regulatory & compliance: the evolution of hospice – new ...€¦ · 15/6/1984 · history...
TRANSCRIPT
© National Hospice and Palliative Care Organization, November 2019
Regulatory & Compliance: The Evolution
of Hospice – New Care Models, Hot Topics
and Preserving Our Integrity
Judi Lund Person, MPH, CHC
Vice President, Regulatory and Compliance
NHPCO
November 2019
1 © National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
Today
• Where we began…. History and philosophy
• OIG reports on survey deficiencies and patient harm
• Hospice program integrity legislation
• FY2020 Hospice Wage Index Final Rule• Rates
• Election statement changes
• Election statement addendum
• Primary Care First/Serious Illness Population Model
© National Hospice and Palliative Care Organization, November 2019
Dame Cicely Saunders
• 1967 – St. Christopher’s Hospice, London
• Introduced idea of “total pain” - physical, emotional, social and spiritual distress
• Each person is an individual to the end
33
© National Hospice and Palliative Care Organization, November 2019
Dame Cicely Saunder’sOriginal Concept of Hospice
4
© National Hospice and Palliative Care Organization, November 2019
Florence Wald
• Dean of the School of Nursing, Yale University
• Attended Cicely Saunders lecture at Yale in 1963
• Saunders presented methods of using palliative care for terminally ill cancer patients
• Focus on personal relationships and preparing themselves for death
• Lecture made "indelible impression"
• Modeled the first hospice in the US after St. Christopher’s Hospice in London
• The Connecticut Hospice opened in 1974
5
© National Hospice and Palliative Care Organization, November 2019
Hospice: The first patient care system in the U.S. to employ care coordination
• Care is available to patients and their families seven days a week, 24 hours a day
• Hospice care closely integrates inpatient care and home-care to ensure coordination and continuity
• The patients, their families, and anyone essential to the patients’ life create the “unit of care”
• Volunteers are crucial to the success of the hospice care model
• Palliative and supportive care is directed at ameliorating the physical, emotional and spiritual discomfort associated with terminal illness
• Anticipatory grief counseling is available for the patient and their family before death and bereavement services are available for the family after the patient has died, including phone calls, follow-up visits and support
6
© National Hospice and Palliative Care Organization, November 2019
Original Hospice Standards and JCAHO Accreditation Program
• NHO Standards of a Hospice Program of CareoReleased in 1979
o Remarkably durable
oDescribed a model of care, not a payment structure
• Joint Commission on Accreditation of Hospitals oBegan work on its hospice accreditation program in 1981
oAt the same time, numerous members of Congress and their aides were hearing from constituents about the miracles hospice care had wrought in the lives of dying patients and their families — or else had personal experiences of their own with hospice — and were eager to help.
7
© National Hospice and Palliative Care Organization, November 2019
Starting with a Demonstration Project• 1978: HEW
o Government would fund and study hospice demonstration projects o Learn about the organization and cost of this new model of careo Secretary Joe Califano had been lobbied hard by another hospice booster,
Connecticut Governor Ella T. Grasso, one evening after missing a flight back home from Connecticut.
• Selection process:o 200 applicationso 26 programs were chosen as demonstration hospices
• Reimbursement:o Cost-based reimbursemento Payment tied to the actual costs of caring for patients
8
© National Hospice and Palliative Care Organization, November 2019
26 Hospice Demonstration Sites – 1980-1982
1. San Diego County Hospice, San Diego, CA
2. San Pedro Peninsula Hospital, San Pedro, CA
3. Hospice of Marin, San Rafael, CA
4. Hospice of Santa Barbara, Santa Barbara, CA
5. Hospital Home Health Care Agency, Torrance, CA
6. Boulder County Hospice, Boulder, CO
7. The Connecticut Hospice, New Haven, CT
8. The Elisabeth Kubler-Ross Hospice, Clearwater, FL
9. Hospice of Miami, Miami, FL
10.University of Massachusetts Medical Center, Worcester, MA
11.Hospice of the Good Shepherd, Waban, MA
12.Hospice of St. Paul, St. Paul, MN
13.Lutheran Medical Center, St. Louis, MO
14. Overlook Hospital, Summit, NJ
15. Hospital Home Health Care & Hospice Care, Albuquerque,
16. NM Cabrini Hospice, New York, NY
17. Genesee Region Home Care Association, Rochester, NY
18. Providence Medical Center, Portland, OR
19. VNA Home Hospice Program, Dallas, TX
20. St. Benedict’s Hospital & Nursing Home, San Antonio, TX
21. VNA of Vermont, Burlington, VT
22. Hospice of Northern Virginia, Arlington, VA
23. Medical College of Virginia, Richmond, VA
24. Community Home Health Care, Seattle, WA
25. Bellin Hospice, Green Bay, WI
26. Rogers Memorial Hospital/ Hospice, Oconomowoc, WI
9
© National Hospice and Palliative Care Organization, November 2019
Draft Legislation (1981)
• Eligibility based on a six-month terminal prognosis
• Hospice care as an alternative to conventional medical care
• A defined hospice interdisciplinary team, including:
• Nurse
• Physician
• Social worker
• Counselor
• Within a separate hospice organization
• Emphasis on care in the patient’s home to the extent possible
• Treating the patient and family together as the unit of care
• Bereavement support for the family after the patient’s death
Introduced in December 1981
House:
H.R. 5180
Sponsored by
• Representative Leon Panetta, D-CA
• Representative Bill Gradison, R-OH
Senate:
S. 1958
Sponsored by
• Senator Bob Dole, D-KS
10
© National Hospice and Palliative Care Organization, November 2019
Benefit Design
• Cost containment potential
• Hospices “on a budget from day one and given responsibility for their own success. It required them to act more like a business. It made them more self-reliant.”
