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Nursing care. Physical therapy. Occupational therapy. Speech-language pathology therapy. Medical social services. Home health aide services called hospice aide services. Physician services. Homemaker services. Medical supplies including drugs and biologicals.

Medical appliances. Counseling services including dietary counseling. Short-term inpatient care in a hospital, nursing facility, or hospice inpatient facility including both respite care and procedures necessary for pain control and acute or chronic symptom management. Continuous home care during periods of crisis, and only as necessary to maintain the terminally ill individual at home. And any other item or service which is specified in the plan of care and for which payment may otherwise be made under Medicare, in accordance with Title XVIII of the Act.

Section a 7 B of the Act requires that a written plan for providing hospice care to a beneficiary who is a hospice patient be established before care is provided by, or under arrangements made by, the hospice program.

And that the written plan be periodically reviewed by the beneficiary's attending physician if any , the hospice medical director, and an interdisciplinary group section dd 2 B of the Act.

The services offered under the Medicare hospice benefit must be available to beneficiaries as needed, 24 hours a day, 7 days a week section dd 2 A i of the Act. Upon the implementation of the hospice benefit, the Congress also expected hospices to continue to use volunteer services, though Medicare does not pay for these volunteer services section dd 2 E of the Act. Medicare Payment for Hospice Care Sections d , a 4 , a 7 , i , and dd of the Act, and the regulations in 42 CFR part , establish eligibility requirements, payment standards and procedures.

Define covered services. And delineate the conditions a hospice must meet to be approved for participation in the Medicare program. Part , subpart G, provides for a per diem payment based on one of four prospectively-determined rate categories of hospice care RHC, CHC, IRC, and GIP , based on each day a qualified Medicare beneficiary is under hospice care once the individual has elected.

This per diem payment is meant to cover all of the hospice services and items needed to manage the beneficiary's care, as required by section dd 1 of the Act.

While payments made to hospices is to cover all items, services, and drugs for the palliation and management of the terminal illness and related conditions, Federal funds cannot be used for the prohibited activities, even in the context of a per diem payment.

However, the prohibition does not pertain to the provision of an item or service for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as the item or service is not furnished for the specific purpose of causing or accelerating death.

Section of the BBA amended section i 2 of the Act, effective for services furnished on or after October 1, , to require that hospices submit claims for payment for hospice care furnished in an individual's home only on the basis of the geographic location at which the service is furnished. Previously, local wage index values were applied based on the geographic location of the hospice provider, regardless of where the hospice care was furnished. Section of the BBA amended sections a 4 and d 1 of the Act to provide for hospice benefit periods of two day periods, followed by an unlimited number of day periods.

The BNAF phase-out reduced the amount of the BNAF increase applied to the hospice wage index value, but was not a reduction in the hospice wage index value itself or in the hospice payment rates. The Affordable Care Act Starting with FY and in subsequent FYs , the market basket percentage update under the hospice payment system referenced in sections i 1 C ii VII and i 1 C iii of the Act are subject to annual reductions related to changes in economy-wide productivity, as specified in section i 1 C iv of the Act.

Since FY , hospices that fail to report quality data have their market basket percentage increase reduced by 2 percentage points. Section a 7 D i of the Act, as added by section b 2 of the PPACA, required, effective January 1, , that a hospice physician or nurse practitioner have a face-to-face encounter with the beneficiary to determine continued eligibility of the beneficiary's hospice care prior to the th day recertification and each subsequent recertification, and to attest that such visit took place.

Medicaid Services CMS finalized in the FY Hospice Wage Index final rule 75 FR that the th day recertification and subsequent recertifications would correspond to the beneficiary's third or subsequent benefit periods. Further, section i 6 of the Act, as added by section a 1 B of the PPACA, authorized the Secretary to collect additional data and information determined appropriate to revise payments for hospice care and other purposes.

