For every CY, all Medicare-certified hospices are required to submit HIS and CAHPS data according to the requirements in 418.312. (2016). We previously finalized a volume-based exemption for CAHPS Hospice Survey Data Collection and Reporting requirements for FY 2021 and every year thereafter (84 FR 38526). Section 4442 of the BBA amended section 1814(i)(2) of the Act, effective for services furnished on or after October 1, 1997, to require that hospices submit claims for payment for hospice care furnished in an individual's home only on the basis of the geographic location at which the service is furnished. Hospitalizations are found by looking at all fee-for-service Medicare inpatient claims. Other commenters requested that this measure recognize visits offered during CHC or GIP care. As required by OMB Circular A-4 (available at https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/circulars/A4/a-4.pdf), in Table 26, we have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this final rule. Thus, the reportability of the actual data used is likely to be better than this simulation. The OFR/GPO partnership is committed to presenting accurate and reliable Response: We appreciate the commenter's concern regarding labor hours provided by type of facility. In addition, we will provide hospices with confidential reporting of their HVLDL and HCI measure scores in the Agency-Level QM report after this rule is finalizedafter August 2021. This indicator identifies whether a hospice is below the 90th percentile in terms of the average Medicare hospice payments per beneficiary. In that memo, which applies to HIS and CAHPS Hospice Survey, CMS granted an exemption to the HQRP reporting requirements for Quarter 4 (Q4) 2019 (October 1, 2019 through December 31, 2019), Quarter 1 (Q1) 2020 (January 1, Start Printed Page 425782020 through March 30, 2020), and Quarter 2 (Q2) 2020 (April 1, 2020 through June 30, 2020). Comment: While the majority of commenters supported the proposed changes; one commenter did not support the use of the pseudo-patient or targeted competency testing. for CMS to publicly report, or a requirement included in the hospice CoPs. The revised labor share for Routine Home Care is 66.00 percent and corresponding the non-labor share is 34.00 percent. L. 113-185), we sought comment on the possibility of revising measure development, and the collection of other data that address gaps in health equity in HQRP (86 FR 19766). Comment: Several commenters stated that the use of pseudo-patients and simulation techniques are common in healthcare and a standard of practice in many formal nursing assistant programs. Reportability analyses found a high proportion of hospices (over 85 percent) that would yield reportable measure scores over 1 year (for more on reportability analysis, see section (2) Update on Use of Q4 2019 Data and Data Freeze for Refreshes in 2021.). A few of these commenters requested that CMS provide further clarification of the frequency of updates to the labor shares with hospice cost report data. The base payments are adjusted for geographic differences in wages by multiplying the labor share, which varies by category, of each base rate by the applicable hospice wage index. However, there are distributional effects of the FY 2022 hospice wage index. The data collected could be used to revise the methodology for determining the payment rates for RHC and other services included in hospice care, no earlier than October 1, 2013, as described in section 1814(i)(6)(D) of the Act. Other comments highlighted the possible impact of claims-based measures on rural and small providers because they may not capture care in rural communities or possibly identified as an outlier due to low volume. Numerator: The total number of live discharges from the hospice followed by hospital admission within 2 days, then hospice readmission within 2 days of hospital discharge within a reporting period. We appreciate the industry's and national associations' engagement in providing input through information sharing activities, including listening sessions, expert interviews, key stakeholder interviews, and focus groups to support HOPE development. We believe that the 1-year 5 percent cap transitional policy provided for FY 2021 was an adequate safeguard against any significant payment reductions, allowed for sufficient time to make operational changes for future fiscal years, and provided a reasonable balance between mitigating some short-term instability in hospice payments and improving the accuracy of the payment adjustment for differences in area wage levels. Catherine Howden, DirectorMedia Inquiries Form a. The FY 2022 hospice payment updates also include an update to the statutory aggregate cap amount, which limits the overall payments per patient that are made to a hospice annually. Medicare Hospice Payment Rate Update for Fiscal Year 2022 documents in the last year, 24 The points are earned without weighting to recognize the tradeoffs for each indicator's specifications. Subsequently, as with HIS-based measures, we will implement a 30-day preview period for claims-based measures, which will serve as the final opportunity for hospices to review their data and alert CMS about any errors in the measure calculations they identify. We want hospices to be successful with meeting the HQRP requirements. Table 12. The FY 2022 RHC rates are shown in Table 2. Overall, the TEP supported each candidate measure and agreed that they were viable for distinguishing hospice quality. Comment: Commenters recommended using simple language to describe HVLDL on Care Compare, to ensure that the average consumer will understand it. The labor shares for IRC and GIP are currently 54.13 percent and 64.01 percent, respectively. We are finalizing similar changes to hospice aide competency standards to those already made with respect to HHAs (see 484.80(c)) in our hospice regulations at 418.76(c)(1)). Comment: A few commenters stated that the survey is too long. 37. legal research should verify their results against an official edition of They encouraged CMS to conduct further analyses before finalizing the measure. 