Regulatory Archives - Page 11 of 13

HOPE is on the Way: Part 3

CMS

by Rowan Report | Apr 26, 2024 | CMS, Medicare Advantage, Regulatory

By Beth Noyce, RN, BSJMC, BCHH-C, COQS
CHAP-certified home health & hospice consultant

This is part 3 of the 3 in the series, outlining the discussions and implications in adopting new outcome and process measures for Hospice care. The final segment addresses future process and outcome measures that the board discussed, but did not yet implement. Read Part 1 on Outcome Measures and Part 2 on Process Measures.

The TEP discussed potential future process and outcome measure concepts that Abt Associates presented to the panel as well.

The process measures included:

Education for Medication Management
Wound Management Addressed in Plan of Care
Transfer of Health Information to Subsequent Provider
Transfer of Health Information to Patient/Family Caregiver

Hope-based outcome measures were:

Patient Preferences Followed throughout Hospice Stay
Hospitalization of Persons with Do-Not-Hospitalize Order

Developing education for medication management as a process measure was a popular concept, and the top priority of the recommended measures with the TEP as they “broadly agreed that CMS should develop this measure,” the report says, citing “a significant need for training in medication management for patients and their caregivers.” They recommended that the measure weigh more heavily when care is provided in a home setting than in a facility setting because hospices are unable to control facility training and hiring practices. One panelist commented that including the phrase “during today’s visit” in the measure is important.

Whether CMS should further develop the process measure addressing wound management in the plan of care was less straight-forward, as panelists provided varied feedback. They generally agreed that this measure is important, as having a record of wound management addressed in the plan of care can hold the staff accountable for treating the wounds. But some members recommended measuring wound management with outcome measures rather than process measures. One panelist cited potential problems from patients’ deterioration over time and another noted that the time frame of this measure is important, and encouraged recording the process of getting care in place once a wound is identified. The panel agreed CMS should carefully define the measure’s specifications.

Because standard practice for most agencies is, when a patient is discharged live, to transfer health information to the subsequent provider and to the patient and family or caregiver, TEP members expressed that the two measures were likely to “top out,” meaning they would almost always be marked “Yes,” making them of no value in differentiating between hospice providers. The group generally discouraged developing these process measures.

The group strongly rejected any merit in developing two outcome measures concerning Patient Preferences Followed Throughout Hospice Stay and Hospitalization of Persons with Do-Not-

Hospitalize Order. The report says “Multiple TEP members described situations in which patients who had preferred not to be hospitalized changed their minds when a crisis occurred. Patients’ preferences and unexpected crises are usually out of the hospice’s control. Although it is still important for hospices to ask patients about their preferences as part of patient-centered care, the TEP did not believe these two items would be practical measures of a hospice’s care quality.”

Dr. McNally expects that Abt. Associates will apply the HQEP TEP’s suggestions to the HOPE tool.

“Oh yeah, they did it,” he says. “Abt would come to a specific meeting with information, data, suggestions, and specific information about how these things would be measured. We’d give feedback. Then they’d come back to the next meeting having incorporated our suggestions,” he explains. “All of us felt very much heard and responded to. It didn’t feel in the least bit perfunctory.”

Whatever specific measures are eventually included in the HOPE tool, Lund Person sees value in its implementation. “Hospice providers have had a woeful lack of outcome measures for hospice patients, which has made the evaluation of quality hospice care based only on process measures and the family’s evaluation of hospice care in the CAHPS® Hospice Survey, she explains. “Implementing HOPE will begin to identify outcome measures that can be compared between providers.”

Lund Person warns of potential challenges as well. “The selection of risk adjustment and stratification must be carefully done to minimize bias and maximize effectiveness of measures,” she says. “In addition, hospice providers have been awaiting the release of the HOPE tool with significant anxiety about content and administrative burden.”

Dr. McNally is confident the HOPE tool will be a healthy change for hospices.

“A lot of my role as a medical director and hospice physician is supporting our nurses,” he says. “They do 95% of the work. I really would like to see this not be burdensome for our hospice nurses. I’m looking forward to seeing what the [HOPE tool] beta testing translates to in our own hospice world.” He added “What I would hope to see is that the tool feels user-friendly to the hospice team, the people who have to use it, and that it also provides useful information to patients and families.”

NAHC’s Wehri says that standardizing processes through the HOPE tool is the key foundational element for the hospice industry. “High quality care is driven by reducing variance through standardized processes, Wehri writes. “Also, CMS will have a better idea of how the type of population a hospice serves impacts some of the clinical care.” This small glimpse into hospice variances that CMS does not currently have could be very helpful in future policy and payment decisions, according to Wehri. “What CMS finds in terms of differences between hospices and their care for patients may be a bit of a surprise to CMS,” she says. “I hope they are pleasantly surprised with the overall quality of care that is revealed.”

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Beth Noyce provides education, consulting, mentoring, compliance assessments and auditing services to home health and hospice agencies and their clinicians in several states. She also now provides patient and family guidance concerning hospice and home health services. Beth loves teaching and helping others succeed. She also makes available recordings of much of her education for her clients’ convenience.

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Private Duty Home Care in Fraud Enforcers’ Crosshairs

Clinical

by Elizabeth E. Hogue, Esq. | Apr 18, 2024 | Clinical, Regulatory, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Some owners and managers of private duty home care agencies mistakenly think that fraud and abuse prohibitions apply only to services paid for by the Medicare Program. In fact, fraud and abuse prohibitions apply to providers if they accept any state or federal funds, including, but not limited to, Medicaid, Medicaid waiver, VA, and Tri-Care. Many private insurers have adopted the prohibitions on fraud implemented by state and federal programs.

Private duty home care agencies are increasingly in the crosshairs of fraud enforcers if they receive reimbursement from Medicaid and/or Medicaid Waiver Programs. The reason for enhanced scrutiny is that both the federal government, which partially funds state Medicaid and Medicaid Waiver Programs, and state governments that also fund these programs are alarmed about the high costs of them.

Conventional wisdom says that there are big bucks to be saved if fraud and abuse in the Programs are controlled and ultimately eliminated. Conventional wisdom also says that enforcement actions in Medicaid Programs have just scratched the surface. According to this “wisdom,” there are big bucks to be recouped from “low-hanging fruit!”

A recent report from the Office of Inspector General of the U.S. Department of Health and Human Services seems to support this perception regarding private duty home care agencies based on the following:

Between 2014 and 2023, at least 34% of fraud convictions in some years were based on private duty home care services. In some years, this percentage was as high as 48%.
In fiscal year 2023, there were 279 criminal convictions related to private duty home care services compared to 66 for registered nurses and 43 for home health agencies.
Recoveries from private duty home care agencies in 2023 totaled $26.4 million.
The amount of civil recoveries reached a 4-year high in 2023 and the combined criminal and civil recoveries were $1.2 billion, resulting in a return on investment of $3.35 for every $1 spent.

The return on investment of more than three times the amount spent is perhaps the most important figure of all. With a three to one return, regulators will not hesitate to “beef up” enforcement actions.

THE CONSEQUENCES OF FRAUD AND ABUSE ARE SEVERE WHEN SERVICES ARE PAID FOR BY THE MEDICAID AND OTHER STATE AND FEDERAL PROGRAMS!

Personal care private duty agencies, don’t believe the myth that only services paid for by the Medicare Program are subject to fraud and abuse enforcement. The consequences may be devastating, including the loss of businesses. Heads up!

©2024 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.
©2024 This article appeared in The Rowan Report. All rights reserved.

