The View From Washington – hospice and palliative care issues

1. The View From Washington – hospice and palliative care issues

2. Recurring Theme in Health Care Reform • Bending the cost curve • Permanent reductions in provider reimbursements • Hospice: $6.8 billion over ten years $$$$$$$$

3. Rate Cuts

4. Budget Neutrality Adjustment Factor (BNAF) • Multiplier to the hospice wage index each year • Began in FY2010 • Spread over 7 years • Final result = (4.2%) rate decrease

5. Productivity Adjustment Reduction Reduction for all Medicare providers • 1.3% reduction in hospital marketbasket over 10 years Additional reduction for hospices: • Beginning in FY2013, an additional -0.3% Net marketbasket increase: 2.4% - 1.3% - 0.3% = 0.8%

6. Changes in Hospice Rates

7. Sample Routine Home Care Rates • Next 10 years • $8.45 increase in routine home care rate

8. Face-to-face encounter

9. CMS Grants Suspension in Enforcement • NHPCO met with CMS on December 21 • CMS granted a 3-month suspension in enforcement of the face-to-face final rule • Contractors (MACs) instructed not to conduct reviews on face-to-face encounters until 2nd quarter 2011 • Opportunity for hospices to get their processes in place and look for problem areas • Face-to-face encounters must still be conducted and should have begun January 1, 2011

10. Questions and Concerns • Same physician for face to face encounter, brief narrative and recertification • “Prior to” language in statute and how to admit new patients to your hospice that have previous hospice experience • Common Working File accessibility and accuracy

11. Transitions on January 1, 2011 • Patients who enter 3rd benefit period or later before the end of 2010: • No face-to-face encounter required until the recertification period is reached after January 1, 2011 • Patients who enter 3rd benefit period or later after January 1, 2011 • Face-to-face encounter required

12. Is the encounter a billable visit? • No, considered an administrative function • If a non-administrative service, such as symptom management, is provided – hospice bills Part A • Documentation for visit needed, whether administrative or for services beyond the face-to-face • Documentation – clear and precise

13. Resources from NHPCO • Tip sheets on certification and recertification process • Sample forms for hospice use • Care maps • In-service education for staff • Compliance checklists • Frequently asked questions

14. Other hospice provisions

15. Medical Review • Hospices with a high percentage of long stay patients (> 180 days) • 100% medical review of those patients over 180 days by the fiscal intermediary • No guidance to MACs yet

16. Cost Report • Modifications being developed now • NHPCO submitted sample worksheets to CMS with recommendations • Expect cost report as vehicle for more data collection

17. Concurrent Care Demonstration Project • On hold until drafting language regarding funding is resolved between Senate Finance Committee and CMS • 3 year demonstration program that would allow patients who are eligible for hospice care to also receive all other Medicare covered services while receiving hospice care • CMS will develop an application process • 2011: Applications available • 2012: Demonstration project to start

18. Concurrent Care for Children • For children in Medicaid and CHIP • Children electing the Medicaid hospice benefit may also receive curative treatments • Effective immediately on enactment – March 23, 2010 • CMS published state Medicaid Director Letter on September 2010 giving direction to the state Medicaid agencies • NHPCO working with state leaders to develop tools for a state-by-state approach to implementation

19. Hospice Payment Reform • No earlier than FY2014 • Originally proposed by the Medicare Payment Advisory Commission (MedPAC) • Considering options for reforming the routine home care rate

20. NHPCO Response • The Moran Project • Data from more than 600 hospice provider numbers • 300,000 patients • 13 million visits • Questions to answer: • What kinds of payment methodologies can be modeled for CMS and MedPAC? • How can NHPCO provide new information to CMS and MedPAC for their consideration in alternative payment models?

21. Performance Measures • 12 measures tested in New York State • Examples: Pain, dyspnea, anxiety, nausea Family prepared for changes in patient’s condition Adverse events – falls, medication errors, complaints • Call for measures in February 2011

22. Hospice Quality Reporting • Mandatory reporting on hospice performance measures – expect Hospice Compare • Those who don’t report face a 2% reduction in marketbasket update • Measures to be published in 2012 for reporting to begin in 2014

23. Other Provisions of Interest

24. Accountable Care Organizations • HHS Secretary must establish by 1/1/2012 • Could be networks of practitioners or joint ventures between hospitals and other providers • CMS requested comments – NHPCO responded on 12/6/2010 • Hospices should look for opportunities to be at the table in these discussions

25. Medical Homes • Focused on primary care and prevention • Stresses coordinated team approach facilitated by information technology • Typically, internal medicine, family practice, geriatrics and general practice physicians

26. Creation of Health Benefit Exchanges • PPACA expands access to health insurance through the creation of Health Benefit Exchanges. • Exchanges can be administered by: • a governmental agency • a nonprofit entity established by the state. • If a state does not create an Exchange by Jan. 1, 2014, HHS will create and operate one.

27. Minimum Essential Benefit Plan Details Essential Benefit Plans (EBPs) • States must cover the cost of benefits over and above the Essential Benefit Plan • At a minimum, the EBPs must include: • outpatient services • emergency services • Hospitalization • maternity and newborn care • mental health services, including behavioral health treatment; • prescription drugs • laboratory services • preventive and wellness services • chronic disease management • rehabilitative services • pediatric services, including dental and vision care

28. Our Goal Ensure that coverage for hospice is included in the Essential Benefits Package.

29. Reviews, Audits and the OIG

30. New Levels of Scrutiny DOJ OIG Legal Oversight OVERSIGHT ZPIC/PSC MIC Compliance Oversight FI/Carrier/MAC RAC Routine Business QIO CERT RISK Source: Strafford Publishing

31. Examples • Cert Audits: Comprehensive Error Rate Testing • Review medical records and claims for compliance with Medicare coverage, coding, and billing rules • RAC: Recovery Audit Contractors • No hospice specific audits yet • Expect audits in 2011 • MIC: Medicaid Integrity Contractors • Proposed recoupment in one audit: $3 million • Questions about eligibility • ZPIC: Zone Program Integrity Contractor • Active in 17 states • Most serious of the audits – payment errors, high volume, high costs • Results of analysis could be extrapolated to entire billing

32. OIG Areas of Risk in 2011 • Duplicate drug claims for MHB and Part D – Report due in mid-spring 2011 • Medicaid • Utilization of the hospice benefit in the nursing home • Hospice services provided to nursing home residents

33. Opportunities in these times • Focus on the continuum of care • What is my hospice the best at? • How can my hospice partner with others to meet the needs of patients and families? • PACE • Palliative care • Pediatric palliative care • Bereavement counseling • Serving veterans

34. We Honor VeteransA National Awareness and Action Campaign

35. Did You Know… • 28% of Americans who die each year are veterans • Over 1,800 veterans die each day • Veterans have special care needs at the end of life, especially if they are combat veterans • It is imperative that hospices step up, acquire the necessary skills and serve these veterans with the dignity they deserve

36. What does We Honor Veterans mean? • Asking about military history and knowing what to do with the answer • Partnering to design care specific to veteran needs • Extending VA and agency “reach” to improve care and access • Improving quality by measuring the impact of VA and agency interventions

37. www.WeHonorVeterans.org • Centralized Information • Educational Resources • Enhancing Partnerships

38. Enroll Your Hospice as a We Honor Veterans Partner Now • Recruit: Get oriented and commit • Level 1: Provide Veteran-centric education • Level 2: Build organizational capacity • Level 3: Develop and strengthen relationships • Level 4: Increase access and improve quality