CMS Provides Quality Reporting and Other Updates in Most Recent Open Door Forum

This article covers only the hospice portion of the most recent CMS Open Door Forum. To read about the home health portion, please see this NAHC Report article.

During the most recent Centers for Medicare & Medicaid Services (CMS) Home Health, Hospice, and DME (Durable Medicare Equipment) Open Door Forum (ODF), the following information and updates were provided.

CMS reminded hospices that the FY2024 annual payment update is based on the CY2022 data submissions.  Hospices must comply with the following HIS and Hospice CAHPS Survey participation requirements to avoid the APU penalty which increases to 4% in FY2024.

  • Submit at least 90% of HIS records within the 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/22 – 12/31/22
  • Ongoing monthly participation in the CAHPS Hospice Survey 1/1/22 – 12/31/22

The February 2022 quarterly refresh for the Hospice Quality Reporting Program is now available on Care Compare. Public reporting of quality measure data has resumed following the temporary exemption to HQRP data submission requirements, and the subsequent data freeze after the November 2020 refresh. Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey measure scores continue to exclude Quarter 1 and Quarter 2 of calendar year 2020.

In December 2021 CMS released revised data for the Hospice Care Index (HCI) in the hospice level Quality Measure (QM) reports available to hospices in their CASPER folder.  CMS identified an issue with the national averages calculations and corrected these in the reports.

CMS is targeting the Care Compare refresh in May 2022 for public display of the HCI and Hospice Visits in Last Days of Life (HVLDL) claims-based measures.

Hospices can access resources available to them regarding the Hospice Quality Reporting Program (HQRP) here.

Hospice Quality Reporting Update for February 2, 2022

  • CAHPS Star Rating
  • CASPER toolkit
  • HIS, HCI, HVLDL

A CAHPS Hospice Survey Star Rating will be added to Care Compare for hospices with the August 2022 refresh. How the star rating is calculated, what will be publicly reported, and information about the current “dry run” and provider preview information are part of the overview.  Stay tuned to NAHC Report for member resources on the CAHPS Hospice Survey Star Rating.

The Centers for Medicare & Medicaid Services (CMS) conducted an overview of the star rating in a webinar on December 16, 2021 and the materials from the webinar – slide deck, transcript, and recording — are now available here.

CMS also updated and rebranded a provider toolkit for hospices, Getting Started with Hospice CASPER Quality Measure Reports: February 2022. The toolkit is to assist hospice providers in understanding and using the CASPER Quality Measure (QM) Reports that now include claims-based measures.  There are two reports:

  • The Hospice-Level QM Report includes the HIS Comprehensive Assessment at Admission (NQF #3235), HCI, and HVLDL measure scores.
  • The Hospice Patient-Level QM Report identifies each patient with a qualifying HIS record used to calculate the hospice-level quality measure values for a select period.

The reports are detailed, and hospices may be especially interested in the Hospice Care Index (HCI) and Hospice Visits in Last Days of Life (HVLDL) information.

NAHC conducted a webinar on these measures in December where we reviewed the most frequently asked questions about the HVLDL and explained the HCI – each of its ten indicators, calculation of the index score, and expected performance for each of the indicators and the index. Information from the webinar and from a hospice’s QM reports are helpful for performance improvement. The recording of the webinar is available here.

Hospice Quality Reporting Update for February 2, 2022

CAHPS Star Rating CASPER toolkit HIS, HCI, HVLDL A CAHPS Hospice Survey Star Rating will be added to Care Compare for hospices with the August 2022 refresh. How the star rating is calculated, what will be publicly reported, and information about the current “dry run” and provider preview information are part of the overview.  Stay tuned…

Important Deadlines for the Hospice Quality Reporting Program

December 31, 2021 is an important date for the hospice quality reporting program (HQRP).  This is the last day of the calendar year (CY) 2021 participation requirements for the CAHPS Hospice Survey and the Hospice Information Set (HIS). Hospices must meet the participation requirements for this year as laid out below or face the two…

Hospice Star Rating, Updated HCI Provider Preview Reports, and HQRP Tip Sheets

A Centers for Medicare & Medicaid Services’ (CMS) webinar on the CAHPS hospice star rating on December 16, 2021 revealed additional detail about the rating, which will be publicly reported on Care Compare beginning in August 2022. CMS is calling this star rating the “Family Caregiver Survey Rating Summary Star” and it will range from one star (worst) to five stars (best).