• Prospective payment
oNew for government
o Four per diem payment categories
o Intended to give hospices more flexibility in how they applied services to individual patients
11
© National Hospice and Palliative Care Organization, November 201912
© National Hospice and Palliative Care Organization, November 2019
Progress
• December 1983: Final regulations published
• June 15, 1984:
o91 certified hospices
o12 applicants withdrew
o5 denied
o41 scheduled for certification visits
• 1985: Legislation passed to make Medicare hospice benefit permanent
• 1992: 1,123 Medicare certified hospices
13
© National Hospice and Palliative Care Organization, November 2019
Growth in Number of Hospice Providers
1,123
2,255
3,250
3,925 4,092 4,199 4,382 4,408 4,569
-
1,000
2,000
3,000
4,000
5,000
1992 2000 2007 2013 2014 2015 2016 2017 2018Number of Hospices
Source: Report to the Congress: Medicare Payment Policy, “Hospice services: Assessing payment adequacy and updating payments,” Medicare Payment Advisory Commission, Washington, DC,
March 2017, p.324. Categories may not sum to total because of missing data for some providers. 2FY2018 data from FY2020 Hospice Wage Index Proposed Rule, April 2019
14
© National Hospice and Palliative Care Organization, November 2019
Number of Medicare Patients in Hospice
534,000
1,055,000
1,219,0001,274,0001,315,0001,324,000
1,381,0001,400,0001,500,000
1,600,000
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2000 2008 2011 2012 2013 2014 2015 2016 2017 2018
Source: FY2020 Hospice Wage Index Proposed Rule, April, 2019
15
© National Hospice and Palliative Care Organization, November 2019
Quiz
• How many hospices were in the original demonstration project?oName 3
• Who introduced the legislation?oHouse?o Senate?
• What year did the Medicare hospice benefit get added to the statute?
• What was unique about the hospice legislation?
• Did any hospice meet the requirements for the Medicare Hospice Benefit when it became law?
• How many Medicare certified hospices were there in 1992?
16
© National Hospice and Palliative Care Organization, November 2019
Today – OIG and Program Integrity
17
© National Hospice and Palliative Care Organization, November 2019
Recent OIG Reports on Hospice Quality and Patient Harm
OIG Reports Released July 2019
• Hospice Deficiencies Pose Risks to Medicare Beneficiaries
Reviewed State agencies’ survey reports for 50 serious (condition-level) deficiencies
• 87% of the hospices surveyed from 2012 through 2016 had a deficiency
• 20% of hospices had serious deficiencies in quality of care
Had a deficiency in 2016?
• Most had multiple deficiencies from 2012 through 2016
• Many had multiple deficiencies within the same year
70% of the hospices with a deficiency in 2016
• Also had at least one other deficiency in the 5-year period
© National Hospice and Palliative Care Organization, November 2019
Most Common Deficiencies from 2012-2016
19
59%
53%
42%
37%
29%
29%
26%
23%
22%
22%
0% 10% 20% 30% 40% 50% 60% 70%
CARE PLANNING
HOSPICE AIDE SERVICES
PATIENT ASSESSMENTS
CLINICAL RECORDS
ORGANIZATION AND …
INFECTION CONTROL
CORE SERVICES
HOSPICE CARE FOR HOSPICE …
PATIENT RIGHTS
DRUGS, BIOLOGICALS, …
% of Hospices with Deficiency
% of Hospices with Deficiency
© National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
Top 5 Survey Deficiencies – All States FY2019
20
Source: www.qcor.cms.gov
© National Hospice and Palliative Care Organization, November 2019
Top 5 L Tags Cited in FY2019
L Tag Number Description
L543 §418.56(b) Standard: Plan of care All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire.
