The commenter was concerned that costsand accordingly labor component costsare based on a small population with high risk of error. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. This measure does not recognize visits during CHC and GIP because these higher levels of care inherently require skilled visits per the COPs in accordance with 418.110 and 418.302. Furthermore, many of these clarifying regulations text changes have been previously addressed in sub-regulatory guidance. Certain events may limit the scope or accuracy of our impact analysis, because such an analysis is susceptible to forecasting errors due to other changes in the forecasted impact time period. The final definitions are as follows: These changes will allow hospices to utilize pseudo-patients, such as a person trained to participate in a role-play situation or a computer-based mannequin device, instead of actual patients, in the competency testing of hospice aides for those tasks that must be observed being performed on a patient. To assess these criteria, we conducted reportability and reliability analysis excluding the COVID-19 affected quarters of data in a refresh instead of the standard number of quarters of data for reporting for each HH QRP measure to model the impact of not using Q1 or Q2 2020 Specifically, we used historical data to calculate HH quality measures under two scenarios: The OASIS-based measures are based on the start of care and calculated using admission dates. 2. 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. Hospice providers are expected to have some rate of live discharges because some patients change their mind about using the hospice benefit and dis-enroll from hospice or their condition improves and they no longer meet the hospice eligibility criteria. The rest of this section presents the component indicators and their specifications. However, providers with substantially higher percent of live discharge than their peers could signal a potential concern with quality of care or program integrity. Final Decision: We are finalizing our proposal to resume public reporting of HIS quality measures in February 2022 using data from Q3 and Q4 of 2020 and Q1 of 2021. Hospice Deficiencies Pose Risks to Medicare Beneficiaries. They also questioned whether CMS expected that use of a revised questionnaire would increase the number of hospices that achieve 75 completed questionnaires and would, therefore, be included in star ratings. Services furnished voluntarily by physicians are not reimbursable. The MAP conditionally supported the HCI for rulemaking contingent on NQF endorsement. Issued by: Centers for Medicare & Medicaid Services (CMS). [10] The proposal to add the HCI also would not change provider burden or costs since it is a claims-based measure that CMS calculates from the Medicare claims data. Given this, weighting each of the two measures at 100 percent would over-emphasize global assessments of care relative to the other aspects of care assessed by CAHPS Hospice Survey measures. Our information gathering activities included soliciting feedback from hospice stakeholders such as providers and family caregivers; seeking input from hospice and quality experts through a Technical Expert Panel (TEP); interviews with hospice quality experts; considering public comments received in response to previous solicitations on claims-based hospice quality initiatives; and a review of quality measurement recommendations offered by the HHS Office of Inspector General (OIG), MedPAC, and the peer-reviewed literature. http://www.medpac.gov/docs/default-source/reports/mar21_medpac_report_to_the_congress_sec.pdf?sfvrsn=0. documents in the last year, 9 Related to the outcome measures and in order to have HOPE pain and symptom measures in the program as soon as possible, we plan to develop process measures, including on pain and symptom management. Denominator: The total number of RHC days provided by a hospice within a reporting period. Hospices which do not report HIS data used for the HIS Comprehensive Assessment Measure will not meet the requirements for compliance with the HQRP. Exceptions and Extensions for Quality Reporting Requirements for Acute Care Hospitals, PPS-Exempt Cancer Hospitals, Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies, Hospices, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, Ambulatory Surgical Centers, Renal Dialysis Facilities, and MIPS Eligible Clinicians Affected by COVID-19. Therefore, the HCI composite yields a more reliable provider ranking. Since April 2012, we have publicly displayed four quarters of HH CAHPS data every quarter, in the months of January, April, July, and October. 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. http://medpac.gov/docs/default-source/reports/mar20_medpac_ch12_sec.pdf. While payments made to hospices are to cover all items, services, and drugs for the palliation and management of the terminal illness and related conditions, Federal funds cannot be used for the prohibited activities, even in the context of a per diem payment. $=.Ydb{f DrE3n"c#f220m :? We solicited comments on these proposals for CAHPS Star Ratings and the public reporting of star ratings no sooner than FY 2022.Start Printed Page 42573. On March 27, 2020, we sent a guidance memorandum under the subject title, Exceptions and Extensions for Quality Reporting Requirements for Acute Care Hospitals, PPS-Exempt Cancer Hospitals, Inpatient Psychiatric Facilities, Skilled Nursing Facilities, Home Health Agencies (HHAs), Hospices, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, Ambulatory