CMS will calculate nine CAHPS Hospice Star Ratings: one for each of the eight publicly reported CAHPS Hospice measures and a Family Caregiver Survey Rating, which is a summary star rating that combines the star ratings of the eight family caregiver experience measures. Only the CAHPS Hospice Summary Star Rating will be publicly reported on Care Compare and only those hospices with 75 or more completed surveys over the reporting period will have their star rating publicly reported. The rating will be updated every other quarter (every 6 months). CMS is using the February 2022 and May 2022 Care Compare refresh period as a “dry run”. This allows hospices to see their star ratings and what the summary star rating would be if it were to be posted on Care Compare.

Again, CMS will not post the Star Rating on Care Compare until August 2022. Hospices can see their first “dry run” ratings in their CMS Preview Report that became available in November 2021. This is an “on demand” report so it does not automatically appear in the CASPER folder. Hospices need to run the report from the “Hospice Quality Reporting Program” report category. The reporting period for the dry run is October 1, 2018 – December 31, 2019; July 1, 2020 – March 31, 2021. More information about how to access the Star Rating Preview Report is found in the Hospice Quality Reporting Measure Specifications User’s Guide.

During the webinar, CMS explained the calculation of the star rating, which is similar to calculations CMS uses in other quality reporting programs. Top-box scores, the proportion of respondents who gave the most favorable response(s) for each of the CAHPS Hospice Survey measures that are publicly reported, are used and adjusted for the case mix of the hospice and mode of survey administration. CMS intended with the calculation to have maximal differentiation between the star categories and to have minimal differentiation of hospices within the star category making the star rating more meaningful. Detailed information regarding the calculation can be found in the CAHPS Star Rating Technical Notes.

A little more than 2000 hospices met the eligibility criteria to be assigned a star rating for the dry run period. This is not an overwhelming majority of hospices so it is possible there are pockets where only some of the hospices will have a publicly reported Star Rating which may make comparison among hospices confusing. Approximately 90 percent of Medicare beneficiaries enrolled in hospice in 2020 were enrolled in a hospice that does have a Star Rating during the dry run.

The slides and recording of the December 16 webinar will also be available soon on the CMS Hospice Quality Reporting webpage. Additionally, NAHC is developing a resource for providers which will be available at the beginning of 2022.

HCI UPDATE
Due to an issue identified with the national averages and percentile calculations for the Hospice Care Index (HCI) measure, CMS revised the data for the HCI Preview Reports. Hospices are able to access these revised reports via the Hospice Quality Reporting Program category in their CASPER folders now.

CMS is targeting the May 2022 refresh for the inaugural public display of the HCI and Hospice Visits in the Last Days of Life (HVLDL) claims-based measures. The eight quarters of claims data used to calculate these measures for a May 2022 refresh would include Q2 2019–Q4 2019 and Q3 2020–Q3 2021. CMS is also planning to provide annual updates to the claims-based measures in November 2022 and each following November refresh. Learn more about HCI and HVLDL in the Q&A on Claims-Based Measures downloadable (PDF) located on the Background and Announcements webpage.

HQRP TIP SHEETS
CMS updated the Hospice Quality Reporting Program (HQRP) resources on December 16 by posting two new Tip Sheets

Second Edition HQRP Public Reporting Tip Sheet
HQRP Compliance Tip Sheet_ FY 2022 and Future Years​
The Second Edition HQRP Public Reporting Tip Sheet explains how CMS will handle the impact of the temporary exemption of quality reporting that occurred due to the COVID-19 Public Health Emergency (PHE) in the HQRP going forward and incorporates the changes to the HQRP from the FY 2022 hospice final rule. The HQRP Compliance Tip Sheet_FY 2022 and Future Years provides information on the HQRP, compliance requirements and how to track compliance.

