Hospice care, fundamentally rooted in palliative care principles, focuses on enhancing the quality of life for individuals facing terminal illness. This approach prioritizes comfort, symptom management, and holistic support for patients and their families, shifting the focus from curative treatments to comprehensive care that addresses physical, emotional, social, and spiritual needs. Understanding the regulatory landscape that governs hospice services is crucial for providers to ensure they deliver high-quality, compliant, and patient-centered care. This article breaks down the key updates from the Fiscal Year (FY) 2018 Hospice Payment Final Rule, highlighting critical changes impacting hospice operations and quality reporting, and contextualizing these within the broader framework of palliative care delivery and, tangentially, Palliative Care Coding Guidelines 2017, although the rule itself primarily addresses payment and quality rather than direct coding changes.
Background on Hospice Care and Medicare Benefits
Hospice care, as defined by Medicare, is palliative care specifically for individuals with a prognosis of 6 months or less. It’s a comprehensive model that encompasses medical, nursing, social, psychological, emotional, and spiritual services, aiming to minimize disruption to patients’ lives while primarily maintaining them in their home environment. The Medicare hospice benefit, established in 1983, reflects the ethos of providing all-inclusive care, pain relief, and symptom management to allow individuals to pass away with dignity, often at home.
Palliative care itself, as defined in Medicare regulations, is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. It addresses a wide spectrum of needs – physical, intellectual, emotional, social, and spiritual – and emphasizes patient autonomy and informed decision-making. While this FY 2018 rule doesn’t directly revise palliative care coding guidelines 2017, it’s important to note that accurate coding within the hospice setting is inherently linked to these broader palliative care principles. Proper coding ensures appropriate reimbursement for the comprehensive services hospices provide, which are centered around palliative care.
The hospice benefit covers a range of services, including:
- Nursing care
- Therapies (physical, occupational, speech)
- Medical social services
- Hospice aide services
- Physician services
- Counseling
- Short-term inpatient care
- Continuous home care
Medicare payments for hospice care are provided on a per diem basis, categorized into four levels of care: Routine Home Care (RHC), Continuous Home Care (CHC), Inpatient Respite Care (IRC), and General Inpatient Care (GIP).
Key Provisions of the FY 2018 Hospice Payment Rule
The FY 2018 Hospice Payment Rule brought several important updates, primarily focused on payment rates, the wage index, and the Hospice Quality Reporting Program (HQRP).
1. FY 2018 Hospice Wage Index
The hospice wage index is adjusted annually to reflect local differences in wage levels across various geographic areas. For FY 2018, the wage index was updated using the FY 2017 hospital pre-floor, pre-reclassified wage index data. This means that hospice payments are adjusted based on the prevailing wage levels in the location where services are provided, accounting for labor costs.
- Budget Neutrality: The application of the updated wage data was designed to be budget neutral across all four levels of hospice care, meaning the update itself was not intended to increase or decrease overall hospice spending.
- Wage Index Floor: The hospice wage index maintains a floor, ensuring that areas with lower wage data still receive a minimum wage index value to support adequate payment levels.
2. FY 2018 Hospice Payment Update Percentage
The hospice payment rates are updated annually. For FY 2018, the payment update percentage was set at 1.0 percent, as mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This update is intended to account for inflation and changes in the costs of providing hospice care.
- Productivity Adjustment: The market basket percentage update, which forms the basis of the hospice payment update, is subject to reductions related to economy-wide productivity changes, as mandated by the Affordable Care Act.
- Quality Reporting Reduction: Hospices that fail to meet quality reporting requirements face a 2 percentage point reduction to their payment update percentage.
3. FY 2018 Hospice Payment Rates
The FY 2018 rule updated the per diem payment rates for each of the four hospice care categories, applying the 1.0 percent payment update percentage.
- Routine Home Care (RHC) Rates: Two different RHC rates were maintained: a higher rate for the first 60 days of hospice care and a lower rate for subsequent days, reflecting the intensity of services typically needed earlier in hospice care.
