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Hospice Proposed Rule Part 2: Quality Reporting, Program Integrity & Comprehensive Assessment

Simione Healthcare Consultants is pleased to publish this second of several updates to review key components of the FY2016 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting proposed rule.  This installment covers quality reporting, program integrity and comprehensive assessment.

Simione Healthcare Consultants can assist with all aspects of hospice operations and service delivery to ensure quality patient care, survey readiness, compliance, and successful operations in accordance with applicable regulations and industry best practices.  To learn more about ways we can assist you with your hospice needs, call 844.215.8820 or email us [email protected]


The FY 2016 Hospice Wage Index Proposed Rule contains several key items specific to quality reporting, the comprehensive assessment and program integrity.  While some of the proposed revisions are new, many are clarifications of current CMS requirements.  Therefore, it is important that hospices implement an ongoing survey readiness program to ensure compliance in these areas and to evaluate the impact of proposed revisions on agency operations.  

Hospice providers are encouraged to review the proposed rule and determine the potential impact on their own operations, as well as the impact on the hospice industry as a whole.  Hospices may submit comments individually and/or through their state associations or national member associations such as the National Hospice and Palliative Care Organization (NHPCO) and the National Association for Home Care and Hospice (NAHC).  The deadline for submission of comments to CMS is June 29, 2015.

Hospice Quality Reporting

The key provisions in the FY 2016 Hospice Wage Index Proposed Rule include the new requirement to measure compliance with submission of the Hospice Item Set (HIS).  Since July 2014, hospices have been required to submit the HIS within 30 days of admission and discharge.  CMS is seeking to align hospice providers with other healthcare setting requirements, such as home health (OASIS) and skilled nursing facilities (MDS), by proposing the implementation of compliance goals for timely HIS submission of admissions and discharges.  Hospices failing to meet these compliance goals will have their reimbursement negatively impacted.  Specifically, they will be subject to a 2% reduction in the market basket rate beginning with the 2018 Annual Payment Update (APU).  The proposed thresholds include:

  • 2016 - 70% threshold must be met
  • 2017 - 80% threshold must be met
  • 2018 and thereafter - 90% threshold must be met

CMS indicates there will no changes to the Hospice Reporting Quality Measures for the FY 2017 reporting cycle, but that CMS reserves the right to add or delete measures if needed.  Beginning with FY 2018, CMS is proposing that once a quality measure is adopted, it will be retained for use in the subsequent FY payment unless otherwise stated by CMS. CMS has proposed criteria for adding or modifying reporting measures.  Based on input from stakeholders, CMS has identified four high priority concept areas for future measure development, and is requesting input from hospices regarding these measures:

  • Patient-reported pain outcome measure that incorporates patient and/or proxy report regarding pain management;
  • Claims-based measures focused on care practice patterns, including skilled visits in the last days of life, burdensome transitions of care for patients in and out of the hospice benefit, and rates of live discharges from hospice;
  • Responsiveness of hospice to patient and family care needs;
  • Hospice team communication and care coordination.

Hospice providers are encouraged to monitor industry research and government agency reports such as Abt Associates and Medicare Payment Advisory Commission (MedPAC) reports, as well as their own data from Program for Evaluating Payment Patterns Electronic Report (PEPPER) reports to get indications for future measures being considered.  Hospices should review their current QAPI program reports, PEPPER reports, and other available data to determine their risk of exposure with these areas.

CAHPS Hospice Survey

Hospice providers have been implementing the requirements for CAHPS® Hospice Survey data collection and reporting since January 2015.  CMS announced in the proposed rule that CAHPS® Hospice Survey data will be publicly reported when at least 12 months of data are available.  Currently, there is no date set for implementation of what will likely be referred to as Hospice Compare.

CMS proposes to continue a requirement that vendors and hospice providers participate in CAHPS® Hospice Survey oversight activities to ensure compliance with Hospice CAHPS® technical specifications and survey requirements.  CMS continues efforts to align processes for Hospice Quality Reporting Requirements, proposing that the reconsiderations and appeals process for hospices failing to meet Hospice CAHPS® data collection requirements will be part of the process already developed for the Hospice Quality Reporting Program (HQRP).

CMS proposes options for dissemination regarding the availability of hospice compliance reports in CASPER files using routine communication methods.  Of note, CMS proposes to publish a list of hospices who successfully meet the reporting requirements for the applicable payment determination on the HQRP Web site.  This list will be updated annually after reconsideration requests are processed. Due to upcoming public reporting of these findings, it is imperative that hospices ensure that staff understand:

  • the questions for both the HIS and the Hospice CAHPS® Survey, and
  • the impact their actions may have on the patient/family experience of care, hospice outcomes, and hospice reimbursement.

Another proposed change is the revision to the HQRP reporting requirement to mandate that new hospices will be responsible for HQRP reporting upon Medicare Certification (CCN) notification.  This would replace the current timeframe of mandatory reporting effective November 1 of the year in which the hospice received initial Medicare certification.  CMS believes this policy will provide sufficient time for new hospices to establish appropriate collection and reporting mechanisms to submit the required quality data to CMS.  New hospices must take steps to become familiar with HQRP and QAPI program requirements during the initial certification process in order to prepare for this requirement.

Program Integrity and Hospice Program Vulnerabilities

CMS also reiterates its focus on program integrity efforts in the 2016 FY Hospice Wage Index Proposed Rule.  CMS references the recent The Institute of Medicine (IOM) report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, among other publications which discuss vulnerabilities in the current health care system, especially where related to those who are approaching the end of life.  To address some of these vulnerabilities, CMS reiterates its efforts to improve oversight, including the recent Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) legislation, which requires increased hospice program oversight through more frequent hospice surveys and medical review efforts.  All of these efforts seek to protect the Medicare hospice beneficiaries, as well as the integrity of the Medicare hospice benefit.

Hospices are encouraged to implement comprehensive regulatory and reimbursement compliance programs and review the OIG Work Plan, reports and advisories for potential target areas.  Examples of focus areas include hospice in assisted living facilities, utilization of Continuous Care, General Inpatient (GIP) level of care in skilled nursing facilities, live discharges, skilled visits within the last seven days prior to patient’s death, and patients with length of stay (LOS) greater than 180 days.

Comprehensive Assessment and Survey Readiness

CMS has identified concerns regarding the comprehensive assessment both at the start of hospice care and ongoing assessment. This key component of the hospice clinical record must contain required elements as outlined in the Conditions of Participation (CoPs) in order to develop, update and revise the ongoing individualized hospice plan of care to recognize all conditions related to the patient’s terminal prognosis.  The comprehensive assessment must include the physical, psychosocial, emotional and spiritual needs of the individual and his or her family.  The complete comprehensive assessment must be reviewed by the hospice team at least every 15 days.

To meet all current requirements, including but not limited to the comprehensive assessment, hospices are encouraged to develop a comprehensive survey readiness program which includes, at a minimum, the implementation of processes to demonstrate compliance with CoPs through:

  • record reviews
  • personnel record reviews
  • staff interviews
  • document review and home visits
  • interdisciplinary group (IDG) meeting notes
  • quality assessment/performance improvement (QAPI) program requirements

Hospices must ensure QAPI programs are agency wide, directed by the governing body and containing process/outcome measures and data collection specific to each hospice’s needs, in addition to the mandated Hospice Quality Reporting Program requirements.  

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