L647 §418.78(e) Standard: Level of activity Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent …
L530 §418.54(c)(6) Standard: Content of the comprehensive assessment Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy
L629 §418.76(h) Standard: Supervision of hospice aides
L555 §418.56(e) Standard: Coordination of services Ensure that the care and services are provided in accordance with the plan of care.
© National Hospice and Palliative Care Organization, November 2019
Complaints from 2012 through 2016
35%
Complaints
Substantiated Complaints Total Compliants
From 2012 through 2016
• More than 700 hospices had severe complaints filed against them
• 35% of severe complaints were substantiated
22
Source: OIG Analysis of CMS Data
© National Hospice and Palliative Care Organization, November 2019
Complaints
• More than 700 hospices had severe complaints filed against them.
• The number of hospices that had severe complaints filed against them grew each year, more than tripling from 78 to 285 from 2012 to 2016.
• The OIG identified 313 hospices as poor performers.
• Each of these hospices were surveyed and had at least one serious deficiency or one substantiated severe complaint in 2016.
• These hospices represent 18 percent of all hospices surveyed nation-wide in 2016.
23
© National Hospice and Palliative Care Organization, November 2019
Characteristics of Poor Performers
• 313 hospice providers identified as poor performers
• 88% had a history of other violations
• 67% were for-profit, similar to hospices nation-wide
• 40 hospices had a history of serious deficiencies
24
• NHPCO clarification with the OIG…
• At least one condition level deficiency or one substantiated severe complaint in 2016
• Both state-surveyed and accrediting organizations
• Accrediting organization survey results are not public
© National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
The OIG Recommendations
to CMS
• Expand the deficiency data that accrediting organizations report to CMS
• Seek statutory authority to include information from accrediting organizations on Hospice Compare
• Include survey reports from State agencies on Hospice Compare
• Educate hospices about common deficiencies and those that pose particular risks to beneficiaries
• Increase oversight of hospices with a history of serious deficiencies.
25
© National Hospice and Palliative Care Organization, November 2019
OIG Recommendations to Identify and Report Concerns
26
Train staff on signs of potential abuse, neglect, and other harm and how to report it Train
Report instances of suspected harm—regardless of perpetrator—to CMS (and to law enforcement when appropriate)
Report
Provide information to beneficiaries and caregivers about making complaints Provide
Report concerns about harm or poor quality of care by other hospices to CMS and the State survey agency Report
Report concerns about hospice fraud to OIG https://tips.oig.hhs.gov/Report
© National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
Recent OIG Reports on Hospice Quality and Patient Harm
OIG Reports Released July 2019
• Safeguards Must Be Strengthened to Protect Beneficiaries from Harm
• 12 cases of harm to beneficiaries receiving hospice care.
• Each case identified vulnerabilities that could have led to the harm and to determine how such harm could be prevented in the future.
• Findings:
• Poor care to beneficiaries
• Abuse by caregivers or others and the hospice failing to take action.
• No serious consequences for the hospice for the harm described
• Not systemic, but concerning
© National Hospice and Palliative Care Organization, November 2019
“A state inspector in Missouri documented the grim details: a deep, poorly treated pressure wound on the patient’s tailbone, apparent pain that caused grimacing and — in a crisis requiring a trip to the emergency room — a “maggot infestation’’ where the feeding tube entered his abdomen”.
- July 9, 2019
28
© National Hospice and Palliative Care Organization, November 2019
Case 2
• The hospice allowed maggots to develop around a beneficiary’s feeding tube
• While under the care of a hospice in his home, a beneficiary developed maggots around his feeding tube insertion site and had to be transferred to the hospital for treatment.
• His caregiver indicated that the beneficiary experienced pain when moved due to a pressure sore and contractures, and specifically mentioned that one reason the beneficiary was in hospice care was to avoid unnecessary pain and trauma associated with hospitalizations
© National Hospice and Palliative Care Organization, November 2019
Case 4
The hospice failed to recognize signs of a possible sexual assault of a beneficiary
• A beneficiary residing in an assisted living facility had blood clots and significant signs of injury to her pelvic area, right upper leg, and right forearm.
• Hospice staff failed to recognize these as signs and symptoms of possible sexual assault and did not report them to the hospice administrator or local law enforcement agency.
• Instead, the hospice obtained a physician’s order for the insertion of a urinary catheter, an invasive procedure. The hospice tried and failed multiple times to insert a catheter, finally transferring the beneficiary to a hospital.
• The hospital staff recognized the signs of possible sexual assault and notified the police.
30
© National Hospice and Palliative Care Organization, November 2019
Reporting Requirements For Surveyors
Are Limited
• Lack of requirements for surveyors to report crimes to law enforcement
• Surveyors may discover beneficiary harm that may have resulted from a crime
• Only guidance provided to surveyors was limited to immediate jeopardy
31
© National Hospice and Palliative Care Organization, November 2019
Barriers to Making
Complaints
• There is identified vulnerability in efforts to prevent and address harm is that beneficiaries, their caregivers, and their families face barriers to making complaints.
