hospice rates 2022 by county and cbsa

on the guidance repository, except to establish historical facts. Our analyses have determined that the optimal balance between these two goals is at 75 completed surveys per hospice. On Thursday, July 29, 2021 the FY 2022 Hospice Wage Index and Payment Update Final Rule went on display on the Federal Register website for public inspection. This table of contents is a navigational tool, processed from the electronic version on GPOs govinfo.gov. We assume that days billed as GIP will include nursing visits. 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. Section 1814(i)(5) of the Act requires the Secretary to establish and maintain a quality reporting program for hospices. [27] The distributional effects of the final FY 2022 hospice wage index do not result in a greater than 5 percent of hospices experiencing decreases in payments of 3 percent or more of total revenue. The commenters requested consideration of the impact of COVID-19 when setting labor shares for future years. They include instances where the patient was no longer found terminally ill and revocations due to the patient's choice. (ii) Performance or improvement on a measure does not result in better patient outcomes. Medicare beneficiary summary file to determine dates of death. This helps hospices apply quality improvement processes to continue improving their performance on the HIS Comprehensive Assessment Measure. Response: We appreciate the commenters highlighting the use of pseudo-patients and simulation techniques in other healthcare setting and agree that the use of these techniques is standard of practice in many formal nursing assistant programs. We appreciate suggestions for new quality measures, as well as comments about the public reporting of quality measures. All other boundaries and names are as of January 1, 2012. While recent news reports[2] !Y,$d Ezg`"LA$' Hospices would need to make sure the date furnished' on the addendum is within the required timeframe (3 or 5 days, depending upon when the request was made). incorporated into a contract. Additionally, several commenters noted that the proposed rule does not state how many hospices will meet the 75 completes threshold. Comment: Several commenters stated that the CAHPS Hospice Survey is unlike other CAHPS surveys in that the respondents are family members or friends of the deceasednot the patients themselves. Response: As stated in the FY 2022 Hospice Wage Index and Rate Update proposed rule . We also required that IRC direct patient care salaries and contract labor costs per day would be greater than 1. .https://www.cms.gov/files/document/guidance-memo-exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf. Recommendations to minimize the information collection burden on the affected public, including automated collection techniques. So, it is not unreasonable to require that the electronically sent addendum also be signed to ensure that the patient is aware of the important information about hospice non-covered items, services, and drugs. Suggested parts of SDOH standardized patient assessment data elements adoption that could apply to hospice in alignment with national data collection and interoperable exchange standards. The proposed labor shares reflect the skilled care (including the number of visits) provided under the hospice per diem payment rates for each level of care. Palliative & Supportive Care, 13(2): 211-216. doi: 10.1017/S1478951513001144. Other patient care salaries are those salaries attributable to patient services including but not limited to patient transportation, labs, and imaging services. Public Health Emergency. A summary of the comments we received on this proposal and our responses to those comments appear below: Comment: A few commenters expressed concern that hospices would not be able to view data close to real time, which might inhibit the ability to use the score to inform continuous quality improvement. One commenter also stated that they were interested in how the percentage of hospices that operate inpatient facilities can be increased and all costs, including contracted costs, can be included. CDT is a trademark of the ADA. Hospices which do not report HIS data used for the HIS Comprehensive Assessment Measure will not meet the requirements for compliance with the HQRP. For this indicator, we identified hospice stays that included 30 or more consecutive days of hospice. 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. Comment: Many commenters expressed concern about publicly reporting data that was collected and/or delivered during the COVID-19 PHE. They suggested that the display of star ratings be delayed because CMS needs to provide additional opportunities for providers to learn about and comment on the details of the methodology. CY 2019 HH PPS final rule with comment period (. Counts are subject to sampling, reprocessing and revision (up or down) throughout the day. Many commenters noted their concern about the distinction between performance measures and quality of care measures. 