On July 29, 2021, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1754-F) that updates Medicare hospice payments and the aggregate cap amount for FY 2022 in accordance with existing statutory and regulatory requirements. This rule rebases the hospice labor shares and clarifies certain aspects of the hospice election statement addendum requirements. In addition, this rule finalizes changes to the Hospice Conditions of Participation (CoPs) and Hospice Quality Reporting Program (HQRP). The final rule also finalizes a Home Health Quality Reporting Program (HH QRP) policy that becomes effective on October 1, 2021, to prepare for public reporting beginning in January 2022.
The final rule (CMS-1754-F) can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/current.
FY 2022 Routine Annual Rate Setting Changes
Under the final rule, the hospices would see a 2.0 percent increase ($480 million) in their payments for FY 2022 relative to FY 2021. This is a result of the 2.7 percent market basket percentage increase reduced by a 0.7 percentage point productivity adjustment. Hospices that fail to meet quality reporting requirements receive a 2 percentage point reduction to the annual hospice payment update percentage increase for the year.
The FY 2022 hospice payment updates also include an update to the statutory aggregate cap amount, which limits the overall payments per patient that are made to a hospice annually. The cap amount for FY 2022 is $31,297.61 (FY 2021 cap amount of $30,683.93 increased by 2.0 percent). As a result of the changes mandated by Division CC, section 404 of the Consolidated Appropriations Act, 2021 (CAA 2021), this rule finalizes conforming regulation text changes at § 418.309 to reflect the new language added to section 1814(i)(2)(B) of the Act, which extends the years that the cap amount is updated by the hospice payment update percentage rather than the consumer price index.
Other Medicare Hospice Payment Policies
This final rule rebases and revises the labor shares for all four levels of care: routine home care, continuous home care, inpatient respite care, and general inpatient care based on the compensation cost weights for each level of care from the 2018 Medicare cost report data for freestanding hospices. The final FY 2022 labor shares are 66.0 percent for routine home care, 75.2 percent for continuous home care, 61.0 percent for inpatient respite care, and 63.5 percent for general inpatient care.
This rule finalizes several clarifying regulation text changes on certain aspects of the hospice election statement addendum requirements that were previously finalized for hospice elections beginning on and after October 1, 2020.
Hospice Conditions of Participation (CoPs)
This final rule makes changes to the hospice CoPs regarding hospice aide competency evaluation standards. In response to the COVID-19 Public Health Emergency (PHE), CMS issued a number of regulatory waivers in order to support providers and suppliers involved in patient care. These waivers promoted greater flexibility and reduced burden, allowing hospices to focus on delivering improved patient care during the COVID-19 PHE. CMS is finalizing the use of the pseudo-patient for hospice aide competency training.
As a complementary change, CMS is also finalizing a policy that requires hospices to conduct a competency evaluation related to the deficient and related skill(s) noted during a hospice aide supervisory visit. This change will allow the hospice to focus on the hospice aides’ specific deficient and related skill(s) instead of assessing multiple areas within the competency evaluation. This will allow existing aides to be re-trained more quickly in order to return to the workforce to provide high quality patient care.
Hospice Quality Reporting Program
As a result of this rule, the HQRP will contain four quality measures that capture care across the hospice stay, including a new measure called the Hospice Care Index. This measure includes 10 indicators of quality that are calculated from claims data. Collectively, the indicators represent different aspects of hospice care and provide a comprehensive characterization of the quality of care furnished by a hospice throughout the stay. This claims-based measure will be publicly reported no earlier than May 2022.
This rule also finalizes the addition of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey Star ratings on Care Compare. Star ratings benefit the public in that they can be easier for some to understand than absolute measure scores, and they make comparisons between hospices more straightforward.
Additionally, the rule finalizes the addition of the claims-based Hospice Visits in the Last Days of Life (HVLDL) measure for public reporting, which supports patient empowerment and transparency of hospice performance. The claims-based measures will utilize eight quarters of data in order to have a larger population for publicly report on small providers, thereby more hospices will be available for consumers to compare. This rule also removes seven individual Hospice Item Set (HIS) measures because a more broadly applicable measure, the Hospice Comprehensive Assessment Measure (NQF # 3235), for the particular topic is available and already publicly reported. This measure helps to ensure all hospice patients receive a holistic comprehensive assessment. Finally, CMS is providing updates regarding its development of a new Hospice Outcome and Patient Evaluation (HOPE) assessment instrument.
Closing the Health Equity Gap in the Hospice Quality Reporting Program – Request for Information (RFI)
Consistent with Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, CMS is committed to addressing the significant and persistent inequities in health outcomes in the United States through improving data collection to better measure and analyze disparities across programs and policies. CMS is working to make the HQRP and CMS’s other quality reporting programs more transparent to consumers and providers, enabling them to make better choices as well as promoting provider accountability around health equity. CMS received feedback in response to this RFI on ways to attain health equity for all patients through policy solutions that apply to the HQRP. This feedback from the public will be valuable in our future policy work. As discussed in the final rule, CMS hopes to provide additional stratified information related to race and ethnicity if feasible. The provision of stratified measure results would allow hospices to understand how they are performing with respect to certain patient risk groups, to support these providers in their efforts to ensure equity for all of their patients, and to identify opportunities for improvements in health outcomes.
Fast Healthcare Interoperability Resources (FHIR) in Support of the Hospice Quality Reporting Program – RFI
CMS is working to further the mission to improve the quality of healthcare for hospice beneficiaries through measurement, transparency and public reporting of data. HQRP and CMS’s other quality reporting programs, are foundational for contributing to improvements in healthcare, enhancing patient outcomes, and informing consumer choice. One of the first areas CMS has identified relative to improving our digital strategy is through the use of Fast Healthcare Interoperability Resources (FHIR)-based standards to exchange clinical information through application programming interfaces (APIs), allowing providers to digitally submit quality information one time that can then be used in many ways. CMS believes that advancing our work with use of these programs standard offers the potential for supporting quality improvements and reporting which will improve care for our beneficiaries.
Home Health Quality Reporting Program
The agency is finalizing its proposal to use three quarters rather than four quarters of data for the January 2022 refresh affecting OASIS-based measures. For certain claims-based measures, we will use three quarters rather than four quarters of data for refreshes between January 2022 and July 2024. Public reporting with refreshed data will begin in January 2022.
The final rule ([CMS-1754-F) can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/current
For further information, see the hospice center webpage: http://www.cms.gov/Center/Provider-Type/Hospice-Center.html
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