• Beneficiaries and others have two primary avenues for registering complaints about the quality of care a hospice provides:
o They can voice a grievance with the hospice
o They can make a complaint to the State agency
32
© National Hospice and Palliative Care Organization, November 2019
The OIG Recommendations
to CMS
• CMS should seek statutory authority to establish additional, intermediate remedies for poor hospice performance
• Strengthen requirements for hospices to report abuse, neglect, and other harm
• Ensure that hospices are educating their staff to recognize signs of abuse, neglect, and other harm
• Strengthen guidance for surveyors to report crimes to local law enforcement
• Monitor surveyors’ use of immediate jeopardy citations
• Improve and make user-friendly the process for beneficiaries and caregivers to make complaints
33
© National Hospice and Palliative Care Organization, November 2019
• Care planning
• Management of aide services
• Beneficiary (comprehensive) assessments
• Vetting staff
• Providing all needed services
• Care coordination
• Quality control
• Participate in CMS-sponsored training
34
Use OIG Analysis to Assess Your Hospice and Improve Where Needed
© National Hospice and Palliative Care Organization, November 2019
NHPCO Action and Legislative Activity• High media attention
o Washington Post, NPR, NBC Nightly News and many other articles and news stories
• NHPCO program integrity measures developed with committee discussions
• Intense work with Congressional committees of jurisdiction
o House Ways and Means
o Senate Finance Committee
• S. 2807 Introduced on November 7 by Senators Portman (R-OH) and Cardin (D-MD)
o https://www.portman.senate.gov/sites/default/files/2019-11/GOE19A43.pdf
o Accrediting Organization survey results public
o Education for surveyors and
o Alternative sanctions
o Education for surveyors
© National Hospice and Palliative Care Organization, November 2019
S.2807 – Major Provisions
Increasing Reported Hospice Data
Disclose accreditation surveys to the same
extent as they’re currently authorized with respect to home
health agency accreditation surveys
Expand the information that
approved accreditation agencies are required to report so that they are comparable to the information that State
and local survey agencies report
Data from both State survey agency and
accrediting organization survey
results shall be included in Hospice
Compare
BILL TITLE: HOSPICE CARE IMPROVEMENT ACT OF 2019 (S. 2807)
© National Hospice and Palliative Care Organization, November 2019
S.2807 – Major Provisions
Improving the Hospice Survey Process
• Surveys every 36 months
o This bill eliminates the 2025 “sunset provision” for the frequency of hospice surveys and makes permanent the requirement for hospice surveys every 36 months.
• Newly certified hospices
o After the date of enactment, any newly-certified hospice program is subject to a standard survey within 12 months of initial certification
• Hospices with alternative sanctions – survey frequency and compliance:
o Any hospice subject to an alternative sanction shall have a standard survey no less frequently than once every 12 months until the entity is found by the State or local survey agency or approved accreditation agency to be in compliance with survey requirements for a period of 24 months
© National Hospice and Palliative Care Organization, November 2019
S.2807 – Major Provisions
Improving the Hospice Survey Process
• Educational information to hospice providers on survey deficiencies and preventing future deficiencies
o If a deficiency is found as part of a standard survey, the State or local survey agency or an approved accreditation agency shall provide educational information, or access to such information, on how to address the deficiency and prevent future deficiencies.
o The information shall be standardized for both educating hospice programs and surveyors from State survey agencies and approved accreditation agencies.
• Joint training and education:
o Establish a process for joint training and education of surveyors from State and local survey agencies, approved accreditation agencies and hospice providers on a regular basis.
oThe education and training will cover changes to regulations, guidelines and policies governing hospice operations as they are implemented and used in the survey process
© National Hospice and Palliative Care Organization, November 2019
S.2807 – Major Provisions
Increasing Payment Reductions for Failing To Report Quality Measures
o Increase from 2% to 4% the percentage of payment reduction when a hospice provider does not participate in quality reporting, beginning in FY2021 and thereafter.
© National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
S.2807 – Major Provisions
Authority To Impose Alternative Sanctions
• Alternative sanctions:
• Suspension of all or part of the payments for all new admissions on or after the date on which the Secretary determines that alternative sanctions should be imposed
• Appointment of temporary management to oversee the operation of the hospice program and to protect and assure the health and safety of individuals under the care of the hospice program while improvements are made
• Implementation of a directed plan of correction under which the Secretary or the temporary manager may direct the hospice program to take specific corrective action to achieve specific outcomes within specific timeframes.
