ATTENTION Hospices! CMS Recruiting Additional Hospices for HOPE Beta Testing

As hospices should already be aware, the Centers for Medicare & Medicaid Services (CMS) and Abt Associates are currently beta testing a draft standardized hospice patient assessment instrument called Hospice Outcomes & Patient Evaluation (HOPE).  Additional hospice providers are needed to complete the testing. Hospices must be Medicare-certified and training for this round of hospices…

ATTENTION Hospices! CMS Recruiting Additional Hospices for HOPE Beta Testing

As hospices should already be aware, the Centers for Medicare & Medicaid Services (CMS) and Abt Associates are currently beta testing a draft standardized hospice patient assessment instrument called Hospice Outcomes & Patient Evaluation (HOPE).  Additional hospice providers are needed to complete the testing.

Hospices must be Medicare-certified and training for this round of hospices is anticipated to occur mid-July 2022 with data collection slated to begin in August 2022 and continue through early fall 2022.

CMS is specifically seeking hospice providers with sufficient registered nurse, social worker, and chaplain staffing to conduct at least 1 – 2 joint visits per week. Hospices currently participating in the beta test may be finding this difficult amidst the workforce shortage causing CMS to recruit more hospices.

It appears that CMS is still aiming for completion of the beta testing in early fall of this year.  Should this occur, there may be time for CMS to analyze the results of the testing and formulate a proposal for use of the HOPE by all hospices in the FY2024 proposed rule.  This proposed rule would be posted in Spring 2023 for public review.

Joint visits are typical in beta testing standardized assessment instruments such as the HOPE for inter-rater reliability, but it is not expected that joint visits will be required when a HOPE tool is implemented in hospice. CMS includes the following additional information about the 1-2 joint visits per week that would occur as part of the HOPE testing:  For joint visits, two registered nurses visit one patient at the same time to complete the HOPE nurse assessment. Two social workers visit the patient at the same time to complete the HOPE social work assessment, and two chaplains visit the patient at the same time to complete the HOPE chaplain assessment. One of the two registered nurses, social workers and chaplains may attend their joint visit via video call, such as Zoom. HOPE assessments are completed at hospice admission, for symptom reassessment and at live discharge.

Recruitment will continue until CMS reaches the desired number of participants (number not specified). Those interested in participating should email HOPETesting@abtassoc.com by June 30, 2022.

NAHC Submits Comments on Proposed FY2023 Hospice Rule

  • Focus on Wage Index Cap, Payment Update, and Health Equity

On Wednesday, March 30, 2022, the Centers for Medicare & Medicaid Services (CMS) issued Medicare Program; FY 2023 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements (https://www.federalregister.gov/public-inspection/2022-07030/medicare-program-fy-2023-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting), the proposed rule governing hospice payment and other policies for fiscal year (FY) 2023.  The rule included:

  • A proposed 2.7% payment update for hospice services for the coming year;
  • Proposed imposition of a permanent 5% cap on reductions in wage index values from one year to the next (a policy CMS is proposing for all Medicare institutional providers);
  • A request for input on specific steps hospices are taking to advance health equity and views on creation of a structural composite measure that would assess a provider’s activities to address access to and quality of care for underserved populations;
  • Updates on elements of the Hospice Quality Reporting Program (HQRP); and a
  • An update on Advancing Health Information Exchange.

NAHC Report summary of the rule is available here.

Since publication of the rule, the National Association for Home Care & Hospice (NAHC) solicited input from hospice members through numerous “listening sessions.”  Following is a summary of NAHC’s comments on the rule that were submitted to CMS:

Proposed Permanent 5% Cap on Wage Index Decreases:  Across the years when wage index values in a large number of geographic areas have undergone changes that could have a significant negative impact on provider payments, CMS has utilized various methods to limit the impact of those changes in the first year so that providers could prepare for the financial impact of the wage index changes.  These methods include applying a 50/50 blend of the existing wage index value and the prospective wage index value for the first year or (as used during 2021) applying a 5% cap on wage index decreases for the first year in which changes to the wage index values are being applied. Given the potential that wage index changes have to create instability and significant negative impacts on certain providers even when wage index values change in only a small number of geographic areas, as part of the proposed FY2023 hospice payment rule CMS proposed a permanent approach to smooth year-to-year changes in providers’ wage indexes by placing a 5% cap on all wage index decreases in future years, regardless of the reason for the decrease.   Under this change, a geographic area’s wage index would not be less than 95% of its wage index calculated in the prior FY. NAHC has had a long-standing policy position that CMS should develop and implement a wage index model that is consistent across all provider types so that all providers have a level playing field from which to compete for personnel, and that supports limiting wage index losses from year to year to minimize dramatic payment reductions due to wage index value changes.

NAHC’s comments support action by CMS to impose a permanent cap on losses due to wage index value declines but suggest that in addition to a 5% cap that CMS analyze the impact of imposing a smaller cap (such as 2% or 3%), provide the public with details of their findings, and impose the most appropriate cap value as part of final action.  Based on their findings, CMS should determine and implement the most appropriate value for the cap on wage index decreases. NAHC also expressed concern that while CMS extended a FY2021 transitional policy imposing a 5% cap on wage index reductions to FY2022 for hospital providers but did not extend that policy to other provider types. NAHC is recommending that CMS retroactively apply the FY2021 transitional policy to hospice and other providers whose wage index values dropped more than 5% between 2021 and 2022.

Proposed FY2023 Hospice Payment Update Percentage 

While CMS has limited discretion when calculating the annual market basket update for hospice providers, NAHC has concerns that the projected 2.7% update is insufficient to address the accelerating financial demands that hospices have faced over the course of the last three years. NAHC’s comments include a wide variety of issues that have resulted in financial strains for hospice providers, including:

  • The Continuing COVID-19 Public Health Emergency
  • Inflationary Pressures
  • Workforce Issues
    • Caregiver Burnout
    • Increased Costs Related to Management Fees, Outsourcing, Recruitment, and Retention
    • Reduced Productivity/Lost Revenue Related to Staff Turnover
  • Resumption of the 2% Sequester
  • Resumption of/Increased Regulatory Oversight

Based on these concerns, NAHC’s comments urge CMS to explore all options available to address the financial strains that providers are undergoing, including the following:

  • Examine trends relative to IHS Global’s forecasts to determine whether more recently available data than used for the final FY2023 rule would result in a higher market basket update and determine whether additional updates could be made during the course of FY2023 to provide additional support to hospice and other providers.
  • Direct various divisions of CMS to examine potential options for hospice regulatory relief, with a particular focus on policies that could help to address issues that contribute to the existing workforce crisis, including reductions in paperwork and more appropriate utilization of various clinical personnel.
  • Engage stakeholders in discussions regarding current waivers and flexibilities related to the COVID-19 PHE, providers’ experience during the PHE relative to these waivers and flexibilities, and policy changes that might be advisable as a result of those experiences.

Updates on elements of the HQRP

While there were no proposed changes to the HQRP NAHC did submit some comments relative to elements of the program. The HOPE (Hospice Outcome and Patient Evaluation) tool is currently in beta testing which is expected to be completed later this year after which time CMS will complete its analysis. It is possible that CMS will include in next year’s proposed hospice rule the full implementation of the HOPE. Hospices and stakeholders such as EMR vendors are requesting CMS share more information about the HOPE prior to any future proposal for full implementation. NAHC also encouraged CMS to include race and ethnicity and SDOH in the HOPE and consider how the HOPE could be utilized as a tool to help hospices with health equity initiatives.

NAHC reiterated recommendations submitted previously urging CMS to develop codes or modifiers for telehealth visits in hospice and supports the recommendation by MedPAC that technology-based visits be reported on claims.