The types of data and information suggested in the PPACA could capture accurate resource utilization, which could be collected on claims, cost reports, and possibly other mechanisms, as the Secretary determined to be appropriate. The data collected could be used to revise the methodology for determining the payment rates for RHC and other services included in hospice care, no earlier than October 1, , as described in section i 6 D of the Act.

FY Hospice Wage Index Final Rule In the FY Hospice Wage Index final rule 76 FR through it was announced that beginning in , the hospice aggregate cap would be calculated using the patient-by-patient proportional methodology, within certain limits.

Existing hospices had the option of having their cap calculated through the original streamlined methodology, also within certain limits. As of FY , new hospices have their cap determinations calculated using the patient-by-patient proportional methodology. If a hospice's total Medicare payments for the cap year exceed the hospice aggregate cap, then the hospice must repay the excess back to Medicare.

In addition, section 3 c of the IMPACT Act requires medical review of hospice cases involving beneficiaries receiving more than days of care in select hospices that show a preponderance of such patients. Section 3 d of the IMPACT Act contains a new provision mandating that the cap amount for accounting years that end after September 30, , and before October 1, be updated by the hospice payment percentage update rather than using the consumer price index for urban consumers CPI-U for medical care expenditures.

If the NOE is filed beyond this 5-day period, hospice providers are liable for the services furnished during the days from the effective date of hospice election to the date of NOE filing 79 FR The FY Hospice Wage Index and Rate Update final rule 79 FR also finalized a requirement that the election form include the beneficiary's choice of attending physician and that the beneficiary provide the hospice with a signed document when he or she chooses to change attending physicians.

In addition, the FY Hospice Wage Index and Rate Update final rule 79 FR provided background, described eligibility criteria, identified survey respondents, and otherwise implemented the Hospice Experience of Care Survey for informal caregivers.

Hospice providers were required to begin using this survey for hospice patients as of Finally, the FY Hospice Wage Index and Rate Update final rule required providers to complete their aggregate cap determination not sooner than 3 months after the end of the cap year, and not later than 5 months after, and remit any overpayments. Those hospices that fail to submit their aggregate cap determinations on a timely basis will have their payments suspended until the determination is completed and received by the Medicare contractor 79 FR A higher per diem base payment rate for the first 60 days of hospice care and a reduced per diem base payment rate for subsequent days of hospice care.

CMS also finalized a service intensity add-on SIA Start Printed Page payment payable for certain services during the last 7 days of the beneficiary's life. A service intensity add-on payment will be made for the social worker visits and nursing visits provided by a registered nurse RN , when provided during routine home care in the last 7 days of life.

The SIA payment is in addition to the routine home care rate. The SIA payment is provided for visits of a minimum of 15 minutes and a maximum of 4 hours per day 80 FR In addition, we finalized a provision to align the cap accounting year for both the inpatient cap and the hospice aggregate cap with the FY for FY and thereafter.

Finally, the FY Hospice Wage Index and Rate Update final rule 80 FR clarified that hospices would have to report all diagnoses on the hospice claim as a part of the ongoing data collection efforts for possible future hospice payment refinements. Determinations about what constitutes a substantive versus non-substantive change would be made on a measure-by-measure basis.

Second, we finalized two new quality measures for the HQRP for the FY payment determination and subsequent years. The exemption is determined by CMS and is for 1 year only. We also rebased IRC per diem rates equal to the estimated FY average costs per day, with a reduction of 5 percent to the FY average cost per day to account for coinsurance.

In addition, we finalized a policy to use the current year's pre-floor, pre-reclassified hospital inpatient wage index as the wage adjustment to the labor portion of the hospice rates.

The addendum must list those items, services, and drugs the hospice has determined to be unrelated to the terminal illness and related conditions, increasing coverage transparency for beneficiaries under a hospice election. Consolidated Appropriations Act, Division CC, section of the CAA amended section i 2 B of the Act and extended the provision that currently mandates the hospice cap be updated by the hospice payment update percentage hospital market basket update reduced by the multifactor productivity adjustment rather than the CPI-U for accounting years that end after September 30, and before October 1, Prior to enactment of this provision, the hospice cap update was set to revert to the original methodology of updating the annual cap amount by the CPI-U beginning on October 1, Division CC, section of CAA revises section i 5 A i to increase the payment reduction for hospices who fail to meet hospice quality measure reporting requirements from two percent to four percent beginning with FY Provisions of the Proposed Rule A.