Surgical Centers, Renal Dialysis Facilities, and MIPS Eligible Clinicians Affected by COVID-19 to the MLN Connects Newsletter and Other Program-Specific Listserv Recipients,[52] Several other commenters also suggested posting a disclaimer that the HIS Comprehensive measure only comes from the admission item set and may not be reflective of subsequent care. Medicare spending per beneficiary is then calculated by dividing the total payments by the total number of unique beneficiaries. Specifications for the HCI Indicators Selected, (1). The MCR captures total overhead costs (including but not limited to administrative and general, plant operations and maintenance, and housekeeping) attributable to each of the four levels of care. Final Decision: We are finalizing the proposal to implement the hospice labor shares in a budget neutral manner through the use of the labor share standardization factors, so that the aggregate payments do not increase or decrease due to changes in the labor share values. Final Decision: We are finalizing the clarifications and addendum regulation text changes at 418.24(c) as proposed, with the exception of requiring the reason that the addendum is not signed to be documented in the patient's medical record. 47. Section 6005(a) of the Omnibus Budget Reconciliation Act of 1989 (Pub. The term contiguous means sharing a border (72 FR 50217). We will make explanatory information available to consumers, while recognizing that keeping the interface as streamlined as possible improves the usability of the site for consumers. Some commenters mentioned there was confusion regarding billing when an addendum is furnished late. The comments pointed out that the process for providers to adapt to the new tool requires at least 6 months or more. Response: We are currently conducting an experiment to test a new version of the survey, including the web mode of administration which may have an impact on response rates and the number of survey completes. Accessible via: https://oig.hhs.gov/oei/reports/oei-02-10-00490.asp. As discussed in this section, the HVLDL and HCI claims-based measures support the Meaningful Measures initiative and address gaps in HQRP. This adjustment is made using the change in the CPI from March 1984 to the fifth month of the cap year. CDT is a trademark of the ADA. We appreciate the comments and request for clarification on whether LPNs are included in visits. A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). This indicator includes both RN and LPN visits to recognize the frequency of skilled nursing visits and to maintain consistency in HCI when using revenue center code 055X. We estimate that aggregate payments to hospices in FY 2022 will increase by $480 million as a result of the market basket update, compared to payments in FY 2021. For complete information about, and access to, our official publications Omnibus Budget Reconciliation Act of 1989, 8. Additionally, we do not believe that we have the authority to apply the outmigration hospital adjustment to the hospice wage index because it is specific to the commuting patterns of hospital employees. We plan to provide opportunities for interaction with stakeholders to discuss our plans and methodology and to receive feedback prior to the start of star ratings display. Under the final rule, the hospices would see a 2.0 percent increase ($480 million) in their payments for FY 2022 relative to FY 2021. Indicator One: Continuous Home Care (CHC) or General Inpatient (GIP) Provided, (2). Currently, the only rural area without a hospital from which hospital wage data could be derived is Puerto Rico. The HCI's component indicators are assigned a criterion determined by statistical analysis of an individual hospice's indicator score relative to national hospice performance. Hybrid quality measures allow for a more comprehensive set of information about care processes and outcomes than cannot be calculated using claims data alone. As discussed in the FY 2022 Hospice proposed rule (86 FR 19718) and above, we proposed to derive Direct patient care salaries and contract labor costs using (for CHC as an example) Worksheet A-1 column 7, lines 26 through 37 on the cost report, which would capture any staff transportation costs reported in these cost centers on Worksheet A-1. HQRP Compliance Checklist illustrates the APU and timeliness threshold requirements. Commenters expressed concern that definitions were unclear. Response: The FY 2022 proposal contemplated a CAHPS-only measure in the short-term. FY 2016 Hospice Wage Index and Payment Rate Update Final Rule, 10. Their salaries and benefits must also be captured in the methodology. Furthermore, each indicator represents either a domain of hospice care recommended by leading hospice and quality experts[13] Medicare Department of Health and Human Services (DHHS) Provider Reimbursement ManualPart 2, Provider Cost Reporting Forms and Instructions, Chapter 43, Form CMS-1984-14. 