Advancing Health Equity

In this year’s proposed rule, CMS expanded on last year’s Request for Information (RFI) on health equity. This year, CMS sought feedback on four questions and a structural composite measure related to health equity. NAHC supports embedding the principles of health equity in the design, implementation, and operationalizing of policies and programs to improve health and reduce disparities for all people served by the Medicare program. In general, hospice readiness to develop and implement health equity initiatives varies greatly. Some hospices report that health equity concepts are new to their organization while others report collecting and analyzing data related to health equity for some time and using it as part of their performance improvement program. Consistent feedback from members indicates that there are hospices operating all along this spectrum and it is important for CMS to consider this variation as it looks to implement requirements and measures related to health equity. NAHC did explain in its comments that hospices are eager to implement health equity initiatives but have been impacted by the workforce shortage and other effects of the COVID-19 pandemic requiring a refocusing of priorities. Therefore, additional time and resources are necessary.

Social determinants of health (SDOH) and other data such as race and ethnicity need to be collected and analyzed for the advancement of health equity initiatives. However, our systems lack standardization for the collection, reporting and analysis of this data. NAHC encouraged CMS to expand its systems to allow for the submission of such data and for CMS to develop and share meaningful reports with this information for hospices that will help them move forward or expand.

NAHC’s comments support introducing a structural composite measure on health equity into the hospice quality reporting program. We believe such a measure is a good starting point for the HQRP and will help hospices learn what is expected and best practices. Dialogue with stakeholders about the development of a structural composite measure is necessary to ensure all components are included and the reporting of such a measure is meaningful while not being overly burdensome to hospice providers. We believe hospices must learn how to incorporate much of the health equity framework into their daily practice before data collection for a structural composite measure is considered. We provided feedback on each of the three domains CMS included as possible components of a structural measure and scoring of the domains. NAHC strongly recommended the utilization of a Technical Expert Panel (TEP) to consider the identification of appropriate measures and their implementation as was done with hospitals in the development of the “Hospital Commitment to Health Equity” measure. We also recommended that as the hospice measure is developed, data be gathered from hospices with feedback and learning opportunities provided to them before any public reporting is considered. NAHC emphasized that CMS should allow for adoption of health equity initiatives with hospices in a manner like that utilized with hospitals – slowly and over the course of years.

Finally, NAHC thanked CMS for its plans to utilize a TEP for the development and implementation of the Special Focus Program (SFP) that is part of the hospice survey reforms finalized last year. NAHC recommended that nomination opportunities to serve on the TEP be open to the public and that the proceedings of the TEP be as transparent as possible and include multidisciplinary and patient/caregiver perspective and that the TEP be charged with advising CMS on the details of implementation of the SFP, including the terms of selection, enforcement, and technical assistance criteria. Due to the complexity of the SFP and potential long-term impacts, this program should not be implemented until the TEP has completed its work in this area and has had the opportunity to consider SFP eligibility, use of other data for SFP eligibility, and SFP graduation.

Advancing Health Information Exchange

NAHC also took the opportunity to respond to the section of the rule highlighting the importance of interoperable health information exchange (HIE) across provider types and settings. NAHC staff reminded CMS that a major reason the majority of hospice and home health providers lack certified EHR technology is as a result of not being eligible for funding from the federal Meaningful Use EHR Incentive program created in 2009, a federal initiative that has provided billions of dollars over the last decade to hospitals, health systems, and physician practices to adopt and maintain Office of the National Coordinator for Health Information Technology (ONC)-certified health information technology (HIT). Not including hospices or other post-acute care (PAC) providers in that program has created an uneven playing field, one in which home-based care providers are further behind in their capacity to procure ONC-certified products which facilitate the kind of seamless interoperability CMS is seeking across the health care system. Special mention was made of how important it is for CMS to work with ONC and Congress to develop an analogous EHR/HIT incentive program for hospice and the PAC sector, particularly if they intend to make progress on their overarching goal to improve social determinant of health (SDOH) data collection and exchange. In order for SDOH information to be valuable, it will need to follow patients across care settings, making interoperability critically important. But merely providing the money to develop the data-sharing tools will not be sufficient to deliver on the health equity promise of more robust SDOH activity – CMS must also begin to articulate the specific expectations it has for providers related to the collection, storing, sharing, and use of SDOH data. In the absence of guidance, many providers are likely to create their own approaches to this work, which will hamper the ability to develop meaningful standards in the future that will help formalize CMS and ONC’s regulatory stance towards health care providers’ SDOH obligations and responsibilities.