HOPE is on the Way: Part 2 – Process Measures

Clinical

by Rowan Report | Apr 18, 2024 | Clinical, CMS, Regulatory

by Beth Noyce, RN, BSJMC, HCS-C, BCHH-C, COQS
CHAP-certified home health & hospice consultant

Process Measures

The outcome measures being considered look at effectiveness of hospice clinical efforts to decrease pain and other symptoms. The process measures paired with them focus on the hospice’s follow up with the patient after moderate or severe symptoms are found during assessment.

Exhibit 6 (below) shows the numerator and denominator for these.

HOPE-based Process Measures

TEP members determined that these two process measures have high face validity. This means the measure items clearly state, or “look like” they will measure what CMS intends them to measure. This allows consumers to see what hospices are assessing and treating. It can also help hospices track how well they are reducing or treating patients’ symptoms.

Katie Wehri, Director of Home Health & Hospice Regulatory Affairs for the National Association for Home Care & Hospice says the face validity of process items is the most important information the HQRP TEP provided to CMS. “Having HOPE items and subsequent measures that actually measure what is intended is key to success,” she says.

Exclusions from Process Measures Success

Exclusions from calculating a hospice’s process measures’ success need careful consideration. Here is the list of options of which patients to exclude:

Patient desired tolerance level for symptoms
Patient preferences for symptom management
Neuropathic pain
Actively Dying (death is imminent)
Other conditions

The report says that reassessing a symptom within two days of identifying that symptom as moderate or severe is fundamental. This is true regardless of the beneficiary’s stated tolerance-level for symptoms. It also said that process measure calculations should include patients with no symptom-management preference. Further, exclusion criteria should be the same for pain and non-pain symptoms.

Neuropathic Pain

The TEP’s recommends including neuropathic pain in the HOPE tool’s pain-reassessment process measure. Including rather than excluding patients suffering neuropathic pain prompts nurses to reassess these patients for changes. The report references research that suggests 40% of hospice patients may experience neuropathic pain. Patients who experience neuropathic pain have more severe and more distressing pain symptoms. [Tofthagen, C., Visovsky, C., Dominic, S., & McMillan, S. (2019). Neuropathic symptoms, physical and emotional well-being, and quality of life at the end of life. Supportive Care in Cancer, 27(9), 3357-3364. doi:10.1007/s00520-018-4627-x]

The TEP agrees that patients with neuropathic pain should be part of the process measure. However, they recommend excluding the same patients from the outcome measure addressing the patient’s pain impact. The report cited TEP discussion that such pain is chronic and not likely to be resolved or decreased within two days when the reassessment captures outcome data.

The TEP broadly agreed that a nurse who assesses a patient who is actively dying (life expectancy of 3 days or fewer based on clinicians’ assessment) as suffering moderate or severe pain should attempt to reassess the patient. Such patientsshould not be excluded.

The panelists agreed that process measures should include patients of all ages. Several TEP members noted that all patients experience pain and non-pain symptoms, and therefore the measures should apply to adults and children alike.

Exclusion Due to Inability to Reassess

When a hospice is unable to reassess a patient for a valid reason process measures should exclude those patients.

Identified exclusion reason were:

discharge, alive or dead
visit refusal
inability to access the patient due to an emergency department or hospitalization event
the patient traveling outside of the hospice’s service area
inability of the hospice to contact the patient or caregiver.

However, the report says, “…hospices should be penalized if reassessment is missing or delayed due to hospice staffing or scheduling issues.”

This article is the second in a series about implementation of HOPE. Next week, Beth Noyce shares details from the panel as it discussed potential future process and outcome measure concepts.

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Home Care Worker Safety: Aftermath of Home Health Nurse Death

Caring for the Caregiver

by Kristin Rowan | Apr 18, 2024 | Caring for the Caregiver, Clinical, Regulatory

by Kristin Rowan, Editor

In October of 2023, nurse Joyce Grayson went to the home (halfway house) of a released convict. She was later found dead in the basement of the house. In addition to adding focus to home care worker safety, the immediate response to this tragic event was an increase in nurses being afraid to do their jobs. Lawmakers in Connecticut vowed to increase protection for visiting nurses to ensure health care worker safety. The nurses requested additional reporting requirements for assaults while lawmakers suggested requiring an escort for high-risk situations.

Elara Caring at Fault Joyce Grayson Home Care Worker Safety

Home Care Worker Safety by Law

Connecticut Senator Saud Anwar recognizes the growing segment of people wanting to age at home. “We want people to be able to get treatment at home,” he said. However, he also recognized the need for more information about potentially dangerous homes. He said at-home health care workers should be aware of what they’re walkin into “if there’s a high-risk situation.” Conn. lawmakers introduced Senate Bill One for Session Year 2024. The bill would require agencies to provide patient information, as applicable, including:

Medical History
- Psychiatric history
- History of violence
- History of substance abuse
- History of domestic abuse,
- Current infections and treatments
- Stability of diagnoses or symptoms over time

Housing Information
- Other persons in the home
- Name and relationship to patient
- Psychiatric history
- History of violence or domestic violence
- Criminal records
- History of substance abuse
Location of Service
- Crime rate
- Presence of hazardous materials
- Presence of firearms or other weapons
- Status of location’s fire alarm system
- Presence of any other safety hazards

The bill also included ongoing safety training, safety assessments, and safety checks including:

A mobile app with patient information
A GPS enabled wearable device that allows staff to contact law enforcement

The Bill included payment rates to offset the cost of implementing all safety items to ensure cost-neutrality.

Implications for Hospice Agencies

Barbara Pearce, interim CEO of Connecticut Hospice, raised some legitimate concerns over the bill. Pearce warns that the background screenings required are lengthy and would result in many patients not receiving hospice care at all. According to Pearce, Connecticut Hospice “had 300 people die within three days, 200 people within two days, and 100 people within one day of entering home hospice care.” None of these patients would have been cared for if the bill had been in place at the time. Pearce discussed her concerns with Conn. lawmakers, who have since changed their approach.

Senate Bill One "Home Care Worker Safety" Moving Forward

Connecticut lawmakers are opting to exclude hospices from the bill for now. Sen Anwar said they plan to write a hospice-tailored bill “in the future” to ensure safety of hospice workers. Anwar continued, “We will have a plan of action to see what can be done to reduce the risk for hospice care workers too because…we want to make sure they’re safe too.”

The Connecticut 2024 legislative session is scheduled to adjourn on May 8. Senate and House representatives are racing the clock to modify the bill before the session ends.

Implication for Home Health

Few, if any, states have laws for home health worker safety. Alaska and Idaho have strict penalties for violence against health care workers. Wyoming introduced a similar bill in 2013, but it was defeated. Oregon passed a law in 2007 to require hospitals and surgery centers to implement safety strategies. Washington state established a law in 1999 that requires the development and implementation of a work-place violence plan. The law includes home health, hospice, and home care agencies, but does not have the detailed measures included in Connecticut’s bill.

If Senate Bill One passes in Connecticut, it could pave the way for additional state or federal regulations for in-home care safety precautions. Violence in home health, hospice, and home care has increased and steps need to be taken to ensure the safety and well-being of caregivers. Keep an eye out for some upcoming product reviews on mobile apps and hand-held emergency devices that allow home care workers to alert the agency, law enforcement, and/or family members before, during, and after a care visit.

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Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

HIPAA: Access to Records

Clinical

by Elizabeth E. Hogue, Esq. | Apr 11, 2024 | Clinical, Regulatory

By Elizabeth E. Hogue, Esq.

A key purpose of the Health Insurance Portability and Accountability Act (HIPAA) is certainly to protect patient information. Another is to help ensure that patients have access to their health information. In fact, the Office of Civil Rights (OCR) of the U.S. Department of Health and Human Services, the primary enforcer of HIPAA, has focused on enforcement actions against providers that do not make information available to patients on a timely basis. OCR launched a right to access enforcement initiative in 2019 that is continuing.