• If education is likely to correct the deficiencies, imposition of a requirement that all hospice program staff attend in-service training programs deemed acceptable by the Secretary
• Secretary has discretion to add other alternative sanctions
© National Hospice and Palliative Care Organization, November 2019
FY2020 Hospice Wage Index Final Rule
4141
© National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
PAYMENT RATE UPDATE
42
© National Hospice and Palliative Care Organization, November 2019
Summary of FY2020 Final Rule Changes
43
2.6% rate increase – applied to
• Rebasing rate for Continuous Home Care (CHC)
• Rebasing rate for Inpatient Respite Care (IRC)
• Rebasing rate for General Inpatient Care (GIP)
-2.72% rate reduction in routine home care (RHC) rates to allow for rebasing for other levels of care
• RHC 1-60 days: Rate reduction of $1.75 per patient care day
• RHC 61+ days: Rate reduction of $0.49 per patient care day
Effective October 1, 2019
© National Hospice and Palliative Care Organization, November 2019
FY2020 Rebased Rates for CHC, IRC and GIP
Code Description
FY2019
Original
Payment
Rates
FY2019
Rebased
Payment
Rates
Wage Index
Standardizati
on Factor
FY2020
Hospice
Payment
Update
FY2020
Payment
Rates
Difference
652 Continuous
Home Care
Full rate = 24
hours of care
$997.38 $1,363.26 X 0.9978 X 1.026 $1,395.63 +$398.25
652 Continuous
Home Care
and SIA Hourly
rate
$41.56 $56.80 X 0.9978 X 1.026 $58.15 +$16.59
655 Inpatient
Respite Care$176.01 $437.86
X 0.9978 X 1.026 $450.10 +$274.09
656 General
Inpatient Care $758.07 $992.99 X 1.0019 X 1.026 $1,021.25 +$263.18
44
© National Hospice and Palliative Care Organization, November 2019
How Did This Happen?
• CMS used 3 years of hospice cost report data to analyze reported costs by level of care with reimbursement rates for each level of care
• Significantly higher costs (compared to reimbursement) for
oCHC
o IRC
oGIP
• Significantly lower costs (compared to reimbursement) for
oRHC 1-60
oRHC 61+
45
© National Hospice and Palliative Care Organization, November 2019
FY2019 Rates Compared to Cost – CHC, IRC, GIP
$56.80
$457.61
$994.45
$41.56
$176.01
$758.07
$0
$200
$400
$600
$800
$1,000
$1,200
CHC Hourly IRC GIPCost FY2019 Payment
CHC$15.24 LESS in reimbursement
IRC$281.60 LESS in reimbursement
GIP$236.38 LESS in reimbursement
46
© National Hospice and Palliative Care Organization, November 2019
RHC Rates – FY2020
Code Description
FY2019
Original
Payment
Rates
FY2019
Adjusted
Payment
Rates
SIA
Budget
Neutrality
Factor
Wage Index
Standardiza-
tion Factor
FY2020
Hospice
Payment
Update
FY2020
Payment
Rates
Difference
651RHC 1-60
days$196.25 $190.91 X 0.9924 X 1.0006 X 1.026 $194.50 -$1.49
651RHC 61+
days$154.21 $150.02 X 0.9982 X 1.0005 X 1.026 $153.72 -$0.49
47
© National Hospice and Palliative Care Organization, November 2019
FY2019 Cost Compared to Reimbursement - RHC
$171.89
$118.95
$196.25
$154.21
0
50
100
150
200
250
RHC 1-60 RHC 61+
Cost Reimbursement
48
RHC 1-60 days$24.36 more in reimbursement compared to cost
RHC 61+ days$35.26 more in reimbursement compared to cost
© National Hospice and Palliative Care Organization, November 2019
Description
No Quality
Reporting
FY2019
Original
Payment
Rates
FY2019
Rebased
Payment
Rates
SIA
Budget
Neutrality
Factor
Wage Index
Standardizatio
n Factor
FY2020
Payment
Update of
2.6% minus 2
% = +0.6%
FINAL
FY2020
Payment
Rates
Difference
RHC 1-60 $192.39 $190.91 X 0.9924 X 1.0006 X 1.006 $190.71 -$1.68
RHC 61+ $151.18 $150.02 X 0.9982 X 1.0005 X 1.0006 $150.72 -$0.46
Service
Intensity
Add-on
$40.74 $56.80 X 0.9978 X 1.0006 $57.02 $16.06
Continuous
Care – 24
hours
$977.78 $1,363.26 X 0.9978 X 1.0006 $1,368.42 $390.64
Inpatient
Respite$172.56 $437.86 X 1.0019 X 1.0006 $441.32 $268.76
General
Inpatient$743.18 $992.99 X 1.0024 X 1.0006 $1,001.35 $258.17
49
© National Hospice and Palliative Care Organization, November 2019
Hospice Cap
• For FY2020 = $29,964.78
Calculation:
FY 2019 cap amount = $29,205.44 x 102.6% = $29,964.78
50
© National Hospice and Palliative Care Organization, November 2019
Changes to Election Statement and Addendum
51 © National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
Election Statement and
Addendum
• Reasons for change:
o More transparency for patients and representatives
o Anecdotal reports of hospices not covering items, services or drugs
o The amount and nature of the non-hospice services being billed to Medicare outside of the hospice benefit suggests that hospice beneficiaries may not be fully informed, at the time of admission or throughout the hospice election, of the items, services, and drugs the hospice has determined to be unrelated to their terminal illness and related conditions
o CMS believes this is necessary information for patients and their families to make informed care decisions