Hospice Utilization and Spending Patterns CMS provides analysis as it relates to hospice utilization such as Medicare spending, utilization by level of care, lengths of stay, live discharge rates, and skilled visits during the last days of life using the most recent, complete claims data.

Stakeholders report that such data can be used to educate hospices on Medicare policies to help ensure compliance. We are still analyzing the effects of the erectile dysfunction treatment PHE as it relates to the following routine monitoring analysis and whether those effects are likely to be temporary or permanent and if such effects vary significantly across hospice providers.

Therefore, for the purposes of providing routine analysis on utilization and spending, in this proposed rule, we used the most complete data we have from FY General Hospice Utilization Trends Since the implementation of the hospice benefit in , there has been substantial growth in hospice utilization.

The number of Medicare beneficiaries receiving hospice services has grown from , in FY to over 1. Similar to the increase in the number of beneficiaries using the benefit, the total number of organizations offering hospice services also continues to grow, with for-profit providers entering the market at higher rates than not-for-profit providers. In its March Report to the Congress, MedPAC stated that for more than a decade, the increasing number of hospice providers is due almost entirely to the entry of for-profit providers.

MedPAC also stated that long stays in hospice have been very profitable and this has attracted new provider entrants with revenue-generating strategies specifically targeting those patients expected to have longer lengths of stay.

In FY , 68 percent 3, out of 4, of hospices were for-profit and 21 percent out of 4, were non-profit, whereas in FY , 61 percent 2, out of 4, were for-profit and 25 percent 1, out of 4, of hospices were non-profit. In FY , for-profit hospices provided approximately 58 percent of all hospice days while non-profit hospices provided 31 percent of all hospice days.

There have been notable changes in the pattern of diagnoses among Medicare hospice enrollees since the implementation of the Medicare hospice benefit from primarily cancer diagnoses to neurological diagnoses, including Alzheimer's disease and other related dementias 80 FR Our ongoing analysis of diagnosis reporting finds that neurological and organ-based failure conditions remain the top-reported principal diagnoses.

Beneficiaries with these terminal conditions tend to have longer hospice stays, which have historically been more profitable than shorter stays. Start Printed Page Hospice Utilization by Level of Care Our analysis shows that there have only been slight changes over time in how hospices have been utilizing the different levels of care. RHC consistently represents the highest percentage of total hospice days as well as the highest percentage of total hospice payments as shown in Tables 3 and 4.

We will continue to monitor the effects of these rebased rates to determine if there are any notable shifts in the provision of care or any other perverse utilization patterns that would warrant any program integrity or survey actions. However, we recognize that a beneficiary may be under a hospice election longer than 6 months, as long as there remains a reasonable expectation that the individuals have a life expectancy of 6 months or less.

Hospice Length of Stay We examined hospice length of stay in three ways. Extremely long lengths of stay influence both the average length of election and average lifetime length of stay. Table 5 shows the average length of election, the median and average lifetime lengths of stay from FYs through Length of stay estimates vary based on the reported principal diagnosis Table 6 lists the top six clinical categories of principal diagnoses reported on hospice claims in FY along with the corresponding number of hospice discharges.

Start Printed Page Hospice Live Discharges Federal regulations limit the circumstances in which a Medicare hospice provider may discharge a patient from its care. Hospices may not discharge the patient at their discretion, even if the care may be costly or inconvenient for the hospice.

However, at any time thereafter, the beneficiary may re-elect hospice coverage at any other hospice election period that they are eligible to receive. Immediately upon hospice revocation, Medicare coverage resumes for those Medicare benefits previously waived with the hospice election. Only the beneficiary or representative can revoke the hospice election. A revocation must be in writing and must specify the effective date of the revocation.

