June 28, 2013
Electronic submission: http://www.regulations.gov
ATTN: CMS-1449-P
Centers for Medicare & Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244-1850
The Hospice Association of America (HAA) is an affiliated organization of the National
Association for Home Care & Hospice (NAHC), the nation’s largest association
representing home health, home care, and hospice organizations. Our membership
includes freestanding hospice organizations as well as hospices that are linked to home
health agencies and to health systems. As such, we appreciate the opportunity to
provide comment in response to Proposed Rule: Medicare Program; FY2014 Hospice
Wage Index and Payment Rate Update; Hospice Quality Reporting Requirements;
and Updates on Payment Reform (CMS-1449-P). The following represent
NAHC/HAA’s comments on a number of issues addressed as part of the proposed rule.
DIAGNOSIS REPORTING ON HOSPICE CLAIMS
Principal Diagnosis and Relatedness Diagnosis Reporting on Hospice Claims
NAHC/HAA appreciate CMS’ reasons for reiterating the need for hospices to follow
ICD-9-CM coding guidelines, and the need to record diagnoses that impact treatment.
We do have an overriding concern that, given current practice by hospice programs and by
Medicare’s Administrative Contractors (MACs), meeting expectations related to proper
diagnosis coding for hospice patients will require significant adaptation. Hospices must engage
a broad range of staff in their efforts (medical directors, inter-disciplinary group (IDG)
members, coding and billing staff, and in some cases must hire additional staff). This will
require time, education, and significant guidance. MACs must also adapt their perspectives on
application of the local coverage decisions (LCDs) and with their medical review processes to
ensure that they are sufficiently sensitive to the combined impact of multiple diagnoses in
establishing a six-month prognosis.
Many hospices have reported to us that they encountered significant challenges when trying to
comply with CMS’ July 2012 directive to include multiple diagnoses on hospice claims. The most
significant issue has been that some electronic medical records systems did not allow additional
diagnoses to flow to the claim. Many of the barriers have been removed but we understand the
modifications may not have been made in all systems until spring 2013. This means that some
barriers may still have been present in the fourth quarter of 2012, which is the period used to
determine that 72 percent of hospices are reporting only one diagnosis on the claim. We are
confident that the majority of hospices are either now in compliance with the requirement to
include multiple diagnoses or are in the process of implementing procedures and technology in
order to be in compliance.
However, there is one barrier that still remains, as we understand it, for some hospices. Some
software systems, while able to include multiple diagnoses, do not distinguish between related
and unrelated diagnoses. We know this will impact the integrity of the data CMS is collecting
and, potentially, payment reform and other policy decisions.
As indicated in the proposed rule, one of the reasons for including related diagnoses on the
hospice claim is to fully describe the patient being treated. Including only related diagnoses may
not provide a clear picture of the patient’s condition. Nor does a higher number of diagnoses
necessarily equate to a higher acuity. The degree to which the condition is causing symptoms
and complications more accurately depicts acuity. In the proposed rule, CMS states that the
hospices should already be including related and unrelated diagnoses in the comprehensive
assessment and plan of care as part of the conditions of participation (CoPs) at §418.54(c)(2),
which requires that the comprehensive assessment “include complications and risk factors that
affect care planning.” The CoPs at §418.56(e)(4) require that the hospice IDG “provide for an
ongoing sharing of information with other non-hospice healthcare providers furnishing services
unrelated to the terminal illness and related conditions.” CMS believes, and we concur, that it is
common for hospices to include the related and unrelated diagnoses on the comprehensive
assessment in order to assure coordinated, holistic, patient care and to monitor the effectiveness
of the care that is delivered. However, complete, comprehensive coding in accordance with the
ICD-9-CM coding guidelines is not commonly applied to hospice comprehensive assessments
and plans of care. These documents are completed by the IDG that is comprised of individuals
who are not typically trained ICD-9-CM coders. The IDG includes related and unrelated
diagnoses in the comprehensive assessment and plan of care by title of disease, condition or
symptom only. A related or unrelated diagnosis of, for instance, fractured pelvis, would appear
as just that on the comprehensive assessment and plan of care. The IDG would not specify if it
were a stress fracture of the pelvis (842.0) or a closed fracture of other specified part of pelvis
(10041).
