Hot Regulatory & Quality Reporting Updates Judi Lund Person, MPH, CHC jlundperson@nhpco.org Jennifer Kennedy, EdD, MA, BSN, RN, CHC jkennedy@nhpco.org National Hospice and Palliative Care Organization Today Regulatory Issues Live discharges Visits in the last days of life Scrutiny Quality measure Physician assistants Hospice medical director concerns Regulatory Relief Opioids Quality Issues No new measures Composite measure Visits when death is imminent Future measures Hospice Compare CAHPS HEART 1
Annual Live Discharge Rates Source: FY2019 Hospice Wage Index Proposed Rule, April 27, 2018 Live Discharges FY2017 Reason for Live Discharge Revocation 44% No longer terminally ill 45% Transferred to another hospice 9% Providers by Percentile 5 th percentile 6.9% 25 th percentile 11.7% Median 17.3% 75 th percentile 25.4% Percentage 95 th percentile 47.6% Percentage of Live Discharges 2
Skilled Visits in Last Days of Life FY2017 On any given day in the last 7 days of life 42% of patients received NO skilled visits RN or SW RN visits on any given day 45% did not receive a visit SW visits on any given day 89% did not receive a visit CMS Concerns We are concerned about the lack of increase in visits to hospice patients at the end of life. Beneficiaries appear to be receiving similar levels of care when compared to time periods prior to the implementation of payment policy reforms may indicate that hospices are not providing additional resources to patients during a time of increased need. Data collection on Hospice Visits When Death Is Imminent in 2017 will inform quality reporting for the Fy2019 annual payment update. 3
PHYSICIAN ASSISTANTS Physician Assistants as Attending Physician for Hospice Patients Effective January 1, 2019 Recognized as designated hospice attending physician Join nurse practitioners and physicians in this role Must function within the scope of practice per state law Investigating prescribing authority 4
PAs Cannot Physician assistants cannot: Certify or recertify terminal illness. No one other than an MD or DO can perform that function. Conduct face to face encounters. The face to face encounter statutory language was not changed when PAs were added as an attending physician Replace the hospice physician in the IDT. MEDICAL DIRECTOR ISSUES 5
Hospice Medical Director Concern on surveys Only 1 hospice medical director per provider number Even if multiple locations Even if large census Can have a physician designee to serve in the absence of the medical director Other physicians employed by or under contract with the hospice CANNOT be called medical director MUST have reporting relationship to medical director shown on the org chart Hospice Medical Director To Do Job titles Job description for medical director Even if position is titled Chief Medical Officer, reference the ONE medical director language in the job description Must state in the job description that this position is the ONE medical director for the hospice Organizational chart for reporting relationships 6
Hospice Medical Director To Do Job titles and job descriptions for other physicians Cannot be called medical director Choose other job titles Update policies and procedures about how a physician designee is chosen when the hospice medical director is unavailable Staff training language is important PEPPER REPORTS 7
Download Rates by State 8
2018 National Hospice PEPPER Downloads # PEPPERs Available: 4,196 # PEPPERs Retrieved: 2,622 Retrieval Rate: 62.5% as of October 20, 2018 Download your PEPPER: www.pepperresources.org States by Download % States over 90% State # of # % Providers Downloads Delaware 8 8 100% District of Columbia 4 4 100% Florida 42 41 97.62% North Carolina 77 71 92.21% Maryland 25 23 92% Washington 31 28 90.32% West Virginia 20 18 90% States less than 50% State # of Providers # Downloads Puerto Rico 40 19 47.50% Utah 86 30 34.88% California 703 232 33% Wyoming 14 4 28.57% Virgin Islands 2 0 0% % 9
Hospice Target Areas 2018 PEPPER Live discharges not terminally ill Live discharges revocations Live discharges 61 179 days Long length of stay CHC in assisted living facility RHC in assisted living facility RHC in nursing facility RHC in skilled nursing facility Episodes with no CHC or GIP Long General Inpatient Care Stays (> 5 days) REGULATORY RELIEF 10
Regulatory Relief NHPCO in discussions with CMS House Ways and Means Committee NHPCO has submitted detailed suggestions to reduce regulatory burden for hospice Testified at a Red Tape Relief Roundtable sponsored by the House Ways and Means Committee More to come Regulatory Relief The Committee prepared a letter to CMS outlining the regulatory relief recommendations for various Medicare providers. On September 4, the letter was sent to CMS (PDF), and included NHPCO s top priority of increased accountability and transparency for government auditors reviewing hospices. Now we wait. 11
Proposed Rule on Burden Reduction September 17, 2018 CMS issues proposed rule on reducing regulatory burden that applies to all Medicare provider types. NHPCO will comment on this proposed rule Due on November 19 Feedback and discussion welcome Proposed Rule: Hospice Requirements for Medication Management Hospice staff with specialty knowledge of hospice medications Medicare hospice Conditions of Participation, 42 CFR 418.106(a)(1), Currently requires the hospice to have an individual with specialty knowledge of hospice medications Proposed to be removed. Reasoning: Industry experts estimate that at least 75 percent and as many as 95 percent of hospices use pharmacy benefit management services Hospices can receive such advice and guidance from PBMs in the absence of regulation 12