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. PDFHospice Indicator Eight: Skilled Nursing Care Minutes per Routine Home Care (RHC) Day, (9). Section 4443 of the BBA amended sections 1812(a)(4) and 1812(d)(1) of the Act to provide for hospice benefit periods of two 90-day periods, followed by an unlimited number of 60-day periods. Star ratings will continue to be calculated and released as we phase in the new survey version. This change will permit the hospice to focus on the hospice aides' specific deficient and related skill(s) instead of completing another full competency evaluation. This policy will apply beginning with FY 2024 annual payment update (APU). Comment: Several commenters expressed concern about the public's ability to understand the meaning of the HIS Comprehensive Measure without being able to see the seven component measures. Therefore using 3 quarters of data for the HIS Comprehensive Assessment Measure would achieve acceptable reportability shown in Table 14. Any such reduction would not be cumulative nor be taken into account in computing the payment amount for subsequent FYs. For the OASIS, the exempted quarters are based upon admission and discharge assessments. + | Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). 4. Resources can be found at https://www.cms.gov/About-CMS/Components/CPI. This cap is optional for hospice services under the Medicaid program. The COVID-19 PHE Exception applied to Q1 and Q2 of 2020. Index Earned Point Criterion: Hospices earn a point towards the HCI if their individual hospice score for gaps in skilled nursing visits greater than 7 days falls below the 90th percentile ranking among hospices nationally. The commenter also claimed that if it is based on no days being reported as contracted on Worksheet S-1, this assumption is also in error. 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. Comment: Many commenters requested clarification related to the use of technology under the Medicare hospice benefit during the PHE. High-quality hospice care not only manages pain and symptoms of the terminal illness, but assesses non-clinical needs of the patient and family caregivers, which is a hallmark of patient-centered care. Therefore, for accounting years that end after September 30, 2016 and before October 1, 2030, the hospice cap amount is updated by the hospice payment update percentage rather than using the CPI-U. (vii) Collection or public reporting of a measure leads to negative unintended consequences other than patient harm. 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. We received many comments this proposal on related questions about publicly reporting claims-based measures using data from the COVID-19 PHE. We proposed allowing the hospice to furnish the addendum within 5 days from the date of a beneficiary or representative request, if the request is within 5 days from the date of a hospice election. [25] A pseudo-patient must be capable of responding to and interacting with the hospice aide trainee, and must demonstrate the general characteristics of the primary patient population served by the hospice in key areas such as age, frailty, functional status, cognitive status and care goals. Numerator: The number of decedent beneficiaries receiving a visit by a skilled nurse or social worker for the hospice in the last 3 days of the beneficiary's life within a reporting period. Update on the Hospice Visits in the Last Days of Life (HVLDL) and Hospice Item Set V3.00, we gave sufficient information in the proposed rule and this final rule to calculate HCI and HVLDL and access specifications. One commenter stated that it is important that CMS address this frequency so that hospices and cost report preparers can ensure that the data submitted on the cost report can be used for the labor share calculations. Comment: Many commenters offered suggestions to modify specific HCI indicators and expressed concerns about specific indicators rather than the HCI as a whole. Hospitalizations are found by looking at all inpatient claims. This document displays the CCN, name, and address of every hospice that successfully met quality reporting program requirements for the fiscal year. There exist some geographic areas where there were no hospitals, and thus, no hospital wage data on which to base the calculation of the hospice wage index. While we recognize the additional context that state survey data would provide, we believe the claims data used to calculate the HCI will provide valuable information to consumers on their own. The QM report will also include results of the individual indicators used to calculate the single HCI score, and provide details on the indicators and HCI overall score to support hospices in interpreting the information. While external circumstances could justify a hospice's poor performance on a single claims-based indicator, it would be unlikely for external circumstances to impact Start Printed Page 42558multiple claims-based indicators considered simultaneously. Specifications for the ten indicators required to calculate the single HCI score are described in this section. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Both the HCI and the HIS Comprehensive Measure are composite measures in that they act as single measures that capture multiple areas of hospice care. Response: We appreciate the support for this comment and agree that a targeted approach is both more efficient and will permit greater focus on remediating the deficient skills. Closing the Health Equity Gap in the Hospice Quality Reporting Program Request for Information (RFI). We believe that a signed addendum indicates the hospice discussed the addendum and its contents with the beneficiary (or representative). We are also revising the provisions at 418.76(h)(1)(iii) to state that if an area of concern is verified by the hospice during the on-site visit, then the hospice must conduct, and the hospice aide must complete, a competency evaluation related to the deficient and related skill(s) in accordance with 418.76(c). However, providers with substantially higher percent of live discharge than their peers could signal a potential concern with quality of care or program integrity. While all patient visits are meaningful, only patients with visits on two different days during the last three days of life will count towards the numerator for this measure. 