In addition, hospice physicians report that the conditions related to the principal diagnosis may
change over time as the patient’s condition changes. Clarification is needed regarding CMS’
expectation for hospice claims with respect to changes in related diagnoses over the course of
the patient’s hospice stay. For instance, if the physician determines the related diagnoses
change mid-month, what codes should the hospice put on the claim – the related diagnoses on
the last billing day of the month, all related diagnoses throughout the billing month, related
diagnoses on the first billing day of the month? If this information is being used to help make
decisions about payment reform (specifically what might be related to the terminal illness and
related conditions) we believe it is necessary to set up a structure whereby the hospice claim
reflects changes in related diagnoses as they occur. Furthermore, there is no definition of
“related” diagnoses in the ICD-9-CM coding guidelines or other CMS or coding guidance.
Clinically, related conditions are any physical or mental condition(s) that are related to or
caused by either the terminal illness or the medications used to manage the terminal illness.
These related conditions, however, may or may not impact the terminal prognosis of a hospice
patient and treatment of such, even if it is palliative treatment, may not be consistent with a
hospice plan of care. For consistency, the term “related” for coding and payment purposes
should be defined; the following definition developed by a working group from the national
hospice associations is offered for consideration: “Related diagnoses are those diagnoses that result
directly from the principal diagnosis, or are interconnected with the principal diagnosis, in a manner that strongly
influences the prognosis that the patient has six months or less to live if the condition follows its normal course.”
As CMS stated in the proposed rule, the certifying physician(s) would be the final arbiter of the
principal diagnosis and diagnoses for related conditions based on their best clinical judgment.
It is important to note that, as hospices work to incorporate appropriate diagnoses on claims,
this should not result in a loss of clinical discretion or override the physician and IDG’s
authority on this score. The factors a hospice should use to determine if it is responsible to
provide and liable for payment of a treatment include weighing the treatment’s expected
benefits and burdens for a patient. Hospices should not be expected to cover a treatment based
purely on the fact that the intervention is a potential course of action for treating one or more of
the patient’s diagnoses. The hospice should only provide and pay for such treatment if the
physician and the IDG determine benefits outweigh the burdens and it, therefore, should be
included in the hospice plan of care.
On a related note, we believe that CMS’ statement indicating “It is our general view
that…’hospices are required to provide virtually all the care that is needed by terminally ill
patients’” fails to acknowledge that under Medicare, hospice beneficiaries are entitled to seek
care and services not related to their terminal diagnosis or related conditions outside the hospice
benefit. As stated in the rule, determination of the terminal diagnosis and conditions that are
and are not related to it remains a clinical decision – it must be made on a case-by-case basis by
trained professionals who are familiar with the case.
CMS has used the words “coexisting”, “additional”, and “secondary” to describe the hospicerelated diagnoses that should be included on hospice claims. Contractors also use these terms,
as well as “comorbid”. “Coexisting” is used in the coding manual in Section IV only and this
section is not applicable to hospices. The term “comorbid” is not used at all in the coding
guidelines. In the past, “secondary” has caused some confusion as many providers consider it as
the second code in a list of diagnoses. Each of these terms has a slightly different meaning
amongst providers and not all are used in the ICD-9-CM coding guidelines. We suggest that in
order to promote consistent data on hospice claims, the terminology used in instructions from
CMS and by contractors should be consistent with the applicable terms in the ICD-9-CM
coding guidance. If not defined, CMS must clarify meaning of a term and use it in a consistent
manner.
We would like to reiterate that the overwhelming majority of NAHC and HAA hospice provider
members have consistently indicated in interactions with our staff a spirit of willingness to
comply with CMS requirements, and in particular, the use of ICD-9-CM coding guidelines.
