MedPAC calls for 20 Percent Cut to Hospice Aggregate Cap

Last week, as expected, the Medicare Payment Advisory Commission’s (MedPAC) March 2022 Report to Congress recommended that:

  • Medicare base payment rates for hospice for Fiscal Year 2023 remain at current levels
  • The hospice aggregate cap should be wage-adjusted and reduced by 20 percent.
  • Hospices be required to report telehealth services on Medicare claims

MedPAC’s chapter on hospice services explores the latest data on hospice utilization and access to care, payment adequacy, quality of care, the hospice aggregate cap, the impact of the COVID-19 public health emergency on hospice services, and potential hospice payment policy directions. This information is combined with the recommendations to Congress for FY2023 listed above. It is important to remember that MedPAC’s recommendations are not required to be implemented. MedPAC is a solely an advisory body to Congress. It would take specific congressional action to put any recommendations into effect.

The recommendation to wage-adjust and reduce the aggregate cap by 20 percent was initially put forth by MedPAC in its 2020 report to Congress. MedPAC estimates that the payment recommendations would decrease hospice spending by $250 million to $750 million over one year and between $5 and $10 billion over 5 years.

“We have had longstanding concerns about MedPAC’s treatment of home health, and the Commission is now on a similar path for hospice care with its recommendations that there be no recognition of cost inflation in 2023 rate setting and the dangerous proposal to reduce the annual aggregate cap by 20 percent,” said NAHC President William A. Dombi. “First, MedPAC relies on Medicare cost reports that intentionally do not include all hospice costs, such as bereavement support. Second, it is readily apparent that the cap reduction proposed would disadvantage any hospice that serves patients with non-cancer diagnoses, such as dementia, as these patients tend to increase risk of exceeding the cap.  We must condemn any proposal that would diminish the breadth of the hospice benefit, particularly one that could trigger the loss of care access for certain patient populations.”

According to MedPAC data from 2020:

  • Hospice care was utilized by over 1.7 million beneficiaries;
  • 47.8 percent of Medicare decedents received hospice care;
  • More than 5000 Medicare certified hospices were in operation;
  • Medicare expended $22.4 billion in payments for hospice services.

KEY FINDINGS

As in analyses from previous years, MedPAC assessed access to care, quality of care, providers’ access to capital, and the relationship between providers’ costs and Medicare payments in making its determination of payment adequacy, which is a key driver in MedPAC’s decision around payment recommendations for hospice.

MedPAC drew the following conclusions:

Beneficiaries’ access to hospice services is believed to be favorable given the growing number of hospice providers.  Further, while the share of decedents using hospice dropped slightly in 2020 compared to 2019 (47.8 percent of Medicare decedents in 2020 vs. 51.6 percent in 2019) as a result of overall deaths increasing more rapidly than hospice enrollments (likely due to the pandemic), the overall number of people receiving hospice continues to increase, as does the volume of services provided (including an increase in the overall length of stay). While the number of rural hospices has declined, MedPAC notes that providers in urban areas provide services to rural areas, and the share of rural decedents using hospice has grown. The chapter discusses some particular concerns related to continuing growth in the number of hospices in California and Texas and patterns of care that may warrant additional oversight.

MedPAC estimates that Medicare hospice payments in 2019 exceeded marginal costs by approximately 17 percent, which they believe provides strong incentives for providers with the capacity to accept new patients.

While data on hospice quality is limited, and was disrupted significantly due to the pandemic, scores based on data through 2019 are generally good. (Hospice Item Set composite measure scores are very high, CAHPS scores are stable, and scores on the Visits in the Last Days of Life measures have improved (there is, however, room for improvement for a subset of providers.) MedPAC continues to support development of additional outcome measures for hospice care, and has continuing concerns about hospices with high live discharge rates, which are discussed at length.

Providers’ access to capital is believed to be adequate, based on growth in the number of for-profit providers.  Less is known regarding non-profit hospices access to capital.

While costs vary substantially by provider type and patient mix, the aggregate Medicare margin for hospice in 2019 was 13.4 percent.  This excludes bereavement and volunteer costs, which would decrease margins by 1.2 percentage points and 0.4 percentage points, respectively.  Above cap hospices in 2019, which MedPAC estimates at 19 percent of all hospices, had a margin of approximately 22.5 percent (10 percent after return of cap overpayments). Margins for 2022 are projected to be approximately 13 percent. MedPAC states that it does not generally anticipate long-term pandemic-related effects in the hospice sector, except for increased wage rates, which are accounted for via CMS’s market basket index.