26. We proposed to use a two-stage approach to calculate these cut-points. This final rule meets the requirements of our regulations at 418.306(c) and (d), which require annual issuance, in the Federal Register, of the hospice wage index based on the most current available CMS hospital wage data, including any changes to the definitions of CBSAs or previously used MSAs, as well as any changes to the methodology for determining the per diem payment rates. This timeframe is based on the CY. edition of the Federal Register. Denominator: The total number of elections with the hospice, excluding hospice elections where the patient elected hospice for less than 30 days within a reporting period. The 2020 Information Gathering Summary report is available at https://www.cms.gov/files/document/12042020-information-gathering-oy1508.pdf. There are four payment categories that are distinguished by the location and intensity of the hospice services provided. As we determine the most appropriate way to display the measure, we will ensure that the scope of the HIS Comprehensive Measure is clear for consumers, who can use the information with other information on the website to make their decisions. In conjunction with the Care Compare launch, we have made additional improvements to other CMS data tools, to help Medicare beneficiaries compare costs. The attachments to OMB Bulletin No. This information would provide additional context to the claims data of whether a hospice provided CHC or GIP. The size exemption is only valid for the year on the size exemption request form. It is possible that not all commenters reviewed last year's rule in detail, and it is also possible that some reviewers chose not to comment on the proposed rule. If you are human user receiving this message, we can add your IP address to a set of IPs that can access FederalRegister.gov & eCFR.gov; complete the CAPTCHA (bot test) below and click "Request Access". The wage index applicable for FY 2022 is available on our website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Hospice-Wage-Index. Comment: One commenter requested that clarification as to how CMS will adjust the labor share if certain types of hospices are found to provide more services and thus, likely have a larger labor share but contribute fewer cost reports. Given the timing of the COVID-19 PHE onset in the U.S., we determined that we would use data that were submitted for Q4 2019. Others noted that the delay could allow time for additional analysis of the measure, and for more transparency about the rationale for it. In order to finalize this proposal in time to release the required preview report related to the January 2022 refresh, which we release 3 months prior to any given refresh (October Start Printed Page 425292021), we needed the rule containing this proposal to finalize by October 2021. The testing helped us develop a plan for displaying HH QRP data that are as up-to-date as possible and that also meet scientifically-acceptable standards for publicly displaying those data. Payments are based upon the location of the beneficiary for routine and continuous home care or the location of the facility for respite and general inpatient care. Under the CAR scenario, the January 2022 refresh data would cover Q3 and Q4 of 2020 and Q1 of 2021, which occur during the flu season. Final Rule Action: We are finalizing as proposed at 418.76(c)(1) our policy that hospices may conduct competency testing by observing an aide's Start Printed Page 42552performance of the task with a patient or pseudo-patient. FY 2023 Final Medicaid State/County Rate Charts (XLS) for every county in every state with all levels of care, based on the national Medicaid rates in Table 1 below. The final rule ([CMS-1754-F)can be downloaded from theFederal Registerat: https://www.federalregister.gov/public-inspection/current, For further information, see the hospice center webpage: http://www.cms.gov/Center/Provider-Type/Hospice-Center.html, CMS News and Media Group In addition, we finalized a policy to use the current year's pre-floor, pre-reclassified hospital inpatient wage index as the wage adjustment to the labor portion of the hospice rates. Comment: Some commenters recommended that the timeframe to furnish the addendum to the beneficiary (or representative) when requested after the first 5 days of a hospice election be changed from 3 days to 5 days. A written clinical explanation, in language the beneficiary and his or her representative can understand, as to why the identified conditions, items, services, and drugs are considered unrelated to the terminal illness and related conditions and not needed for pain or symptom management. Palliative care is at the core of hospice philosophy and care practices, and is a critical component of the Medicare hospice benefit. We will continue to engage all stakeholders throughout this process. For example, for the CY 2022 data collection year, the Reference Year, is CY 2021. In the FY 2016 Hospice final rule (80 FR 47186) adopted seven factors for measure removal, and in the FY 2019 Hospice final rule (83 FR 38636) adopted the eighth factor for measure removal. We appreciate and understand the importance of provider input and involvement in ensuring that this document is effective in increasing coverage transparency for beneficiaries. However, we believe that the single measure currently continues to show sufficient variability to differentiate hospices and therefore provides value to patients, their families, and providers. Response: As stated in section III F(3)(e). No single quality measure within the portfolio is expected, or necessarily intended, to provide that view on its own. They stated that social workers and counselors provide direct patient care along with nurses and hospice aides in both routine home care and general inpatient care. As finalized in the FY 2016 Hospice Wage Index and Payment Rate Update final rule (80 FR 47192), hospices' compliance with HIS requirements beginning with the FY 2020 APU determination (that is, based on HIS-Admission and Discharge records submitted in CY 2018) are based on a timeliness threshold of 90 percent. This does not constitute a change to the requirements of the CoPs. Instead, progress on HCI will occur over longer time frames, and annual updates are sufficient to support hospices' efforts to improve. Consequently, we determined to freeze the data displayed, that is, holding data constant after the October 2020 refresh without subsequently updating the data through October 2021. 