Home Health & Hospice Week

Brace for serious payment changes ahead.

Switching from the current Hospice Item Set tool to the new HEART assessment tool may be a big change — but that could be only the beginning of the upheaval for hospices.

“At this time, we envision HEART as a patient assessment tool that would replace the HIS,” the Centers for Medicare & Medicaid Services says in its 2018 final rule for hospice payment. The Hospice Evaluation & Assessment Reporting Tool “would provide richer data to offer a broader, more comprehensive picture of quality of care received by hospice patients and their families,” according to the rule published in the Aug. 4 Federal Register.

The HEART provision is one of the most significant in the rule, judges Lynn Stange with Weatherbee Resources Inc. in Hyannis, Massachusetts. HEART’s impact on the industry will be similar to that of OASIS on home health agencies.

HEART’s role won’t stop at quality, most likely. “We believe HEART may provide data that could inform future payment refinements,” CMS says in the rule.

However, “comments in the final rule clearly show that CMS is not, at this time, focused on using HEART for payment refinements,” notes Katie Wehri with Healthcare Provider Solutions in Nashville.

CMS takes pains to reassure hospices that HEART’s payment role isn’t a done deal. “We realize that before a patient assessment can be used for payment purposes, it must undergo rigorous testing to investigate whether data items are reliable and valid predictors of resource utilization... [E]xtensive testing of HEART data items will need to occur before we can make a final determination about whether HEART will prove useful in informing future payment refinements,” says the rule.

In fact, a whole host of testing will be required before HEART is ready at all. Payment analysis “would be in addition to the analyses that will be conducted to determine the scientific soundness of the data items themselves, as well as in addition to analyses conducted to inform the development of future quality measures,” CMS says. “Thus, at this time, we cannot say definitively whether HEART will be used for payment refinements.”

Hospice Is Different, Commenters Stress

Commenters on the proposed rule had a raft of suggestions and cautions for CMS in developing HEART for both quality and payment purposes, in fact. One of the main ones: accommodating and recognizing hospice’s unique purpose.

“We agree with the points raised by commenters about the overall focus of HEART and aims to develop a tool that addresses the holistic nature of hospice, incorporating medical, psychosocial, spiritual, and other aspects of care that are important for patients and their caregivers,” CMS reassures in the rule. “We also appreciate commenters’ specific suggestions regarding the need for a flexible assessment, which would incorporate input from various members of the IDT and accommodate circumstances unique to hospice, such as care of patients who are imminently dying, patients’ and caregivers’ right to decline services or treatment, and the fact that hospice is delivered in multiple settings.”

Tricky: “One commenter stated that CMS should not hold providers accountable for outcomes of care that are not feasible for all hospice patients,” the rule notes. For example, “the commenter … suggested CMS not hold providers accountable for decreases in function and activities of daily living since this is an expected trajectory among hospice patients.”

“We will take these suggestions into consideration for future rulemaking and the continued development of HEART and any associated quality measures,” CMS responds. “We recognize and agree with the commenter that some outcomes of care are not achievable for dying patients and will work to ensure that any future outcome measures are appropriate for the hospice population.”

Bottom line: “Any changes to the hospice payment methodology would be subject to the rulemaking process, which allows for public comment on any payment proposal,” CMS points out. “Although this is a potential use of the data, until extensive analysis and testing is conducted, we cannot make a final determination on the role HEART may play in future payment refinements.”

Watch Burden Carefully, Hospices Tell CMS

Regardless of whether HEART is used for payment or quality, multiple commenters urged CMS to rein in the burden of the new tool — particularly in circumstances where the patient is imminently dying. The beginning of a hospice election is also difficult, because “clinicians and staff are developing a relationship with the patient and family and … hospices must balance the collection of important data necessary to deliver care with the need to not overwhelm the patient and family unit during this time.”

Important: “Several commenters noted the tradeoff between time spent on assessment tools and regulatory requirements and time spent delivering care and addressing patient and family needs,” CMS says in the rule. “Commenters noted that time spent completing HEART would be time spent away from providing direct care and implored CMS to keep this tradeoff in mind in the development of HEART.”

Further, “commenters recommended CMS to ensure that HEART data elements are overall meaningful and contribute to care planning, and cautioned CMS against the creation of a patient assessment tool that would simply be an exercise in ‘filling out forms’ and ‘checking off boxes’.”

CMS aims to make HEART “minimally burdensome and not duplicative,” it says. “CMS will keep this tradeoff at the forefront of HEART development to ensure that HEART does not detract from the primary mission of hospice care.”

CMS continues, “HEART should not impose burden on patients and families, especially during this early time in hospice care, and in instances where hospice patients are admitted close to death. It is our objective to ensure that HEART aligns with clinical practices so that collection of data for HEART poses no additional burden on patients and families beyond what hospices collect as part of usual care delivery.”