NAHC Submits Comments on Proposed FY2023 Hospice Rule

Focus on Wage Index Cap, Payment Update, and Health Equity On Wednesday, March 30, 2022, the Centers for Medicare & Medicaid Services (CMS) issued Medicare Program; FY 2023 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements (https://www.federalregister.gov/public-inspection/2022-07030/medicare-program-fy-2023-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting), the proposed rule governing hospice payment and other policies for fiscal year (FY) 2023.  The rule…

Request for Hospices to Beta Test HOPE

As hospices are already aware, CMS and Abt Associates are currently testing a draft standardized hospice patient assessment instrument called Hospice Outcomes & Patient Evaluation (HOPE).  CMS has decided to expand the HOPE Beta Test, and Abt Associates are seeking additional Medicare-certified providers to start training and data collection in late January or early February. Data collection will continue at least through July 2022.

The Abt team will recruit hospices on a rolling basis until they have reached the desired sample size, until January 20, 2022.

Abt is seeking mid-to-large size hospices with sufficient registered nurse, social worker and chaplain staffing to conduct joint visits to complete in-person assessments with some of their patients in addition to usual care. This flyer explains the joint visits and may be helpful for hospices to review as they consider participation.

Medicare-certified hospice providers in any state are eligible to participate, but Abt is interested especially in recruiting hospices from states where there is currently no participants, listed (alphabetically) here:

  • Alabama, Alaska, Arkansas, Florida, Georgia, Hawaii, Indiana, Kentucky, Mississippi, Missouri, Oregon, Rhode Island, South Carolina, South Dakota, Utah, Vermont, and Wyoming.

More than one hospice branch/office in one organization may participate.

Hospice providers interested in participating should email the Abt HOPE Testing team at HOPETesting@abtassoc.com and provide their: Hospice name, mailing address and CCN; and a Contact name, email address and phone number.

Jennifer Riggs, PhD RN is the HOPE Testing Lead for Abt Associates. Email HOPETesting@abtassoc.com with any questions.

Request for Hospices to Beta Test HOPE

As hospices are already aware, CMS and Abt Associates are currently testing a draft standardized hospice patient assessment instrument called Hospice Outcomes & Patient Evaluation (HOPE).  CMS has decided to expand the HOPE Beta Test, and Abt Associates are seeking additional Medicare-certified providers to start training and data collection in late January or early February.…

Hospice Quality Reporting Program 2021 Information Gathering Report

The Centers for Medicare & Medicaid Services (CMS) has released the Hospice Quality Reporting Program 2021 Information Gathering Report, which provides information from literature reviews and expert interviews that supports expansion of the hospice quality reporting program. Specific topics include treatment of moderate to severe pain, patient preferences, spiritual care, social needs, medication management, and other topics related to hospice quality.

CMS anticipates expanding the Hospice Quality Reporting Program (HQRP) over the next several years to include additional meaningful quality measures to help consumers make informed decisions when selecting a hospice for end-of-life-support. This expansion includes introducing the Hospice Outcomes & Patient Evaluation (HOPE), and may be introduced for possible hospice use for FY2024, although CMS has not provided a date.

There are only a handful of current measures publicly reported as part of the HQRP.  This is slim compared to other provider types and due in part to the lack of a tool for the HQRP that collects data while care is being delivered to the patient, as the HOPE will do.  The Hospice Information Gathering Report supports the efforts to expand the HQRP by reviewing available resources to inform HOPE development and related quality measures. Technical Expert Panel (TEP) deliberations, in addition to discussions with the HOPE development team, the hospice quality measurement development team, and federal stakeholders, identified areas where additional information could support the HQRP expansion.

This Report provides insight into the specific aspects CMS focused on for each of the topics addressed in the Report – treatment of moderate to severe pain, patient preferences, spiritual care, social needs, medication management, and other topics related to hospice quality – why and what was discovered.  Links to all the resources reviewed are available and hospices may find these helpful for understanding how best to address the issues CMS identified in each of the topic areas.