Proposed Rule: Hospice Requirements for Sharing Medication Policies with Patients and Families Requirement for sharing medication policies and procedures with patients, families and caregivers: Replace the requirement, at 418.106(e)(2)) Add a requirement that hospices provide information regarding the use, storage, and disposal of controlled drugs to the patient or patient representative, and family. User friendly format: CMS suggests a patient and family friendly, understandable format that will help in patient and caregiver comprehension Conflict: New opioid law conflicts with this user friendly requirement by requiring the hospice to share policies and procedures with patients and families. NHPCO will work with CMS to clarify. Proposed Rule: Orientation of SNF and ICF/IID Staff Responsibility for staff orientation: Move from hospice only responsibility Move to joint responsibility of hospice and nursing facility CMS reasoning: This will give hospices more freedom to develop innovative approaches and avoid effort duplication with other hospices that are orienting the same facility staff. Challenge: This could require adjustments in nursing facility contracts. 13
Proposed Rule: Hospice Aide Training and Competency Requirements Aide training: CMS proposes to defer the aide training and competency requirements to State licensure, regardless of their content or format and allow states to have the flexibility to meet the needs of the population in their state. CMS Reasoning: Would simplify the hiring process for hospice aides The hospice would no longer be required to ensure that the aide applicant meet both the state licensure, certification or registration requirements and also meet the training and competency requirements in the hospice CoPs. Proposed Rule: Annual Emergency Preparedness Training Program Change frequency for emergency preparedness training: CMS proposes one testing exercise per year for outpatient service providers (including all hospices). Types of training: Providers participate in: Community based full scale exercise (if available) or Conduct an individual facility based functional exercise every other year. In the opposite years: Allow these providers to conduct the testing exercise of their choice, which may include: Community based full scale exercise (if available) Individual, facility based functional exercise Drill Tabletop exercise or workshop that includes a group discussion led by a facilitator For hospices with inpatient facilities, the two exercises per year still applies 14
Discussion OPIOID ISSUES 15
Opioid Shortages Shortages Injectables Could have new supply later in 2018 Likely will be an ongoing issue Pfizer manufacturing challenges an issue Hurricane Maria and Puerto Rico a factor DEA approved new manufacturing quotas to increase supply Could be months before available Proper Disposal Current Requirements Drugs belong to the ultimate user after death The ultimate user controls the disposal Home hospice and homecare personnel are not authorized to receive pharmaceutical controlled substances from ultimate users for the purpose of disposal A member of the hospice patient s household may dispose of the patient s pharmaceutical controlled substances, but the home hospice or homecare provider cannot do so unless otherwise authorized by law (for example, under state law) to dispose of the decedent s personal property TRANSLATION: The hospice staff may instruct or supervise the disposal, but may not take possession of the drug MAY BE DIFFERENT STATE RULES 16
Changes Coming Congress approved the final Opioid Package (SUPPORT) on Wednesday afternoon, October 3, 2018. The new law allows for qualified hospice employees to safely dispose of expired or no longer needed medication. President Trump signed the bill into law on October 24, 2018 Don t change practice yet. Wait for CMS and DEA guidance Scrutiny on Hospice 17
Federal Scrutiny Department of Justice (DOJ) False Claims Act violation Medicare fraud and abuse Office of the Inspector General (OIG) Hospice in a nursing facility Hospice in a assisted living facility Hospice and Part D drugs Hospice general inpatient level of care OIG REPORT ON HOSPICE CARE 18
OIG Portfolio on Hospice Vulnerabilities in the Medicare Hospice Program Affect Quality Care and Program Integrity: An OIG Portfolio (OEI 02 16 00570) Posted on 7/30/18 https://oig.hhs.gov/oei/reports/oei 02 16 00570.asp The portfolio synthesizes OIG's body of work on the Medicare hospice benefit. It covers hospice care since 2005 and describes the growth in hospice utilization and reimbursement. The portfolio also summarizes key vulnerabilities that OIG has identified and continues to monitor. What the OIG Found The OIG identified vulnerabilities in the program. Hospices do not always provide needed services to beneficiaries and sometimes provide poor quality care. In some cases, hospices were not able to effectively manage symptoms or medications, leaving beneficiaries in unnecessary pain for many days. Found that beneficiaries and their families and caregivers do not receive crucial information to make informed decisions about their care. 19
