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March 26, 2010
A Closer Look at the Health Care Reform Provisions Impacting Hospice
Earlier this week, we sent you an important update on the passage of the health reform legislation and next steps for the hospice community. We’ve heard from many of you over the past days – offering words of encouragement, sounding off on the Hospice Action Network Facebook page, and writing in with questions about specific provisions. We invite you to keep it coming! We love to hear your thoughts and concerns.
We also wanted to share with you what we know about the various provisions impacting the hospice community. In some cases, you will see that there is not yet much information. Many of the provisions will be implemented by the Health and Human Services Secretary, and administered through the Centers for Medicare & Medicaid Services (CMS). But, in order to do that, we believe that the first order of business for the Administration will be to appoint a CMS Administrator to delve into the details of implementation and oversight. With that said, here’s what we do know (updates in red):
Market Basket Cuts & Productivity- Incorporates a productivity adjustment reduction into the market basket update beginning in fiscal year 2013, as well as a market basket reduction of .3 percent for hospice providers from fiscal years 2013-2019. Note that these cuts will not take effect until FY 2013. An important update: NHPCO has been able to confirm that the actual impact of the cuts will be $6.8 billion, rather than the $7.8 billion we previously reported. The NHPCO Regulatory Team has crafted a comprehensive tool for hospice programs to utilize in determining the combined impact of the reimbursement reductions. You can find the NHPCO Medicare Rate Calculator here.
Hospice Payment Reforms – (1) This provision would require the Secretary to collect data and update Medicare hospice claims forms and cost reports by 2011. We have no additional information on this provision at this time.
(2) Based on this information, the Secretary would be required “implement revisions to the methodology for determining the payment rates for routine home care and other services included in hospice care” no earlier than FY 2014 (Oct 1st, 2013). NHPCO has retained The Moran Company, a Washington-based healthcare research and consulting firm, to collect the most recently available patient-level hospice data in order to model potential alternative payment systems. These models will inform NHPCO’s discussions with MedPAC and CMS regarding future hospice payment reform strategies and improvements in documentation. For more information on the Moran Study, please see the full project description.
(3) After January 1, 2011, a hospice physician or nurse practitioner must have a face-to-face encounter with each hospice patient to determine continued eligibility for hospice care prior to the 180th-day recertification and each subsequent recertification, and attest that such visit took place. In addition, the Secretary will medically review certain patients in hospices with high percentages of long-stay patients. Many questions on the billability of recertification visits have arisen. NHPCO is working with legal counsel and physician billing consultants to determine whether the visit is billable and will provide resources for members with further details.
Medicare Hospice Concurrent Care Demonstration Program- Directs the HHS Secretary to establish a three-year demonstration program that would allow patients who are eligible for hospice care to also receive all other Medicare covered services while receiving hospice care. The demonstration would be conducted in up to 15 hospice programs in both rural and urban areas and would undergo an independent evaluation of its impact on patient care, quality of life and spending in the Medicare program. This exciting development has been a NHPCO priority for some time. It will be several more months before the Secretary of HHS sets up the specifications and moves forward with the site selection application process. The Secretary may also wait until a CMS Administrator is appointed to oversee any demonstration projects from the health care reform law. NHPCO will continue to track this issue and will keep our members updated on details we learn about the site selection application process.
Curative and Palliative Care for Children in Medicaid and CHIP-Allows children who are enrolled in either Medicaid or CHIP to receive hospice services without foregoing curative treatment related to a terminal illness. CMS will need to inform State Medicaid and CHIP programs of the change and it might require some states to modify their programs in order to be in compliance with this new option. Effective date: 2013
Independent Payment Advisory Board- Creates an Independent Payment Advisory Board (IPAB) tasked with presenting Congress with comprehensive proposals to reduce excess cost growth and improve quality of care for Medicare beneficiaries as well as the private health system. When Medicare costs are projected to be unsustainable, the Board’s proposals will take effect unless Congress passes an alternative measure that achieves the same level of savings. Congress would be allowed to consider an alternative provision on a fast-track basis. Requires the Board to make non-binding Medicare recommendations to Congress in years in which Medicare growth is below the targeted growth rate. Beginning in 2020, requires the Board to make binding biennial recommendations to Congress if the growth in overall health spending exceeds growth in Medicare spending. Hospice Advocates may remember, that NHPCO joined a large group of patient, provider and health advocacy organizations in opposition to this provision, which would remove Congressional authority over Medicare and place it with political appointees. The law specifies that recommendations by IPAB cannot reduce payments rates to providers who experience a reduction to their inflationary update in excess of a reduction due to productivity in a year when the recommendation would take effect. The additional .3 reduction for hospice, above the productivity adjustment, provides the exemption for hospice. The hospice exemption is good through December 31, 2019.