In-person visits of all kinds (nurse, aide, social worker) decreased in 2020, attributable mostly to the pandemic. While we know that many hospices utilized telehealth and audio-only technologies to make up for the decrease in in-person visits, because hospices cannot report telehealth visits on claims, MedPAC lacks the quantitative data needed to determine the extent to which telehealth was used to supplement in-person visits. To address this data shortcoming, one of MedPAC’s official recommendations is that the HHS Secretary should require that hospices report telehealth services on Medicare claims. NAHC applauds this recommendation, as we have consistently asked CMS to create telehealth codes for hospice so that the full scope of services is captured and can inform future policy.

AGGREGATE CAP RECOMMENDATION

The hospice chapter provides in-depth analysis related to the recommendation to modify the aggregate cap, and updates a simulation on the impact of the policy. Under the new analysis, 33 percent of hospices would exceed the cap under the new policy (as compared with the 19 percent of hospices that exceeded the aggregate cap in 2019), and overall hospice outlays would be reduced by 3.7 percent (based on 2019 data and assumption of no behavioral change in response to the policy change). The policy is estimated to reduce payments for hospices in the top two length of stay quintiles — by five percent for those in the fourth quintile and 15 percent for those in the fifth quintile.

NAHC strongly opposes the recommendation to reduce the cap across-the-board by 20 percent. We recognize that MedPAC’s interest in this policy stems from concerns about what they see as inappropriately long LOS for certain kinds of hospice patients. While NAHC welcomes targeted, data-driven program integrity solutions that focus on truly fraudulent or abusive provider behavior, a 20 percent cap cut is an blunt tool that would negatively impact access to care by introducing disincentives to serve patients that have a more unpredictable disease trajectory, such as those with dementia, who, despite their less predictable illness course, are in fact eligible for hospice care based on the clinical judgement of the certifying physician. Additionally, the cap reduction recommendation could further exacerbate health disparities in hospice access and utilization. The individuals most likely to have their access to hospice impacted by the cap reduction (those with dementia and other neurological diagnoses) are also more likely to be from underserved minority communities that already have lower rates of hospice utilization and poorer end-of-life care outcomes. Finally, by disincentivizing hospice care for certain patients, a 20 percent cap reduction could result in increased overall Medicare outlays, as those individuals who might have received cost-saving hospice care end up utilizing more expensive and aggressive care such as hospital, ER, and nursing home services. Research has shown that hospice use by Medicare beneficiaries is associated with significantly lower total health care costs across all payers, without cost-shifting to families.

The shortcomings of the cap reduction proposal notwithstanding, MedPAC remains concerned about providers with very long lengths of stay and high profit margins, and in 2021’s report they put forward a number of ideas for additional payment reforms that might help address these concerns. While the 2022 report does not go into as much detail on these various reform options, it does once again encourage further exploration of a “compliance threshold” policy aimed at hospices that have care patterns that have raised concerns (including high live discharge rates or patients with very long lengths of stay).  Under such a policy, if a hospice provider exceeds the threshold, payment rates would be reduced for all patients. This and other payment reform ideas are preliminary at this point, but NAHC expects that MedPAC will continue to more thoroughly explore them in the future.

NEW SECTION ON MEDICARE SPENDING OUTSIDE OF THE HOSPICE BENEFIT

This year, the report includes a new section focused on analysis of Medicare spending on hospice beneficiaries that takes place outside of the Medicare hospice benefit (Part A, Part B, and Part D outside spending). Key data points highlighted in this section include:

  • In 2018, Medicare spent $1.1 billion (an additional 5.6 percent) on nonhospice services for beneficiaries enrolled in hospice (Beneficiaries spent an additional $177 million on cost sharing for nonhospice services while enrolled in hospice in 2018)
  • Of the total $1.3 billion of non-hospice spending (Medicare and patient cost-sharing): 40 percent of this 2018 non-hospice spending was for Part D drugs; 23.1 percent was for physician and supplier services; 13.6 percent was for outpatient hospital services; and 13.3 percent was for inpatient hospital services.
  • 47 percent of beneficiaries using hospice in 2018 received at least one Part A or Part B service or Part D drug during their hospice stay.
  • Hospices that exceeded the aggregate cap, had a long average length of stay, or had a high live-discharge rate were more likely to have high non-hospice spending.