A hospice cannot revoke a beneficiary's hospice election, nor is it appropriate for hospices to encourage, request, or demand that the beneficiary or his or her representative revoke his or her hospice election.

From FY through FY , the average live discharge rate has been approximately 17 percent per year. Of the live discharges in FY , The remaining 1. Start Printed Page Finally, we looked at the distribution of live discharges by length of stay intervals. Figure 2 shows the live discharge rates by length of stay intervals from FY through FY We found that the majority of live discharges occur in the first 30 days of hospice care and after days of hospice care.

The proportion of live discharges occurring between the lengths of stay intervals was relatively constant from FY to FY where approximately 25 percent of live discharges occurred within 30 days of the start of hospice care, and approximately 32 percent occurred after a length of stay over days of hospice care.

This cost curve reflects hospices' higher service intensity at the time of the patient's admission and the time surrounding the patient's death. In the FY Hospice Rate Update final rule 80 FR , we established two different payment rates for RHC to reflect the cost of providing hospice care throughout the course of a hospice election.

We finalized a higher base payment rate for the first 60 days of hospice care and a reduced base payment rate for days 61 and later. To reflect higher costs associated with the last 7 days of life, in FY , we implemented the service intensity add-on payment SIA for RHC when direct patient care is provided by a RN or social worker during the last 7 of the beneficiary's life.

The SIA payment is equal to the CHC hourly rate multiplied by the hours of nursing or social work provided on the day of service up to 4 hours , if certain criteria are met 80 FR This effort represented meaningful advances in encouraging visits to hospice beneficiaries during the time preceding death and where patient and family needs typically intensify.

To examine the effects of the SIA payment, we analyzed claims since the implementation of the SIA payment to determine if there was an increase in RN and social worker visits in the last seven days of life.

In CY the year preceding the SIA payment , the percentage of beneficiaries who did not receive a skilled nursing or social worker visit on the last day of life when the last day of life was RHC was nearly 23 percent. Our analysis shows a slight decline in the number of beneficiaries who did not receive an RN or social worker visit on the last day of life when the last day of life was RHC where the percentage trended downward to just over 19 percent in CYs to This trend is similar for the 4 days leading up to the end of life when the last 4 days of life were RHC , meaning beneficiaries are receiving more skilled nursing and social worker visits during the last days of life since implementation of the SIA payment.

Table 7 shows the percentage of decedents not receiving skilled visits at the end of life for CY through CY Start Printed Page To further evaluate the impact of the SIA, we examined the total amount of minutes provided by skilled nurses and social workers in the last 7 days of life and overall there were only modest changes from CY to CY , as shown in Table 8.

Non-Hospice Spending During a Hospice Election The Medicare hospice per diem payment amounts were developed to cover all services needed for the palliation and management of the terminal illness and related conditions, as described in section dd 1 of the Act.

Hospice services provided under a written plan of care POC should reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. B of this rule, a hospice must routinely provide all core services directly by hospice employees and they must be provided in a manner consistent with acceptable standards of practice. Under the current payment system, hospices are paid for each day that a beneficiary is enrolled in hospice care, regardless of whether services are rendered on any given day.

Additionally, when a beneficiary elects the Medicare hospice benefit, he or she waives the right to Medicare payment for services related to the treatment of the terminal illness and related conditions, except for services provided by the designated hospice and the attending physician. This represents an increase in non-hospice Medicare spending for Parts A and B of Whereas there is minimal beneficiary cost sharing under the Medicare hospice benefit,[] non-hospice services received outside of the Medicare hospice benefit are subject to beneficiary cost sharing.

Start Printed Page Hospices are responsible for covering drugs and biologicals related to the palliation and management of the terminal illness and related conditions while the patient is under hospice care. For a prescription drug to be covered under Part D for an individual enrolled in hospice, the drug must be for treatment completely unrelated to the terminal illness or related conditions.