Hospice Value Based Purchasing/Promoting High Value Health Care- Provides the Secretary of HHS the authority to test value-based purchasing programs for long-term care providers, including hospice providers, no later than January 1, 2016. The value-based purchasing program that applies to hospice is only a pilot program and given the 6 year timeline HHS has been given to launch it, this is in the very, very preliminary stages. The concept of value based purchasing generally is in various stages of development/application across provider groups and NHPCO plans to stay in touch with CMS on this issue.
Quality Reporting- Requires hospice to report on quality measures determined by the Secretary (endorsed by the new quality measure consensus-based entity) or face a 2 percent reduction in their market basket update. While not specified in the Act, the consensus entity will likely have to take up consideration of hospice quality measures in 2011.
- Measures published no later than October 1, 2012 for reporting to begin in fiscal year 2014 (begins Oct 1st 2013).
- Reductions would not be calculated into a provider’s baseline for the following fiscal year and are not cumulative.
- The Secretary must determine the form, manner and timing for the submission of quality data to CMS.
The Secretary will also establish procedures to make this data available to the public (via the CMS website), making sure that hospices have the opportunity to review the data prior to its release. CMS has experience in collecting, analyzing and posting data for hospitals and to a more limited extent, nursing home facilities.
While hospice measures must be endorsed by the contracting entity under Section 1890(a) of the Social Security Act, the Secretary does have the discretion to apply measures that have not been endorsed so long as “due consideration” has been given to the measures by a consensus organization identified by the Secretary. The rationale for such measures must be published in the Federal Register.
The contracting entity (the National Quality Forum) is given a great many new requirements under the Act and is required to modify how it conducts its business. For instance, they are directed to convene multi-stakeholder process that is transparent (Section 3104). Participants in the group will be selected through a public nominations process with opportunity for comment and will represent those who will be affected by the quality measures. They must report their input to the Secretary no later than February 1st, beginning in 2012.
For more information about the duties and responsibilities of the contracting entity responsible for coming up with consensus based performance measurements, please refer to the following link: http://www.ssa.gov/OP_Home/ssact/title18/1890.htm
In addition, NHPCO met with CMS just this week to suggest existing and additional models to help guide the agency in the formulation of the quality measures.
Nationwide Program for National and State Background Checks on Direct Patient Access Employees of Long-term care Facilities and Providers - Establishes a national program for long- term care facilities and providers to conduct screening and criminal and other background checks on prospective direct access patient employees.
This is an extension of a pilot program established under Section 307 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). States must enter in an agreement with HHS to conduct background checks under the nationwide program on a State basis, comply with all of the requirements set forth under the Act and provide partial funding for the program (the bill sets aside $160M in federal funds). Seven states participated in the original pilot program from January 2005 through September 2007 (AK, ID, IL, MI, NV, NM, WI). While the pilot program did not appear to apply to hospice, the new nationwide program does include hospice providers.
For more information about the pilot program, please refer to the CMS website.
Funding for the program is authorized for fiscal years 2010 through 2012 and funds are set aside for the Inspector General to conduct an evaluation of the program. Since States must submit to an application process and individually enter into an agreement with the Secretary of HHS, getting the nationwide program up and running could take up to a year or more.
Advancing Research and Treatment for Pain Care Management - Authorizes an Institute of Medicine (IOM) Conference on Pain Care to evaluate the adequacy of pain assessment, treatment, and management; identify and address barriers to appropriate pain care; increase awareness; and report to Congress on findings and recommendations. Also authorizes the Pain Consortium at the National Institutes of Health to enhance and coordinate clinical research on pain causes and treatments. Establishes a grant program to improve health professionals’ ability to assess and appropriately treat pain. The law specifies that the HHS Secretary has one year from when funds are appropriated to enter into an agreement with the IOM. A report must be submitted to Congress summarizing the findings and recommendations of the Conference by June 30, 2011. Any grant programs would be subsequent to the report to Congress.
Education and training programs in pain care- Secretary may make grants available to hospices and others to develop and implement pain care education and training programs for health care professionals. The bill specifies that funding is authorized for fiscal years 2010 through 2012, however no further details on the grants programs are currently available.
We hope this information is helpful to you. NHPCO will continue to provide updates as additional information becomes available. As always, if you have any questions about this information, please contact advocacy@nhpco.org. Also, for more thoughts on the next steps for the hospice community, please take a look at this month’s View from the Hill.
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