Many report that industry practice of utilizing LCDs (which has been directed by the MACs)
has been the overriding method for many years to establish appropriate diagnoses; these LCDs
have included a relatively small number of what some reference as “hospice appropriate”
diagnoses. Therefore, the majority of hospices have not been skilled in application of the
broader ICD-9-CM coding guidelines, and many have not traditionally utilized ICD-9-CM
coders in their operations. We understand that most are either training current staff,
contracting for, or hiring coders at this time, as well as engaging hospice physicians and other
members of the IDT to operationalize a more thorough approach to identifying and reporting
principal and related diagnoses for hospice clients. While not an excuse for failure to closely
follow ICD-9-CM coding guidelines, CMS must recognize that this is a paradigm shift in the
way nearly all hospices have been operating. Hospices are moving toward compliance but for
many this is a significant transition that has been complicated by technological barriers; time
and guidance is needed to ensure that hospices are appropriately modifying their approach to
CMS requirements.
Adult Failure to Thrive (AFTT), Debility, and Dementia Diagnoses
CMS has consistently communicated since July 2012 that hospices are to follow ICD-9-CM
guidelines, and believes that, based on its application of coding guidelines, adult failure to thrive
(AFTT) and debility are inappropriate for use as principal diagnoses in hospice care. CMS
further states that it believes that the private sector requires compliance with ICD-9-CM coding
guidelines and AFTT and debility diagnoses are not used as primary diagnoses for hospice
patients in the private sector. We have found, in communications with hospice provider
members, that the private sector does not routinely require a principal diagnosis other than
AFTT or debility. Also, we note that approximately 90% of all hospice patients are Medicare
beneficiaries.
Per ICD-9-CM coding guidelines, debility should not be used as a primary diagnosis and AFTT
should only be used if no other more specific diagnosis is present. However, given the existence
of LCDs related to debility that are utilized by some MACs, ICD-9-CM coding
experts/consultants have advised us that use of debility as a principal diagnosis in the hospice
setting is permissible. For many years, hospices have been operating under the impression that
hospice patients need to fit into one of these LCDs. The LCDs include AFTT and debility. In
fact, some MACs have even educated providers on documentation that would/would not
support eligibility for hospice care under these diagnoses. Furthermore, hospices have not
utilized ICD-9-CM trained coders because of this – most hospices have instead taken the
clinical information about the patient and categorized the patient into the best fitting LCD
diagnosis and that became the hospice patient’s principal diagnosis. It is very clear now that
this approach may not meet ICD-9-CM guidelines; however, a sufficient amount of time is
needed for hospices to hire or train existing staff in ICD-9-CM coding guidelines, revise
documentation systems, and implement all procedures necessary for full compliance.
Hospice providers concur with CMS that in most cases a hospice will have a more specific
diagnosis than debility or AFTT that is most contributory to the terminal condition. However,
there are some instances where the patient does not have any other specific diagnosis that can
be used per the ICD-9-CM coding guidelines or where the patient and family members do not
want to subject the patient to additional tests. We offer the following cases where the hospice
physician has indicated there is not a diagnosis more specific than AFTT:
 Patient has lost 20 pounds in the last 6 months and now weighs 73.2 pounds. She
is bed bound and does not eat when a few months ago she was eating most of her
meals. Patient is dependent in all ADLs but was not a few months ago. Hospice
physician suspects cancer due to several factors but patient and family refuse
testing and are requesting hospice. What are hospices to do when the patient
refuses further testing which is consistent with his/her right to choose a
palliative approach to care? Should the coding guidelines related to uncertain
diagnosis be utilized or should the beneficiary be denied hospice care if the most
appropriate diagnosis, according to ICD-9-CM coding guidelines, is AFTT?
 Patient referred to hospice after a recent fall and pelvis fracture. The fracture was
surgically treated. Patient has documented diagnoses of dementia, A fib, CHF and
has a pacemaker. She had to move to an ICF due to requiring more care. Since
that time, she’s lost 15 pounds, has been to a gerontology-psych unit with med
changes, and has had several meds discontinued including Coumadin that was
treatment for A-Fib. Discontinuing the Coumadin increases the patient’s chances
of death but what diagnosis would this fall under? The clinicians note a marked
change in short period of time in terms of muscle wasting, weight loss, skin
turgor, nutritional intake, etc. None of the diagnoses, in the physician’s opinion,
were of such a severe nature that it is the condition causing a terminal state.