While it lacks hard data to prove its hypothesis, MedPAC states that it believes much of the Part A and Part B services paid for outside the hospice benefit are related to the beneficiaries’ terminal condition and related conditions, and therefore should be considered duplicative of what the hospice itself should cover. To address these non-hospice spending concerns, which are also the focus of a recent OIG Data brief on the same topic, MedPAC recommends a number of potential options to explore, including:

  • More audits of hospice spending
  • Some kind of bundled payment mechanism that would incorporate all services a hospice beneficiary would need, regardless of whether they are related to the terminal condition and related conditions
  • A payment penalty for hospices that exceed a non-hospice spending threshold.

NAHC believes that much of the non-hospice spending for beneficiaries is not in the control of hospices, and therefore they should not be punished with more penalties or administrative burden as a result of behavior that they have no tools or authority to influence.

We will continue to engage with MedPAC and members of Congress to educate them on the realities of the hospice benefit and how it is implemented, and oppose problematic policy recommendations that would negatively impact patients, families, and providers.

MedPAC calls for 20 Percent Cut to Hospice Aggregate Cap

Earlier this week, as expected, the Medicare Payment Advisory Commission’s (MedPAC) March 2022 Report to Congress recommended that: Medicare base payment rates for hospice for Fiscal Year 2023 remain at current levels The hospice aggregate cap should be wage-adjusted and reduced by 20 percent. Hospices be required to report telehealth services on Medicare claims MedPAC’s…

NAHC Urges CMS to Collect Data on Technology-based and Chaplain Visits

Prior to the COVID-19 Public Health Emergency (PHE) many hospice providers had significant success with use of technology-based visits; however, there were a number of hospices that did not utilize technologies to their fullest extent because they believed they were required to provide all visits in-person. Early in the PHE, the Centers for Medicare & Medicaid Services (CMS) communicated that hospices are permitted to use telecommunications technologies to deliver hospice visits provided that such visits and technologies are specified by the Interdisciplinary Team (IDT) on the plan of care and that the goals of care (as outlined) are met.

In response to CMS’ clarification, hospice providers throughout the nation began to utilize technology more broadly in hospice care delivery, and found that, when used appropriately, this mode of care can provide substantial benefits to patients, family members, and hospice staff. However, CMS instructed hospices to not report these visits on hospice claims, which raised significant concern that CMS would not have accurate information on the full scope of services being provided to hospice patients, and that CMS and others would have no way of determining the impact that use of telecommunications technologies has on the quality of hospice care. The National Association for Home Care & Hospice (NAHC) has communicated to CMS a number of times since the start of the PHE that data on hospice “virtual” visits should be collected.

On a related matter, CMS has never required collection of data on chaplain visits on hospice claims, although previously, when the Hospice Item Set (HIS) data was directly submitted by hospice organizations and CMS gathered date for the Hospice Visits When Death is Imminent (HVDII) measure pair, the number of chaplain visits delivered during the last seven days of life was collected. The HVDII measure pair has been replaced with a claims-based measure (Hospice Visits in the Last Days of Life), which does not assess chaplain visits. As chaplains are essential members of the hospice IDT and the provision of chaplain services is a distinguishing element of the hospice benefit, NAHC and others have strongly urged CMS to collect data on chaplain visits on claims.

During the January 2022 meeting of the Medicare Payment Advisory Commission (MedPAC), the Commission approved a recommendation that the Secretary of Health & Human Services collect data on telehealth visits going forward as long as the agency permits telehealth visits in hospice. In putting forth the recommendation for the MedPAC March 2022 Report to Congress, Commission staff noted that, “Requiring hospices to report telehealth visits would increase the program’s ability to monitor beneficiary access to care.”  MedPAC’s recent action prompted the national hospice associations  (NAHC, NHPCO, LeadingAge, and NPHI) to join together in a letter to CMS Administrator Chiquita Brooks-LaSure urging that CMS:

  • Implement a modifier or HCPCS code and create a field on the hospice claim for telehealth visits from any discipline, to more accurately represent the full range of visits that hospices provide
  • Take the necessary steps to establish a HCPCS code specifically for chaplains in hospice and require reporting of chaplain visits on claims

The full letter to Administrator Brooks-LaSure is available HERE.  NAHC will provide updates on this and related issues in future issues of NAHC Report.