After a hospice election, many maintenance drugs or drugs used to treat or cure a condition are typically discontinued as the focus of care shifts to palliation and comfort measures. However, those same drugs may be appropriate to continue as they may offer symptom relief for the palliation and management of the terminal prognosis.

Start Printed Page Analysis of Part D prescription drug events PDEs data suggests that the current use of prior authorization PA by Part D sponsors has reduced Part D program payments for drugs in four targeted categories analgesics, anti-nauseants, anti-anxiety, and laxatives , which are typically used to treat common symptoms experienced during the end of life.

Under CMS's current policy, Part D sponsors are not expected to place hospice PA requirements on categories of drugs other than the four targeted categories listed above or take special measures beyond their normal compliance and utilization review activities. Under this policy, sponsors are not expected to place PA requirements on maintenance drugs, for beneficiaries under a hospice election, though these drugs may still be subject to standard Part D formulary management practices.

This policy was put in place in recognition of the operational challenges associated with requiring PA on all drugs for beneficiaries who have elected hospice and because of the potential barriers to access that could be created by requiring PA on all drugs.

These categories include beta blockers, calcium channel blockers, corticosteroids, and insulin. Table 10 details the various components of Part D spending for patients receiving hospice care for FY Our ongoing monitoring and analysis have shown that the hospice benefit has evolved. Originally providing services primarily to patients with cancer, to now primarily patients with neurological conditions and organ-based failure. We are particularly interested in how this change in patient characteristics may have influenced any changes in the provision of hospice services.

As mentioned in the above analysis, after the implementation of the SIA in FY , the number of beneficiaries who did not receive an RN or social worker visit on the last day of has decreased. We are soliciting comments regarding skilled visits in the last week of life, particularly, what factors determine how and when visits are made as an individual approaches the end of life.

Given the comprehensive and holistic nature of the services covered under the Medicare hospice benefit, we continue to expect that hospices are providing virtually all of the care needed by terminally ill individuals. That is, there may be items, services, and drugs that should be covered under the Medicare hospice benefit but are being paid under other Medicare benefits. We are soliciting comments as to how hospices make determinations as to what items, services and drugs are related versus unrelated to the terminal illness and related conditions.

That is, how do hospices define what is unrelated to the terminal illness and related conditions when establishing a hospice plan of care. Likewise, we are soliciting comments on what other factors may influence whether or how certain services are furnished to hospice beneficiaries. Finally, we are interested in stakeholder feedback as to whether the hospice election statement addendum has changed the way hospices make care decisions and how the addendum is used to prompt discussions with beneficiaries and non-hospice providers to ensure that the care needs of beneficiaries who have elected the hospice benefit are met.

FY Proposed Labor Shares 1. These proportions were based on skilled nursing facility wage and nonwage cost limits and skilled nursing facility costs per day 48 FR through We describe our proposed methodology for deriving the compensation cost weights for each level of care using the MCR data below.

We note that we did explore the possibility of using facility-based hospice MCR data to calculate the compensation cost weights. However, very few providers passed the Level I edits as described in more detail below and so these reports were not usable. Proposed Methodology for Calculating Compensation Costs We are proposing to derive a compensation cost weight for each level of care that consists of five major components. For each level of care, we are proposing to use the same methodology to derive the components.

Our analysis, however, found that many providers were not reporting salaries on the detailed level of care worksheets A-1, A-2, A-3, A-4, column 1 , but rather reporting total costs reflecting salary and non-salary costs for these services for each level of care on Worksheets A-1, A-2, A-3, A-4, column 7. Therefore, we are proposing to estimate other patient care salaries attributable to CHC, RHC, IRC, and GIP by first calculating the ratio of total facility reflecting all levels of care other patient care salaries Worksheet A, column 1, lines 38 through 46 to total facility other patient care total costs Worksheet A, column 7, lines 38 through This proposed methodology assumes that the proportion of salary costs to total costs for other patient care services is consistent for each of the four levels of care.