19. However, in its comment, MedPAC concluded that the aggregate level of payments could be reduced and would still be sufficient to cover hospice providers' costs and preserve beneficiaries' access to care. Therefore, MedPAC recommended a zero percent update for FY 2022 for all hospice providers. Thus, we proceeded with including Q4 2019 data in measure calculations for the October 2020 refresh. We believe HCI does reflect hospice quality because the HCI indicators were identified as quality issues by the Office of Inspector General,[38,39,40] This assessment is necessary because it provides an overview of the items, services and drugs that the patient is already utilizing as well as helps determine what the hospice may need to add in order to treat the patient throughout the dying process. Response: We are currently conducting an experiment to test a shorter version of the CAHPS Hospice Survey. 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). The specifications for Indicator One, CHC or GIP services provided, are as follows: The OIG has found instances of infrequent visits by nurses to hospice patients. Commenters requested sufficient time to understand the measures, set up monitoring systems (sometimes with vendor support), assess trends in their performance relative to national benchmarks, and develop plans for quality improvement, as CMS normally provides. The exemption is determined by CMS and is for 1 year only. Closing the Health Equity Gap in Post-Acute Care Quality Reporting ProgramsRequest for Information, VI. Comment: Many commenters offered suggestions to modify specific HCI indicators and expressed concerns about specific indicators rather than the HCI as a whole. Response: As discussed in the CMS-10390 Supporting Statement published October, 23, 2020 and HIS V3.00 approved by OMB on February 16, 2021, we pursed a re-specification of the HVWDII measure concept using Medicare claims data because claims data also capture RN and medical social worker visits by hospice. The commenters stated that the hospice cost report in its current form does not suit all data purposes for hospice policy changes, and does not fully support calculation of the hospice payment rate labor shares. 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. We disagree with the commenter that the cost report in its current form does not support the calculation of the hospice payment rate labor shares. Information about this document as published in the Federal Register. We are also amending the requirement at 418.76(h)(1)(iii) to specify 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 of the deficient skill and all related skill(s) in accordance with 418.76(c). 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. We believe that this will benefit the hospice and the patient by allowing new aide trainees and aides requiring remedial training and competency testing to begin serving patients more quickly while protecting patient health and safety. While we received comments, this update is statutorily required and self-implementing. Refinements to repricing: For CY 2022, CMS will reprice the CY 2017-2019 historical hospice . The COVID-19 PHE Exception applied to Q1 and Q2 of 2020. 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. For purposes of the RFA, we consider all hospices as small entities as that term is used in the RFA. Comment: We received several comments expressing concern about the timing for publicly reporting HVLDL and HCI on Care Compare and the Provider Data Catalogue. Response: We appreciate the commenters' recommendations; however, these comments are outside the scope of the proposed rule. (2020, March 27). The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) (Pub. A list of the beneficiary's current diagnoses/conditions present on Start Printed Page 42546hospice admission (or upon plan of care update, as applicable) and the associated items, services, and drugs, not covered by the hospice because they have been determined by the hospice to be unrelated to the terminal illness and related conditions; 6. CMS DISCLAIMER. Comment: A few commenters questioned whether it is CMS's intent for the CAHPS to be the sole star rating vehicle for hospice care or whether there would be another star rating for HOPE measures when it is implemented? We sought public comment on quality measure concepts and considerations for developing hybrid measures based on a combination of data sources. This will allow us to maximize the number of hospices that will have CAHPS scores displayed on Care Compare, protect the reliability of the data, and report as much of the most recent data as possible. The day occurs during the last sevendays of the patient's life, and the patient is discharged. We define a hospice stay by a sequence of consecutive days for a particular beneficiary that are billed under the hospice benefit. In the FY 2012 Hospice Wage Index and Rate Update final rule (76 FR 47320 through 47324), we implemented a HQRP as required by those sections. Section 1814(a)(7)(B) of the Act requires that a written plan for providing hospice care to a beneficiary who is a hospice patient be established before care is provided by, or under arrangements made by, the hospice program; and that the written plan be periodically reviewed by the beneficiary's attending physician (if any), the hospice medical director, and an interdisciplinary group (section 1861(dd)(2)(B) of the Act). We recognize that the HIS Comprehensive Assessment Measure reflects high scores and is improving over time, which may cause the measure to also become topped out in the future. To calculate the percentage, for each hospice we divided the number of live discharges that are followed by a hospitalization (within 2 days of hospice discharge) and then followed by a hospice readmission (within 2 days of hospitalization) in a given reporting period by the number of live discharges in that same period. 