 Patient is 102 year old female. She is choking on liquids. She eats 80-100%
breakfast, yogurt only for lunch and 50-60% of dinner. Daughter states they are
all small amounts to begin with. She had been eating 100% of all 3 meals with
normal portion sizes. She is sleeping 16-20 hours of the day and previously had a
normal sleeping habit of 8-10 hours. She had been able to ambulate independently
and now requires assist. She also has some increasing BLE edema at 1-2+. Her
BNP is 20100, which does show severe CHF but is not diagnostic of longevity and
there is not another BNP for comparison. No heart medications except atenolol
and does not need any oxygen at this time. She has history of CKD but her
creatinine is only 1.27. She is alert and oriented and refuses any further work up
or intervention.
 Patient is 96-year-old nursing home resident hospitalized 4 times in last 6
months (2 UTI, 2 aspiration pneumonia). Weight loss from 153 lb to 125 lb over
last five months. No current infection but continues to cough with any eating or
drinking regardless of diet modifications. No chronic conditions other than
osteoporosis.
In the proposed rule, CMS states “For beneficiaries eligible for the Medicare hospice benefit, access to
hospice care or the continuation of hospice care should not be affected or limited by the following ICD–9–CM
coding guidelines for diagnosis reporting on claims.” We fear that not being able to utilize the AFTT
diagnosis as the principal diagnosis, within the confines of the ICD-9-CM coding guidelines, has
already and will continue to negatively affect access to hospice care for some beneficiaries. We
believe CMS data would show an increase in live discharges of hospice patients since the release
of the proposed rule and this clarification. We also believe there are instances where hospices
have not admitted patients meeting eligibility criteria at 418.20 because of the future RTP edit
regarding AFTT. The coding of claims does occur after the patient has elected hospice services,
as recognized by CMS in the proposed rule clarification; however, a hospice must still know the
principal diagnosis of the patient before admitting the patient because hospices cannot afford to
accept patients and provide care to patients for which they will not be paid.
NAHC/HAA have also heard concerns expressed that an outright prohibition on use of AFTT or
debility in hospice as a principal diagnosis (without a similar prohibition on providers other
than hospice) may lead to difficulties in efforts to coordinate care across settings and over time
as diagnoses in use by varying providers will not be consistent. We pass that comment along for
your consideration.
NAHC/HAA, as well as its members, recognize and appreciate the need to use the most specific
causative diagnosis for hospice patients in accordance with ICD-9-CM coding guidelines. Since
these guidelines do allow the use of AFTT in some instances, CMS should reconsider an outright
prohibition on use of this diagnosis. Perhaps CMS could meet its intended goal through
contractor review of medical records for hospices that have a percentage of claims with AFTT as
the principal diagnosis that is above the 80th percentile (or some other target) for the MAC
region.
Use of Diagnosis(es) from Recent Hospitalization
CMS has expressed concern that study of diagnosis coding of patients who have gone from the
inpatient setting to hospice has revealed that hospice claims, with some frequency, do not
include the diagnosis(es) for which the patient was previously hospitalized. Based on
discussion with hospice providers and individuals with expertise in ICD-9-CM coding, it is our
understanding that it is not always appropriate to use the diagnoses from a recent
hospitalization for subsequent care. For example, if a patient has recently undergone cancer
surgery and the treating physician believes that the cancer has been removed, it is actually
inappropriate to use diagnosis codes that would indicate that the cancer is still present. We
offer this as a potential explanation for why some hospice claims do not reflect the same
diagnosis as may have been used for the patient’s prior hospitalization.
PROPOSED UPDATE TO THE HOSPICE QUALITY REPORTING PROGRAM (HQRP)
Hospice Information Set (HIS)
NAHC/HAA are pleased to see hospice quality being measured and appreciate CMS’ need for a
hospice-specific item set. NAHC/HAA also appreciate the need to utilize properly vetted
hospice quality measures and the attention paid to choosing measures that most hospices are
already utilizing.