Providers must give medical information to patients and their representatives within thirty days of requests. When they fail to do so, they may be subject to enforcement action by OCR. Following are two examples of recent enforcement actions.

OCR announced on April 1, 2024, that Essex Residential Care in New Jersey will pay a civil money penalty of $100,000 to resolve violation of HIPAA’s right of access standard. This is the 48th settlement reached under the right of access initiative. OCR received a complaint in May of 2020 from the personal representative of the estate of a patient who passed away. Following an investigation by OCR, the personal representative, who was the son of the patient, received the records in November of 2020. The provider did not contest the fine.

In another recent case, the daughter of a patient who passed away was appointed as the personal representative of her mother’s estate. She made multiple requests to Phoenix Healthcare for a copy of her mother’s medical records. She finally received the records one year after her initial request. Phoenix Healthcare initially received a civil money penalty of $250,000 for failure to provide timely access.

The provider appealed. An administrative law judge (ALJ) upheld the violation and ordered Phoenix to pay a civil money penalty of $75,000. The Departmental Appeals Board affirmed the ALJ’s decision. Then Phoenix agreed to settle for $35,000 and waived the right to further appeals. While it may seem in this case that the provider’s appeals significantly lowered its costs, it is important to note that the provider also undoubtedly expended significant resources on two appeals of OCR’s enforcement action.

Providers have placed a great deal of time and effort into the protection of healthcare information in compliance with HIPAA. Rightfully so, but providers seem to have lost sight of the fact that HIPAA is also about ensuring that patients and their representatives have timely access to their records. Now is the time for providers to conduct intensive education of staff members about HIPAA’s requirements regarding access in order to avoid enforcement actions like those described above.

©2024 Elizabeth E. Hogue, Esq. All rights reserved. No portion of this material may be reproduced in any form without the advance written permission of the author. For more information on how to get access to this or any other article, please contact The Rowan Report.

Adding Insult to Injury: Change Healthcare Attacked Again

Admin

by Kristin Rowan | Apr 11, 2024 | Admin, CMS, Regulatory

by Kristin Rowan, Editor

For a few weeks now, we have been covering the Change Healthcare cyberattack by ALPHV/BlackCat and the subsequent updates from CMS. Pharmacy and medical orders have been delayed, providers and patients are suffering, and CMS has issued “guidance” with no real solution. Underground reports indicate that Change Healthcare paid $22 million to BlackCat following the first cyberattack and that BlackCat stole 6TB of data from the system. Change Healthcare has refused to respond to questions about the alleged payment. Three weeks after the attack, Change Healthcare started to come back online, starting with the pharmacy services, which returned on March 7th. Parent company UnitedHealth Group indicated that other services would return in the coming weeks.

Legal Action

More than 87% of physicians are see more than a 20% drop in daily claim submissions. As of April 9th, physicians are still reporting issues with cash flow and anticipate higher than expected losses due to financing and loans that may be needed to cover them as the effects of the attack continue. Rivals of Change Healthcare are reportedly onboarding hundreds of customers who have left the organization. One of these, Availity, has processed more than $5 billion in claims that were left unprocessed by Change Healthcare’s system and has onboarded 300,000 providers with a backlog of more than 50 health systems waiting to start using the platform.

The attack has caused long-term disruptions, delays, cash flow problems, patient care disruptions, prescription delays, and billing issues. Some physician practices have started using personal money to cover payroll and other expenses. The US Department of Health and Human Services (HHS) has launched a formal inquiry into Change Healthcare’s data protection standards. This inquiry follows six class action lawsuits filed against the organizations. Physicians were still reporting significant impacts on their claims.

Adding Insult to Injury

Change Healthcare has barely gotten their systems up and running were still putting out fires when they were hit again. CyberAttack On April 8, RansomHub contacted Change Healthcare and alleged to have 4TB of data stolen from the system and are demanding an extortion payment to keep the data private . RansomHub has threatened to sell the data, which includes US military personnel and patient data, medical records, and financial data, to the highest bidder in 12 days if the ransom isn’t paid.

Among the prevailing theories as to why Change Healthcare has been hit again is that the first ransom was supposed to have been split between ALPHV/BlackCat and an associate known as “notchy”, but ALPHV absconded with the ransom, leaving the other with nothing. Looking for a payout equal to what they lost, notchy partnered with RansomHub to try to recoup their losses. A second theory is that ALPHV and RansomHub are one in the same and that ALPHV went to ground after the ransom payout and have resurfaced as RansomHub. RansomHub, however, claims that after ALPHV went to ground, some of their affiliates joined the RansomHub operation and this is how they came by the data. Either way, it seems that the data stolen in the first attack was not returned after the ransom was paid and Change Healthcare is still susceptible to further extortion. This also means that the Change Healthcare system was not hacked a second time, but rather this is just an extension of the first data breach.

No word yet on whether Change Healthcare and UnitedHealth Group will pay the second ransom demand.

We will continue to follow this story and provide updates as it impacts payment and claims processing.

# # #

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. www.therowanreport.com One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

HOPE is on the Way: Part 1 – Outcome Measures

Clinical

by Rowan Report | Apr 11, 2024 | Clinical, CMS, Regulatory

By Beth Noyce, RN, BSJMC, HCS-C, BCHH-C, COQS
Home health & hospice consultant

The Hospice Outcome Patient Evaluation is a step closer to implementation.

After four years of considering options, the Technical Expert Panel (TEP) has finished its work that will inform future Hospice Quality Reporting Program results. The TEP considered quality measures to include in hospice’s future assessment tool and best choices for risk adjustment and exclusion.

The panel convened in 2019 “[we are] committed to improving the quality of care given to hospice patients,” says the 2022-2023 TEP Summary Report: Hospice Quality Reporting Program. The panel aimed to ensure that hospice quality measures are meaningful for hospice beneficiaries, transparent to hospice providers, and useful to consumers. They considered quality measures from both HOPE and claims data.

“From day one it was very clear Medicare wanted to make this a very different experience for hospice teams and make it a more valuable thing for consumers,” says Dr. Jeff McNally, Hospice Medical Director at Utah’s Intermountain Hospice,” describing his participation on the HQRP TEP. “I was actually encouraged and inspired by it,” he says. “It was the first time I had first-hand experience working with any kind of CMS entity.

“The reality is some clinicians in the field and leaders don’t have the best things to say about CMS,” he explains, but “whatever we were considering we always circled back to whether it would be burdensome to the clinical team and would it be valuable to consumers.”

The panel initially planned to meet multiple times in person, with two meetings per year and potential virtual meetings as needed. “Then COVID hit,” Dr. McNally says. “It slowed the process considerably. We never did meet again in person.”

The HQRP TEP met eight times over four years, virtually after the initial meeting. McNally described participants as coming to each meeting prepared with data and proposals for HOPE measures for which they would request input from panelists.”

From TEP recommendations early in their work, Abt Associates developed two outcome measures and two process measures in harmony with hospice’s central tenet to manage symptoms:

Process measures:
- Timely Reassessment of Pain Impact
- Timely Reassessment of Non-Pain Symptom Impact
Outcome measures:
- Timely Reduction of Pain Symptom Impact
- Timely Reduction of Non-Pain Symptom Impact

“The most important [recommendations] were some of the outcome measures about symptom management,” McNally explains. “What should we be helping agencies show that they’re doing well? And how do we do that? Deciding which ones, and how many symptom management measures to use and the most valuable way to show it in a fair way.”

During the past two years, TEP members prioritized which of the risk-adjustment factors suggested by Abt. Associates should apply to outcome measures and which exclusions should apply to both outcome and process measures.

