regulatory & compliance: the evolution of hospice – new ...€¦ · 15/6/1984 · history...

© 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


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


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


Dame Cicely Saunder’sOriginal Concept of Hospice

4


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

https://en.wikipedia.org/wiki/Palliative_care


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


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


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


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


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


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


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


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


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


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


Today – OIG and Program Integrity

17


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


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



Top 5 Survey Deficiencies – All States FY2019

20

Source: www.qcor.cms.gov

http://www.qcor.cms.gov/


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.


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


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


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



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


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


https://tips.oig.hhs.gov/


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


“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


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


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


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


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


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


• 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


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

https://www.portman.senate.gov/sites/default/files/2019-11/GOE19A43.pdf


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)



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



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



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.




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


FY2020 Hospice Wage Index Final Rule

4141



PAYMENT RATE UPDATE

42


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


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


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


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


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


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


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


Hospice Cap

• For FY2020 = $29,964.78

Calculation:

FY 2019 cap amount = $29,205.44 x 102.6% = $29,964.78

50


Changes to Election Statement and Addendum

51 © 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


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


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


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


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.


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


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


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


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


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


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.


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


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


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


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


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



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.

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New Models: Primary Care First & Serious Illness Population (SIP) Models New Hampshire is one of the 26 eligible states

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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)

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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


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)

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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.

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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


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

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• 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

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SIP Model Payment


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


$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


$50 withhold forfeited = -$50 PMPM; Total PMPM = $225

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• 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.

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Proactive Engagement


• 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.

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What’s Next?

https://innovation.cms.gov/Files/x/pcf-faqs.pdf


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?

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QUESTIONS

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Contact us at NHPCO for Regulatory and Quality Assistance

Regulatory questions

Email us at: [email protected]

Quality questions

Email us at: [email protected]

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NHPCO members enjoy unlimited access to Regulatory and Quality Assistance


mailto:[email protected]

mailto:[email protected]

regulatory & compliance: the evolution of hospice – new ...€¦ · 15/6/1984 · history...

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