Hospice in the Headlights. Hospice diagnoses maner. Hospice diagnoses maner HOSPICE DIAGNOSES MATTER 10/21/16

Transcription

1 Hospice in the Headlights FY 2017 Hospice Final Rule & Quality Repor<ng CMS says: HOSPICE DIAGNOSES MATTER Beth Noyce, RN, BSJMC, Hospice & Home Health Consultant HCS-H, HCS-D, COS-C AHCC Advising Board Member noyceconsulkng.com Hospice diagnoses maner Hospice dx list must include all condi<ons related & unrelated to terminal prognosis; On each hospice plan of care. On each hospice claim form. That support the applicable physician s cerkficakon of terminal illness (CTI) statement. Hospice diagnoses maner Hospice diagnosis coding must: Be complete & comprehensive. Follow official coding guidelines. Avoid non-specific & manifestakon codes as principal diagnosis/terminal illness. 1

2 Hospice diagnoses maner CMS applauds hospice s shiz toward principal dx specificity in response to 2014 & 2015 final rules. Hospice diagnoses maner FY 2015 hospice claims: 37% bore just one dx. Terminal illness only. 17% bore two diagnoses: How many were ekology/ manifestakon pairs? PotenKally only terminal illnesses here, too. How clear can the picture be with only two diagnoses? Hospice diagnoses maner FY 2015 hospice claims 46% bore at least three diagnoses: At least one condikon besides terminal illness. BeNer, but really? Fewer than ½ of all hospice beneficiaries have > 2 diagnoses? Hospice diagnoses maner CMS says again in the FY 2017 Final Rule: Unless there is clear evidence that a condikon is unrelated to the terminal prognosis all condi<ons are considered to be related to the terminal prognosis and the responsibility of the hospice to address and treat. 2

3 Hospice diagnoses maner The Medicare hospice benefit requires the hospice to cover all reasonable and necessary palliakve care related to the terminal prognosis, as described in the pakent s plan of care. Hospice diagnoses maner Medicare payment is allowed for covered Medicare items and services that are unrelated to the terminal illness and related condikons (that is, the terminal prognosis). FY 2016 Hospice Final Rule Hospice diagnoses maner Hospice must provide virtually all care of hospice pakents. PaKent-care needs unrelated to terminal illness are rare. Hospice physician must document why any needs are unrelated to terminal prognosis. CMS requires clear clinical evidence. FY 2017 Payment Updates: FOLLOW THE MONEY 3

4 Hospice UKlizaKon Trends FY 2000: About 0.5 million hospice beneficiaries $2.8 million FY 2015: Follow the Money 1.4 million hospice beneficiaries $15.5 billion Future: Expected 7% increase annually Follow the Money NoKce of ElecKon (NOE) must clearly iden<fy any non-hospice aqending physician; Specify anending physician is pakent s choice; PaKent must submit signed document to hospice provider to change anending physician choice. CMS response to receiving bills from mulkple non-hospice physicians claiming to be the pakent s anending physician. Follow the Money File nokces of eleckon, revocakon, terminakon promptly to prevent erroneous non-hospice billing: Must be accepted by MAC within 5 days to avoid responsibility for inappropriate nonhospice Medicare billing. CMS encourages quality processes to ensure NOE informakon accuracy. UnKmely filing results from inaccurate informakon or transcribing errors. Follow the Money "Hospices Should Improve Their ElecKon Statements [NOE] and CerKficaKons of Terminal Illness [CTI]. OIG report

5 Follow the Money The OIG recommends that CMS: Develop and disseminate model text for eleckon statements. Instruct surveyors to strengthen their review of eleckon statements and cerkficakons of terminal illness. Educate hospices about eleckon statements and cerkficakons of terminal illness. Provide guidance to hospices regarding the effects on beneficiaries when they rev OIG report Hospice Program for EvaluaKng Payment PaNerns Electronic Reports (PEPPER): Provider-specific data about CMS targets with risk of improper payments due to billing, coding and/or admission necessity issues. Hospice PEPPER Compares agency to others in the nakon, MAC jurisdickon, and state. Agencies that don t access reports are in the dark. Hospice PEPPER Pinpoint areas in need of audikng and monitoring, idenkfy other potenkal problems and to help hospices achieve CMS goal of reducing and prevenkng improper payments. 5

6 Hospice PEPPER Provides suggeskons of how to respond to at risk status. CMS analyzes claims data to: Inform further hospice payment reform. IdenKfy whether beneficiaries and their families receive hospice care as intended. Monitor hospice trends, benefit vulnerabilikes & billing prackces. CMS vows to conknue monitoring errant provider behavior, including examples in the FY 2017 Hospice Proposed Rule, such as: Unbundling services covered under the Medicare hospice benefit. Inappropriately providing & billing GIP level of care. Non-hospice Medicare spending for hospice-elected beneficiaries. Follow the Money 2017 Hospice Proposed Rule CY 2012 to FY 2014 non-hospice spending during hospice elec<on declined 15.4 percent. 6

