Hospice Updates and Quality Reporting FY2014 Rule Summary

1. Components Of FY2014 Proposed Hospice Wage Index Rule – Posted April 29, 2013 Hospice Wage Index And Payment Rate Update Hospice Quality Reporting RequirementsUpdates On Payment Reform

2. FY2014 Hospice Wage IndexProposed Rule

3. Wage Index Tables • FY2014 wage index tables • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/index.html • NHPCO will issue wage index calculator and state-by-state charts in coming days • Watch NHPCO website at www.nhpco.org/regulatory

4. Rate Comparisons

5. Big Changes Coming • Coding requirements – NO debility or adult failure to thrive • Implementation of HIS – Hospice Item Set for all patients • Implementation of Hospice Experience of Care survey (Hospice CAHPS) • Payment Reform • Cost report changes

6. Questions and Comments

7. Multiple Diagnoses on Claim Form Debility, Adult Failure to Thrive Alzheimer’s and Other Dementias Using ICD-9-CM Coding Conventions

8. Clarifications on Coding Requirements • “All of a patient’s coexisting or additional diagnoses” related to the terminal illness or related conditions should be reported on the hospice claims • 72% of hospice claims report only one diagnosis • CMS conclusions.....

9. Debility and Adult Failure to Thrive • Diagnoses found in “Symptoms, Signs, and Ill-Defined Conditions” section of ICD-9-CM • “Debility” and “adult failure to thrive” SHOULD NOT be used as principal hospice diagnoses on the hospice claim form • Reference – ICD-9-CM Coding Manual • Choose the diagnosis “most contributory” to the terminal illness • Claims with this diagnosis will not be paid and will be returned to provider (RTP)

10. Alzheimer’s and Other Dementias • Diagnoses in coding classification “Mental, Behavioral, and Neurodevelopmental Disorders” • Not allowable as a principal diagnosis per ICD-9-CM coding guidelines • Diagnoses in ICD-9-CM coding classification “Diseases of the Nervous System and Sense Organs” • Can be used as principal diagnoses per ICD-9-CM coding guidelines

11. Final Message on Coding Conventions • Imperative that hospice providers follow ICD-9-CM coding guidelines and sequencing rules for all diagnoses • Pay particular attention to dementia coding • Dementia codes found in more than one ICD-9-CM coding chapter • Code the most definitive, contributory terminal illness in the principal diagnosis field • with all other related conditions in the additional diagnoses fields for hospice claims reporting

12. Questions and Comments

13. Quality Reporting

14. Quality Reporting • 2013/2014 Data Collection and Submission • QAPI structural measure • NQF #0209 – pain measures • CMS proposes that these measures discontinued after FY2014 data collection year OR • CMS proposes to continue using #0209 until another pain outcome measure is available

15. New Quality Reporting • Hospice Item Set (HIS) • Proposed to implement July 1, 2014 • Data on admission and discharge of every patient • Data collection to include information for 7 new quality measures • Hospices who fail to report quality data via the HIS system in 2014 will have a 2% marketbasket reduction for FY2016 • Public reporting on hospice quality measures • Not initiated prior to 2017

16. Seven New Quality Measures

17. HIS Forms Now Available • http://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS1252151.html?DLPage=1&DLSort=1&DLSortDir=descending

18. HIS Publishes HIS Forms • One form for each admission • Administrative information • Measure support information • Preferences • NQF #1641 – Treatment preferences • NQF #1647 – Beliefs/Values Addressed (if desired by the patient) • Health conditions • NQF #1634 Pain Screening • NQF #1637 Pain Assessment • NQF #1638 Dyspnea Treatment • NQF #1639 Dyspnea Screening • Medications • NQF #1617 - Patients treated with an opioid who are given a bowel regimen

19. HIS Publishes HIS Forms • One form for each discharge • Demographic data • Reason for discharge

20. New Quality Reporting • Hospice Experience of Care Survey • Post-death caregiver survey • Hospices required to contract with a vendor for survey administration and quarterly data submission • Proposed start date: CY2015 • First quarter – “dry run” for at least 1 month • Mandatory compliance – April 1, 2015 • Fewer than 50 deaths in year: exempt

21. CMS Website Location • http://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10475.html?DLPage=1&DLFilter=hospice&DLSort=1&DLSortDir=descending

22. Three Experience of Care Surveys • Home • Nursing Home • Inpatient • Set of core questions with additional setting specific questions • Location at death determines which version is used

23. Reconsideration process for hospice quality reporting • A process will be created to allow hospices that have been notified of non-compliance with hospice quality reporting requirements • May request reconsideration of FY 2014 payment determinations

24. Questions and Comments

25. Hospice Payment Reform

26. Payment Reform Options • U-shaped model of resource use • Considering a tiered approach with payment tiers based on length of stay • Short-stay add-on payment • Case-mix adjustment • Rebase ( ) the routine home care rate • Site of service adjustment for hospice patients in nursing facilities

27. U-shaped Model • Higher payments at the beginning of care • Higher payments in the last days of life • Lower payments in the “middle” of care • No determination on number of days or payment level

28. Short stay add-on • Could improve payment accuracy • Somewhat like home health Low Utilization Payment Amount (LUPA)

29. Case mix adjustment • Could be considered when more diagnosis data is available • Contingent on data gathering from multiple diagnoses on claim form

30. Rebase the Routine Home Care Rate Note: No action proposed on this issue this year.

31. CMS Commentary on Rebasing • Do not have the data to support rebasing six of the nine cost components described in the 1983 final rule • Drugs, supplies, and equipment costs -- not available from hospice claims data • Cost report data not sufficiently detailed • Could consider rebasing: • Nursing • Home health aide • Social services/therapy • Comprise 69.7% of RHC rate • Use FY2011 cost report data matched to FY2011 claims data

32. Site of service rate adjustment for nursing home patients on hospice • Issues • Growth • OIG Report in 2011 – 263 hospices have 66% or more patients in nursing homes • Possible efficiencies – multiple patients in one nursing home, < drive time and < mileage • Higher aide visits and time for hospice patients in nursing homes • NO action proposed on this issue this year

33. Additional Data Collection • January 2013, CMS received comments regarding additional data collection • Considering input • Additional data to be issued as a change request (CR) this spring or summer

34. Interested Policymakers • MedPAC – U-shaped curve and modeling • June 2013 Report to Congress • CMS • Abt Associates and Technical Expert Panel • Extensive analysis of claims and cost report data • HHS Assistant Secretary for Planning and Evaluation • ASPE • Extensive data analysis – especially visits and visit length

35. Value Based Purchasing • Value based purchasing – pilot testing • Utilize already implemented measures • Implement pilot by January 1, 2016

36. Questions and Comments

37. Want to send comments? • Go to www.regulations.gov • In the search box, type hospice • The proposed rule, CMS-1449-P, will come up. Click the blue “Comment Now” box to submit your comments. • An official letter from your hospice may be attached.

38. Address • Address the letter as follows: Marilyn Tavenner, Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS–1449–P P.O. Box 8010 Baltimore, MD 21244–8010 • Comments are due June 28, 2013

39. Thank you for your time and input!