What the OIG Found Hospice billing concerns Hospices' inappropriate billing costs Medicare hundreds of millions of dollars billing for an expensive level of care when the beneficiary did not need it. Fraud Schemes Some fraud schemes involved enrolling beneficiaries who are not eligible for hospice care, while other schemes involve billing for services never provided. What the OIG Found Payment system concerns the current payment system creates incentives for hospices to minimize their services and seek beneficiaries who have uncomplicated needs. A hospice is paid for every day a beneficiary is in its care, regardless of the quantity or quality of services provided on that day. While CMS made some changes to payments, the underlying structure of the payment system remains unchanged. 20
OIG Recommendations to CMS Recommend that CMS implement 15 specific actions that relate to 7 areas for improvement. CMS should strengthen the survey process to better ensure that hospices provide beneficiaries with needed services and quality care. CMS should also seek statutory authority to establish additional remedies for hospices with poor performance. CMS should develop and disseminate additional information on hospices, including complaint investigations, to help beneficiaries and their families and caregivers make informed choices about hospice care. OIG Recommendations to CMS CMS should educate beneficiaries and their families and caregivers about the hospice benefit, working with its partners to make available consumer friendly information. CMS should promote physician involvement and accountability to ensure that beneficiaries get appropriate care. CMS should strengthen oversight of hospices Analyze claims data to identify hospices that engage in practices that raise concerns. Take steps to tie payment to beneficiary care needs and quality of care to ensure that services rendered adequately serve beneficiaries' needs, seeking statutory authority if necessary. 21
HOSPICE QUALITY REPORTING PROGRAM No Changes No new quality reporting measures for FY 2019. Failure to comply with HIS and CAHPS submission requirements will result in a 2% reduction in a provider s reimbursement rate. 22
Time period for HIS Data Review CMS confirms that there be a specified time period (4.5 months) for HIS data review and a correlating data correction deadline for public reporting at which point the data is frozen for the associated quarter. Any record level data correction after the data frozen date will not be incorporated into measure calculation for public reporting on the CMS Hospice Compare Web site. Composite Measure The Hospice and Palliative Care Composite Process Measure was approved by NQF in July 2017 and will be reported in Hospice Compare in November 2018 refresh. Measure is calculated based on a 12 rolling month data selection period, to be eligible for public reporting with a minimum denominator size of 20 patient stays. 23
Visits when Death is Imminent Measures Will be reviewed by NQF for approval when 4 quarters of acceptable data are determined by CMS. After receiving NQF approval, the measure pair will be eligible to be reported on Hospice Compare. Exact timeline for public reporting of this measure pair will be announced through regular sub regulatory channels once necessary analyses and measure specifications are finalized but will be reported sometime in 2019. Change to HIS Measure Display CMS will no longer directly display the 7 component measures as individual measures on Hospice Compare, once the Composite measure is displayed. They will still provide the ability to view these component measures by reformatting the display of the component measures allowing users the opportunity to view the component measure scores that were used to calculate the main composite measure score. 24
Change to HIS Measure Display Expandable Text Posted On Hospice Compare CMS feels it is important for consumers to be able to distinguish between process, outcome, and consumer feedback measures. CMS has decided to separate the data into two sections on the Hospice Compare Web site: 'Family experience of care' and 'Quality of patient care'. Both sections have accompanying text explaining their data source. 25
Hospice Public Use File (PUF) Data PUF data will be added to Hospice Compare as a separate information section of website Hospice PUF contains information on utilization, payment, submitted charges, primary diagnoses, sites of service, and hospice beneficiary demographics organized by CMS Certification Number and state. Could add other publicly available CMS data to Hospice Compare through sub regulatory guidance Future Measures CMS will announce to providers any future intent to publicly report a quality measure on Hospice Compare or other CMS website, including timing, through sub regulatory means. Announced on HQRP website MLN e news national provider association calls Open Door Forums 26
Where to Look for Future Measures CMS added future quality measure development to the Provider Engagement Opportunities webpage. This addition to the webpage will keep stakeholders informed of hospice measures that CMS has submitted to the National Quality Forum (NQF) Measure Application Process (MAP). Hospice Public Use File (PUF) Data Examples of PUF use by a consumer: patient has a specific need, like receiving hospice care in a nursing home, information from the PUF could help this patient or their loved ones determine if a provider in their service area has provided care in this setting conditions treated by the hospice could show a patient with dementia if a hospice specializes or is experienced in caring for patients with this condition 27
