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3/22/2012
1
The View from Washington – What’s
Ahead for Hospice and Palliative
Care
Judi Lund Person, MPH
NHPCO
© National Hospice and Palliative Care Organization, 2012
Today we will discuss…
• Current trends in hospice and project their
trajectory in 2012
• Key areas in health reform that will impact
hospice and palliative care
• Survey deficiencies, fraud and abuse
• Hospice and palliative care and its focus in
2012
BASIC HOSPICE DATA
Patients Served by Hospice in the US
1982-2010
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
20
06
20
08
20
09
20
10
Number of Patients
Number of
Patients
Source: National Hospice and Palliative Care Organization, 2012
Number of Hospices
0
500
1000
1500
2000
2500
3000
3500
4000
1985 1990 1996 1999 2003 2005 2007 2008 2009 2010
Number of Hospices
Number of Hospices
Source: Centers for Medicare and Medicaid Services, 2011 Data Compendium
Diagnoses of Hospice Patients - 2010
Cancer
35.6%
Debility Unspecified
13.0%Dementia
13.0%
Heart Disease
14.3%
Kidney Disease
2.4%
Liver Disease
1.9%
Lung Disease
8.3%
Stroke or
Coma 4.2%
Other 5.4%Motor Neuron,
1.6%
HIV/AIDS, 0.3%
Source: National Hospice and Palliative Care Organization, 2012
3/22/2012
2
Length of Stay in Hospice
67.4
20.0
69.5
21.3
69.0
21.1
67.4
19.7
0
10
20
30
40
50
60
70
80
Average Length of Stay Median Length of Stay
Da
ys
of
Ca
re
2007 2008 2009 2010
Source: National Hospice and Palliative Care Organization, 2012
RATE CUTS – A PRIMER
Rate cuts already in place
• Phase out of the BNAF
– FY2012 – third year of seven year phase out
– Multiplier to the wage index reduced each year
– Invisible to providers but shows up in wage index calculation of rates
• Productivity adjustment reductions
– Required in the Affordable Care Act
– Begins in FY2013
– Original estimates of 1.5% for all Medicare providers
– Additional 0.3% for hospice providers
Budget Neutrality Adjustment Factor
• Multiplier to the wage index
• .4% reduction in wage index value each year
• Invisible to the provider
• Already figured in to wage index values when
published in the summer of each year
• Completely phased out in FY2016
Productivity Adjustment Reductions
• % reduction to the marketbasket increase
• Reductions figured when rate updates are
announced in the summer of each year
• % reduction estimated to be 1.6% each year
for FY2013 – FY2019
• Marketbasket increase estimate: 2.4%
• Calculation is marketbasket minus 1.6%
Productivity Adjustment Reductions
• Marketbasket increase for FY2013:
2.4%
- 1.6% (productivity adjustment reduction)
0.8% marketbasket increase
Routine home care rate in FY2012: $151.03
Estimated FY2013 rate: $152.24
3/22/2012
3
Super Committee failure
• Impasse announced in November 2011
• Did not meet goal for identifying $1.2 trillion
to reduce the federal deficit
• Next step - sequestration
– Automatic across-the-board cuts for Medicare
providers and defense spending
– No more than 2 percent reduction of overall
spending on hospice and would last for ten years
Additional 2% cuts
and Congressional action
• Go into effect January 1, 2013
• Congress still has time and political pressure to come up with alternative ways to get to the savings.
• Current budget environment: hospice could be hit under any scenario Congress might pursue
• Vigilance required in hospice community in its advocacy engagement throughout 2012
What can be done?
• Sequestration: – Cuts are technically triggered and already written into
law
• NHPCO advocacy: – Given the other cuts facing the hospice community, an
additional 2 percent would be devastating to patient access
– Engage in discussions on any and all alternatives that Congress will be pursuing to avoid sequestration. We expect there to be many moving targets
– Vigilance will be key in 2012
2012 as an election year?
• Presidential election year
• Full House of Representatives
• One third of the Senate
• More attention paid to:
– Deficit reduction
– Attempts to reign in entitlement spending
• Hospice is a part of that discussion
Opportunities for advocacy
www.hospiceactionnetwork.org
The network is:– Developing new ways to engage with Congress from home
– Two opportunities for NHPCO members to go to the Hill as part of a organized lobby day for a united hospice community
Advocacy focus for 2012
– Vigilance
– Hill presence
– CMS presence
– Unified message on the Hill
Never more important than this year!