The report describes risk adjustment as using statistics to exclude “confounding factors,” or elements that are outside of a hospice’s control, from calculations that could make a hospice’s performance appear either better or worse than it is. In essence, risk adjustment increases the fairness in outcome-measure calculations while exclusions do the same for both outcome and process measures.

For the outcome measures being considered, the report says that the “TEP broadly agreed that risk adjustment is very important because it accounts for external factors outside hospices’ control and more accurately reflects the quality of care provided.”

Judi Lund Person, Principal of LundPerson & Associates, LLC, agrees. “The discussion of risk-adjustment factors is vitally important to the success of upcoming process measure implementation,” says Lund Person.

Determining which risk-adjustment factors to bring to the table was not easy. “There were some nuance things that we hashed out to try and decide how to weigh some factors in risk adjustment” for outcome measures, McNally explains.

Exhibit 5 (below) summarizes the TEP’s rankings of risk adjustors suggested.

While the TEP’s priorities seem clear, the discussion concerning each risk adjustor was more complex. The TEP broadly agreed that the most important risk-adjustment factors are age and diagnosis. Some diseases are more difficult to manage than others, and patient condition tends to decline with age regardless of provider activity. Therefore, the TEP recommended that CMS adjust for these factors to ensure that common external factors do not adversely affect reported hospice care quality.

Here’s part of the nuance – the TEP also raised concerns that how well other patients with certain diseases or of certain age groups are treated might be valuable to some patients and their families seeking care for someone of the same age group or condition. Panelists fretted over possibly obscuring that information for consumers seeking hospice care by adjusting for those risk factors.

Living situation as a risk adjustor ranked as important to TEP members because hospices have no control over what level of assistance is available to patients. Similarly, site of service ranked high as a risk adjustor because, said some panelists, care is delivered very differently across settings, and patients and/or caregivers tend to provide higher hospice satisfaction ratings for hospices in home settings than for those in facilities,” according to the report.

Lund Person, who is also former Vice President of Regulatory and Compliance at the National Hospice and Palliative Care Organization (NHPCO), notes that the TEP recognized living situation and site of service as “important” risk adjustment recommendations.

“Identifying site of service will help to distinguish between care at home and care in a facility,” she says. Also vital, she continues, “is the recommendation from the TEP to consider length-of-stay as a risk-adjustment factor, including the differences between a 4-day length of stay and a 6-month length of stay.”

One TEP member cautioned that using payment sources, IV therapy, and risk of hospitalization as risk adjustors might tempt some hospices to use them to distort a hospices’ apparent care quality.

TEP members did not recommend using as risk adjustors gender, clinical symptoms, functional status and management of care needs. They did not discuss why they rejected gender, but several agreed that using clinical symptoms would not be of value because of their high correlation with diagnoses. Because hospice providers typically see hospice patients decline in ADL and IADL abilities, and hospice goals are focused on comfort rather than functional improvement, functional status was on the TEP’s “Do Not Include” as a risk adjustor list. And finally, one TEP member strongly opposed adjusting for patients’ medication management, supervision or safety assistance needs (management of care needs), explaining that “the public and CMS should hold hospices accountable for planning around oral medication, injectable medication management, and supervision and safety assistance,” the report says.

The TEP did suggest that using some risk adjustment factors as part of the HQRP could assist hospices internally with quality improvement while others would be more valuable to patients and families. For example, Patients and families would benefit from more straightforward risk adjustment that helps them select a hospice,” the report says, “including factors such as diagnosis. For publicly reported data used to select a hospice, the TEP suggested using demographic factors (including age but excluding gender), socioeconomic factors, living situation, and diagnoses.”

Dr. McNally hopes eventually to use HPRP data to promote Intermountain Hospice’s care. Intermountain Hospice is part of Intermountain Health, a health care provider with presence in multiple states. “You can’t take the current metrics to doctors’ offices and families to show anything meaningful,” he says. “It’d be great to have metrics we could take to our neurology docs and other docs,” he says. “I really think we provide better care and more options when patients stay within our system.

This article is the first in a series about implementation of HOPE. Next week, Beth Noyce shares details from the panel as it evaluated process measures.

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CMS Hospice Payment Rate FY 2025 Proposal

CMS

by Kristin Rowan | Apr 4, 2024 | CMS, Regulatory

By Kristin Rowan, Editor

On March 28, CMS issued a new proposed rule to update Medicare hospice payments. Here’s what we know.

The new proposed rule:

Would change the existing hospice wage index
Clarifies current policy related to the hospice “eletion statement” and the “ntoice of election”
Adds clarifying language around hospice certification
Includes a request for information to get comments on implementing a separate payment mechanism for high-intensity palliative care services
Proposes that Hospice Quality Reporting Program (HQRP) measures be collected through the Hospice Outcomes and Patient Evaluation (HOPE), adding two new measures
Also proposes changes to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey

The new proposed rule includes a net 2.6% increase in payments over FY 2024. This includes a 3% market-based update, and a 0.4% cut for productivity. Submitting quality data is a requirement of the net pay. Hospices that do not submit quality data will be penalized 4%, netting a 1.4% decrease in payments. The propsed rule for 2025 is .5% lower than the 2024 hospice payment increase.

The National Hospice and Palliative Care Organization (NHPCO) says the rate increase is good, but not high enough. NHPCO COO and Interim CEO, Ben Marcantonio said, “To continue providing the high level of care our patients and their families deserve, hospices require a payment rate that accurately reflects the current economic challenges. We know that hospice care has demonstrated $3.5 billion in annual savings for Medicare, which underscores the critical importance of investing in hospice to ensure continued beneficiary access to quality end-of-life care.”

Palliative Care

CMS is interested in feedback and proposals from hospice agencies for providing complex palliative treatments and high-intensity hospice care when that care negatively impacts hospices financially. CMS aims to care for high-cost patients through palliative care rather than acute care. The NHPCO agrees with the CMS proposal to fund palliative care separately from standard hospice or acute care. CMS will take feedback and proposals through May 28, 2024. Comments can be submitted electronically at http://www.regulations.gov, by following the “Submit a Comment” instructions. Comments can also be sent by regular or express mail. Addresses can be found in the full proposed rule. Follow the search instructions at http://www.regulations.gov to see all submitted comments.

The proposed rule can be viewed starting April 4, 2024 at the Federal Register at https://www.federalregister.gov/public-inspection.

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OIG Says Providers Can Offer Services to Caregivers

Clinical

by Elizabeth E. Hogue, Esq. | Mar 28, 2024 | Clinical, Regulatory

by Elizabeth E. Hogue, Esq.,

Primary caregivers – often patients’ family members – are crucial players in home care. Without them, it can be impossible to provide home care services and to keep patients in their homes. If patients cannot care for themselves, reliable caregivers are an essential prerequisite for the provision of all types of home care.

Caregivers have a very “hard row to hoe” because caregiving is physically, emotionally, intellectually, and spiritually demanding. Is it possible that enhanced assistance for caregivers can positively impact quality of care? Intuitively, the answer to this question seems to be “yes.” What additional assistance may be helpful and can providers offer it?

Here are some initial ideas for helpful assistance:

Caregiver support groups
More intensive education about patients’ clinical conditions, with an emphasis on signs and symptoms of changes in patients’ conditions and what to do about them
Assistance from volunteers, especially for patients who are chronically ill

The next question is whether providers can offer additional assistance, such as the activities described above. This issue has been addressed by the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions. The OIG has clearly stated that providers may not give patients or potential patients free items or services that cost more than $15.00 at a time or more than $75.00 in aggregate per calendar year.