We have noted in our review of the HIS documents and the HQRP Reference Table that the
calculation for NQF #1647 and NQF #1641 require the extraction of medical record
documentation of events that can occur at any time during the patient’s stay in hospice.
Specifically, NQF #1647 asks if there is a documented discussion of spiritual/religious concerns
or documentation that the patient/family did not want to discuss. To be included in the
measure calculation, the discussion or documentation of refusal can occur at admission or
anytime throughout the patient’s enrollment in hospice care. In the Admission HIS there is a
question that would capture this information but there is not a corresponding question on the
Discharge HIS. This prevents an accurate calculation of the NQF #1647 measure. Likewise,
NQF #1641 asks if preferences for life-sustaining treatment are documented in the medical
record. There are questions on the Admission HIS pertaining to this but not the Discharge HIS,
which prevents an accurate calculation of the NQF #1641 measure. Adding the content of
questions F2000, F2100, and F3000 on the Admission HIS to the Discharge HIS would allow for
calculation of the measures according to the NQF data details.
Also, the measure details state “brief statements about an order written about life
sustaining treatment, such as ‘Full Code’ or ‘DNR/DNI’ do not count in the numerator.”
We suggest including this in the HIS Descriptions in order to collect accurate data for use in
calculating the measure. Also, we suggest indicating in the HIS Descriptions that a review of
advance directive documents is acceptable for this measure as is discussion with a surrogate
decision maker in the case where patients do not self-report.
The numerator for NQF #1637 collects data on whether a pain screening occurred at the time of
the admission to hospice. In order to be counted as a yes, the pain screening must also have
screened for the severity of pain if pain was present. The Admission HIS categorizes pain
severity as “None”, “Mild”, “Moderate”, “Severe”, or “Pain Not Rated”. These categories are not
defined in the HIS Descriptions, which leaves determination of the most appropriate severity to
the clinician conducting the pain screening. Therefore, the data results for this Admission HIS
question may not be statistically valid. This data is not required per the NQF #1637 measure
calculation and utilizing it to make determinations about the quality of hospice care would lead
to inaccurate determinations.
We assume there will be instruction for providers in completing the HIS documents other than
what is in the HIS Descriptions and that these additional instructions would include the
timeframes in which providers have to complete Admission HIS and Discharge HIS and
timeframes for submission of the data to CMS.
Regarding the timeframe for implementation of the HIS, we encourage CMS to allow sufficient
time for software vendors to make necessary changes to capture the correct data in their systems
and for downloading of the information in preparation for submission. A start date of July 2014
may not be sufficient time depending on when the final HIS documents and instructions are
released.
The PRA Burden Estimate for the HIS is a total of 29 minutes for each hospice per patient – 19
minutes for the Admission HIS and 10 minutes for the Discharge HIS. It is our sense that, given
the vulnerability and frailty of the population, CMS has underestimated the amount of time the
screenings may take. Additionally, we believe that CMS must include sufficient time in its
estimate to ensure that hospices are able to train their staff to ensure proper compliance with
the collection requirements, and conduct ongoing oversight.
NAHC and HAA applaud CMS for its careful consideration of an appropriate timeline for public
reporting of hospice quality data, proper estimates of the increased burden on providers, and its
inclusion of hospice providers in the process.
UPDATE ON HOSPICE PAYMENT REFORM AND DATA COLLECTION
NAHC/HAA support efforts to better align payment with costs and the thorough approach
CMS has taken to gathering needed information to make informed decisions on this important
topic. We continue to believe that the ultimate goals must be accuracy and relative simplicity,
as well as ensuring that incentives that could negatively affect patient access to care are
minimized. This is particularly a concern relative to implementation of more than one major
change to the payment system at the same time. We urge that CMS use these as guiding
principles in continuing payment reform efforts.