52
© National Hospice and Palliative Care Organization, November 2019
Changes to the Hospice Election
Statement
• Effective October 1, 2020 (FY 2021)
• Hospice election statement will be amended to include:
o Information about the holistic, comprehensive nature of the Medicare hospice benefit
o A statement that, although it would be rare, there could be some necessary items, drugs, or services that will not be covered by the hospice because the hospice has determined that these items, drugs, or services are to treat a condition that is unrelated to the terminal illness and related conditions
o Information about beneficiary cost-sharing for hospice services
53
© National Hospice and Palliative Care Organization, November 2019
Changes to the Hospice Election
Statement
• Notification of the beneficiary’s (or representative’s) right to request an election statement addendum that includes a written list and a rationale for the conditions, items, drugs, or services that the hospice has determined to be unrelated to the terminal illness and related conditions
• Statement that immediate advocacy is available through the Beneficiary-Family Care Centered Quality Improvement Organization (BFCC-QIO) if the beneficiary (or representative) disagrees with the hospice’s determination
54
© National Hospice and Palliative Care Organization, November 2019
CMS Comment on Relatedness
• CMS reiterated their “long-standing position that services unrelated to the terminal illness and related conditions should be exceptional, unusual and rare given the comprehensive nature of the services covered under the Medicare hospice benefit as articulated upon the implementation of the benefit.”
• 48 FR 56008, 56010, December 16, 1983
• CMS cited the NHPCO’s “Determining Relatedness to the Terminal Prognosis Process Flow” in the final rule as an example of clinical decision-making process workflows. Go to the NHPCO website/Regulatory/Determining Terminal Prognosis
55
© National Hospice and Palliative Care Organization, November 2019
CMS adds new requirement for election statement addendum
56
New requirement
To be provided to patients and representatives upon request
Title: “Patient Notification of Hospice Non-Covered Items, Services, and Drugs.”
Effective October 1, 2020 (FY 2021) the signed addendum will also serve as a new condition for payment.
© National Hospice and Palliative Care Organization, November 2019
Addendum Details
57
Details
Effective Date October 1, 2020 (FY2021)
Addendum requirement Required to issue the addendum detailing non-covered items, services upon request
If requested at admission Within 5 days after admission
If requested after the start of care
Within 72 hours
Acknowledgement Signature required – but not required to agree with hospice determination
© National Hospice and Palliative Care Organization, November 2019
Items to be covered on addendum
• Required components:
o Name of the hospice;
o Beneficiary’s name and hospice medical record identifier;
o Identification of the beneficiary’s terminal illness and related conditions;
o A list of the beneficiary’s current diagnoses/conditions present on hospice admission (or upon plan of care update, as applicable) and the associated items, services, and drugs, not covered by the hospice because they have been determined by the hospice to be unrelated to the terminal illness and related conditions;
58
© National Hospice and Palliative Care Organization, November 2019
Items to be covered on addendum (cont.)
• Required components: o A written clinical explanation, in language the beneficiary
and his or her representative can understand, as to why the identified conditions, items, services, and drugs are considered unrelated to the terminal illness and related conditions and not needed for pain or symptom management.
o Accompanied by a general statement that the decision as to whether or not conditions, items, services, and drugs is related is made for each patient and
o The beneficiary should share this clinical explanation with other health care providers from which they seek services unrelated to their terminal illness and related conditions;
o References to any relevant clinical practice, policy, or coverage guidelines.
59
© National Hospice and Palliative Care Organization, November 2019
Items to be covered on addendum (cont.)
• Required components:
o Information on the following domains:
▪ Purpose of Addendum
▪ Right to Immediate Advocacy
o Name and signature of Medicare hospice beneficiary (or representative)
o Date signed
o Statement that signing this addendum (or its updates) is only acknowledgement of receipt of the addendum (or its updates) and not necessarily the beneficiary’s agreement with the hospice’s determinations.