In Advisory Opinion No. 18-05; issued on June 18, 2018; the OIG also addressed the circumstances under which providers can establish “caregiver centers” that provide or arrange for free or reduced-cost support services to caregivers in local communities. The provider that requested this Advisory Opinion recognized the difficulties faced by primary caregivers and, consequently, established a caregiver Center.

The Center is staffed primarily by volunteers. Private donations fund the Center and none of its costs are shifted to any federal health care program.

The Center either directly or, in collaboration with local nonprofit organizations, provides free and fee-based services to caregivers. Free services include, but are not limited to, access to a resource library, various educational sessions, a short-term equipment lending program, and free on-site respite care during events sponsored by the Center and attended by caregivers. The Center offers or partners with other providers in the community to offer stress reduction workshops, low-cost ride-share programs, and additional respite care.

The provider does not specifically market the Center’s services, but information is available on its website, social media pages, and in brochures. These sources make it clear that every caregiver is eligible to use the Center’s services, regardless of healthcare provider or payor.

Center staff members do not market, promote, or make referrals for any medical items or services that are reimbursable by federal care programs and do not provide any items or services that are reimbursable by federal health care programs. Referrals for services include a comprehensive list of local service providers offering requested services, without recommending any provider over another.

In response to this request, the OIG first stated that the key question is whether these services are likely to influence caregivers to select the provider or items or services reimbursable by the Medicare or State health care programs in the future. The OIG then acknowledged that the services provided have intangible, psychological value to caregivers. Some of the services relieve caregivers of expenses they might otherwise have incurred. The OIG also noted that many of the support services take place on the provider’s premises, which might encourage selection of the provider for future services. The OIG also acknowledged that this arrangement does not fit into any safe harbor or exception under the federal anti-kickback statute.

Nonetheless, the OIG said that it would not impose sanctions on the provider because:

The services offered at the Center primarily benefit caregivers, not patients.
The Center’s services are available to all caregivers.
The provider does not actively market the Center and its services.
The Center is unlikely to increase costs to federal health care programs.

Caregivers have a tough job and need the support of home care providers. Based on this Advisory Opinion, the OIG has provided guidance about how home care providers of all types can expand their support for caregivers.

No portion of this material may be reproduced in any form without the advance written permission of the author.

Cost of Home Health Care Services Increased Nationwide

CMS

by Kristin Rowan | Mar 28, 2024 | CMS, Regulatory, Uncategorized

By Kristin Rowan, Editor

Illumifin, an insurance administration and claims solution provider for long term care (LTC) insurance, has released its 2023 Cost of Care study. The longitudinal study is now in its tenth year and includes national, state, and regional costs of services across skilled nursing, adult day care, home health care, and assisted living facilities.

The study found that the average rate for a home health aide in 2023 was $30.62 per hour, a 5.2% increase over 2022. The average per-rate visit for a registered nurse was $147.72, a 1.6% decrease over the prior year. Assisted living facility rates are up .6 – 3.8% nationwide, while skilled nursing facility rates decreased .4 – 1.0%.

The full press release from Illumifin is here.

To access the full study, contact Jennifer Frost by email at jenniferfrost@illumifin.com.

As costs continue to rise, CMS will need to adjust its proposed per-episode base pay cut for FY 2025. We continue to report on the proposed cuts from CMS and MedPAC, who argue home health agencies are being overpaid, even as costs of supplies and hourly pay go up.

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MedPAC Recommends More Pay Cuts

CMS

by Kristin Rowan | Mar 20, 2024 | CMS, Regulatory

By Kristin Rowan, Editor

In December, 2023, The Medicare Payment Advisory Committee (MedPAC) recommended a 22% payment reduction for hospice providers. This week, they’ve recommended additional cuts once again.

MedPAC has just released the March, 2024 Medicare Payment Policy Report, issued to Congress. The initial statement from MedPAC recognized the long-lasting impact of the COVID-19 pandemic on healthcare providers and the record inflation rates. The commission admits that the pandemic has caused burnout and personal risk to clinicians and other health care workers. The commission also admits that the effects of COVID-19, PHE-related policy changes, and emergency funding made it difficult to interpret the indicators of adequacy in Medicare’s payment rates.

The commission openly states that the fundamental problem with FFS Medicare payments is that providers are paid more when they deliver more services, whether or not those services provide value. The call for additional payment reforms to force providers to coordinate care over time and across care settings and to eliminate what may be necessary services that MedPAC doesn’t deem valuable.

Home Health Agencies

The commission reports the Medicare margins for HHAs at 22.2 percent in 2022. The commission calculates these margins excluding some fixed costs. The margins, according to the commission, indicate that FFS Medicare payments exceed the costs of care. This should incentivize HHAs to take on additional beneficiaries, as the margins are calculating using only costs that diminish by volume.

The commission notes a drop in HHA use in 2022 and lists possible causes including:

The number of FFS Medicare beneficiaries is lower due to the increased enrollment in Medicare Advantage
Lower use of inpatient hospital care among FFS beneficiaries
Hospitalized FFS beneficiaries were less likely to be discharged to home health care (no reason for this was given)
More FFA beneficiaries are using SNFs after hospitalization (no reason for this was given)
The staffing shortages reported by HHAs limit the volume of services they can provide

The commission implies that the staffing shortages are not a factor in the decline in HHA usage. The Department of Commerce’s employment data indicates staffing levels that are currently higher than pre-pandemic levels. Even though the data includes HHAs, hospice, private duty, pediatric agencies, and other home care providers, the commission still contends that Medicare HHAs comprise a significant enough share of this group to conclude there is no staffing shortage nationwide.

The commission also reports that the decrease in the number of HHAs nationwide is not a factor in the decline of HHA usage, because most beneficiaries still live in an area with at least on HHA. The commission recognizes that the number of employees and contract laborers is not used to calculate access to care, even though it is a factor. They also admit that an HHA does not need to serve an entire area to be counted as serving the area, and that the capacity to serve additional beneficiaries is not considered.

The report recognizes that preventable readmissions to hospitals is lower among for-profit and free-standing HHAs than for hospital-based care. However, the commission dismisses this data in favor of the all-cause measure of hospitalization, which is much higher for HHAs. This measure covers 60 days and includes all hospitalizations for any cause and includes community-admitted and home health admitted patients. Essentially, MedPAC is assigning a 14.2 percent hospitalization rate to all home health patients, regardless of the cause of hospitalization, whether or not it is deemed preventable, and whether or not it is in any way related to the initial 30-day-period of post acute care.

The average cost of a 30-day period increased by 4 percent in 2022, due to a higher cost per visit. The HHAs are combatting this by reducing the number of in-person visits per 30-day period. Since MedPAC did not track telehealth visits, there is no data on the overall cost per visit, regardless of whether it was in person or remote. HHAs are working within the PDGM model for reimbursement by lowering their overall costs per 30-day period through telehealth visits, remote patient monitoring, and other technologies implemented to increase efficiency in HHAs. MedPAC wants to penalize this by reducing payment rates. This will only serve to push HHAs to further decrease the number of visits, which will impact quality of care, satisfactions rates, and rehospitalization rates.

The commission concludes that because the payments exceed the costs, the benefits of home health care are devalued as a substitute for more costly care options. MedPAC argues that the overpayment since 2000 creates higher expenditures for beneficiaries, but fails to provide data to this effect.

As noted by NAHC, there are flaws in MedPACs calculations as well as in the foundation of their position:

Exclusions such as taxes, telehealth, and marketing in cost calculations incorrectly inflate the margins
MedPAC relies heavily on the CMS calculations for budget-neutrality, which NAHC has already refuted as incorrect, bordering illegal formulas
The data used in these calculations omitted all HHAs that are hospital-based.