Among its conclusions, CMS found that evidence supports the current HQRP measures under development for treating moderate to severe pain. In other areas (risk adjustment for neuropathic pain, patient and proxy concordance of patient symptom management preferences, and psychosocial outcomes), CMS found limited evidence for the hospice setting.  However, CMS provided information from other settings to support HQRP activities in these instances.

CMS explored evidence for future potential areas of measure development, such as medication management, finding gaps concerning the reasonable use of medications at the end of life and the engagement of patients and caregivers.  Those interested in the future path of the HQRP and its measures should read this report and investigate some of the tools and resources CMS found to be promising for providing/assisting in providing good quality care to patients.

More information about CMS’ efforts to expand the HQRP can be found in the 2019 Information Gathering Report and the  2020 Information Gathering Report.

Hospice Quality Reporting Program 2021 Information Gathering Report

The Centers for Medicare & Medicaid Services (CMS) has released the Hospice Quality Reporting Program 2021 Information Gathering Report, which provides information from literature reviews and expert interviews that supports expansion of the hospice quality reporting program. Specific topics include treatment of moderate to severe pain, patient preferences, spiritual care, social needs, medication management, and other…

Hospice Quality Reporting Program 2021 Information Gathering Report

The Centers for Medicare & Medicaid Services (CMS) has released the Hospice Quality Reporting Program 2021 Information Gathering Report, which provides information from literature reviews and expert interviews that supports expansion of the hospice quality reporting program. Specific topics include treatment of moderate to severe pain, patient preferences, spiritual care, social needs, medication management, and other topics related to hospice quality.

CMS anticipates expanding the Hospice Quality Reporting Program (HQRP) over the next several years to include additional meaningful quality measures to help consumers make informed decisions when selecting a hospice for end-of-life-support. This expansion includes introducing the Hospice Outcomes & Patient Evaluation (HOPE), and may be introduced for possible hospice use for FY2024, although CMS has not provided a date.

There are only a handful of current measures publicly reported as part of the HQRP.  This is slim compared to other provider types and due in part to the lack of a tool for the HQRP that collects data while care is being delivered to the patient, as the HOPE will do.  The Hospice Information Gathering Report supports the efforts to expand the HQRP by reviewing available resources to inform HOPE development and related quality measures. Technical Expert Panel (TEP) deliberations, in addition to discussions with the HOPE development team, the hospice quality measurement development team, and federal stakeholders, identified areas where additional information could support the HQRP expansion.

This Report provides insight into the specific aspects CMS focused on for each of the topics addressed in the Report – treatment of moderate to severe pain, patient preferences, spiritual care, social needs, medication management, and other topics related to hospice quality – why and what was discovered.  Links to all the resources reviewed are available and hospices may find these helpful for understanding how best to address the issues CMS identified in each of the topic areas.

Among its conclusions, CMS found that evidence supports the current HQRP measures under development for treating moderate to severe pain. In other areas (risk adjustment for neuropathic pain, patient and proxy concordance of patient symptom management preferences, and psychosocial outcomes), CMS found limited evidence for the hospice setting.  However, CMS provided information from other settings to support HQRP activities in these instances.

CMS explored evidence for future potential areas of measure development, such as medication management, finding gaps concerning the reasonable use of medications at the end of life and the engagement of patients and caregivers.  Those interested in the future path of the HQRP and its measures should read this report and investigate some of the tools and resources CMS found to be promising for providing/assisting in providing good quality care to patients.

More information about CMS’ efforts to expand the HQRP can be found in the 2019 Information Gathering Report and the  2020 Information Gathering Report.

NAHC Submits Comments on FY2022 Hospice Proposed Rule

On April 14, 2021 the FY2022 Wage Index and Payment Rate Update, Hospice Conditions of Participation Updates, Hospice and Home Health Quality Reporting Program Requirements proposed rule was published. In addition to the proposed payment updates the rule contains numerous provisions on a wide variety of topics and solicits feedback on a number of issues.  To read a…