60
© National Hospice and Palliative Care Organization, November 2019
Addendum as a condition of payment
• The election statement addendum is a condition for payment
• CMS will collaborate with the MACs to establish clear guidelines on the use of the addendum as a condition for payment
• Not punitive – rather it is to keep patients at the forefront of their decision-making, with adequate information to make care choices
61
© National Hospice and Palliative Care Organization, November 2019
Using the addendum to communicate with non-hospice providers or suppliers
62
Sharing of information with other non-hospice healthcare providers and suppliers necessary to ensure coordination of
services and to meet the patient, family, and caregiver needs. [ § 418.56(e)(5)]
The coordination requirements include that the hospice must develop and maintain a system of
communication and integration amongst all providers furnishing care to the terminally ill patient.
© National Hospice and Palliative Care Organization, November 2019
Regulatory Relief Final Rule: Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction
Issued September 30, 2019Effective November 29, 2019
63© National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
Final Rule On Regulatory
Burden –Hospice Aide
Training
• Defers hospice aide training and competencies to state licensure requirements.
o If there are no state requirements, hospices will still be required to ensure that their hospice aides meet Federal standards for hospice aide training.
64
© National Hospice and Palliative Care Organization, November 2019
Final Rule On Regulatory Burden –Person on Staff with Specialty Knowledge of Hospice Medications
65
Removes requirements to have a person on the hospice staff that has specialty knowledge of hospice medications
• COP language removed:
• “an individual with education and training in drug management as defined in hospice policies and procedures and State law, who is an employee of or under contract with the hospice, to ensure that drugs and biologicals meet each patient’s needs.”
Does not relieve the hospice of ongoing IDG review and documentation regarding safe, appropriate, and effective use of medications
Drug profile still required as part of the patient’s comprehensive assessment
Included as part of the IDG’s ongoing assessment and plan of care update for the patient
Discussions with the patient and family would be in a manner and language that the patient and family understand
© National Hospice and Palliative Care Organization, November 2019
Final Rule On Regulatory
Burden – Drug Disposal in the
Home
• Follows the statutory requirement in the SUPPORT Act that the hospice must share the written policies and procedures for drug disposal in the home with patients, families and caregivers.
oCMS encourages hospices to develop easily understood materials that explain safe storage, use, and disposal of controlled drugs to patients, their families, and caregivers in addition to meeting the statutory requirement.
66
© National Hospice and Palliative Care Organization, November 2019
Final Rule on Regulatory Burden –Orientation of SNF and ICF/IID Staff
67
Existing COP § 418.112(f) revised:
Clarifies that a hospice must consult with and share
responsibility with the facility to assure facility staff
orientation and training
Language was added to COP §418.112 (c) to include a written agreement that negotiates the mechanism and schedule for
the orientation of staff to occur
The goal is for shared responsibility between the
facility and the hospice regarding orientation and
training of facility staff
Note: Not necessary to adjust SNF written contracts for this
requirement
© National Hospice and Palliative Care Organization, November 2019
© National Hospice and Palliative Care Organization, November 2019
CMS Published A Final Rule On
Regulatory Burden –
Emergency Preparedness
• Changes in emergency preparedness requirements for hospice inpatient facilities and home-based hospice care.
o Testing (for inpatient providers/suppliers): Increases the flexibility for the testing requirement so that one of the two annually-required testing exercises may be an exercise of the facility’s choice; and
o Testing (for outpatient providers/suppliers): Decreases the requirement for facilities to conduct two testing exercises to one testing exercise annually.
68
© National Hospice and Palliative Care Organization, November 2019
New Models: Primary Care First & Serious Illness Population (SIP) Models New Hampshire is one of the 26 eligible states
69
© National Hospice and Palliative Care Organization, November 2019
In 2021, Primary Care First Model will include 26 diverse regions
Regions
• Greater
Buffalo (NY)
• Greater
Kansas City
(KS and MO)
• Greater
Philadelphia
(PA)
• North
Hudson-
Capital
region (NY)
• Ohio and
Northern
Kentucky
(OH and KY)
70
Statewide
• Alaska
• Arkansas
• California
• Colorado
• Delaware
• Florida
• Hawaii
• Louisiana
• Maine
• Massachusetts
• Michigan
• Nebraska
Statewide
• New Hampshire
• New Jersey
• North Dakota
• Ohio
• Oklahoma
• Oregon
• Rhode Island
• Tennessee
• Virginia
© National Hospice and Palliative Care Organization, November 2019
Two Model Types and Five Models
Primary Care First
Primary Care First
PCF High Needs Population (SIP)
Direct Contracting
Professional Care
Global
Geographic
(The Direct Contracting model is delayed. CMS will be releasing details later this fall)
71
© National Hospice and Palliative Care Organization, November 2019
What is the SIP Option?
SIP is one component of the broader Primary Care First model Practices have three options:
1) Practices may choose to participate only in the PCF-General component of Primary Care First, and not in the SIP component, i.e. “PCF-General practices”;
2) Practices may choose to participate only in the SIP component of Primary Care First, and not in the PCF-General component, i.e. “SIP-only practices”;
3) Practices may choose to participate in both the SIP and PCF-General components of Primary Care First, i.e. “hybrid practices.”
