Fiscal Year 2022 Hospice Payment Rate Update Proposed Rule CMS-1754-P
Today, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1754-P) that would provide routine updates to hospice base payments and the aggregate cap amount for FY 2022 in accordance with existing statutory and regulatory requirements. This proposed rule also includes a comment solicitation regarding hospice utilization. In addition, this rule proposes to rebase the hospice labor shares and clarify certain aspects of the hospice election statement addendum requirements.
This rule proposes changes to the Hospice Conditions of Participation (CoPs) and Hospice Quality Reporting Program (HQRP). The proposed rule also includes a Home Health Quality Reporting Program (HH QRP) proposal to display publicly three quarters of certain outcome and assessment information set (OASIS) data due to the COVID-19 public health emergency (PHE) exemptions of the 2020 first and second quarter data.
CMS is committed to addressing consistent and persistent inequities in health outcomes by improving data collection to measure and analyze disparities across programs and policies that apply to the HQRP. We will obtain this feedback through this request for information (RFI) on ways to achieve health equity for all patients through policy solutions that apply to the HQRP and our other quality reporting programs.
The proposed rule (CMS‑1754-P) can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection
Proposed Medicare Hospice Payment Policies
CMS is proposing to rebase and revise the labor shares for all four levels of care using 2018 Medicare cost reports (MCR) data for freestanding hospice facilities. This rule also proposes several clarifying regulation text changes on certain aspects of the hospice election statement addendum requirements that were finalized for hospice elections beginning on and after October 1, 2020.
This proposed rule also includes hospice data analysis and solicits comments from the public, including hospice providers, patients and advocates, on hospice utilization and spending patterns. These comments will help inform potential future policy development.
Additionally, this rule proposes changes to the CoPs regarding hospice aide competency evaluation standards. These proposals would make permanent certain flexibilities allowed during the COVID-19 PHE.
Routine Annual Rate Setting Changes
As proposed, hospices would see a 2.3 percent ($530 million) increase in their payments for FY 2022. The proposed 2.3 percent hospice payment update for FY 2022 is based on the estimated 2.5 percent inpatient hospital market basket reduced by the multifactor productivity adjustment (0.2 percentage point). Hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to the annual market basket update for FY 2022.
The hospice payment update includes a statutory aggregate cap that limits the overall payments per patient that is made to a hospice annually. Prior to the passage of the Consolidated Appropriations Act, 2021 (CAA 2021), the annual update to the hospice cap amount would revert to its the original methodology of updating the cap amount by the Consumer Price Index for Urban Consumers (CPI-U) beginning after FY 2025. Division CC, section 404 of CAA 2021 extends the current calculation (i.e., hospital market basket reduced for multifactor productivity instead of the CPI-U) for updating the hospice cap amount through FY 2030. In accordance with the requirements of Division CC, section 404 of CAA 2021, we are proposing conforming regulation text changes to reflect the new language added. The proposed cap amount for FY 2022 is $31,389.66 (FY 2021 cap amount of $30,683.93 increased by 2.3 percent).
Hospice Labor Shares
This rule proposes to rebase and revise the labor shares for continuous home care, routine home care, inpatient respite care, and general inpatient care based on the compensation cost weights for each level of care from the 2018 MCR data for freestanding hospices. The proposed labor share for continuous home care is 74.6 percent, for routine home care is 64.7 percent, for inpatient respite care is 60.1 percent, and for general inpatient care is 62.8 percent.
Hospice Conditions of Participation
This rule proposes changes to the hospice CoPs regarding hospice aide competency evaluation standards. In response to the COVID-19 PHE, CMS issued a number of regulatory waivers in order to support providers and suppliers involved in patient care. This includes issuing a waiver for hospice aide competency testing to allow for the use of pseudo-patients. We issued this waiver to promote greater flexibility and reduce burden, allowing hospices to focus on delivering improved patient care during the COVID-19 PHE. The agency believes that this PHE waiver should be made permanent and is proposing the use of the pseudo-patient for hospice aide competency training.