Hospice Star Rating, Updated HCI Provider Preview Reports, and HQRP Tip Sheets

A Centers for Medicare & Medicaid Services’ (CMS) webinar on the CAHPS hospice star rating on December 16, 2021 revealed additional detail about the rating, which will be publicly reported on Care Compare beginning in August 2022. CMS is calling this star rating the “Family Caregiver Survey Rating Summary Star” and it will range from…

Important Deadlines for the Hospice Quality Reporting Program

December 31, 2021 is an important date for the hospice quality reporting program (HQRP).  This is the last day of the calendar year (CY) 2021 participation requirements for the CAHPS Hospice Survey and the Hospice Information Set (HIS). Hospices must meet the participation requirements for this year as laid out below or face the two percent annual payment update penalty in payment year 2023.

Annual Payment Update HIS CAHPS
FY2023 Submit at least 90 percent of all HIS records within 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/21 – 12/31/21. Ongoing monthly participation in the Hospice CAHPS survey 1/1/2021 – 12/31/2021**Unless exempt
FY2024 Submit at least 90 percent of all HIS records within 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/22 – 12/31/22. Ongoing monthly participation in the Hospice CAHPS survey 1/1/2022 – 12/31/2022

A hospice is exempt from the CAHPS Hospice Survey requirements for CY2021 if it has served fewer than 50 survey-eligible decedents/caregivers in CY 2020 (January 1, 2020 through December 31, 2020 [or from assignment of CCN]).  These hospices must apply for the exemption and must do so annually if eligible for different years.  The Participation Exemption for Size Form for the calendar year CY2021 CAHPS Hospice Survey data collection and reporting requirements is available to complete and submit here.  Eligible hospices must complete and submit this from no later than December 31, 2021 in order to receive the exemption.

January 1, 2022 begins the CY2022 participation requirements for the HQRP that impacts the 2024 payment year. The penalty for not meeting the HQRP participation requirements during CY2022 jumps to 4%, which is applied in the FY 2024 payment update. Therefore, hospices are strongly encouraged to ensure that they are meeting the submission requirements as shown in the table above beginning January 1, 2022 in order to avoid this increased penalty. Hospices should review their Timeliness Compliance Threshold Report now to ensure they meet the 90% HIS submission requirement and check the CAHPS Hospice Survey Data Warehouse to ensure their CAHPS vendor is submitting data as required.

The Timeliness Compliance Threshold Report is one of the reports in a hospice’s CASPER folder. See the CASPER Hospice Reporting User’s Guide for information on accessing this report. For your hospice to access and review the data submitted by your survey vendor, a login to the CAHPS Hospice Survey Data Warehouse (https://kiteworks.rand.org) is required.

Important Deadlines for the Hospice Quality Reporting Program

December 31, 2021 is an important date for the hospice quality reporting program (HQRP).  This is the last day of the calendar year (CY) 2021 participation requirements for the CAHPS Hospice Survey and the Hospice Information Set (HIS). Hospices must meet the participation requirements for this year as laid out below or face the two percent annual payment update penalty in payment year 2023.

Annual Payment Update HIS CAHPS
FY2023 Submit at least 90 percent of all HIS records within 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/21 – 12/31/21. Ongoing monthly participation in the Hospice CAHPS survey 1/1/2021 – 12/31/2021**Unless exempt
FY2024 Submit at least 90 percent of all HIS records within 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/22 – 12/31/22. Ongoing monthly participation in the Hospice CAHPS survey 1/1/2022 – 12/31/2022

A hospice is exempt from the CAHPS Hospice Survey requirements for CY2021 if it has served fewer than 50 survey-eligible decedents/caregivers in CY 2020 (January 1, 2020 through December 31, 2020 [or from assignment of CCN]).  These hospices must apply for the exemption and must do so annually if eligible for different years.  The Participation Exemption for Size Form for the calendar year CY2021 CAHPS Hospice Survey data collection and reporting requirements is available to complete and submit here.  Eligible hospices must complete and submit this from no later than December 31, 2021 in order to receive the exemption.