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. The hospice cap runs from October 1st of each year through September 30th of the following year. Section 1814(i)(5)(D)(iii) of the Act requires that the Secretary publish selected measures applicable with respect to FY 2014 no later than October 1, 2012. Comment: The majority of commenters supported the clarifications and proposed regulation text changes regarding the election statement addendum. Beginning with January 2022, we will resume reporting four quarters of HH CAHPS data. Likewise, the proposal to publicly report the claims-based HVLDL quality measure would not result in reduced provider burden and related costs. The fifth column shows the effect of the hospice payment update percentage as mandated by section 1814(i)(1)(C) of the Act, and is consistent for all providers. 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. In particular, claims do not fully capture patients' clinical conditions, patient and caregiver preferences, or hospice activities such as telehealth, chaplain visits, and specialized services such as massage or music therapy. Response: We appreciate MedPAC's comments; however, we are required by law to update the hospice cap amount from the preceding year by the hospice payment update percentage, in accordance with section 1814(i)(2)(B)(ii) of the Act. At this point, we are still assessing the impact of all waivers and flexibilities on beneficiaries and the delivery of healthcare services under the PHE. Both indicator three and indicator four of the HCI recognize concerning patterns of live discharge impacting patient experience and quality of care. Commenters noted that hospices were not included in the EHR Incentive Program, which provided grants to hospices to develop HIT systems. Finally, the FY 2016 Hospice Wage Index and Rate Update final rule (80 FR 47144) clarified that hospices would have to report all diagnoses on the hospice claim as a part of the ongoing data collection efforts for possible future hospice payment refinements. (6) The availability of a measure that is more strongly associated with desired patient outcomes for the particular topic. All regulations will take effect on October 1, 2021. Additionally, creating a comprehensive quality measure capturing a variety of related care processes and outcomes in a single metric will provide consumers and providers an efficient way to assess the overall quality of hospice care, which can be used to meaningfully and easily compare hospice providers to make a better-informed health care decision. Furthermore, we expect that hospices will have processes in place when they are obtaining a signed addendum from a beneficiary or representative. Register, and does not replace the official print version or the official within a FY. Response: We will not include data from Q1 and Q2 2020 in Star Rating calculations, as hospices were exempted from submitting these quarters of data to CMS due to the COVID-19 PHE. We received many comments emphasizing that financial incentives would encourage providers to adopt new HIT systems and work to reduce burden using FHIR and EHR. Section III.A of this final rule includes a summary of comments from the public, including hospice providers as well as patients and advocates, regarding the presented analysis in the FY 2022 hospice proposed rule on hospice utilization, spending patterns and non-hospice spending during a hospice election. (10) Date the hospice furnished the addendum. With just one click, patients can find information that is easy to understand about doctors, hospitals, nursing homes, and other health care services instead of searching through multiple tools. The proposed labor shares are based on MCR data for freestanding hospice facilities. Ways CMS can promote health equity in outcomes among hospice patients. The testing helped us develop a plan for posting data as early as possible, for as many hospices as possible, and with scientific acceptability similar to standard threshold for public reporting. Additionally, we believe that both the requirements at 418.76(h) are exempt from the PRA. 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. In September 2020, we launched Care Compare, a streamlined redesign of eight existing CMS healthcare compare tools available on Medicare.gov, including Hospice Compare. These covered services include: Nursing care; physical therapy; occupational therapy; speech-language pathology therapy; medical social services; home health aide services (called hospice aide services); physician services; homemaker services; medical supplies (including drugs and biologicals); medical appliances; counseling services (including dietary counseling); short-term inpatient care in a hospital, nursing facility, or hospice inpatient facility (including both respite care and procedures necessary for pain control and acute or chronic symptom management); continuous home care during periods of crisis, and only as necessary to maintain the terminally ill individual at home; and any other item or service which is specified in the plan of care and for which payment may otherwise be made under Medicare, in accordance with Title XVIII of the Act. We then proposed to multiply these noncapital nonbenefit overhead costs for each level of care times the