NHPCO Listening Session FY2016 Proposed Wage Index Rule Posted on Federal Register Public Inspection Desk: April 30, 2015 Published in Federal Register May 5, 2015 National Hospice and Palliative Care Organization, May 2015 NON-HOSPICE SPENDING DURING A MEDICARE HOSPICE ELECTION 2 1
FY2013 Medicare A and B Outside Hospice Benefit Part A or B Service Percentage of $$ Spent DME 6.4% Inpatient care 28.6% Outpatient Part B services 16.6% Other Part B services (physician, practitioner, labs and diagnostic tests, ambulance transports, and physician office visits) 38.8% Skilled Nursing Facility Care 5.3% Home Health Care 4.3% 3 FY2013 Medicare Part D Payments Outside Hospice Benefit Medicare Part D spending: FY2013: $347.1 million CY2012: $334.9 million 4 2
Four case studies on frequent hospice diagnoses Case studies presented for following diagnoses chronic airway obstruction congestive heart failure cerebral degeneration lung cancer Citation of : Typical symptoms Evidence-based practice interventions/ recommendations Comments on Medicare spending outside the hospice benefit 5 Concurrent Payments for Services Provided to Hospice Patients Lung Cancer, CY 2013 Total $3,405,083 6 3
Concurrent Payments for Services Provided to Hospice Patients with COPD, CY 2013 Total $10,400,319 7 Analysis reveals: CMS Concern Clinical based practices are not being covered under the Medicare hospice benefit. Potential systematic unbundling of the Medicare hospice benefit May be valuable analysis to inform policy stakeholders 8 4
Assessment of Conditions and Comorbidities Required by Regulation We continue to state that those circumstances would be exceptional and unusual and that hospices continue to be required to provide virtually all the care that is needed by terminally ill patients. 9 Assessment of Conditions and Comorbidities Required by Regulation Comorbidities are recognized as important factors contributing to the overall status of an individual should be considered when determining terminal prognosis. Mental health comorbidities must also be considered not uncommon for terminally ill individuals to have underlying mental health conditions could contribute to their prognosis and/or affect the plan of care 10 5
% of Claims with One Diagnosis 11 All diagnoses on the claim form Therefore, we are clarifying that hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual. Includes the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs. 12 6
Comprehensive Assessment CMS states: we are concerned that hospices may not be conducting a comprehensive assessment nor updating the plan of care as articulated by the CoPs to recognize the conditions that affect an individual s terminal prognosis. 13 WHAT DO YOU THINK? 14 7
Marketbasket Increase Proposed increase for hospice payment rates for FY 2016 by 1.8 percent Increase is NET after Medicare provider-wide productivity adjustment and 0.3% hospicespecific productivity adjustment 15 Proposed FY2016 Routine Home Care 2 different rates 60 days or less 61 days or more % increase for 60 days or less = 15% % decrease for 61+ days = -8% 16 8
Proposed Rates Description 2016 Rates 2015 Rate Difference % Increase Routine Home Care $159.34 1-60 days $188.20 $ 28.86 15.33% 61+ days $147.34 $(12.00) -8.14% Continuous Home Care Full Rate = 24 hours of care $946.65 $929.91 $16.74 Hourly Rate $ 39.44 $38.75 $0.69 Inpatient Respite Care General Inpatient Care $167.78 $164.81 $2.97 $721.53 $708.77 $12.76 17 Count of Days Mitigate potential high rates of discharge and readmissions, propose: count of days follow the patient For hospice patients who are discharged and readmitted to hospice within 60 days of that discharge: his or her prior hospice days will continue to follow the patient AND count toward his or her patient days for the receiving hospice upon hospice election 18 9
Count of Days For hospice patients who are discharged and readmitted to hospice more than 60 days after that discharge: his or her prior hospice days will begin again at the 1-60 day count 19 Service Intensity Add On (SIA) payment that would result in an add-on payment equal to Continuous Home Care (CHC) hourly payment rate multiplied by the amount of direct patient care provided by a: registered nurse (RN) or social worker provided during the last 7 days of a beneficiary s life, If certain criteria are met 20 10
Certain Criteria Day billed as RHC Applies to any length of stay SIA payment is at the continuous care hourly rate ($39.44/hour) for up to 4 hours a day Visit must be by RN or SW Last 7 days of life In person no telephone visits by social workers Patient cannot reside in SNF or NF 21 SIA Budget Neutral Propose to make the SIA payments budget neutral through an annual determination of the SBNF Then be applied to the RHC payment rate The SBNF for the SIA payments would be calculated for each FY using the most current and complete fiscal year utilization data available at the time of rulemaking 22 11
23 WHAT DO YOU THINK? 24 12
Quality Components One significant change 30 days to submit admission and discharge record in HIS will stay the same Use the submission deadlines to assess further penalties Goal is to get up to 90% compliance with submission deadlines for admissions and discharges 2016 70% good, below 70% - 2% mkt basket penalty 2017 80% threshold 2018 90% threshold 25 No new measures Measures All measures currently in place may not stay Criteria for dropping measures HIS measures if everyone doing really well, may not stay as a measure Additional criteria 26 13
New Hospices Start reporting on the date you receive your provider number 27 Hospice Compare Will have Hospice Compare Still not date for public reporting 28 14
HIS Reporting Error reports, aggregated for submissions How you are doing on measures Your own report Some time before the end of 2015 29 WHAT DO YOU THINK? 30 15
Update Wage Index for 2010 Census 50/50 blend of the existing CBSA designations New CBSA designations outlined in a February 28, 2013, OMB bulletin 37 counties urban -> rural 105 counties rural -> urban 31 0.8 Hospice Floor Hospital wage index values which are less than 0.8 are still subject to the hospice floor The hospice floor equates to a 15 percent increase, subject to a maximum wage index value of 0.8 32 16
BNAF Year 7 of the 7-year BNAF phase-out finalized in the FY 2010 Hospice Wage Index final rule (74 FR 39407) 33 WHAT DO YOU THINK? 34 17
Virtually All We continue to expect hospices to adhere to the long-standing policy to provide virtually all care during a hospice election as articulated in the 1983 Hospice Care proposed and final rules as well as most recently in FY 2015 Hospice Wage Index and Payment Rate Update final rule. 35 Program Integrity Program integrity and oversight efforts including but not limited to medical review MAC audits Zone Program Integrity Contractor actions, Recovery Auditor activities, or suspension of provider billing privileges, are being considered to address fraud and abuse 36 18
Future The proposed RHC rates and SIA payment would advance hospice payment reform incrementally as mandated by the Affordable Care Act while simultaneously maintaining flexibility for future refinements 37 Future Implementation Implemented within the current constructs of the hospice payment system No major overhaul of the claims processing system or related claims/cost report forms would be required Minimizing burden for hospices as well as for Medicare CMS needs to further assess whether the four levels of care current payment amounts amounts after implementation of the SIA will align with the actual cost of providing hospice services 38 19
WHAT DO YOU THINK? 39 40 20