NAHC Urges CMS to Collect Data on Technology-based and Chaplain Visits

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MedPAC Recommends 20 Percent Cut to Hospice Aggregate Cap

  • Payment Freeze, Aggregate Cap and Telehealth Visit Reporting Highlighted

Late last week, the Medicare Payment Advisory Commission (MedPAC), an advisory body to the U.S. Congress, verbally approved the following recommendations:

  • For fiscal year (FY) 2023, the Congress should eliminate the update to the 2022 Medicare base payment rates for hospice and wage adjust and reduce the hospice aggregate cap by 20 percent; and
  • The Secretary of Health and Human Services should require that hospices report telehealth services on Medicare claims.

A formal vote will be taken at a January 2022 meeting.

On an annual basis, MedPAC reviews draft policy recommendations for inclusion in its annual Report to Congress: Medicare Payment Policy issued each March. The Commissioners met to discuss a wide array of preliminary recommendations that included discussion of hospice payment and related issues.

The first recommendation is a repeat of recommendations from the previous two reports; MedPAC staff indicated that based on existing analysis they do not believe these changes would negatively impact access to hospice care or willingness or ability of hospice providers to care for beneficiaries.

The second recommendation regarding telehealth services was motivated by the expanded use of telecommunications-based visits during the public health emergency (PHE) and the need to know the extent to which telehealth visits are being conducted and access to care during the PHE.

The National Association for Home Care & Hospice (NAHC) has strongly urged the Centers for Medicare & Medicaid Services (CMS) to begin collection of data related to telecommunications-based visits to ensure more complete knowledge of services that are being provided as part of the hospice benefit.

In arriving at these recommendations MedPAC examined a great deal of data regarding the Medicare hospice program that provides insights into existing hospice payment adequacy as viewed through four separate lenses:

  • Beneficiaries’ access to care, including the supply of providers; use, length of stay, and visits; and marginal profit
  • Quality of care, including findings of the CAHPS Hospice Survey and visits at the end of life – while quality data were not available due to the PHE, there was a slight improvement in the share of patients receiving at least one visit from a nurse or other clinician in last three days of life in 2019. MedPAC also indicated that while in-person visits declined during 2020 that does not necessarily reflect a reduction in quality but more likely was due to the PHE
  • Hospices’ access to capital, including provider entry and financial reports and mergers and acquisition activity – continued growth in the number of for-profit providers (7 percent increase) and continued favorable perspectives on the sector by investors indicates positive access to capital
  • Medicare payments and hospices’ costs, including overall Medicare margins in 2019 and the projected overall Medicare hospice margin in 2022 – the 2019 Medicare hospice margin was 13.4 percent, and four of five provider quintiles average margins of over 10 percent. Non-profit hospices and provider-based hospices generally experience lower margins.

Following are some key data provided during the meeting:

  • Medicare hospice outlays grew to $22.4 Billion in 2020;
  • In 2020, over 5,000 providers served over 1.7 million beneficiaries;
  • The number of hospice providers grew by 4.5 percent during 2020, largely driven by the growth in for-profit hospice providers;
  • Hospice deaths in 2020 increased by 18 percent;
  • The number of decedents using hospice increased by 9 percent;
  • The share of decedents using hospice declined to 47.8 percent in 2020 (from 51.6 percent in 2019;
  • Total number of hospice users increased by 6.6 percent between 2019 and 2020;
  • The number of hospice days increased by 4.9 percent in 2020;
  • During 2020 more hospice patients were cared for at home, in assisted living facilities, and in hospitals, while fewer were cared for in nursing facilities and hospice facilities;
  • Average length of stay increased from 92.5 days in 2019 to 97.0 days in 2020, while the median length of stay remained stable at 18 days;
  • Average in-person visits per week decreased from 4.3 visits in 2019 to 3.5 in 2020, with aide visits experiencing the largest decline, although nursing visits also declined (likely offset to some extent by use of telehealth visits);
  • Marginal profit in 2019 was 17 percent; and
  • During 2019, 19 percent of hospices exceeded the aggregate cap (margin prior to recoupment was 22.5 percent and 10 percent afterward).

While time for general discussion was limited, Commissioners expressed a great deal of interest in this sector, including the status of the Medicare Advantage VBID Hospice Component Model (a CMS demonstration model under which hospice is being covered as part of the MA benefit package), concerns about access to care in rural areas, concerns about the impact of the workforce shortage on hospice care, request for further exploration of live discharges in hospice care, and the degree to which the hospice population has changed and reflects a higher proportion of patients with cognitive disease.

A copy of the slides used during the staff presentation is available HERE.  In the coming days, a copy of the full transcript of the meeting will be posted HERE.

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