On April 27, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1692-P) that would update fiscal year (FY) 2019 Medicare payment rates and the wage index for hospices serving Medicare beneficiaries. The public comment period for this proposed rule ends on June 26, 2018. For further information, see http://www.cms.gov/Center/Provider-Type/Hospice-Center.html.
This rule proposes updates to the hospice payment rates for fiscal year (FY) 2019, as required under section 1814(i) of the Social Security Act (the Act). This proposed rule provides an update on the Hospice QRP consistent with the requirements of section 1814(i)(5) of the Act, as added by section 3004(c) of the Affordable Care Act. In accordance with section 1814(i)(5)(A) of the Act, starting in FY 2014, hospices that fail to meet quality reporting requirements receive a 2.0 percentage point reduction to their payments.
Advancing My HealthEData: Request for Information from Stakeholders
In addition to payment and policy proposals, CMS is releasing a Request for Information (RFI) to obtain feedback on positive solutions to better achieve interoperability or the sharing of healthcare data between providers. Specifically, CMS is requesting stakeholder feedback through a RFI on the possibility of revising Conditions of Participation related to interoperability as a way to increase electronic sharing of data by providers. This will inform next steps to advance this critical initiative.
In responding to the RFI, commenters should provide clear and concise proposals that include data and specific examples. CMS will not respond to RFI comment submissions in the final rule, but rather will actively consider all input in developing future regulatory proposals or future sub-regulatory guidance.
This rule proposes to enable more efficient use of Hospice Compare data by no longer directly displaying the 7 component measures from which a composite measure is calculated on Hospice Compare, once the composite measure is displayed. CMS would still provide the public the ability to view these component measures in a manner that avoids confusion on Hospice Compare. CMS plans to achieve this by reformatting the display of the component measures so that they are only viewable in an expandable/collapsible format under the composite measure itself, thus allowing users the opportunity to view the component measure scores that were used to calculate the main composite measure score.
This proposed rule would advance CMS’s Meaningful Measures initiative. In the FY 2016 Hospice Final Rule (80 FR 47186), CMS adopted seven factors for measure removal. This rule proposes to adopt an eighth factor to consider when evaluating measures for removal from the HQRP measure set: The costs associated with a measure outweigh the benefits of its continued use in the program. CMS believes costs can be multi-faceted and include not only the burden associated with reporting, but also the costs associated with complying with the program. For example, it may be costly and burdensome for health care providers to report a measure for which our analyses show that there is no meaningful difference in performance or there is little room for continued improvement.
Although CMS recognizes that one of the main goals of the HQRP is to improve beneficiary outcomes by incentivizing health care providers to focus on specific care issues and making public data related to those issues, CMS also recognizes that those goals can have limited utility where, for example, the publicly reported data is of limited use because it does not meaningfully distinguish provider performance, or it cannot be easily interpreted by beneficiaries and used to influence their choice of providers. In these cases, removing the measure from the HQRP may better accommodate the costliness of program administration and compliance without sacrificing improved health outcomes and beneficiary choice.
The rule proposes to remove measures based on this factor on a case-by-case basis. For example, a measure that is costly and burdensome might be retained for health care providers to report if CMS concludes that the value to beneficiaries is so high that it justifies the reporting burden. The goal is to move the program forward in the least burdensome manner possible, while maintaining a parsimonious set of meaningful quality measures and continuing to incentivize improvement in the quality of care provided to patients.
Routine Annual Rate Setting Changes
As proposed, hospices would see a 1.8 percent ($340 million) increase in their payments for FY 2019. The proposed 1.8 percent hospice payment update percentage for FY 2019 is based on an estimated 2.9 percent inpatient hospital market basket update, reduced by a 0.8 percentage point multifactor productivity adjustment and by a 0.3 percentage point adjustment set by the Affordable Care Act.
The hospice payment system includes a statutory aggregate cap. The aggregate cap limits the overall payments made to a hospice annually. As mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (Pub. L. 113-185) (IMPACT Act), the cap amount for accounting years that end after September 30, 2016 and before October 1, 2025 must be updated by the hospice payment update percentage, rather than the Consumer Price Index (CPI). Therefore, the cap amount for FY 2019 will be $29,205.44 (2018 cap amount of $28,689.04 increased by 1.8 percent).
Hospice Regulations Text Changes Due to the Bipartisan Budget Act of 2018
Section 51006 in the Bipartisan Budget Act of 2018 amended section 1861(dd)(3)(B) of the Social Security Act such that, effective January 1, 2019, physician assistants are recognized as attending physicians for Medicare hospice beneficiaries. This statutory change expands the definition of attending physician to include physician assistants in addition to physicians and nurse practitioners. We are proposing regulatory language to reflect that change.
Improving Transparency for Patients
This proposed rule updates the quality reporting program for hospices, including a review of quality measures using the meaningful measures framework, and proposes updates to the public reporting of these measures on Hospice Compare.
The proposed rule would revise data review and correction timeframes for data submitted using the Hospice Item Set (HIS). To ensure that data reported on Hospice Compare is accurate and to align with other post-acute care quality reporting programs, we propose that hospices have 4.5 months after the end of each CY quarter to review and correct HIS data that is to be publicly reported. This proposed policy would go into effect January 1, 2019. This proposal would not impact the current 36-month timeframe providers have to correct records via modification and inactivation requests.
CMS proposes to display the data as shown from the CMS Public Use Files (PUFs) and/or other publicly available CMS data to the Hospice Compare Website or present the data after additional calculations to help consumers make an informed decision in their selection of a hospice. Any calculation will be performed on data exclusively from the source file like the PUF or other publicly available CMS data. The information we anticipate placing on the Hospice Compare Web site includes data from the PUFs that is based on adjudicated claims. A new section of the Hospice Compare Web site will be developed to display this select information in a consumer-friendly format.
CMS follows a standard, consistent process in determining the readiness for a quality measure to be publicly reported, and perform the necessary analysis to determine and demonstrate that our measures meet the NQF Measure Evaluation Criteria for reliability, validity, and reportability, prior to publicly reporting provider performance on these quality metrics. CMS is proposing to announce to providers any future intent to publicly report a quality measure on Hospice Compare, including timing, through sub-regulatory means.
CMS proposes to add for FY 2019 public reporting on the CMS Hospice Compare website the HIS-based Hospice Comprehensive Assessment Measure (NQF #3235) and Hospice Visits when Death is Imminent Measure Pair.
As previously finalized (81 FR 52156), the Hospice Quality Reporting Program consists of both HIS and the CAHPS® Hospice Survey. This proposed rule offers future CAHP® Hospice Survey data submission deadlines for the FY 2023, FY 2024, and FY 2025 annual payment updates (APUs). The proposed FY 2019 rule continues the survey data collection of previously finalized CAHPS® measures for reporting on Hospice Compare.
The proposed rule went on display on April27, 2018 at the Federal Register’s Public Inspection Desk and will be available under “Special Filings,” at http://www.federalregister.gov/inspection.aspx.