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. 2020. 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. For example, we calculated reweighted compensation cost weights by ownership-type (proprietary, government and nonprofit), by size (based on RHC days) and by region. We believe that updating the data in January 2022 by more than a year relative to the October 2020 freeze data can assist the public by providing more relevant quality data and allow CMS to display more recent HHA performance. Comment: We received seven comments in support of the proposed hospice update percentage of 2.3 percent. One commenter requested a minimum of 6 months from the date final specifications are available for EMR and other vendors to respond to any changes in the HQRP. The fourth column shows the effect of the final rebased labor shares. 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). As we proposed, the labor shares are rounded to three decimal places consistent with the labor shares used in other Prospective Payment Systems (PPS) (such as the inpatient prospective payment system (IPPS) and the Home Health Agency PPS). One commenter stated that their hospice revisited the way relatedness is defined, and realized that many diagnoses that were previously thought to be unrelated were related. from 40 agencies. The HCI will help to identify whether hospices have aggregate performance trends that indicate higher or lower quality of care relative to other hospices. While hospice is not included in the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act of 2014) (Pub. The wage index and labor share standardization factors for each level of care are shown in the Tables 2 and 3. The ADA is a third-party beneficiary to this Agreement. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. In 2020, the TEP explored potential quality measure constructs that could be derived from HOPE and their specifications. The .gov means its official. New Documents This interdisciplinary, holistic scope of the HIS Comprehensive Assessment Measure better aligns with the public's expectations for hospice care. Many commenters noted that there is a great deal of variation among FHIR systems, which could impede the adoption of a standard system across hospices. If we were to delay our data extraction point to 12 months after the last date of the last discharge in the applicable period, we would not be able to deliver the calculations to hospices sooner than 18 to 24 months after the last discharge. We will notify the public about any system migration updates using subregulatory mechanisms such as web page postings, listserv messaging, and webinars. In October 2020, our contractor convened a workgroup of family caregivers whose family members have received hospice care to provide input on this measure concept from the family and caregiver perspective. First, it would reduce the proportion of hospices that would have CAHPS Hospice Survey data displayed on Care Compare. As stated earlier, we pre-emptively issued the March 27, 2020 CMS Guidance Memorandum making 2019 Q4 and Q1 and Q2 2020 exempt from reporting requirements. Star ratings benefit the public in that they can be easier for some to understand than absolute measure scores, and they make comparisons between hospices more straightforward. Additionally, other provider types, such as IPPS hospitals, home health agencies (HHAs), SNFs, IRFs, and the dialysis facilities all use CBSAs to define their labor market areas. HQRP and CMSs other quality reporting programs, are foundational for contributing to improvements in healthcare, enhancing patient outcomes, and informing consumer choice. Specifically, we compared submission rates in Q4 2019 to average annual rates (Q4 2018 through Q3 2019) to assess the Start Printed Page 42579extent to which hospices had taken advantage of the exemption, and thus the extent to which data and measure scores might be affected. In the FY 2022 IPPS proposed rule[5] The commenters stated that certain costs are not consistently reported by hospices despite these costs being in compliance with cost reporting instructions. In the FY 2021 Hospice Wage Index and Payment Rate Update final rule (85 FR 47079), we finalized a 1-year transition for fiscal year (FY) 2021 only, to mitigate the resulting short-term instability and negative impacts on certain providers and to provide time for providers to adjust to their new labor market delineations. In particular, we will continue to host HQRP Forums to allow hospices and other interested parties to engage with us on the latest updates and ask questions on the development of HOPE and related quality measures. Comment: A few commenters requested more details about if and how we will include patient-mix adjustment. The rule implemented temporary changes to the hospice payment requirements to provide broad flexibilities to furnish services using telecommunications technology in order to avoid exposure risks to health care providers, patients, and the community during the PHE. A commenter stated that as currently structured, the penalty is a negative incentive to furnish the addendum in a timely manner if a hospice misses the initial required timeframe. Therefore, hospice providers with larger costs (reflecting larger utilization) would have a larger weight in the proposed labor shares. The hospice must note (on the addendum itself) the reason the addendum was not signed and the addendum would become part of the patient's medical record. The seven HIS process measures are also available by visiting the data catalogue at https://data.cms.gov/provider-data/topics/hospice-care. 