1. NHPCO Listening Session FY2016 Proposed Wage Index Rule
Posted on Federal Register Public Inspection Desk: April 30, 2015
Published in Federal Register
May 5, 2015
© National Hospice and Palliative Care Organization, May 2015

2. Non-Hospice Spending during a Medicare hospice election

3. FY2013 Medicare A and B Outside Hospice Benefit
Part A or B Service
Percentage of $$ Spent
DME
6.4%
Inpatient care
28.6%
Outpatient Part B services
16.6%
Other Part B services (physician, practitioner, labs and diagnostic tests, ambulance transports, and physician office visits)
38.8%
Skilled Nursing Facility Care
5.3%
Home Health Care
4.3%

4. FY2013 Medicare Part D Payments Outside Hospice Benefit
Medicare Part D spending:
FY2013: $347.1 million
CY2012: $334.9 million

5. Four case studies on frequent hospice diagnoses
Case studies presented for following diagnoses
chronic airway obstruction
congestive heart failure
cerebral degeneration
lung cancer
Citation of :
Typical symptoms
Evidence-based practice interventions/ recommendations
Comments on Medicare spending outside the hospice benefit

6. Concurrent Payments for Services Provided to Hospice Patients Lung Cancer, CY 2013
Total
$3,405,083

7. Concurrent Payments for Services Provided to Hospice Patients with COPD, CY 2013
Total
$10,400,319

8. CMS Concern Analysis reveals:
Clinical based practices are not being covered under the Medicare hospice benefit.
Potential systematic unbundling of the Medicare hospice benefit
May be valuable analysis to inform policy stakeholders

9. Assessment of Conditions and Comorbidities Required by Regulation
We continue to state that those circumstances would be “exceptional and unusual” and that hospices continue to be required to provide virtually all the care that is needed by terminally ill patients.

10. Assessment of Conditions and Comorbidities Required by Regulation
Comorbidities are recognized as important factors
contributing to the overall status of an individual
should be considered when determining terminal prognosis.
Mental health comorbidities must also be considered
not uncommon for terminally ill individuals to have underlying mental health conditions
could contribute to their prognosis and/or
affect the plan of care

11. % of Claims with One Diagnosis

12. All diagnoses on the claim form
Therefore, we are clarifying that hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual.
Includes the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs.

13. Comprehensive Assessment
CMS states:
… we are concerned that hospices may not be conducting a comprehensive assessment nor updating the plan of care as articulated by the CoPs to recognize the conditions that affect an individual’s terminal prognosis.

14. What do you think?

15. Marketbasket Increase
Proposed increase for hospice payment rates for FY 2016 by 1.8 percent
Increase is NET after Medicare provider-wide productivity adjustment and 0.3% hospice-specific productivity adjustment

16. Proposed FY2016 Routine Home Care
2 different rates
60 days or less
61 days or more
% increase for 60 days or less = 15%
% decrease for 61+ days = -8%

17. Proposed Rates $159.34 $188.20 $ 28.86 15.33% $147.34 $(12.00) -8.14%
Description
2016 Rates
2015 Rate
Difference
% Increase
Routine Home Care
$159.34
1-60 days
$188.20 $
15.33%
61+ days
$147.34
$(12.00)
-8.14%
Continuous Home Care Full Rate = 24 hours of care
$946.65
$929.91
$16.74
Hourly Rate
$ 39.44 
$38.75
$0.69
Inpatient Respite Care
$167.78
$164.81
$2.97
General Inpatient Care
$721.53
$708.77
$12.76

18. Count of Days
Mitigate potential high rates of discharge and readmissions, propose:
count of days follow the patient
For hospice patients who are discharged and readmitted to hospice within 60 days of that discharge:
his or her prior hospice days will continue to follow the patient AND
count toward his or her patient days for the receiving hospice upon hospice election

19. Count of Days
For hospice patients who are discharged and readmitted to hospice more than 60 days after that discharge:
his or her prior hospice days will begin again at the 1-60 day count

20. Service Intensity Add On
(SIA) payment that would result in an add-on payment equal to
Continuous Home Care (CHC) hourly payment rate
multiplied by the amount of direct patient care provided by a:
registered nurse (RN) or
social worker
provided during the last 7 days of a beneficiary’s life,
If certain criteria are met

21. Certain Criteria Day billed as RHC Applies to any length of stay
SIA payment is at the continuous care hourly rate ($39.44/hour) for up to 4 hours a day
Visit must be by RN or SW
Last 7 days of life
In person – no telephone visits by social workers
Patient cannot reside in SNF or NF

22. SIA Budget Neutral
Propose to make the SIA payments budget neutral through an annual determination of the SBNF
Then be applied to the RHC payment rate
The SBNF for the SIA payments would be calculated for each FY using the most current and complete fiscal year utilization data available at the time of rulemaking

24. What do you think?

25. Quality Components One significant change
30 days to submit admission and discharge record in HIS – will stay the same
Use the submission deadlines to assess further penalties
Goal is to get up to 90% compliance with submission deadlines for admissions and discharges
2016 – 70% good, below 70% - 2% mkt basket penalty
2017 – 80% threshold
2018 – 90% threshold

26. Measures No new measures All measures currently in place may not stay
Criteria for dropping measures
HIS measures – if everyone doing really well, may not stay as a measure
Additional criteria

27. New Hospices
Start reporting on the date you receive your provider number

28. Hospice Compare Will have Hospice Compare
Still not date for public reporting

29. HIS Reporting Error reports, aggregated for submissions
How you are doing on measures
Your own report
Some time before the end of 2015

30. What do you think?

31. Update Wage Index for 2010 Census
50/50 blend of the existing CBSA designations
New CBSA designations outlined in a February 28, 2013, OMB bulletin
37 counties urban -> rural
105 counties rural -> urban

32. 0.8 Hospice Floor
Hospital wage index values which are less than 0.8 are still subject to the hospice floor
The hospice floor equates to a 15 percent increase, subject to a maximum wage index value of 0.8

33. BNAF
Year 7 of the 7-year BNAF phase-out finalized in the FY 2010 Hospice Wage Index final rule (74 FR 39407)

34. What do you think?

35. Virtually All
We continue to expect hospices to adhere to the long-standing policy to provide “virtually all” care during a hospice election as articulated in the 1983 Hospice Care proposed and final rules as well as most recently in FY 2015 Hospice Wage Index and Payment Rate Update final rule.

36. Program Integrity
Program integrity and oversight efforts including but not limited to
medical review
MAC audits
Zone Program Integrity Contractor actions,
Recovery Auditor activities, or
suspension of provider billing privileges,
are being considered to address fraud and abuse

37. Future…
The proposed RHC rates and SIA payment would advance hospice payment reform incrementally as mandated by the Affordable Care Act while simultaneously maintaining flexibility for future refinements

38. Future Implementation
Implemented within the current constructs of the hospice payment system
No major overhaul of the claims processing system or related claims/cost report forms would be required
Minimizing burden for hospices as well as for Medicare
CMS needs to further assess whether the
four levels of care
current payment amounts
amounts after implementation of the SIA
will align with the actual cost of providing hospice services

39. What do you think?