CMS Issues Medicaid Guidance on Change Healthcare Hack

CMS

by | Mar 20, 2024 | CMS, Vendor Watch

From the NAHC News Desk,

March 19, 2024

On March 15th, the Centers for Medicare & Medicaid Services (CMS) issued a Center Informational Bulletin (CIB) that provides guidance and flexibilities to mitigate the impacts on providers resulting from the Change Healthcare Hack. In the guidance, CMS advises state Medicaid agencies that certain requirements will not be enforced, until June 30th, to enable ongoing funds to flow to providers and to prevent disruption of access to Medicaid services, prevent associated negative health outcomes, and avoid solvency issues for providers.

The most important component of the guidance is the ability for states to make interim payments to providers to avoid operational disruptions. Federal law and regulation does not allow for “advance payments” in Medicaid fee-for-service systems, despite their availability in Medicaid managed care environments; however, states can make interim payments to providers subject to reconciliation with actual services delivered.

CMS stresses that such interim payments are not advanced payments or prepayments prior to services furnished by providers, but rather are payments for services furnished that are subject to final reconciliation once the state has access to individual claims data currently inaccessible due to the cybersecurity incident.

The flexibilities CMS discusses in the guidance include:

  • Modifying required timelines for public notice, public process, and Tribal consultation and to obtain an earlier effective date for certain kinds of SPAs than would otherwise be possible;
  • Use interim payment methodologies to pay providers without current period claims data, as long they are determined via current approved payment rates, limiting the interim payments to the amount expected for each specific provider based on recent history, and reconciling the interim payments with final payments based on the actual services provided once they can be properly identified. These could be effective retroactively to the date when claims payment processing was disrupted due to the cybersecurity incident and could last until June 30, 2024;
  • Suspend beneficiary cost sharing requirements described in their state plans when necessary to avoid service disruptions for Medicaid beneficiaries for services affected by the hack;
medicaid

CMS also includes language urging Medicaid managed care plans to make prospective payments to impacted providers and reiterating that plans do not need prior CMS authority to make prospective payments to providers. CMS also indicates that plans can:

  • Suspend or modify prior authorization requirements;
  • Allow early prescription refills and/or extend the length of prescription refills;
  • Extend existing prior authorizations;
  • Suspend out-of-network requirements; and
  • Modify or update cost-sharing requirements to be consistent with any changes that are made in the Medicaid state plan.

The full guidance is available online at: https://www.medicaid.gov/sites/default/files/2024-03/cib031524.pdf.

MedPAC Recommends More Pay Cuts

CMS

by | 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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Kristin Rowan

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.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. 

editor@homecaretechreport.com

 

CMS Hospice Payment Rate FY 2025 Proposal

CMS

by | 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.

# # #

Kristin Rowan

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

HOPE is on the Way: Part 1 – Outcome Measures

Clinical

by | 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.

# # #

©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

 

HOPE is on the Way: Part 3

CMS

by | 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