NAHC, along with other agencies, will continue to advocate on behalf of HHAs, hospice providers, and other home-based care agencies in front of Congress to ensure these disastrous cuts will not become permanent inclusions in Medicare policy. We will continue to bring you updates as this issue continues to unfold.

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©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only.

editor@homecaretechreport.com

President Biden’s Proposed Budget has Indications for Medicare and Medicaid

Regulatory

by Kristin Rowan | Mar 13, 2024 | Regulatory

From the NAHC Newsdesk,

March 12, 2024

On Monday, March 11th, President Biden released a $7.26 trillion proposed budget for fiscal year (FY) 2025, which begins October 1st, 2024. While the White House budget is simply a request and Congress has final say on government spending, it does provide a window into the president’s priorities and where his administration wants to direct its efforts going forward. Lawmakers have not yet finalized spending for the current fiscal year — which runs through Sept. 30 — and will need to begin negotiating funding legislation for FY2025 simultaneously with ongoing debates over current fiscal year appropriations.

The FY2025 budget requests more than $130.7 billion to fund the Department of Health and Human Services (HHS). In addition to this $130.7 billion of requested appropriations, HHS also projects spending over $1.7 trillion on mandatory programs, such as Medicare and Medicaid, that are not subject to the annual appropriations process. Notably, the budget also would extend the Medicare sequester cuts by one year until 2032 (they were previously extended through 2031 by The Infrastructure Investment and Jobs Act of 2021), which would provide savings of around $7.6 billion. The budget also proposes to increase contributions to the Medicare trust fund and extend its projected solvency by increasing taxes on earned and unearned income for those individuals with annual income over $400,000 from 3.8% to 5%.

Over the coming weeks members of the Executive Branch will be testifying before key committees in the House and Senate to provide additional detail around the recommendations put forth in the budget documents. As additional relevant detail is made available, it will be covered in “NAHC Report.”

Provisions of interest in the Budget include:

Medicare

Multiple provider types:

HOME HEALTH

Create a Permanent Medicare Home Health Value-Based Purchasing Program:
The Home Health Value-Based Purchasing Model, which the CMS Innovation Center launched in 2016 and expanded nationwide in 2022, successfully improved the quality of home healthcare at lower cost without evidence of adverse risks. This proposal converts the expanded model into a permanent Medicare program, similar to value-based purchasing programs already in place for other Medicare providers. [Budget Neutral]

HOSPICE

The Budget proposes to implement a new “value-based purchasing” (VBP) program for hospices (and many other provider sectors that do not already have a VBP program) starting in CY2027. No further details are provided about this VBP-for-hospice program, or the other sectors’ VBP programs, other than that they would be budget-neutral, and that CMS would consider granting “hardship exemptions” to certain providers. NAHC reminds members that just last week, CMMI decided to terminate the Value-Based Insurance Design (VBID) hospice “carve-in” demonstration at the end of CY2024 (the demo had been set to run through CY2030). Over the years, various policy stakeholders have floated different Medicare hospice benefit (MHB) payment reforms, and 2010’s Affordable Care Act legislation called on CMS to pilot test a VBP program for hospices, which it has not done to-date.

Medicaid

Mirroring previous year proposals, the budget includes $150 billion over 10 years to improve and expand Medicaid home and community-based services (HCBS).

The budget also proposes to require that states report on the national Medicaid Adult and HCBS Quality Reporting measures. Notably, this budget proposal seeks legislative authority to mandate this reporting while CMS included a mandate for states to submit HCBS Quality Reporting in their 2023 proposed Medicaid Access rule.
The Budget proposes to require a Medical Loss Ratio (MLR) for Medicaid and CHIP managed care organizations, with required remittances if plans do not meet the minimum standard. Current law allows, but does not require, states to impose a MLR on their health plans.
Proposes to authorize CMS to negotiate supplemental drug rebates on behalf of interested States in order to leverage savings from pooled purchasing power. (5.18 billion savings) As discussed in the State of the Union address, President Biden’s budget includes a proposal to create a Federal option that provides health care coverage to low-income individuals in States that have not expanded Medicaid. As a corollary to this proposal, the budget includes incentives for states to retain existing Medicaid expansions not default to the Federal Option. The budget contains several proposals to strengthen and streamline services for dual eligible individuals including:
- Aligning Medicare Savings Programs and Part D Low income Subsidy Eligibility Methodologies to make it easier for states and individuals to determine eligibility and enroll in both.
- Extending the Qualified Medicare Beneficiary (QMB) certification period. Currently states can limit QMB eligibility to periods less than one year, whereas this proposal would establish a 12-month eligibility certification. Provide CMS with the authority to unify appeals processes for Medicare and Medicaid review for individuals enrolled in integrated managed care plans by waiving amount-in-controversy minimums and allowing benefits to continue while an appeal is pending.
- Allow retroactive coverage of Medicare Part B premiums for QMB applicants.

A proposal to allow CMS to issue partial deferrals and disallowances that target issues of noncompliance in managed care environments and to provide CMS with additional managed care enforcement options.

DEPARTMENT OF LABOR (DOL)/HEALTH CARE WORKFORCE

The President’s Budget proposes to establish a national, comprehensive paid family and medical leave program administered by the Social Security Administration to ensure all workers can take up to 12 weeks of leave to care for a seriously ill loved one. Further, the President continues to call on Congress to require employers to provide at least seven paid sick days per year to all workers, and to ensure that employers cannot penalize workers for taking time off to address the health needs of a family member.
The Budget expands workforce training along with creating career pathways to in-demand jobs through an $8 billion mandatory Career Training Fund.
Broadens Access to Registered Apprenticeships: The Budget increases support for Registered Apprenticeships, a training tool for future workforces in a number of in-demand industries, including health care.

- The proposal seeks to invest $70 million in the Strengthening Community college training program, which builds community colleges’ capacity to design and deliver high-quality, evidence-based training programs.

- Invests in Caregivers Support Programs through the VA. Recognizing the critical role family caregivers play in supporting the health and wellness of veterans, the Budget provides critical funding for the Program of General Caregivers Support Services. The Budget also specifically provides $2.9 billion for the Program of Comprehensive Assistance for Family Caregivers, which includes stipend payments and support services to help empower family caregivers of eligible veterans.

- Nursing Workforce Development — The FY 2025 budget includes $320 million for Nursing Workforce Programs, an increase of $20 million above FY 2023. The budget includes an additional $10 million to address national nursing needs, train more nurses, and strengthen workforce capacity in education, practice, and retention. HRSA will support an increase in the number of nurses trained to provide prenatal care through investments in perinatal maternal healthcare in rural and underserved community settings to increase access and improve the quality of patient care. The investment also increases the number of nurse faculty and clinical preceptors which are critical to expanding nurse training and producing more new nurses.

- The budget also includes an increase of $10 million for Advanced Nursing Education to bolster the maternal and perinatal workforce by supporting maternal health nurses available to provide specialized care. The program will continue to increase the number of qualified nurses in the primary care workforce, including nurse practitioners, clinical nurse specialists, and Sexual Assault Nurse Examiners.

- Health Care Workforce Innovation Program — The FY 2025 budget invests $10 million for a new program to jumpstart strategies to grow the healthcare workforce and address healthcare workforce shortages across disciplines such as physicians, nursing, and behavioral health. This new program would invest in innovative approaches to accelerate the transformation of healthcare workforce training to support a modern, robust, and diverse workforce training pipeline.

HRSA supports the health workforce through health professions scholarships and loan repayments in return for service in underserved and rural communities. The FY 2025 budget requests $16.3 billion for HRSA, which is $2.0 billion above FY 2023. This total includes $8.3 billion in discretionary budget authority and $8.0 billion in mandatory funding and other sources.