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. For the CAHPS Hospice Survey, 2.1 percent more hospices submitted data in Q4 2019 than in Q4 2018. However, OMB occasionally issues minor updates and revisions to statistical areas in the years between the decennial censuses. Removal of the Seven Hospice Item Set Process Measures From Public Reporting, (2). The commenter stated that this disregards the essence of the hospice interdisciplinary team which cares for the patient and family as a unit of care. It is these four quality measures, the HIS Comprehensive Assessment Measure, HCI, HVLDL, and CAHPS Hospice Survey that make up the FY 2022 HQRP requirements. CMS received feedback in response to this RFI on ways to attain health equity for all patients through policy solutions that apply to the HQRP. In addition, we are providing a provider-specific impact analysis file, which is available on our website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Regulations-and-Notices.html. 20. One commenter stated that it is difficult to attract nurses to their geographic area because of the increase in the median home price between January 2021 and May 2021. One commenter suggested including a statement that data cover care provided during the COVID-19 PHE for eight quarters. We are revising the provisions at 418.306(b)(2) to change the payment reduction for failing to meet hospice quality reporting requirements from 2 to 4 percentage points. The addendum must be titled Patient Notification of Hospice Non-Covered Items, Services, and Drugs; 3. Register documents. We are revising the provisions at 418.76(c)(1) that requires the hospice aide to be evaluated by observing an aide's performance of the task with a patient. We also considered using three years of data for HVLDL and HCI, and determined that three years did not yield the same benefit (that is, inclusion of hospices) relative to cost (that is, lag in reporting), and thus proposed using two years of data. A Rule by the Centers for Medicare & Medicaid Services on 08/04/2021. One commenter stated concern that due to hospice MCRs not being audited, as well as some sections of the cost report offering multiple methods of reporting, there is a general lack of consistency in the way that the reports are completed by hospice providers that will necessarily distort the average labor figures. For questions regarding home health public reporting, contact Charles Padgett (410) 786-2811. End users do not act for or on behalf of the CMS. The specifications for Indicator Three, Early Live Discharges, are as follows: The rate of live discharge that occurred 180 days or more after hospice enrollment identifies another potentially concerning pattern of live discharge from hospice. The FY 2022 rates for hospices that do not submit the required quality data would be updated by the FY 2022 hospice payment update percentage of 2.0 percent minus 2 percentage points. To implement this process, hospices would not be able to submit corrections to the underlying claims snapshot or add claims (for those claims-based measures) to this data set at the conclusion of the 90-day period following the last date of discharge used in the applicable period. HVLDL indicates the hospice provider's proportion of patients who have received visits from an RN or medical social worker (in-person) on at least two out of the final three days of the patient's life. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. (2020). Application of the COVID-19 PHE Affected Reporting (CAR) Scenario To Publicly Display Certain HH QRP Measures (Beginning in January 2022 Through July 2024), 6. In order to support provider and supplier communities due to the COVID-19 PHE, CMS has issued an unprecedented number of regulatory waivers under our statutory authority set forth at section 1135 of the Act. 2. CMS form 1984-14 was proposed and subject to public comments. Waiver or Modification of Requirements Under Section 1135 of the Social Security Act. This document has been published in the Federal Register. In the FY 2014 Hospice Wage Index and Payment Rate Update final rule (78 FR 48234), and in compliance with section 1814(i)(5)(C) of the Act, we finalized the specific collection of standardized data items, known as the HIS, that support the following NQF-endorsed measures: These measures were adopted to increase public awareness of key components of hospice care, such as pain and symptom management and non-clinical care needs. Notice and comment are unnecessary because we are conforming the regulation to statute and there is no discretion on the part of the Secretary. We also received feedback from several commenters about additional factors which should be considered when collecting data about health equity and disparities. Accessible via: https://oig.hhs.gov/oas/reports/region9/91803022.pdf. . To date we have not received reports of claims denials resulting from the implementation of the election statement addendum and the current regulations at 418.24. Register, and does not replace the official print version or the official We also support hospices providing necessary visits in the last days of life such that two visits occurring on the same day may be necessary. Comment: Some commenters expressed concern that the HCI will become topped out, with 85 percent of hospices scoring a 7 or better, limiting the measure's ability to differentiate between hospices. Hospice caregivers also welcomed the addition of new quality measures to the HQRP to better differentiate between hospices. In September 2020, we launched Care Compare, a streamlined redesign of eight existing CMS healthcare compare tools available on Medicare.gov, including Hospice Compare. Because of quality implications for hospices who pursue such business models, the live discharge after long hospice enrollments was included in the index. Validity analyses showed that hospices' HCI scores align with family caregivers' perceptions of hospice quality, as measured by CAHPS Hospice survey responses (NQF endorsed quality measure #2651). Using 3 quarters of data for the February 2022 refresh would allow us to begin displaying Q3 2020, Q4 2020, and Q1 2021 data in February 2022, rather than continue displaying November 2020 data (Q1 2019 through Q4 2019).