As a complementary change, we are also proposing that hospices conduct a competency evaluation related to the deficient and related skill(s) noted during a hospice aide supervisory visit. This change would allow the hospice to focus on the hospice aides’ specific deficient and related skill(s) instead of assessing multiple areas within the competency evaluation. This will allow highly skilled aides to be trained more quickly in order to provide high quality patient care while protecting patient health and safety.
Hospice Quality Reporting Program
CMS is proposing a new measure in the HQRP called the Hospice Care Index. This single measure includes 10 indicators of quality that are calculated from claims data. Collectively, the indicators represent different aspects of hospice care and aim to convey a comprehensive characterization of the quality of care furnished by a hospice. If finalized, this measure would be publicly reported no earlier than May 2022.
CMS is also proposing to add Consumer Assessment of Healthcare Providers and Systems (CAHPS®), Hospice Survey Star ratings on Care Compare. 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, the rule proposes the addition of the claims-based Hospice Visits in the Last Days of Life (HVLDL) measure for public reporting. Public reporting of this claims-based measure supports patient empowerment and transparency of hospice performance by informing individuals seeking hospice services. This public reporting incentivizes hospices to provide high quality care. CMS also proposes removal of the seven individual Hospice Item Set (HIS) measures because a more broadly applicable measure, the Hospice Comprehensive Assessment Measure (NQF # 3235) for the particular topic is available and already publicly reported. This measure helps to ensure all hospice patients receive a holistic comprehensive assessment. Finally, CMS is also announcing an update on the Hospice Outcome and Patient Evaluation (HOPE) assessment instrument.
Home Health Quality Reporting Program
To meet the January 2022 public reporting refresh cycle for Home Health Facilities, CMS is including a HH QRP proposal in the FY 2022 Hospice Payment Rate Update proposed rule. The agency proposes using three quarters rather than four quarters of data for the January 2022 refresh affecting OASIS‑based measures. For some claims-based measures, we are also proposing to use three quarters rather than four quarters of data for refreshes between January 2022 and July 2024. For Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS), there are no changes. The expected most recently available four quarters of HHCAHPS will publicly report for these refresh cycles. The HH QRP proposal is being included in this proposed rule because it is necessary to finalize this work by October 1, 2021, for public reporting beginning in January 2022.
Fast Healthcare Interoperability Resources (FHIR) in Support of the Hospice Quality Reporting Program – RFI
CMS is working to further the mission to improve the quality of healthcare for hospice beneficiaries through measurement, transparency and public reporting of data. HQRP and CMS’s other quality reporting programs, are foundational for contributing to improvements in healthcare, enhancing patient outcomes, and informing consumer choice. One of the first areas CMS has identified relative to improving our digital strategy is through the use of Fast Healthcare Interoperability Resources (FHIR)-based standards to exchange clinical information through application programming interfaces (APIs), allowing clinicians to digitally submit quality information one time that can then be used in many ways. Accordingly, we are requesting information on advancing to digital quality measurement and the use of FHIR. CMS believes that advancing our work with use of these programs standard offers the potential for supporting quality improvements and reporting which will improve care for our beneficiaries.
Closing the Health Equity Gap in the Hospice Quality Reporting Program - RFI
Consistent with Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, CMS is committed to addressing the significant and persistent inequities in health outcomes in the United States through improving data collection to better measure and analyze disparities across programs and policies. CMS is working to make the HQRP and CMS’s other quality reporting programs more transparent to consumers and providers, enabling them to make better choices as well as promoting provider accountability around health equity. CMS is seeking feedback in this RFI on ways to attain health equity for all patients through policy solutions that apply to the HQRP and our other quality reporting programs.
The proposed rule went on display on April 8, 2021 at the Federal Register’s Public Inspection Desk and will be available under “Special Filings,” at https://www.federalregister.gov/public-inspection
For further information, see the hospice center webpage: http://www.cms.gov/Center/Provider-Type/Hospice-Center.html
Public comments on the proposal will be accepted until June 7, 2021.