ratio of total facility overhead salaries (Worksheet A, column 1, lines 4 through 16) to total facility noncapital nonbenefit overhead costs (which is equal to Worksheet B, column 18 (total costs), line 101 less the sum of Worksheet B, columns 0 (direct patient care costs), column 1 (fixed capital), column 2 (moveable capital) and column 3 (employee benefits), line 101). Response: As stated in the FY 2022 Hospice Wage Index and Rate Update proposed rule (86 FR 19717), we did Start Printed Page 42535explore the possibility of using facility-based hospice MCR data to calculate the compensation cost weights; however, very few providers passed the Level I edits and so these reports were not usable. For HVLDL, where higher scores indicate better quality of care, the national average score was 65.5 percent in FY 2019, where 965 hospices did not meet the reportability threshold. The CR also updates the FY 2023 hospice aggregate cap amount. We recognize that there are many regional variations in care delivery trends. 47. A higher value in these scores indicates that HIS Comprehensive Assessment Measure values are relatively consistent for patients admitted to the same hospice and variation in the measure reflects true differences across providers. https://www.qualityforum.org/Projects/c-d/Cost_and_Resource_Project/2158.aspx. One commenter stated that with only those cost reports from providers that have a hospice inpatient unit being used to determine the GIP and inpatient respite labor costs, they are concerned because one of their two affiliated hospices does have an inpatient unit, and yet they sometimes refer patients to contracted facilities for these levels of care as well. We will continue to evaluate the impact of the COVID-19 PHE. corresponding official PDF file on govinfo.gov. Given the findings about stability in claims measure scores, and the cost of updating more frequently, all PAC settings update claims-based measures annually. Local, state, and federal government websites often end in .gov. Indeed, they noted that Questions such as How often did your family member get the help he or she needed for trouble breathing or How often did your family member get the help he or she needed for constipation are difficult for family members to answer if their loved one did not experience issues with those symptoms.. Overlapping inpatient claims were combined to determine a full length of a hospitalization (looking at the earliest from date and latest through date from a series of overlapping inpatient claims). We are also considering developing hybrid quality measures that would be calculated using claims, assessment (HOPE), or other data sources. Table 20 displays the original schedule for public reporting of OASIS and HH CAHPS Survey measures prior to the Q1 and Q2 2020 data impacted by the COVID-19 PHE. Index Earned Point Criterion: Hospices earn a point towards the HCI if their individual hospice score for percentage of decedents receiving a visit by a skilled nurse or social worker in the last 3 days of life falls above the 10th percentile ranking among hospices nationally. (2) For accounting years that end after September 30, 2016, and before October 1, 2030, the cap amount is the cap amount for the preceding accounting year updated by the percentage update to payment rates for hospice care for services furnished during the fiscal year beginning on the October 1 preceding the beginning of the accounting year as determined pursuant to section 1814(i)(1)(C) of the Act (including the application of any productivity or other adjustments to the hospice percentage update). In the FY 2017 Hospice Wage Index and Rate Update final rule (81 FR 52160), CMS finalized several new policies and requirements related to the Hospice Quality Reporting Program (HQRP). Response: As stated in the proposed rule, we will display CAHPS Hospice Survey star ratings no sooner than FY 2022. on 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. As described in the August 8, 1997 Hospice Wage Index final rule (62 FR 42860), the pre-floor and pre-reclassified hospital wage index is used as the raw wage index for the hospice benefit. Another exclusion was made prior to reporting the numbers in Table B.1. Response: We thank all the commenters for their thoughtful suggestions and feedback related to future of quality measure development for the HQRP. In the FY 2020 Hospice Wage Index and Payment Rate Update final rule (84 FR 38484), we discussed our interest in developing quality measures using claims data, to expand data sources for quality measure development. We noted this revised statutory requirement in our proposed rule (86 FR 19726) and are codifying the revision at 418.306(b)(2). How do I know if I am in the right place? The HQRP seeks to align with the other settings. Relatedly, in the HIS V3.00 PRA Submission, CMS-10390 (OMB control number: 0938-1153), we finalized the proposal to remove Section O from the HIS. Calculating and Publicly Reporting Claims-Based Measure as Part of the HQRP, (3). Comment: Several comments recommended that CMS not implement HCI because the indicators seem to emphasize medical services, focused heavily on services provided by RNs/LPNs, or do not account for the full interdisciplinary group (for example, claims do not account for spiritual care). The 'Wage Index' links contain the listing of Core Based Statistical Area (CBSA) codes and the corresponding wage index. