able to distinguish between related and unrelated on the claim, and will hold the hospice responsible for all diagnoses, regardless of relatedness. NHPCO strongly believes that the unique physical condition of each terminally ill individual makes it necessary for decisions regarding what is related to the terminal prognosis to be made on a case by case basis, and it should be made by the hospice physician, in consultation with the patient s attending physician, if they have one. o Some longstanding, preexisting, chronic conditions will have an effect on, or be related to, the patient s terminal prognosis, and 8 NHPCO Talking Points on FY2016 Hospice Wage Index Proposed Rule, June 2015

9 some will not. Making that determination is patient-specific and requires the clinical expertise of a hospice physician. NHPCO is concerned about the burden of implementing this requirement at the same time hospices are struggling to comply with new ICD-10 coding requirements. 7. Readiness for These Changes by October 1 st As noted above, NHPCO is supportive of many of the proposed changes, and looks forward to working with CMS and assisting its members in implementing these changes. However, the proposed rule leaves un-answered certain key questions, and until CMS finalizes this proposed rule, sometime in August, hospices and their software and other vendors are unable to even begin preparing with certainty. We have significant concerns about the ability of CMS, the MACs, and hospices to be able to put in place and test the system changes, and conduct the necessary education and training in order for these changes to be implemented on October 1, 2015 without significant problems. In addition to the necessary changes in Medicare claims and billing processes, the changes in hospice payment rates also affect Medicaid programs in the 49 states that have a Medicaid hospice benefit, since the Social Security Act requires that payment for Medicaid hospice care be in amounts no lower than the amounts, and using the same methodology, under Medicare. Although patients covered under the Medicaid hospice benefit account for only about 4-5% of all patients, that s not an insignificant number, and making changes in 49 different state Medicaid systems will take time and effort. NHPCO Recommendations: In light of the magnitude of these changes, and of significant problems with implementing other new requirements, some of which are ongoing, we urge CMS to undertake testing and a dry-run of the changes, prior to implementation, even if this requires a delay in the implementation date. We urge CMS to reach out to Medicaid staff and to state Medicaid agencies during the rulemaking process to assess their ability to implement these changes in accordance with the timeframes set for implementation. As soon as the rule is finalized, CMS should immediately communicate the changes to state Medicaid programs and provide whatever assistance possible to help them implement these changes. 9 NHPCO Talking Points on FY2016 Hospice Wage Index Proposed Rule, June 2015

FY2018 Hospice Wage Index Final Rule

FY2018 Hospice Wage Index Final Rule To: NHPCO Provider Members From: NHPCO Health Policy Team Date: August 2, 2017 Summary at a Glance On August 1, 2017, the Federal Register posted the FY2018 Hospice