3/22/2012
4
Hospice care in the nursing home
• Series of Office of Inspector General reports
• MedPAC analysis of hospice care in the nursing home suggested:– Economies of scale
– Potential for duplication of services
– Suggested rate reduction
• CMS also analyzing volume, costs, visits by discipline and comparisons to hospice home care
• Continued area of vulnerability
• No action yet
Preparing your hospice for rate cuts…
• Streamline operations
• Efficiencies
• Staffing and staff caseloads
– A good resource for this analysis is the NHPCO Staffing Guidelines, found at www.nhpco.org/quality
• Service area reductions
• Services that could be reduced
• Look for ways to increase charitable giving as a way to cover some costs
HOSPICE CHANGES DUE TO
AFFORDABLE CARE ACT
Face-to-face encounters -- challenges
with implementation
• Availability of physicians and nurse practitioners
• Time available from part-time or contract employees
• Creating a system for tracking which patients need a face-to-face encounter and when
• Is there a symptom management component? Can it be billed?
• Discharge when face-to-face is not timely
HELP proposed legislation
• The HELP legislation, S722 and HR 3506, will:
– Expand the list of health care professionals to conduct
the face-to-face to include:
• Physician assistants
• Clinical nurse specialists
– Will expand the timeframe for completion of face-to-
face to up to 7 days after admission
– Will require a two year pilot of payment reform before
finalizing
– Will require hospices to be surveyed every three years
Hospice Payment Reform
• ACA provision: Reform hospice payments no earlier than FY2014
• Analysis of data currently underway
• CMS contractors continue to analyze
– Claims data
– Hospice cost reports
• Technical Advisory Panel convened
• Meetings continue in late February/early March
3/22/2012
5
CMS Concurrent Care Demo
• 15 hospice sites nationwide
• Focused on Medicare patients
• Patients can receive both curative therapies
and hospice care concurrently
• RFP to be released by CMS pending
Congressional appropriation for demos
Concurrent Care Demonstration
could…
• Promote partnerships with other care
providers and professionals
• Create a seamless continuum of care and
services
• Hospice services can be provided without the
exclusion of other services that patients may
want, need and could benefit from
Concurrent Care Demo Status
• Demo not funded in Affordable Care Act
• CMS Administrator interested in pursuing
• Expect more delay in roll out of information
Concurrent Care for Children
• Medicaid and SCHIP
• Mandatory coverage
• Eligible for hospice services
• All other services for which the child is eligible
may continue to be provided
Resources Available
Website:
www.nhpco.org/pediatrics
• Download toolkit
• Review Questions and
Answers from CMS about
concurrent care for children
29
QUALITY REPORTING
3/22/2012
6
Mandatory Hospice Quality Reporting
• Quality Reporting Begins in 2012
• Mandatory data collection period – first year:
– October 1, 2012 – December 31, 2012
• After 2012:
– The data collection period will be January 1 –
December 31
– Reporting will be done annually
– The number and types of measures will increase
Miss the deadlines?
• Mandatory reporting
• Measures required – no choice in what
measures should be reported
• Hospices who miss the 2013 reporting
deadlines will face a 2% cut in their hospital
marketbasket increase (hospice
reimbursement rate “inflation adjustment”) in
FY2014
TOP 10 MEDICARE HOSPICE SURVEY
DEFICIENCIES FOR FY 2010
33
34#1
§418.56(b) Standard: Plan of care
• L543
– All hospice care and services furnished to patients
and their families must follow an individualized
written plan of care established by the hospice
interdisciplinary group in collaboration with the
attending physician (if any), the patient or
representative, and the primary caregiver in
accordance with the patient’s needs if any of them
so desire
35
L543 deficiency examples
• Example #1:
– Plan of care listed hospice aide visit frequency for
5x/wk
• Hospice aide visited 1x/week
• No explanation for missed visits or why visit frequency
was not met in the clinical record
• Example #2:
– Patients with different terminal diagnoses
• Plan of care showed 25 prn visits for nurse, aide and SW
36
3/22/2012
7
37#2
§418.56(c) Standard:
Content of the plan of care
• L545
– The hospice must develop an individualized written
plan of care for each patient. The plan of care must
reflect patient and family goals and interventions
based on the problems identified in the initial,
comprehensive, and updated comprehensive
assessments. The plan of care must include all
services necessary for the palliation and
management of the terminal illness and related
conditions
38
L545 deficiency example
• Patient resided in ALF
• Patient assessed with multiple skin tears
• Specific orders for wound care were included in
the plan of care but no frequency for the
wound care was indicated
• IDG notes/documentation showed no
information regarding wound care, skin care or
the fact that the patient resided in an ALF
39 40#3
§418.76(h) Standard: Supervision of
hospice aides
• L629
– (1) A registered nurse must make an on-site visit to
the patient’s home:
• (i) No less frequently than every 14 days to assess the
quality of care and services provided by the hospice aide
and to ensure that services ordered by the hospice
interdisciplinary group meet the patient’s needs. The
hospice aide does not have to be present during this visit.