To estimate overhead salaries for each level of care, we first propose to calculate noncapital non-benefit overhead costs for each level of care to be equal to Worksheet B, column 18, less the sum of Worksheet B, columns 0 through 3, for line 50 CHC , or line 51 RHC or line 52 IRC or line 53 GIP. We then are proposing to multiply these non-capital non-benefit overhead costs for each level of care times the ratio of total facility overhead salaries Worksheet A, column 1, lines 4 through 16 to total facility non-capital non-benefit overhead costs which is equal to Worksheet B, column 18 total costs , line less the sum of Worksheet B, columns 0 direct patient care costs , column 1 fixed capital , column 2 moveable capital and column 3 employee benefits , line We then are proposing to multiply these non-capital overhead costs for each level of care times the ratio of total facility overhead benefits Worksheet B, column 3, lines 4 through 16 to total facility noncapital overhead costs Worksheet B, column 18, line less the sum of Worksheet B, columns 0 through 2, line This proposed methodology assumes the ratio of total overhead benefit costs to total noncapital overhead costs is consistent among all four levels of care.

Proposed Methodology for Deriving Compensation Cost Weights To derive the compensation cost weights for each level of care, we first are proposing to begin with a sample of providers who met new Level I edit conditions that required freestanding hospices to fill out certain parts of their cost reports effective for freestanding hospice cost reports with a reporting period that ended on or after December 31, Fixed capital costs Worksheet B, column 0, line 1 , movable capital costs Worksheet B, column 0, line 2 , employee benefits Worksheet B, column 0, line 3 , administrative and general Worksheet B, column 0, line 4 , volunteer service coordination Worksheet B, column 0, line 13 , pharmacy and drugs charged to patients sum of Worksheet B, column 0, line 14 and Worksheet A, column 7, line Applying these Level I edits to the freestanding hospice MCRs resulted in 3, providers that passed the edits four were excluded.

Then, for each level of care separately, we are proposing to further trim the sample of MCRs. We outline our proposed trimming methodology using CHC as an example. We also propose that CHC direct patient care salaries and contract labor costs per day would be greater Start Printed Page than 1. The facilities that remained after this trim reported detailed direct patient care costs and other patient care costs for which we could then derive direct patient care salaries and other patient care salaries per the methodology described earlier.

This additional trim resulted in a sample that consists of approximately 20 percent of IRP providers and 28 percent of GIP providers that passed both the Level I edits and the trims that required total costs and compensation costs to be greater than zero, and direct patient care salaries and contract labor costs per day to be greater than 1, as well as total costs to be greater than compensation costs. Finally, to derive the proposed compensation cost weights for each level of care for each provider, we are proposing to divide compensation costs for each level of care by total costs for each level of care.

We are proposing to then trim the data for each level of care separately to remove outliers. Following our example for CHC, we are proposing to simultaneously remove those providers whose total CHC costs per day fall in the top and bottom one percent of total CHC costs per day for all CHC providers as well remove those providers whose compensation cost weight falls in the top and bottom five percent of compensation cost weights for all CHC providers.

Since we have to limit our sample for IRC and GIP compensation cost weights to those hospices providing inpatient services in their facility, we conducted sensitivity analysis to test for the representative of this sample by reweighting compensation cost weights using data from the universe of freestanding providers that reported either IRC or GIP total costs.

For example, we calculated reweighted compensation cost weights by ownership-type proprietary, government and nonprofit , by size based on RHC days and by region.

Our reweighted compensation cost weights for IRC and GIP were similar less than one percentage point in absolute terms to our proposed compensation cost weights for IRC and GIP as shown in Table 11 and, therefore, we believe our sample is representative of freestanding hospices providing inpatient hospice care.

Table 11 provides the proposed labor share for each level of care based on the compensation cost weights we derived using our proposed methodology described previously. We invite comments on our proposed methodology to derive the labor shares for each level of care.

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