Eli's Hospice Insider

Be sure you're collecting data now or lose money in 2014.

Hospices' problems with one of the two quality measures Medicare is using hasn't stopped CMS from requiring data collection on it.

Back in July, the Centers for Medicare & Medicaid Services proposed continuing data collection on two measures for hospices: the structural measure on whether a hospice has a Quality Assessment and Performance Improvement (QAPI) program that includes at least three quality indicators related to patient care; and National Quality Forum-endorsed measure #209 on pain management.

Multiple commenters on the proposed rule expressed concern about #209. "Only patients who can self-report at both the initial assessment and the 48-hour mark should be included," urged Hospice of Dubuque in its comment letter on the proposed rule published in the July 13 Federal Register. "Otherwise, for public reporting, the percentages reported by hospices that experience very short lengths of stay will be negatively skewed against those with longer stays."

Many patients are referred late to hospice, pointed out A*Med Community Hospice in Texas. "They come on with pain or shortness of breath and once the pain is controlled or anxiety due to shortness of breath, they are able to relax and let go and they die within a day or two," the A*Med representative said in the hospice's comments. "It doesn't make sense that this would count as a negative outcome."

The bottom line: "I have worked many years in hospice and have seen evidence that patients can't let go and die until their pain is relieved or anxiety is relieved," the A*Med rep continued.

To include patients who can't respond "does not provide CMS or the public with a true picture of how well the hospice is able to provide comfort within 48 hours to those patients who are able to complete the survey," stressed Arkansas Hospice in its comments. "Keeping those patients who cannot self-report within 48 to 72 hours in the denominator skews the data and will not give anyone an idea of the quality of care this measure is seeking to capture."

Death and disease progression aren't the only reasons patients may not be able to respond, pointed out Leading Age (formerly the American Association of Homes and Services for the Aging). Some pediatric patients and those with dementia also may be unable to express their pain.

Some ideas: CMS should allow hospice clinicians to use pain scale tools such as pain faces or the ESAS-R scale, Leading Age suggested. And others (such as hospice staff or caregivers) should be able to report their observations for the measure, other commenters offered.

The 48-hour timeframe for reporting may be too long anyway, suggested Agrace HospiceCare in Wisconsin. "The current pain measure does not align with best practice, in that a nurse would not wait 48 hours to evaluate pain that was present on admission," the hospice says in its comment letter. "Having to measure the patient's response in this late timeframe means that the nurse is reassessing at an earlier time for best practice, and then an additional time simply to meet the requirements of data collection."

CMS response: "We ... acknowledge potential issues with measure specifications that were detailed by commenters," CMS says of the #209 comments. But "we are finalizing this proposal as proposed," the agency concludes in the 2013 home health prospective payment system final rule published in the Nov. 8 Federal Register.

Observers hope CMS will consider such changes before it publicly reports hospices' quality data, or bases payment rates on it. The agency notes in the rule that it will not publicly report data until a standardized data set tool is in place, to start. "It is essential that the data we make available to the public be meaningful data and that comparing performance between hospices requires that measures be constructed from data collected in a standardized and uniform manner," CMS says in the final rule.

Data Content Doesn't Affect Payment -- Yet

For now, the 2 percent reduction to Medicare payment rates due to hospices' failure to report quality data will rely solely on whether hospices submit data, CMS notes. It won't depend on what the actual data shows or how agencies rank in comparison to their peers. But hospices should expect that to come eventually (see related story, p. 91).

When the cuts hit: As previously finalized, CMS will reduce hospices' payment rates by 2 percent in fiscal year 2014 if they fail to collect data on the two measures during this quarter and submit it by Jan. 31 (QAPI) and April 1 (#209) of next year. Then CMS will transition to a calendar year reporting system, it finalizes in this rule.

For example: Hospices must submit data collected in all of calendar year 2013 by April 1, 2014. That data will then impact hospices' fiscal year 2015 rates, which take effect in October 2014.

CMS expects to start data collection on additional measures on CY 2015, which would be due for reporting in April 2016 and would impact payment in FY 2017 (October 2016). The agency continues to evaluate these measures for inclusion: 1617 Patients treated with an opioid who are given a bowel regimen; 1634 Pain Screening; 1637 Pain Assessment; 1638 Dyspnea Treatment; 1639 Dyspnea Screening; and 0208 Family Evaluation of Hospice Care.