January 1, 2022 begins the CY2022 participation requirements for the HQRP that impacts the 2024 payment year. The penalty for not meeting the HQRP participation requirements during CY2022 jumps to 4%, which is applied in the FY 2024 payment update. Therefore, hospices are strongly encouraged to ensure that they are meeting the submission requirements as shown in the table above beginning January 1, 2022 in order to avoid this increased penalty. Hospices should review their Timeliness Compliance Threshold Report now to ensure they meet the 90% HIS submission requirement and check the CAHPS Hospice Survey Data Warehouse to ensure their CAHPS vendor is submitting data as required.

The Timeliness Compliance Threshold Report is one of the reports in a hospice’s CASPER folder. See the CASPER Hospice Reporting User’s Guide for information on accessing this report. For your hospice to access and review the data submitted by your survey vendor, a login to the CAHPS Hospice Survey Data Warehouse (https://kiteworks.rand.org) is required.

Important Deadlines for the Hospice Quality Reporting Program

December 31, 2021 is an important date for the hospice quality reporting program (HQRP).  This is the last day of the calendar year (CY) 2021 participation requirements for the CAHPS Hospice Survey and the Hospice Information Set (HIS). Hospices must meet the participation requirements for this year as laid out below or face the two…

CMS Open Door Forum Shares Hospice Star Rating Info

During the most recent Centers for Medicare & Medicaid Services (CMS) Home Health, Hospice, and DME (Durable Medicare Equipment) Open Door Forum (ODF), the following information and updates were provided.

Hospice providers should note that CMS has resumed the provider enrollment revalidation process along with some other provider enrollment processes that were temporarily suspended during a portion of the COVID-19 Public Health Emergency.  See previous NAHC Report coverage here and the September 2, 2021 MLN Connects newsletter.

UPDATES

Hospices will see the resumption of public reporting of quality data with the February 2022 Care Compare refresh.  Provider preview reports for this refresh can now be accessed via the Certification and Survey Provider Enhanced Reports (CASPER) application. These reports preview data that will be displayed in the Care Compare website in February 2022. The Hospice Item Set (HIS) measure scores are based on fewer than the standard number of quarters due to data exemptions in response to the COVID-19 Public Health Emergency (PHE), and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey measure scores exclude Quarter 1 and Quarter 2 of calendar year 2020 (but still include eight quarters).

The Provider Preview Reports remain in CASPER for 60 days only so hospices are encouraged to save a copy of their preview reports for later reference.

Learn more about HIS Provider Preview Reports here and about the CAHPS Preview Reports here. Hospice QRP Key Dates for Providers can be found here.

CMS notified hospices that the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey Star Rating will be available to the public on Care Compare in August 2022.  (See previous NAHC Report coverage here). Hospices will first see their star ratings on the preview reports for February this month (November 2021) and also available in the May 2022 provider preview reports. CMS is considering this the “dry run” period.  The star rating will not be publicly reported during this period.

Hospices will see the star rating for each of the eight CAHPS measures in the preview reports but only the summary star will appear on Care Compare.  CAHPS Hospice Survey Provider Preview Reports include both quality measure scores and Star Ratings. Again, CAHPS Hospice Survey Star Ratings will not be publicly reported until August 2022.

CMS shared that it is planning an upcoming HQRP Forum which will include CAHPS information.

  • Thursday, December 16, 2021
  • 2:30 PM – 3:30 PM Eastern

Hospices should mark this on their calendars and stay tuned to NAHC Report for more information. We will provide an update when CMS releases registration information.

Hospices had questions about the CAHPS Star Rating including, in particular, the methodology for calculating the star rating. A CMS slide deck providing an overview of the star rating inclusive of the methodology is available here. Additional information pertaining to the star rating is available here.

Resources for the HQRP and CAHPS Hospice Survey Star Rating are available on the HQRP webpage and the CAHPS Hospice Survey webpage.

In other HQRP news, CMS responded to a question about the timing of the transition to the iQIES system stating that this transition is not scheduled to occur in 2022.