PROGRAM INTEGRITY AND OVERSIGHT EFFORTS

- The Budget includes a proposal to “Increase Private Equity and Real Estate Investment Trust Ownership Transparency in Long-Term Care Facilities.” This proposal continues the Administration’s aggressive oversight of Wall Street activity in health care and would require skilled nursing facilities with either of these ownership types, whether direct or indirect, to provide additional financial disclosures above and beyond other provider types.

- The budget also includes a proposal that would modify the requirement that owners with a five percent or greater direct or indirect ownership must be reported on the provider/supplier’s enrollment application, to require owners with any percentage-level of interest be reported.

- HHS states that “top priorities that would require additional funding for CMS include:
  - Increasing Medicare fee-for-service medical review, including the possible adoption of artificial intelligence (AI) and natural language processing technologies;
  - Addressing vulnerabilities identified by the Vulnerability Collaboration Council, report recommendations from the Government Accountability Office (GAO) and HHS-OIG, and emerging issues;
  - Increasing nursing home enforcement (e.g., ownership reporting validation, reviewing Part D data of beneficiaries who reside in nursing facilities, and supporting DOJ in cases brought under the False Claims Act related to quality of care) and enforcement of home and community-based services (HCBS); and
  - Quickly addressing fraud scams, as needed, above current levels.”

HHS states that OIG’s “key focus areas” will include managed care, nursing homes, and home and community-based services.

Health Equity

SURVEYS AND CERTIFICATIONS (MEDICARE & MEDICAID)

Generally and across provider types, CMS indicates in many places in the budget documents that they are struggling with survey backlogs, primarily amongst state survey agencies (SSAs), and mostly as a result of both lingering COVID impacts and multi-year stagnant funding from Congress for Survey & Certification activities. CMS states that “With years of flat funding, the Survey and Certification program can no longer meet statutory frequency requirements or adequately guarantee the safety and quality of care for patients receiving care in CMS certified facilities.”
They also write that “CMS forecasts an increased number of complaint surveys pending and overdue for investigation across all provider types, including some immediate jeopardy complaints. The concern with the backlog is further confounded by the aforementioned increasing number of complaints being reported as well as surveyors finding more serious quality of care issues when conducting onsite surveys. These findings result in longer surveys and possible onsite revisit surveys. They also indicate a general worsening in the quality of services being provided to patients and residents.”
Specifically for the hospice program, CMS states that “CMS did not meet the FY 2020 – FY 2022 target of 98% [of hospices surveyed within the last 36-months, as required by law] due to the COVID-19 Public Health Emergency (PHE) and reprioritization of survey activities based on guidance published throughout the PHE.”
“While Accrediting Organizations have eliminated backlogs resultant from the PHE, SAs still face challenges. As SAs reduce the backlog, we anticipate meeting the target goal of hospice facilities surveyed within the required 36 months in the upcoming years.” CMS indicates that for FY2022, the most recent year with complete data, 87.1 percent of hospices were surveyed in the last 36 months.

NAHC POSITION: “This is important data for NAHC’s advocacy around CMS’ flawed Special Focus Program (SFP) design and the CMS’ plan to launch the program at the end of 2024. Given that hospice surveys are such a critical component of the SFP algorithm, it is important that CMS use accurate and up-to-date survey data; however, the budget language here seems to indicate that CMS is not caught up on the hospice survey backlog and may not be able to ensure that all hospices have indeed been surveyed in the last 36 months for at the near future.”

The budget requests $492 million for Survey and Certification, an increase of $85 million or 21 percent above FY 2023, to fund Medicare and Medicaid provider survey and certification activities. If funded at this level, CMS claims it would have sufficient resources to ensure states:
- - Complete approximately 85% of the recertification surveys for statutory facilities (up from the current 65% via FY2024 levels), survey projected complaints in all facility types at an Actual Harm, Immediate Jeopardy (IJ), and Non-IJ High levels, address a portion of the current complaint backlog, and a proportional recertification survey frequency rate for non-statutory facilities with a focus on those facility types with higher beneficiary risks.
  - CMS also states that at this level, Hospice and ESRD facilities will have funding to perform initial surveys on new providers wanting to enter the program to gain Medicare and/or Medicaid certification

Additionally, the budget proposes, effective in FY 2026, to shift the funding mechanism for nursing home surveys from discretionary to mandatory appropriation and to increase the amounts to a level necessary to achieve a 100 percent nursing home survey frequency, adjusted annually for inflation.

ADMINISTRATION FOR COMMUNITY LIVING (FUNDING FOR AGING AND DISABILITY COMMUNITY-BASED ORGANIZATIONS)

- The proposal includes $2.7 billion for ACL, which is an increase of $70 million on paper above FY 2023 amounts, but it effectively represents an approximately $112 million increase due to eliminating $42 million of earmarks in the accounting tables.

- ACL requests an additional $10 million to expand their Direct Care Workforce Strategies Center and fund capacity-building grants to states to support building partnerships among state Medicaid, aging, disability, and workforce agencies; coordinating and leveraging programs and funding streams; and developing and testing strategies to attract, train and retain direct care professionals.

ACL also requests $1.1 billion for nutrition services, which is the largest part of the Older Americans Act and would be an increase of $83 million above FY 2023.

HEALTH RESOURCES AND SERVICES ADMINISTRATION

- HRSA — $320M line item for Nursing Workforce Development (pg. 25):
  - Nursing Workforce Development &mndash; The FY 2025 budget includes $320 million for Nursing Workforce Programs, an increase of $20 million above FY 2023. The budget includes an additional $10 million to address national nursing needs, train more nurses, and strengthen workforce capacity in education, practice, and retention. HRSA will support an increase in the number of nurses trained to provide prenatal care through investments in perinatal maternal healthcare in rural and underserved community settings to increase access and improve the quality of patient care. The investment also increases the number of nurse faculty and clinical preceptors which are critical to expanding nurse training and producing more new nurses.
  - The budget also includes an increase of $10 million for Advanced Nursing Education to bolster the maternal and perinatal workforce by supporting maternal health nurses available to provide specialized care. The program will continue to increase the number of qualified nurses in the primary care workforce, including nurse practitioners, clinical nurse specialists, and Sexual Assault Nurse Examiners. (pg. 30)

- HRSA — $10m line item for a Health Care Workforce Innovation Program (pg. 25)
  - Health Care Workforce Innovation Program – The FY 2025 budget invests $10 million for a new program to jumpstart strategies to grow the healthcare workforce and address healthcare workforce shortages across disciplines such as physicians, nursing, and behavioral health. This new program would invest in innovative approaches to accelerate the transformation of healthcare workforce training to support a modern, robust, and diverse workforce training pipeline.(pg. 30)

HRSA — $51m line item for Medical Student Education (pg. 25)
- HRSA — “HRSA supports the health workforce through health professions scholarships and loan repayments in return for service in underserved and rural communities. The FY 2025 budget requests $16.3 billion for HRSA, which is $2.0 billion above FY 2023. This total includes $8.3 billion in discretionary budget authority and $8.0 billion in mandatory funding and other sources. (pg. 27)

DOJ Announces Financial Incentives for Whistleblowers

Regulatory

by Elizabeth E. Hogue, Esq. | Mar 13, 2024 | Regulatory

by Elizabeth E. Hogue, Esq.,

DOJ Says “Knock on Our Door Before We Knock on Yours”

On March 7, 2024, the U.S. Department of Justice (DOJ) announced a new pilot program that includes financial incentives for whistleblowers to report violations. The new pilot program will be launched later this year following a process to develop and implement the pilot, which is expected to take ninety days.