CAHPS Update Extending CAHPS requirements to future years (FY2023 and every year thereafter) No changes to CAHPS process. CAHPS Study The CAHPS Hospice Survey team has recently decided to launch a study of the cover letter and phone script to determine how it can be made more readable to all members of the public. This research will include a review of the grade level of each item and feedback from respondents. 28
Updates to Provider Demographic Information If inaccurate or outdated demographic data are included on the Preview Report or on Hospice Compare, hospice providers should follow guidance in the How to Update Demographic Data document in the downloads section of the Public Reporting: Background and Announcements page on the CMS HQRP Website. MORE ON QUALITY REPORTING 29
HEART Update CMS convened a Technical Expert Panel meeting in Fall 2017 and, after further analysis, CMS began pilot testing (Pilot A) an early version of the HEART. Concerns were raised during Pilot A testing, and further testing phases are being delayed at this time. CMS is working diligently to retool the HEART following the lessons learned from Pilot A. There will be significant interaction between CMS and stakeholders via Special Open Door Forums (SODF). What Measures are in the Pipeline? At this time, CMS is developing a claims based Transitions from Hospice Care, Followed by Death or Acute Care, Measure. The intent of the Transitions from Hospice Measure is to assess negative outcomes following hospice live discharge, including death or acute care use shortly after discharge, as these outcomes represent potentially burdensome transitions to patients and families. 30
Draft Measure Description Transitions from Hospice Care, Followed by Death or Acute Care will estimate the risk adjusted rate of transitions from hospice care, followed by death within 30 days or acute care use within 7 days Outcome measure Status of This Measure Updates to the measure specifications: CMS and the measure developer contractor will take the suggested modifications in to consideration, continue to conduct data analysis, and discuss with national experts and stakeholders to determine potential measure modifications. 31
Status of This Measure Changes to Measure Specs: CMS and the measure developer contractor will perform further analysis to test the effects of several recommendations, such as excluding hospice patients who were discharged for reasons other than being no longer terminally ill and exploring potential methods for including Medicare Advantage patients. CMS and the measure developer will also consider feedback requesting further training and explanation about how the measure will eventually be implemented. Measure Next Steps The Transitions from Hospice Measure will be included on the 2018 2019 Measures Under Consideration(MUC) list that will be posted by December 1, 2018. Stakeholders may comment on the posted MUC list, that will include the Transitions from Hospice Care Measure, prior to the NQF Post Acute Care/Long Term Care Workgroup (December, 2018) and NQF Coordinating Committee Workgroup (January, 2019). For updates on the workgroup activities and opportunities to provide comments, please visit http://www.qualityforum.org/map/. 32
Meaningful Measure Areas for Future Measure Consideration CMS identified the following as High Priority areas for future hospice measure development Effective Prevention and Treatment Symptom management outcome measures are a high priority for the HQRP. There is a lack of tested and endorsed outcome measures for hospice across domains of hospice care, including symptom management (e.g.; physical and other symptoms). Symptom management is a central aspect of hospice care. 33
Communication/Care Coordination and/or Patient and Family Engagement Patient preference for care is difficult to measure at end of life when patients may or may not be able to state their preferences, and may have changes in their preferences. However, a central tenet of hospice care is responsiveness to patient and family care preferences; as much as possible, patient preferences should be incorporated into new measure development Making Care Safer Timeliness/responsiveness of care. While timeliness of referral to hospice is not within a hospices control, hospice initiation of treatment once a patient has elected the hospice benefit is under the control of the hospice. Responsiveness of the hospice during time of patient or family need is an important indicator about hospice services for consumers in particular. 34
Communication/Care Coordination Measurement of care coordination is integral to the provision of quality care and should be aligned across care settings. New NHPCO Resources Clinical Guide to General Inpatient Care Referral and Admission Models 35
Member Benefits NHPCO members have unlimited access to regulatory and quality information News Briefs Regulatory Alerts Regulatory Round Up (monthly compilation of all regulatory issues) Podcasts Resources on specific topics Contact us with specific questions regulatory@nhpco.org or quality@nhpco.org 36
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