PROPOSED FY2017 Payment Rule Payment and Oversight

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1 CMS Proposed FY2017 Hospice Payment Rule Implications for the Hospice Industry National Association for Home Care & Hospice August 18, 2015 Hospice Payment and Oversight ProposedFY2017 Payment Update Percentage ProposedFY2017 Payment Rates Hospice Aggregate, Inpatient Cap Aggregate Cap Values Accounting Year Self Reporting Hospice PEPPER Trends in Hospice Utilization/Provider Behavior 1

2 FY2017 Hospice Rule Payment Update PROPOSED Proposed Hospital market 2.8 percent * basket Productivity 0.5 * adjustment Add l ACA reduction 0.3 Net market basket 2.0 percent * 3 FY2017 Hospice Rule Payment Rates PROPOSED Code/Description FY2016 Rate Proposed FY2017 Rate 651/Routine Home Care days 1 60 $ $ /Routine Home Care days 61+ $ $ Rates NOT adjusted for wage index, sequester or failure to meet HQRP requirements 4 2

3 FY2017 Hospice Rule Payment Rates PROPOSED Code/Description FY2016 Rate Proposed FY 2017Rate 652 Continuous Home Care (hourly rate for SIA) 655 Inpatient Respite 656 General Inpatient Care $ ($39.37/hr.) $ ($40.16/hr.) $ $ $ $ Rates are not adjust for wage index, sequester or failure to meet HQRP requirements 5 FY2017 Hospice Rule Wage Index PROPOSED Full transition to 2010 CBSAs BNAF no longer a factor in payment rule NOT published in Federal Register available online at: Type/Hospice Center.html 3

4 Hospice Cap Issues IMPACT Act changed Aggregate Cap update factor from CPI U to Medicare Percentage Update effective for 2016 Cap year: 2016 Aggregate Cap $ 27, self report by March 31, 2017 FY2016 Rule adopted TRANSITION to Federal fiscal year effective with 2017 Cap year 2017 Aggregate Cap $ 28, self report by February 28, 2018 INPATIENT CAP ACCOUNTING YEAR TRANSITION TIME FRAMES 2016 CAP Year days of care Nov. 1, 2015 Oct. 31, CAP Year days of care Nov. 1, 2016 Sept. 30, CAP Year days of care Oct. 1, 2016 Sept. 30,

5 AGGREGATE CAP ACCOUNTING YEAR TRANSITION TIME FRAMES Streamlined Patient by patient (Proportional) Patients Payments Patients Payments /28/15 9/27/16 11/1/15 10/31/16 11/1/15 10/31/16 11/1/15 10/31/ /28/16 9/30/17 11/1/16 9/30/17 11/1/16 9/30/17 11/1/16 9/30/ /1/17 9/30/18 10/1/17 9/30/18 10/1/17 9/30/18 10/1/17 9/30/18 9 TARGET AREAS Live Discharges/No Longer Terminally Ill (excludes transfer, revocation, discharge for cause, move out of service area) Live Discharges/ Revocations (NEW) Live Discharges/LOS days (NEW) HOSPICE PEPPER April 11, 2016 Long Length of Stay (greater than 180 days) CHC in ALF RHC in ALF RHC in NF RHC in SNF Claims with Single Dx Code (NEW) No GIP or CHC (NEW) 10 5

6 HOSPICE PEPPER Potential future target area: Visits at the end of life PEPPER Update Training: What s New in the Q4FY15 Hospice PEPPER When: Thursday, April 28, 1:00 2:00 pm CT Resources/Hospices Trends in Hospice Utilization, Behavior Hospice 2015 $15.5 Billion spent on 1.4 million beneficiaries Actuary projects 7% growth rate going forward Dx on claims FY % of claims single diagnosis FY % single; 63% 2 Dx; 46% 3 Dx Shift in Dx coding / Diagnosis trends toward neurological conditions and unspecified Dx Unspecified/manifestations no longer permitted as principal Dx 6

7 Dx Coding Trends FY2002 FY Lung Cancer 1. Debility 2. CHF 2. Lung Cancer 3. Debility 3. CHF 4. COPD 4. COPD 5. Alzheimer s 5. AFTT 6. CVA/Stroke 6. Alzheimer s 7. Prostate Cancer 7. Senile Dementia (uncomp) 8. AFTT 8. CVA/Stroke 9. Breast Cancer 9. Heart Disease (unspec) 10. Senile Dementia 10. Prostate Cancer (uncomp) FY2013 FY Debility 1. Alzheimer s 2. CHF 2. CHF (unspec) 3. Lung Cancer 3. Lung Cancer 4. COPD 4. COPD 5. Alzheimer s 5. Senile degeneration/brain 6. AFTT 6. Parkinson s 7. Senile Dementia 7. Heart Disease, (uncomp) unspec. 8. Heart Disease 8. CVA/Stroke unspec. 9. CVA/Stroke 9. Cerebral atherosclerosis 10. Dementia in other10. Breast Cancer Dis w/o Behav Dist Non hospice Spending CMS continues to track out of hospice spending; data representing Part A/B, Part D spending trends: Parts A and B Part D CY 2012 $710.1 Million $334.9 Million FY2013 $694.1 Million $347.1 Million FY2014 $600.8 Million $291.6 Million 7