Use of a Low Utilization Payment Adjustment (LUPA)-type Add-on for Short Stay
Patients
We read with interest CMS’ comments about potential use of a low utilization payment
adjustment (LUPA) – akin to the adjustment used under home health reimbursement -- to help
better compensate hospices for the increased costs associated with short-stay patients. CMS has
indicated that this change could be implemented in conjunction with the current payment
model. We recognize that CMS may not have fully developed how such an adjustment would
be implemented, and are interested in gaining insight into how a LUPA-type adjustment would
be applied. For example, would the payment be added only for patients who have not
previously been on hospice care and for whom the hospice stay ends in death? Or would the
payment adjustment be added to all short-stay patients, regardless of whether they were
previously served by hospice or their short stay ended in live discharge? It is important to note
that the early days of service for all patients are cost-intensive, but we also understand that
CMS would not want to create a payment system under which very short stays might be
encouraged. Given requirements that payment reform be budget neutral in the first year, we are
also interested in learning how budget neutrality would be achieved and how it would impact
categories of providers. Finally, it is unclear whether such a payment change, in isolation, would
adequately realign payment incentives under the current payment system.
Rebasing of Routine Home Care (RHC) Rate
We read with some concerns the CMS discussion and Abt Report references to rebasing of
routine home care (RHC). The available materials indicate that under rebasing, RHC rates
could drop by 10 percent or more. CMS notes that budget neutrality would be applied in the
first year of payment reform, so the aggregate reduction in RHC would be reprogrammed into
the system. However, given the widely recognized limitations on cost data, it is unclear how
CMS might determine the appropriate payment element(s) to which these “excess” payments
would be applied. At this time cost data inadequacies and inaccuracies would not allow CMS to
reallocate these payments appropriately. It is also unclear how this might impact certain
categories of providers. While budget neutrality would be applied in the initial year, it is a
serious concern that policymakers could view rebasing of RHC as a means to achieve financial
savings -- this is a serious threat given that average provider margins are estimate to be in the 6-7
percent range (and do not take into account increasing expenses from growing regulatory
requirements, certain unreimbursed costs, and the impact of some federal budget-related
reductions). Finally, as referenced above, if rebasing were implemented in combination with
other payment reforms, CMS risks injecting new incentives into the system that could lead to
shifts in practice that result in loss of access to hospice care.
Site of Service Adjustment for Hospice Patients in Nursing Facilities
Payment and services for hospice patients in nursing facilities has been a long-standing area of
interest to CMS, the Office of the Inspector General, the Medicare Payment Advisory
Commission (MedPAC), and others. This is a complex issue that warrants in-depth
exploration. MedPAC findings indicate that some hospice providers serving large populations
of hospice patients in nursing facilities accrue higher financial margins, and that, on average,
hospice patients in nursing facilities have longer stays on the hospice benefit. We have long
believed that the degree to which hospices are able to serve multiple clients in a single location
is a major factor in this phenomenon, as these hospices are able to take advantage of efficiencies
that other hospices may not. We continue to believe that any effort to reduce payments for
hospice services provided to nursing facility patients should be applied to cases where the
“clustering” of clients allows for such increased efficiencies. To do otherwise puts hospices that
do not have patients “clustered” in facilities at greater financial risk, and could discourage some
hospices from entering into contracts to care for patients in nursing facilities. This would
negatively affect access to care for an extremely vulnerable population.
CMS has, most recently, discussed findings that hospice patients in nursing facilities receive
more hospice aide services than their counterparts living in the community, with the conclusion
that hospice aide services may be substituting for aide services that the facility is obligated to
provide. However, it is unclear whether nursing facility patients on hospice services actually
receive less aide services than their non-hospice counterparts from the facility. This would be an
appropriate analysis that may help to establish whether substitution of care (hospice aide for
nursing facility aide) is, in fact, taking place. We would encourage that level of inquiry.
Hospice patients in the community may have additional caregivers beyond those provided by
the hospice, and these caregivers may be either paid (for example, a live-in personal care aide) or
unpaid (a spouse, adult child, neighbor, etc.). These willing caregivers may, in some instances,
be providing care that would otherwise be rendered by the hospice aide, thereby reducing
resource use by the hospice for those services.