- Service Intensity Add-on (SIA): The SIA payment, introduced in FY 2016, continued in FY 2018. This add-on provides additional payment for direct patient care provided by registered nurses or social workers during the last seven days of a patient’s life when receiving RHC, recognizing the increased intensity of care needed at the very end of life.
- Updated Payment Rates: The final rule detailed the specific updated payment rates for RHC (both initial and subsequent days), CHC, IRC, and GIP, reflecting the 1.0 percent update and budget neutrality adjustments.
4. Hospice Cap Amount for FY 2018
The hospice aggregate cap limits the total amount of Medicare payments a hospice can receive annually. For the 2018 cap year, the cap amount was updated to $28,689.04, reflecting the 1.0 percent hospice payment update percentage.
- IMPACT Act Impact: The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) mandated that for accounting years ending after September 30, 2016, and before October 1, 2025, the hospice cap be updated by the hospice payment update percentage, rather than the Consumer Price Index for Urban Consumers (CPI-U).
5. Updates to the Hospice Quality Reporting Program (HQRP)
The HQRP aims to promote quality and accountability in hospice care. The FY 2018 rule included updates and clarifications regarding this program.
- Retention of Measures: The rule reinforced the policy that measures adopted for the HQRP remain in place for subsequent years unless they are proposed for removal, suspension, or replacement.
- Changes to Measures: Non-substantive changes to measure specifications, such as updates to coding, could be implemented without new rulemaking, streamlining the process for maintaining relevant and up-to-date measures. Substantive changes, however, would still require notice-and-comment rulemaking.
- Previously Adopted Measures: The rule reaffirmed the previously adopted quality measures for FY 2018 payment determination and future years, which included measures focused on pain screening and assessment, dyspnea treatment, treatment preferences, beliefs/values addressed, bowel regimen for opioid users, Hospice Visits when Death is Imminent Measure Pair, and Hospice and Palliative Care Composite Process Measure—Comprehensive Assessment at Admission.
- Measure Concepts Under Consideration: CMS discussed potential future measure areas, including claims-based measures focusing on potentially avoidable hospice care transitions and access to different levels of hospice care. These concepts aimed to address continuity of care and appropriate utilization of hospice benefits.
- Data Submission: The rule clarified policies for new hospice facilities regarding data submission and payment penalties, ensuring new providers are aware of their reporting obligations. It also reiterated the data submission mechanisms, timelines, and deadlines for the Hospice Item Set (HIS) and CAHPS® Hospice Survey.
- Hospice Evaluation & Assessment Reporting Tool (HEART): CMS provided an update on the development of HEART, a potential new data collection mechanism intended to be a comprehensive patient assessment tool, potentially replacing the HIS in the future. HEART is envisioned to collect richer clinical data for quality reporting and potential payment refinement purposes.
- Reconsideration and Appeals: The rule outlined the procedures for hospices to request reconsideration of non-compliance decisions related to HQRP requirements.
- Public Reporting: CMS detailed plans for public display of quality measures and other hospice data on the Hospice Compare website, enhancing transparency for consumers and stakeholders.
Conclusion
The FY 2018 Hospice Payment Rule represents the ongoing evolution of Medicare hospice regulations, with a focus on refining payment methodologies and enhancing quality reporting. While not directly focused on palliative care coding guidelines 2017, the rule underscores the importance of comprehensive, high-quality palliative care within the hospice benefit. By understanding these updates, hospice providers can navigate the regulatory landscape effectively, ensuring financial stability and, most importantly, delivering optimal, patient-centered palliative care to those facing the end of life. The rule emphasizes data-driven quality improvement and transparency, pushing the hospice industry towards continuous enhancement of care delivery for beneficiaries and their families.
Disclaimer: As a large language model, I am not qualified to provide healthcare or legal advice. Please consult with healthcare professionals and regulatory experts for specific guidance related to hospice care and compliance.