• Primary Care First is geared towards advanced primary care practices that are ready to accept financial risk in exchange for greater flexibility, increased transparency, and performance-based payments that reward participants for outcomes.
• In Primary Care First, CMS will provide payments that are higher than historical Medicare fee-for-service (FFS) payments, in the aggregate, for participating practices that care for complex, chronically ill patients.
72
© National Hospice and Palliative Care Organization, November 2019
Background: PCF/SIP
➢Participants:
oParticipating practices will generally include primary care practitioners, as well as other clinicians that are managing high need, seriously ill populations.
➢Patient Eligibility:
oSeriously Ill Population (SIP) patients lacking
▪ Primary care practitioner or
▪ Care coordination
© National Hospice and Palliative Care Organization, November 2019
Timing of RFA
➢Timing:
oApplication period: October 24, 2019 through January 22, 2020.
oPractice and payer selections: Winter-Spring 2020
oStart Date: January 2021
oDuration: 6 performance years, 2 cohorts
▪ 2021 through 2025
▪ 2022 through 2026
74
© National Hospice and Palliative Care Organization, November 2019
• Pays practices primarily for outcomes
• Significant step away from FFS and towards population-based payment.
• The payment structure has two elements:
1. Total Primary Care Payment (TPCP): a lump-sum professional population-based payment
(PBP) paid on a quarterly basis and a flat $40.82 base rate per-visit primary care fee.
2. Performance-Based Adjustment (PBA): During performance year two and in subsequent
performance years, a practice’s TPCP will be adjusted based on its performance on five
quality and patient experience of care measures, as well as a measure of acute hospital
utilization (AHU).
• One time payment: $325 for first face-to-face visit with beneficiary
75
SIP Model Payment
© National Hospice and Palliative Care Organization, November 2019
SIP Model Examples Adjusted for Quality
Indicators Upfront PMPM Base Rate SIP Quality Adjustment (PMPM base rate)
✓ High quality (> 70th percentile relative to reference population
✓ ALOS < 8 months✓ Successful transition
$275 base rate - $50 quality withhold = $225
$50 withhold paid back plus$50 bonus = $50 PMPM; Total PMPM = $325
x Satisfactory Quality (50th to 70th
percentile relative to reference population)
✓ ALOS < 8 months✓ Successful transition
$275 base rate - $50 quality withhold = $225
$50 withhold paid back, no bonus paid out = $0 PMPM;Total PMPM = $275
x Low Quality (< 50th percentile relative to reference population)
x ALOS > 8 monthsx Poor transition
$275 base rate - $50 quality withhold = $225
$50 withhold forfeited = -$50 PMPM; Total PMPM = $225
76
© National Hospice and Palliative Care Organization, November 2019
• NHPCO has been meeting regularly with CMMI regarding the structure of the
PCF/SIP model at the staff level and through the National Coalition for Hospice
and Palliative Care (Coalition).
• Town Hall Event for NHPCO Members- May, 2019
• Formal Recommendations submitted to CMMI on behalf of the Coalition- June, 2019
• Staff level conversations with CMMI- Weekly
• October 24 CMMI Announcement of PCF/SIP RFA- NHPCO Staff in attendance
• Policy Alert to members October 24 2019
• We will continue to work closely with CMMI and monitor how key model
components are implemented in practice.
77
Proactive Engagement
© National Hospice and Palliative Care Organization, November 2019
• NHPCO will continue to be the go-between members and CMMI. CMS is expecting our continued feedback and is aware that there are a lot of questions regarding the details of the RFA.
• NHPCO will offer the following services to members who want to pursue the SIP Model:
• Learning Collaborative (Monthly)
• Technical Assistance (Ongoing)
• Connections to individualized TA and Contract Services (Ongoing)
• Connections to Health IT Vendors (Ongoing)
• To review the RFA please visit this link.
• To review CMS FAQs for the RFA please visit this link.
78
What’s Next?
© National Hospice and Palliative Care Organization, November 2019
What Should Your Hospice Do?
• Review what health plans and physician practices you currently work with
• Are they interested in applying for the VBID model for MA?
• Are they interested in applying for the PCF or SIP model?
• Can you help them?
• Can you be their partner?
79
© National Hospice and Palliative Care Organization, November 201980
© National Hospice and Palliative Care Organization, November 2019
QUESTIONS
81
© National Hospice and Palliative Care Organization, November 2019
Contact us at NHPCO for Regulatory and Quality Assistance
Regulatory questions
Email us at: [email protected]
Quality questions
Email us at: [email protected]
82
NHPCO members enjoy unlimited access to Regulatory and Quality Assistance
© National Hospice and Palliative Care Organization, November 2019