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). While CMS agrees that all patient visits are meaningful, based on our analyses, we found that RN and medical social worker visits correlate well with the CAHPS quality measures for would recommend the hospice. However, while a hospice can choose to document the reason for an unsigned addendum in the medical record, as well as on the addendum, it is not required. The commenter stated that they believe their patients and their representatives would welcome this option; however, it is unclear whether mailing the form is acceptable for CMS. Therefore, the hospice payment update percentage for FY 2022, based on more recent data, is 2.0 percent. This policy will apply beginning with FY 2024 annual payment update (APU). The specifications for Indicator Eight, Skilled Nurse Care Minutes per RHC Day, are as follows: Our regulations at 418.100(c)(2) require that [n]ursing services, physician services, and drugs and biologicals . Catherine Howden, DirectorMedia Inquiries Form We are finalizing our proposal to remove the seven HIS process measures from the HQRP as individual measures, and no longer applying them to the FY 2024 APU and thereafter. The SIA payment is equal to the CHC hourly rate multiplied by the hours of nursing or social work provided (up to 4 hours total) that occurred on the day of service, if certain criteria are met. Under section 1135 of the Act, the Secretary may temporarily waive or modify certain Medicare, Medicaid, and Children's Health Insurance Program (CHIP) requirements to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the programs in the emergency area and time periods, and that providers who furnish such services in good faith, but who are unable to comply with one or more requirements as described under section 1135(b) of the Act, can be reimbursed and exempted from sanctions for violations of waived provisions (absent any determination of fraud or abuse). We are revising the hospice aide requirements to allow the use of the pseudo-patient for conducting hospice aide competency evaluations. Response: We acknowledge and appreciate the commenters' concerns regarding labor costs and understand the challenges created by the PHE. Response: As stated previously, we recommend that hospices use data from their vendors for quality improvement, rather than wait for publicly-reported data. Section 418.3 is amended by adding definitions for Pseudo-patient and Simulation in alphabetical order to read as follows: Pseudo-patient means a person trained to participate in a role-play situation, or a computer-based mannequin device. Continuous home care may be covered for as much as 24 hours a day, and these periods must be predominantly nursing care, in accordance with the regulations at 418.204. Further information about these requirements may be found at: http://www.hhs.gov/ocr/civilrights. We believe the information provided in the proposed and final rule allows for commenters to replicate, with their own claims data, the indicators, thresholds, and points earned. Response: We acknowledge the commenters' concern that the proposed rule did not explicitly state when we plan to propose any revisions to the hospice labor shares beyond FY 2022. Comment: A number of commenters suggested that CMS continue providing the option for hospices to view detailed information about the individual measures that make up the HIS Comprehensive Assessment measure to support quality improvement. That is, how do hospices define what is unrelated to the terminal illness and related conditions when establishing a hospice plan of care. We received a total of 32 comments pertaining to the proposed revision to the CoPs. The intent was to provide an illustrative example so hospices can modify and develop their own forms to meet the content requirements. Response: While these comments are out of scope of the proposed rule, we appreciate and welcome all feedback related to the late penalty; ABN and expansion of the addendum; signatures; exceptional circumstances; and educating hospice providers. Response: We appreciate commenters' interest in having the HCI reflect how prepared hospices are to provide key services to patients. Response: We appreciate commenters' concerns regarding the administrative burden in quality reporting. The commenter claimed that the proposed methodology only captures salaries and benefits of physicians, nurse practitioners, RNs and hospice aides. Index Earned Point Criterion: Hospices earn a point towards the HCI if their average Medicare spending per beneficiary falls below the 90th percentile ranking among hospices nationally. (3) CMS may remove a quality measure from the Hospice QRP based on one or more of the following factors: (i) Measure performance among hospices is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made. Additionally, in the event that a beneficiary (or representative) does not request the addendum, we expect hospices to document, in some fashion, that an addendum has been discussed with the patient (or representative) at the time of election, similar to how other patient and family discussions are documented in the hospice's clinical record. These commenters believed that the existing process measures provide more valuable and transparent information about hospice performance than the HIS Comprehensive Assessment composite measure.

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