An additional aspect of the hospice/nursing facility care dynamic is that hospices at times
supply services that may be similar to what would otherwise be provided by the facility, but
with greater investment of time. For example, a hospice aide may provide a bath of longer
duration (an hour) that the facility would have otherwise provided in 15 minutes. The longer
duration may be due to the increasing frailty of the patient that results from the presence of a
terminal condition. Both are “baths” but are appreciably different in terms of resource use.
It should be noted that hospices experience higher costs for nursing facility residents. Hospices
are required to provide orientation in the hospice philosophy to nursing facility staff, conduct
additional coordination of care efforts and (depending on the agreement between the hospice
and the facility) provide bereavement services for nursing facility staff. Relative to Medicaid,
hospices are paid by the state 95 percent of the room and board rate and in the vast majority of
cases must pay the facility 100 percent of the payment. In some states, room and board
payments are case-mix adjusted and hospices are paid at lower levels for room and board for
hospice patients than the state provides for non-hospice patients. This increases the amount of
costs that hospices incur providing services to nursing facility patients, and raises further
concerns about proposals to reduce payment for hospice services in nursing facilities without a
clearer picture of where such reductions might (or might not) be appropriate.
Hospice providers are bound, by the Conditions of Participation (as noted in the proposed rule),
to provide services “depending on a patient’s needs.” Patients in nursing facilities reside there
because they are frail or have needs that can not otherwise be provided in the community. These
patients’ frailty will, in most cases, increase with the onset and progression of a terminal
condition, and care needs may increase. These patients’ needs may well exceed those of patients
who are still able to reside in the community. Each hospice patient must be examined
individually and care must be provided according to that patient’s individual needs and
according to the plan of care. Hospices take this responsibility very seriously, and many
regularly examine the care they are providing in the community and in nursing facilities to
ensure that they are using the same standard of care across settings.
CMS notes that a payment adjustment for hospice care provided to nursing facility patients may
well be implemented in conjunction with hospice payment reform and that in the first year a
budget neutrality adjustment would be applied. We believe it appropriate for CMS to consider
whether implementation of other payment changes (such as a tiered payment model) that
reduce incentives for hospices to focus on long stay patients could (at least in significant part)
have the desired impact on the delivery of hospice care in nursing facilities. If such is the case,
inclusion of an additional payment change (such as a reduction in payment for services to
patients in nursing facilities) may be unnecessary and could have a harmful and unnecessary
impact on providers and, in turn, patients residing in nursing facilities.
Payment Reform/Tiered Payment
We appreciate CMS’ discussion in the proposed rule of payment reform, as well as release of the
Abt technical report. These are helpful tools for use by the hospice community. We look
forward to a continuing dialogue between the industry and CMS on this important issue.
The tiered payment model that Abt has developed has much to commend it – it is relatively
simple yet provides a somewhat more targeted payment approach than models with fewer tiers.
It is difficult to provide a complete judgment without review of how Medicare would pay for
patients whose hospice stays end with revocation or discharge. We also note that under the
model, RHC days are grouped based on the beneficiary’s lifetime length of stay. As mentioned
previously, hospices incur increased charges at the beginning of a hospice stay even if the patient
has previously been on hospice care. Further, information on patients’ previous hospice history
is not always up to date in CMS’ information systems – this is sometimes due to a delay in
submission of election and claims by a previous hospice provider. Absent changes to
information systems and provider practice, hospices will have difficulty knowing definitively
what reimbursement they will receive for care provided. This could lead to significant financial
instability for some hospices.
While the Abt tiered model is not designed with a particular “optimal” length of hospice stay in
mind, it would be helpful to know how application of the model will affect providers with
varying lengths of stay to determine how the model might alter incentives for these providers.
CMS and Abt may want to conduct such an analysis once the remainder o f the model has been
developed.
In closing, we are appreciative of the opportunity to comment on the proposed rule. If you are in
need of any clarification of our comments or if we can be of assistance in any other way, please
feel free to contact us.
Sincerely,
Theresa M. Forster
Executive Director, HAA
Vice President for Hospice Policy & Programs, NAHC
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