The DOJ likens this new program to “the days of ‘Wanted’ posters across the Old West” in the sense that law enforcement has historically benefited by offering rewards for tips and information. When whistleblowers help the DOJ discover significant misconduct, they may benefit financially from monies recovered.

The goals of the pilot program are to:

Produce more evidence for successful white-collar criminal prosecutions
Impose more significant penalties on wrongdoers
Aid in prosecution of large-scale misconduct

Here are some details:

The core principle is that when individuals help DOJ identify significant misconduct that is otherwise unknown to DOJ, they may qualify to receive a portion of any resulting recoupments.
Payments to whistleblowers will be available only when:
- All victims are properly compensated before whistleblowers
- Whistleblowers provide truthful information
- Information provided by whistleblowers is not already known to the DOJ
- Whistleblowers are not involved in criminal activity
- No other relevant financial disclosure incentive exists

The DOJ says that it expects the pilot program to increase the likelihood that employees will decide to report misconduct to the DOJ without first notifying companies that employ them. This result will significantly decrease benefits to companies that decide to self-report because the benefits of self-reporting are available only when the government does not already know about the misconduct. This incentive may produce a race to the DOJ by employers and their employees reminiscent of races to the courthouse.

These incentives also underscore the importance of making it clear in Compliance Programs that employees and contractors are required to report alleged misconduct to their employers/partners first before they tell outside third-parties. Certain woe will come to companies that ignore these allegations or, God forbid, retaliate against potential whistleblowers!

The DOJ and other fraud enforcers are generally enamored with whistleblowers and the information they provide. They are perhaps even more enamored with encouraging companies to self-report.

No portion of this material may be reproduced in any form without the advance written permission of the author.

CMMI Terminates Hospice Carve-In Demonstration

Regulatory

by Rowan Report | Mar 6, 2024 | Regulatory

From the NAHC News Desk,

Late on Monday, March 4, the Center for Medicare and Medicaid Innovation (CMMI) announced it plans to formally end the Value-Based Insurance Design (VBID) Medicare Advantage hospice “carve-in” demonstration on December 31, 2024, and that it will not accept applications to the previously released CY 2025 Request for Applications (RFA) for the hospice component of the Model. In its announcement, CMMI stated that it made the decision to terminate the demo “after carefully considering recent feedback about the increasing operational challenges of the Hospice Benefit Component and limited and decreasing participation among MAOs that may impact a thorough evaluation”. CMMI recently solicited input on the carve-in via a public request for information (RFI).

NAHC was pleased to be able to provide detailed comments to the RFI highlighting our members’ ongoing concerns and frustrations with the demonstration and registering our deep skepticism that the model was necessary or appropriate for hospice patients and families. We are pleased to see CMMI has decided to end this particular demo, and we look forward to continuing to work with them to advance innovation in care delivery and payment models for people with serious illness.

Since the carve-in was first announced, NAHC has maintained our strong opposition to the premise that incorporating hospice into the Medicare Advantage was necessary or would lead to positive outcomes. In 2019, NAHC emphasized our “unqualified opposition” to the program when it was first unveiled, and after more details were released in the model’s first request for applications (RFA); We have continued to stress our concerns since model implementation began, working with our hospice members to solicit feedback and translate those experiences into direct advocacy with CMS, CMMI, and members of Congress. As early evaluation data and inputs highlight, the model has been extremely burdensome for both hospices and participating plans, and has had no measurable positive impact on beneficiary or family outcomes, care experiences, or Medicare spending.

In the announcement about the model’s termination at the end of 2024, CMMI stated that the decision is not a result of the demo “not meeting its goals”, and that the agency will continue its evaluations of the hospice component to assess its overall impact. Over the course of the three years of the model, it was clear to NAHC that the demo was not meeting CMMI’s stated goals to drive greater care continuity and higher quality hospice care for beneficiaries and families. We also questioned the premise that a carve-in would save the Medicare program money in the long run. Contrary to what the VBID evaluators found, the seminal 2023 NORC research demonstrated that hospice utilization in the traditional Medicare program saves billions of dollars a year while delivering high-quality care.

CMS also indicated in their notification that later this year, they will issue additional guidance to ensure that “all obligations of any impacted organization may be met in a timely and reasonable manner so that hospice beneficiaries in the Hospice Benefit Component maintain a coordinated, seamless care experience.” NAHC will be following up directly with CMMI to better understand what may be included in this guidance and when it may be released.

Increasing access to hospice care remains NAHC’s primary policy goal. We are committed to working to improve more timely connection to hospice, reducing the percentage of very short stays that make it difficult to benefit fully from the hospice model, and ensuring every provider is capable of delivering high-quality, person-and-family-centered services. We appreciate our engagement with CMMI on the carve-in over the years, and we welcome the opportunity to collaborate with them on new ways to support seriously and terminally-ill people and their families.

CMS Announces Multi-Pronged Effort to Strengthen Direct Care Workforce

Admin

by Elizabeth E. Hogue, Esq. | Mar 6, 2024 | Admin, CMS, Regulatory

by Elizabeth E. Hogue, Esq.,

CMS recently issued guidance about how to build and maintain worker registries, i.e., management platforms, that make qualified health workers easy to find so that more individuals who receive Medicaid-covered home and community-based services (HCBS) can receive care in settings of their choice. Worker registries are designed to answer these questions: Who is qualified to provide HCBS in each state and how can Medicaid recipients find them?

On February 27, 2024, CMS announced several new initiatives and Resources from the Administration for Community Living’s (ACL) Direct Care Workforce (DCW) Strategies Center to address the shortage of workers who provide direct care to elderly and disabled clients. New initiatives include several types of assistance that are intended to help states strengthen their systems for recruiting, retaining, and developing direct care workers; and a national hub to connect states, stakeholders, and communities to best practices and other resources related to the direct care workforce.

Specifically, DCW Intensive Technical Assistance will facilitate collaboration among state agencies and with stakeholders to improve recruitment, retention, training, and professional development of direct care workers. The DCW Strategies Center will provide up to two hundred fifty hours of individualized technical assistance on a variety of issues for up to six teams involving multi-agency state teams.

A coach will be assigned to each team and have access to subject matter experts to support them in addressing states’ unique needs. Support provided through this initiative will be coordinated by a consortium led by ADvancing States in partnership with the National Association of State Directors of Developmental Disability Services and the National Association of State Medicaid Directors.

The DCW Peer-Learning Collaborative will bring representatives of four to six states into working groups focused on a particular topic. The DCW Strategies Center will host monthly virtual meetings focused on group learning to facilitate information sharing on best practices, innovative strategies, and demonstrated models for growing the direct care workforce. In addition, each participating state will receive up to seventy hours of individual technical assistance on a topic or issue important to each state. Each participating state is expected to accomplish at least one policy or program-related milestone as a result of participation in this initiative.

CMS also announced the official launch of the DCW Strategies Center website at https://acl.gov/dcwcenter. This website is intended to serve as the national hub for resources about best practices, promising strategies, upcoming events, webinars, and technical assistance opportunities to strengthen and expand local direct care workforces.

CMS acknowledges in the announcement that low wages, lack of benefits, limited opportunities for career growth, and other factors have resulted in a continuing shortage of critical workers. The shortage reached crisis levels, says CMS, during the COVID-19 pandemic and currently continues, with more than three-fourths of service providers that decline new clients and more than half of providers cutting services.

According to CMS, the problem described above must be addressed in order to help ensure that people who need assistance have options other than moving to a nursing home or other institutional setting.

Now is the time for providers of private duty or home care services and the associations that represent them to work intensively with state programs, especially Medicaid Programs, to maximize available assistance as described above.

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