100-04 Medicare Claims Processing Transmittal 10929, Change Request 12354 dated August 4, 2021. Hospice Rates for Providers that Have Submitted the Required Quality Data Federal Fiscal Year 2022 Effective Retroactive to October 1, 2021 . The comprehensive assessment includes all areas of hospice care related to the palliation and management of a beneficiary's terminal illness. L. 116-260) to change the payment reduction for failing to meet hospice quality reporting requirements from 2 to 4 percentage points. For hospice elections beginning on or after October 1, 2020, in the event that the hospice determines there are conditions, items, services, or drugs that are unrelated to the individual's terminal illness and related conditions, the individual (or representative), non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement. We are also finalizing regulatory changes that are not directly related to PHE waivers that will clarify or align some policies that have been raised as concerns by stakeholders. The labor shares showing the revised methodology are provided in Table 1. Accessible via: https://oig.hhs.gov/oas/reports/region9/91803022.pdf. We exclude all claims for a beneficiary if a beneficiary ever had two overlapping hospice days on separate claims. The specifications for Indicator Ten, Visits Near Death, are as follows: As discussed during the NQF's January 2021 MAP meeting, the HCI summarizes information from ten indicators with each indicator representing key components of the hospice care received, recognizing care delivery and processes. We conducted analyses of those data to ensure that their use was appropriate. Approved Hospice CAHPS vendors must successfully submit data on the hospice's behalf to the CAHPS Hospice Survey Data Center. Fast Healthcare Interoperability Resources (FHIR) in Support of the Hospice Quality Reporting Program RFI. In addition to the Preview Report, we will also include claims-based measure scores in the Hospice Agency-Level QM Report in CASPER. Particularly during the last few days before death, patients (and caregivers) experience many physical and emotional symptoms, necessitating close care and attention from the hospice team and drawing increasingly on hospice team resources. Since the HIS Comprehensive Assessment Measure captures all seven processes collectively, we believe that public display of the individual component measures is not necessary. For these reasons, adding disclaimer text as suggested would not help consumers seeking information make decisions about care options. 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. In the proposed rule, we proposed to introduce Star Ratings for public reporting of CAHPS Hospice Survey results on the Care Compare or successor websites no sooner than FY 2022. As discussed in section III.B of this rule, we are finalizing to rebase and revise the labor shares for CHC, RHC, GIP and IRC using MCR data for freestanding hospices (CMS Form 1984-14, OMB Control Number 0938-0758) for 2018. Response: We agree that hospice care is interdisciplinary care delivered by clinical and non-clinical staff supporting the patient's plan of care. If they did not experience the symptom, the instructions say to skip to another question. [343536] Physical symptoms of actively dying can often be identified within three days of death in some patients.[37]. Calculating and Publicly Reporting Claims-Based Measure as Part of the HQRP, (3). The supervising RN then determines the scope of the competency testing required, which may include a full competency testing of all skills if warranted, such as when multiple areas of deficient practice are noted. Effective Federal Fiscal Year 2023 (October 1 - September 30), there were no counties that changed their status, CBSA name and/or CBSA number. This indicator identifies whether a hospice is below the 90th percentile in terms of the percentage of live discharges that occur within 7 days of hospice admission during the fiscal year examined. We do not have a policy for `exceptional circumstances' (that is floods, hurricanes, etc.) [20] The commenter suggested that more research and data are required on the use of pseudo-patients and changes to competency requirements prior to making a policy decision. We then simultaneously removed those providers whose total IRC costs per day fall in the top and bottom one percent of total IRC costs per day for all IRC providers as well remove those providers whose compensation cost weight falls in the top and bottom five percent of compensation cost weights for all IRC providers. The COVID-19 PHE Exception applied to Q1 and Q2 of 2020. Update on Use of Q4 2019 HH QRP Data and Data Freeze for Refreshes in 2021, 5. Medicare hospice: Use of general inpatient care. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. J723MLCb{Cl%@7* . Final Decision: In this final rule, we are not making any revisions to the HIS Comprehensive Assessment Measure. The median reliability scores for the HIS Comprehensive Assessment Measure are also very similar in both CAR and SPR scenarios. Therefore, we would consider the hospice claims data to be complete for purposes of calculating the claims-based measures at this point.
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