7 Without clear evidence that a condikon is unrelated to the terminal prognosis, all condikons are considered to be related, to the terminal prognosis and the responsibility of the hospice to address and treat. Follow the Money 2017 Hospice Proposed Rule Follow the Money 2017 Hospice Proposed Rule Table 4 Drug Cost Sources for Hospice Beneficiaries FY 2014 Drugs Received Through Part D Beneficiaries shouldered much of the cost that CMS says hospices likely should have covered under the hospice benefit. RouKne Home Care (RHC): Per diem pay at 2 levels conknues. Reinforces CMS findings that early hospice care is more costly than later hospice care rates for CHC, Respite, GIP: 7

8 2017 hospice cap amount = $28, cap amount ($27,820.75) X FY 2017 hospice payment update percentage (2.1%) Hospice payment cap amount updated by percentage rather CPI-U: 11/1/16 10/1/2025; Aligned FY 2017 & later cap accounkng years for: InpaKent cap, and; Hospice aggregate. The hospice aggregate cap is calculated based on total reimbursement across all levels of care. Plus: Hospice inpakent cap limits total payments to the hospice for inpakent care (general or respite) to 20% of the provider s total hospice-elected care days. Service Intensity Add-on (SIA) Payment to conknue: CHC hourly rate mulkplied by the hours of RN and social work provided (up to 4 hours total) that occurred on the day of service. In-person care of pakent/family. Last 7 days of life. Discharged dead. Budget neutral. Reinforces CMS view that hospice care needs increase near death. CMS focus conknues on live discharges, end-of-life visits DO HOSPICES PROVIDE CARE PROPERLY? 8

9 CMS will conknue to monitor concerning provider behavior, such as: High live-discharge rates. Excluding some dx. from the claim & POC. Late nokce filing (eleckon, revocakon, discharge). Too few end-of-life visits. FY 2014 claims data shows: On any given day during the last 7 days of a hospice pakent s life: Almost 49% received no SN visit; 91% received no social worker visit. FY 2014 claims data shows: JAMA: On the last 2 days of life: 81,478 (12.3 %) received no professional staff visits in the last 2 days of life. FY 2014 Medicare claims data comparing hospice providers pakent trends: Hospices whose pa<ents had the highest non- Medicare spending also had: 90% higher live discharge rates; 58% higher average lifekme hospice days. 9

10 CMS: Some hospices may be using the Medicare Hospice program inappropriately as a longterm care (custodial) benefit rather than an end of life benefit for terminal beneficiaries... CMS: Hospices may be admiyng beneficiaries who do not legikmately meet hospice eligibility criteria. CMS: Office of the Inspector General (OIG): Do hospices target pakents with long lengths of stay or certain diagnoses because they may offer the hospices the greatest financial gain? In 2014, 28.9% of RouKne Home Care hospice pakents did not receive a skilled visit on the last day of life. Skilled = nurse, social worker, or therapist 2014 Abt Medicare Hospice Payment Reform Report 10

11 PaKents more likely to receive a skilled visit in the last 2 days of life were those who: Died on a weekday rather than a weekend. Died within 5 days of hospice admission. Were younger than age 85. Hospices least likely to visit pakents at the end of life were: Smaller hospices. Hospices in operakon for 5 years or less. In more urban states (NJ, MA, OR, WA, MN). States with the best rates of visits in the last days of life were some more rural states (ND, WI, TN, KS, VT). CMS: We urge providers to adhere to appropriate guidelines with respect to the hospice levels of care. Fair warning: ADR focus on levels of care. RHX or CHC? Respite or GIP? A March 2016 OIG report: 1/3 of GIP billing was inappropriate. Cost to Medicare in 2012: $268 million. CMS quotes OIG report: Hospices commonly billed for GIP when the beneficiary did not have uncontrolled pain or unmanaged symptoms. 11

12 CMS: We expect to analyze more recent hospice claims and cost report data as they become available to determine whether addi<onal regulatory proposals to reform and strengthen the Medicare hospice benefit are warranted. HIS & CAHPS Survey for Hospice Quality ReporKng Program (HQRP) FY 2017 HQRP UPDATES Hospice Quality Updates CMS policy codified: Adopted quality measures will be retained for use in the subsequent fiscal year payment determinakons unkl otherwise stated. Hospice Item Set (HIS) to become part of a future pakent-assessment tool to capture more informakon. Won t replace Hospice CAHPS survey. PaKent-survey star rakngs. PaKent-care quality star rakngs: Part of comprehensive assessment. Capture process measures Future (potenkally) pakent outcomes. 12

