Eli's Hospice Insider

Medicare focus shifts from reimbursement to quality in 2017.

Get ready to face the music on two new quality measures — one addressing visits in the last days of life and one a forerunner to your star rating.

The Centers for Medicare & Medicaid Services shift from reimbursement changes to quality developments “is no surprise since the FY 2016 rule contained significant payment refinements and other payment-related policy changes,” notes software vendor Delta Health Technologies on its blog.

In the proposed rule released April 21, CMS outlines the two new quality measures: “Hospice Visits when Death is Imminent” and “Hospice and Palliative Care Composite Process Measure — Comprehensive Assessment at Admission.”

Timeline For Skilled Vs. Unskilled Visits Different In Proposed Measure

The frequency of visits in the last days of life has been receiving a lot of attention from both CMS and outside observers recently. A recent Journal of the American Medical Association article pointed out that the number of visits in the last seven days of life varies widely by provider (see Eli’s Hospice Insider, Vol. 9, No. 4).

History: Back in March 2014, CMS revealed statistics at an industry conference showing that 10 percent of hospice beneficiaries didn’t receive a skilled visit in the last 48 hours (see Eli’s Hospice Insider, Vol. 7, No. 7). Then in last year’s payment reform, CMS implemented Service Intensity Add-on payments for RNs and social workers in that timeframe to encourage provision of those visits.

The JAMA study pegged the figure at 12 percent in 2014 and noted wide variations based on geography and day of the week the patient died. Now CMS is addressing the issue with its newly proposed visit measure, which is actually a pair of measures combined.

Part 1: The first part “assesses the percentage of patients receiving at least 1 visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life,” CMS explains in the proposed rule published in the April 28 Federal Register. That part of the measure “addresses case management and clinical care,” the agency says.

Part 2: The second part “assesses the percentage of patients receiving at least 2 visits from medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life,” CMS says. It “gives providers the flexibility to provide individualized care that is in line with the patient, family, and caregiver’s preferences and goals for care and contributing to the overall well-being of the individual and others important in their life.”

The combo measure aims to positively impact both care quality and finances. “The last week of life is typically the period in the terminal illness trajectory with the highest symptom burden. Particularly during the last few days before death, patients experience myriad physical and emotional symptoms, necessitating close care and attention from the integrated hospice team,” CMS says in the rule. “Clinician visits to patients at the end of life have been demonstrated to be associated with improved outcomes such as decreased risk of hospitalization, emergency room visits, and hospital death, and decreased distress for caregivers and higher satisfaction with care.”

CMS hopes that “[c]ollecting information about hospice staff visits for measuring quality of care, in addition to the requirement of reporting visits from some disciplines on hospice claims, will encourage hospices to visit patients and caregivers and provide services that will address their care needs and improve quality of life during the patients’ last days of life,” according to the proposed rule.

CMS cites the JAMA study in the rule, and also notes its own figures from contractor Abt Associates showing that 29 percent of Routine Home Care hospice patients did not receive a skilled visit on the last day of life.

Bonus: CMS also likes this measure because, unlike the other existing measures, it addresses care at the end of life. Hospices’ seven other measures all cover “the hospice initial and comprehensive assessment period.”

Logistics: Hospices would report data for this measure pair using four new elements CMS would add to the HIS tool, CMS proposes. The agency has submitted a request for approval to the Office of Management and Budget for HIS version 2.00.0 under the Paperwork Reduction Act process. Data collection would begin in April 2017.

Adapting to collecting the new data associated with this change will be “the most immediate challenge” hospices face in this rule, expects Theresa Forster with the National Association for Home Care & Hospice. Fortunately hospices have some time to ramp up before the April 2017 deadline hits, Forster notes.

Prepare: “Begin planning now,” Forster urges. You’ll “want those processes to be airtight.”

Composite Measure To Serve As Star Rating Rough Draft

CMS’s other proposed measure is actually a composite of the seven measures for which hospices have submitted data since 2014:

NQF #1617 Patients Treated with an Opioid who are Given a Bowel Regimen;
NQF #1634 Pain Screening;
NQF #1637 Pain Assessment;
NQF #1638 Dyspnea Treatment;
NQF #1639 Dyspnea Screening;
NQF #1641 Treatment Preferences;
NQF #1647 (modified) Beliefs/Values Addressed (if desired by patient).

“This composite quality measure for comprehensive assessment at admission addresses high priority aspects of quality hospice care,” CMS maintains in the rule. “A composite measure serves to ensure all hospice patients receive a comprehensive assessment for both physical and psychosocial needs at admission.”

This composite measure aims to “incentivize hospices to conduct all desirable care processes for each patient and provide services that will address their care needs and improve quality during the time he/she is receiving hospice care,” CMS says in the rule.

Star rating proxy: It also will give potential patients and referral sources “a single measure regarding the overall quality and completeness of assessment of patient needs at hospice admission, which can then be used to meaningfully and easily compare quality across hospice providers and increase transparency.” This measure likely would be available for Hospice Compare, which kicks off next spring or summer, earlier than the official star ratings to begin at a later, unspecified time (see related story, p. 45).

Logistics: Hospices already collect the data for the composite measure on the HIS tool. “No new data collection will be required; data for the composite measure will come from existing items from the existing 7 HQRP component measures,” CMS clarifies. The agency plans to start calculating the measure in April 2017.

CMS will request National Quality Forum endorsement for both measures, it says.

Changes: As for the existing measures and HIS tool, CMS does propose to add an item to the tool to refine the pain assessment (#1637) measure, the agency notes in the rule. And it proposes to add “new administrative items for patient record matching and future public reporting of hospice quality data.”

Note: See the proposed HIS items in a PRA package at www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRAListing-Items/CMS-R-245.html.