8 Live Discharge Rates Live discharge rates peaked at 21.8% in 2006; 2014 average rate was 17.4% CMS continues to track some hospices have VERY high rates using hospice as LTC benefit? Changes to payment system may create incentive to inappropriately discharge patients live following first 60 days of care Pre hospice Spending For FY2014 decedents, CMS evaluated spending prior to hospice election to help assess variability of needs for patients with different Dx. The neurological Dx cost less outside of hospice, higher LoS on hospice. Dx at Admission Alzheimer s Dementia Parkinson s 180 day lookback median 90 day lookback median 30 day lookback median $64.87 $78.62 $ Cancers $ $ $ Mean Lifetime Hospice Days All Dx $ $ $

9 Monitoring of Payment Reform Real time monitoring, analysis At aggregate and individual provider levels Will be used for future policy decisions AND targeted program integrity HQRP Update Maintain current HQRP measures Two new quality reporting measures Hospice Visits When Death Is Imminent Hospice And Palliative Care Composite Process Measure Comprehensive patient assessment instrument Hospice Compare web site Public reporting of hospice quality data 9

10 PROPOSED FY2017 Rule Two New Measures Hospice Visits When Death Is Imminent addresses whether a hospice patient and their caregivers needs were addressed by the hospice staff during the last days of life Paired measure Measure 1 assesses percentage of patients receiving at least 1 visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life and addresses case management and clinical care. PROPOSED FY2017 Rule Two New Measures Hospice Visits When Death Is Imminent Measure 2 assesses percentage of patients receiving at least 2 visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life and gives providers the flexibility to provide individualized care that is in line with the patient, family, and caregiver s preferences and goals for care and contributing to the overall well being of the individual and others important in their life 10

11 Two New Measures Hospice Visits When Death Is Imminent Data would be collected via the HIS Discharge Four new items added to the HIS Discharge record O5000 Level of care in final 3 days O5010 Number of hospice visits in final 3 days O5020 Level of care in final 7 days O5030 Number of hospice visits in 3 6 days prior to death No earlier than April and Guidance/Legislation/PaperworkReductionActof1995/PRA Listing.html 11

12 Two New Measures Hospice Visits When Death Is Imminent Measures added to the HIS Admission AO550 Patient ZIP code A1400 Payor information JO905 Pain active problem JO900 change skip pattern for pain screen No earlier than April and Guidance/Legislation/PaperworkReductionActof1995/PRA Listing.html 12

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14 Two New Measures Hospice Visits When Death Is Imminent Data would be collected via the HIS Discharge Four new items added to the HIS Discharge record No earlier than April and Guidance/Legislation/PaperworkReductionActof1995/P RA Listing.html 14

15 Two New Measures Hospice and Palliative Care Composite Process Measure Data on seven care processes will be captured Calculates the percentage of patients who received all care processes at admission Individual components assessed separately for each patient and aggregated into one score for each hospice Serves to ensure all hospice patients receive a comprehensive assessment for both physical and psychosocial needs at admission Comprehensive Patient Assessment Comprehensive Patient Assessment Instrument Being considered by CMS Different data collection mechanism Potential enhancement of current HIS to be more in line with other post acute care settings Two purposes Provide quality data necessary for HQRP requirements and the current function of the HIS Provide additional clinical data that could inform future payment refinements. 15

16 Comprehensive Patient Assessment Comprehensive Patient Assessment Instrument Allows more detailed clinical information collection Symptom burden Functional status Patient, family, and caregiver preferences Information for use in development of future quality measures Data used for both quality and payment purposes Comprehensive Patient Assessment Comprehensive Patient Assessment Instrument Does not replace Existing requirements for assessments CAHPS hospice survey/other HQRP collection efforts (except HIS) Regular submission of claims data Replaces current HIS Two time points Admission Discharge 16

17 HQRP Update Maintaining all current HQRP measures in FY2017 Codify that if measures currently used in the HQRP undergo non substantive changes in specifications in NQF reendorsement process, CMS would subsequently utilize the measure with the new endorsed status in the HQRP without going through new notice and comment rulemaking CMS could modify a measure Numerator Calculation period Denominator Risk adjustment Setting Look back period Revisions to data elements used to collect the data required for the measure HQRP Update Timeliness Threshold Moves to 80% in 2017 for HIS, impacting FY2019 payment CASPER CMS working on timeliness compliance threshold report CAHPS hospice survey Must collect data monthly Jan Dec 2017, impacting FY2019 payment Exempt for FY2019 payment update < 50 survey eligible decedents/caregivers submission and acceptance of exemption request form 17

18 HQRP Update Timeliness Threshold CAHPS hospice survey exemptions proposal hospices receiving CCN after January 1, 2017 (newness) Hospices receiving CCN after January 1, 2018 (newness) Public Reporting Public Reporting and Hospice Compare Calendar year Hospice demographic data General information about hospice quality reporting Calendar year 2017 All seven HIS quality measures Individual measure scores Denominator smaller than 20 patient stays not reportable Hospice Compare site 18

19 Public Reporting Public Reporting and Hospice Compare Will not report CAHPS hospice survey data until have at least 12 months Preview reports in CASPER Hospice Compare site will feature 5 star rating eventually Development and implementation announced in future rule making MCCM Medicare Care Choices Model (MCCM) Five year model (ending 2020) 130 hospices, 39 states Phase 1 begins 2016, Phase 2 begins 2018 Encourages greater and earlier use of Medicare/Medicaid hospice benefit Improve quality of life and care? Increase beneficiary, caregiver, and family satisfaction? Reduce Medicare/Medicaid expenditures? 19

20 Questions/Comments 28/ /medicare program fy 2017 hospicewage index and payment rate update andhospice quality reporting Comments due: COB Monday, June 20 Theresa M. Forster Katie Wehri 20