Home Health Care Policies: On April 30, 2015, the Centers for Medicare & Medicaid Services (CMS) issued its proposed rule governing payment and policy changes for the 2016 fiscal year beginning October 1, 2015. The proposed rule contains numerous policy changes in the hospice arena as described here. The National Association for Home Care & Hospice (NAHC) submitted comments and recommendations on the proposal earlier this week.
NAHC’s comment letter to CMS includes general comments on the rule, specific policy concerns and suggestions related to the proposed payment and quality changes, and makes recommendations related to implementation of the proposed changes. NAHC notes at the start of its letter that a particular concern in analyzing the proposed payment changes is that CMS has not released the technical report that reflects information about the proposed payment reforms for hospice; failure to release the report has made it more challenging to assess alternative payment changes. For this reason, NAHC has urged CMS to release the technical report as soon as possible so that the hospice community has more information related to the decisions that CMS made on payment reform.
PAYMENT REFORM. As part of the proposed rule, CMS provided additional data about patterns of care and spending inside and outside of the hospice benefit while patients are on hospice care. NAHC notes that a hospice’s deliberate failure to cover items and services that are part of the hospice bundle is inappropriate and should be addressed through enforcement mechanisms. However, NAHC also notes that problems with the timeliness of data on hospice elections posting to the Common Working File (CWF) has contributed to inadvertent spending outside of the hospice benefit. Further, NAHC comments that CMS’ systems issues have created significant financial losses and operational burdens with respect to the timely filing requirements for the hospice Notice of Election (NOE) and Notice of Termination/Revocation (NOTR) that went into effect in October 2014. NAHC urges CMS to take steps to mitigate the negative impact of the NOE/NOTR timely filing requirements and, over the longer term, to overhaul data systems to allow for more timely processing of beneficiary status. NAHC also cautions CMS against any “blanket determination that all care provided to patients on hospice is the responsibility of the hospice” -- a patient’s right to care outside of hospice for conditions that are not related to the terminal prognosis must be preserved.
Relative to CMS’ proposed two-tiered payment system for routine home care (RHC), NAHC notes that the Medicare Payment Advisory Commission (MedPAC) has estimated that it takes 21 days for a hospice to “break even” on the provision of care after a patient first elects hospice care. NAHC requests that CMS provide information about how the changes to the RHC rates will impact the timing on when a hospice might generally expect to “break even” relative to payment for services. NAHC also urges CMS to conduct ongoing analysis of the adequacy of the payment changes with particular attention to the overall impact on hospices that provide care predominantly to patients with shorter lengths of stay. NAHC also expresses concerns about the inadequacy of CMS’ data systems and their limited ability to provide accurate information related to a patient’s history of hospice use as this will contribute to ongoing challenges for hospices in determining the appropriate payment rates and planning financially for patients coming onto service.
In its letter, NAHC expresses strong opposition to CMS’ proposal to not permit Service Intensity Add-on payments when such services are provided to patients residing in nursing facilities or skilled nursing facilities. NAHC notes that “a prohibition against coverage of SIA services based on a patient’s residence creates unfair and negative incentives that could limit equal access to service for extremely vulnerable patients.” NAHC also urges CMS to reconsider its decision to limit SIA payment only to services provided by Registered Nurses (RNs) and Social Workers. NAHC believes that this add-on should also be permitted for services provided by Licensed Practical Nurses (LPNs)/Licensed Vocational Nurses (LVNs). NAHC also urges CMS to collect data on chaplain visits and in future rulemaking to consider extension of the SIA payment to chaplain services, as well, and to conduct study of resource intensity for patients that transfer from one hospice to another or are readmitted late in an episode of care to determine whether an SIA policy should be instituted in such cases to help cover the high costs at the beginning of care that might be associated with patients being readmitted onto service. Finally, NAHC urges ongoing analysis of the extent to which care cots in the last seven days of life are adequately compensated under the new payment structure.
NAHC addresses numerous implementation issues as part of its comments; of particular concern is whether the new RHC rates would apply to new admissions or to all patients on service; NAHC recommends that the payment rates be implemented for new admissions onto care. Additionally, NAHC expresses concern that there may not be sufficient time between release of the final hospice payment rule and the beginning of the 2016 fiscal year and suggests that CMS only implement the new payment system after it has completed all of the required systems changes and allowed for a “dry run” to ensure a smooth transition.
HOSPICE QUALITY REPORTING. NAHC expresses support for most of the changes that CMS is proposing as part of the quality reporting section of the rule. However, NAHC does caution against use of claims data-based measures (which CMS has identified as a priority area for future measures) unless CMS can ensure that measures can be directly linked to quality of care.
DIAGNOSES ON CLAIMS. NAHC expresses concern that CMS is issuing as a clarification a directive to hospice providers that they should be including all diagnoses on claims -- whether related or not related to the terminal prognosis. This clarification is at odds with a clarification issued last year that instructed hospices to include only related diagnoses on hospice claims. NAHC cautions that sufficient time should be allowed before CMS undertakes any monitoring or enforcement action relative to diagnoses on claims as systems changes will be required to ensure that all diagnoses can flow to the claim, but also raises questions about CMS’ future intent relative to this clarification.
A final rule on the FY2016 hospice payment and quality changes will be issued some time later this summer; NAHC will report on CMS’ disposition of the issues mentioned above and other items discussed in the proposed rule at that time. NAHC’s comment letter on the proposed hospice payment rule is available here.