13 CMS: We believe that the development of a hospice pakent assessment tool... would allow us to gather more detailed clinical informakon, beyond the pakent diagnosis and comorbidikes that are currently reported on hospice claims. Hospice InformaKon Set (HIS): Submission rates to HIS QIES ASAP and 30-day-from-event submission deadline to avoid 2% market basket update reduckon 2 fiscal years later: CY 2016: at least 70% for FY 2018 CY 2017: at least 80% for FY 2019 CY 2018: at least 90% for FY

14 Agencies may request extension/exempkon for reporkng HIS data without payment reduckon penalty: Within 30 days of extraordinary circumstances beyond the provider s control; By only to HospiceQRPReconsideraKons@cms.hhs.gov Requests for extension/exempkons from submiyng HIS data must: Be for a specified Kme period; Comply with all criteria listed at CMS HQRP Extensions and ExempKons Request web page. Extraordinary Circumstances: Natural or man-made disasters prevenkng Kmely submission of quality data. A disaster may be widespread or affect mulkple structures or isolated and affect a single site only. Hospice Compare Web Site goes live mid 2017: HIS data will be accessible to hospice via CASPER prior to public reporkng. CAHPS : Includes standard survey administrakon protocols that allow for fair comparisons across hospices. Will report publicly when at least 12 months of data are available. 5-star rakngs Hospices with < 50 survey-eligible decedents/caregivers during CY 2017 are exempt from CAHPS Hospice Survey data colleckon & reporkng requirements for FY 2020 payment determinakon. Must submit exemp<on form annually. Consider that CASPER informa<on can inform QAPI in valuable ways. 14

15 Hospices that receive CNN azer 1/1/17 are exempt from FY 2019 APU Hospice CAHPS requirement. Does hospice adapt to pakent needs? NEW HOSPICE QUALITY MEASURES New Hospice Quality Measures EffecKve April 1, 2017 Measure 1 addresses case management and clinical care. Measure 2 gives providers the flexibility to provide individualized care that is in line with the pakent, family, and caregiver s preferences and goals for care and contribukng to the overall well-being of the individual and others important in their life. Quality Measure 1: Hospice Visits when Death is Imminent This two-measure set addresses whether a hospice pakent and their caregivers needs were addressed by the hospice staff during the last days of life. 15

16 Quality Measure 1: Hospice Visits when Death is Imminent CMS: The last week of life is typically the Kme with the highest symptom burden. PaKents experience myriad physical & emokonal symptoms, necessitakng close care & anenkon from the IDG. Hospice responsiveness during Kmes of pakent and caregiver need is important to hospice consumers. Quality Measure 1: Hospice Visits when Death is Imminent Clinician visits to pakents at the end of life are associated with improved outcomes such as: Decreased risk of hospitalizakon, emergency room visits, & hospital deaths. Decreased distress for caregivers. Higher saksfackon with care. New Hospice Quality Measures Quality Measure 1: Hospice Visits when Death is Imminent (first measure) 1. Assesses the percentage of pakents receiving at least 1 visit from registered nurses, physicians, nurse prackkoners, or physician assistants in the last 3 days of life and addresses case management and clinical care. New Hospice Quality Measures Quality Measure 1: Hospice Visits when Death is Imminent (second measure) 2. Assesses the percentage of pakents receiving at least 2 visits from medical social workers, chaplains or spiritual counselors, licensed prackcal nurses, or hospice aides in the last 7 days of life. 16

17 New Hospice Quality Measures Quality Measure 2: Hospice and PalliaKve Care Composite Process Measure Comprehensive Assessment at Admission Hospice Quality Updates Captures 7 individual care processes currently gathered in the HIS. Will display composite results on Hospice Compare. EffecKve April 1, CMS promises preparatory educakon. Hospice Quality Updates CMS uses HQRP data to: Inform further hospice payment reform. IdenKfy whether beneficiaries and their families receive hospice care as intended. IdenKfy hospice providers not using the hospice benefit correctly: For example, as long-term care solukon for home-health-ineligible seniors. References FY 2017 Hospice Proposed & Final Rules FY 2015 & 2016 Hospice Final Rules R3378CP hnps:// Assessment-Instruments/Hospice-Quality-ReporKng/ Extensions-and-ExempKon-Requests.html NAHC.org MBPM Spending in the Last Year of Life and the Impact of Hospice on Medicare Outlays, 2015 ConnecKng Health and Care for the NaKon, A Shared NaKonwide Interoperability Roadmap

18 Beth From noyceconsulkng.com, click OCT 2016 Beth Noyce, RN, BSJMC, Hospice and Home Health Consultant HCS-H, HCS-D, COS-C, AHCC Advising board member 18