41
L629 deficiency example
• Supervision of hospice aides varied from 16
days to more than 30 days
� Remember! If the RN makes a supervisory visit on a Tuesday,
the next supervisory visit is due by the Tuesday, which occurs
14 days later
42
3/22/2012
8
43#4
§418.56(d) Standard:
Review of the plan of care
• L552
– The hospice interdisciplinary group (in collaboration
with the individual’s attending physician, if any)
must review, revise and document the
individualized plan as frequently as the patient’s
condition requires, but no less frequently than
every 15 calendar days
44
L552 deficiency example
• Patient was admitted with debility on
10/28/10
• Plan of care was updated 12/09/10 and then
again on 12/29/10
45 46#5
§418.54(b) Standard: Timeframe for
completion of the comprehensive
assessment • L523
– The hospice interdisciplinary group, in consultation
with the individual’s attending physician (if any),
must complete the comprehensive assessment no
later than 5 calendar days after the election of
hospice care in accordance with §418.24.
47
L523 deficiency example
• Patient admitted to hospice on 12/6/10
• Psychosocial assessment by MSW completed
12/23/10.
• Initial assessment by chaplain 1/20/11
48
3/22/2012
9
49#6
§418.54(d) Standard: Update of the
comprehensive assessment
• L533
– The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient’s response to care. The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.
50
L533 deficiency example
• No evidence that:
– Hospice nurses performed complete and accurate
pain assessments and were not communicating and
updating changes in pain status to the IDG
– The IDG, when assessing the patients pain status
consistently considered the most recent pain
assessment documentation by the RN
51 52#7
§418.56(c)(2) - Scope and frequency of
services
• L547
– A detailed statement of the scope and frequency of
services necessary to meet the specific patient and
family needs.
L547 deficiency example
• Plan of care contained services that are
missing the frequency of the care to be
provided
54
3/22/2012
10
55#8§418.54(c)(6) - Drug profile
• L530
– A review of all of the patient's prescription and over-the-
counter drugs, herbal remedies and other alternative
treatments that could affect drug therapy. This includes,
but is not limited to, identification of the following:
• (i) Effectiveness of drug therapy
• (ii) Drug side effects
• (iii) Actual or potential drug interactions
• (iv) Duplicate drug therapy
• (v) Drug therapy currently associated with laboratory
monitoring
56
L530 deficiency examples
• Incomplete drug profiles
• Medication changes were not documented
• Duplicate medications were not monitored
57 58#9
§418.114(d) Standard:
Criminal background checks
• L795
– The hospice must obtain a criminal background
check on all hospice employees who have direct
patient contact or access to patient records.
Hospice contracts must require that all contracted
entities obtain criminal background checks on
contracted employees who have direct patient
contact or access to patient records.
59
L795 deficiency examples
• Directly employed hospice staff– no evidence
of criminal background checks completed
• Contractual agreements reviewed did not
require criminal background checks,
specifically inpatient and respite services,
pharmacy services and DME
60
3/22/2012
11
61#10
§418.64(d) - Counseling services
Bereavement counseling
• L596
– (1) - Bereavement counseling. The hospice must:
• (i) Have an organized program for the provision of bereavement
services furnished under the supervision of a qualified
professional with experience or education in grief or loss
counseling
• (ii) Make bereavement services available to the family and other
individuals in the bereavement plan of care up to 1 year
following the death of the patient. Bereavement counseling also
extends to residents of a SNF/NF or ICF/MR when appropriate
and identified in the bereavement plan of care
62
§418.64(d) - Counseling services
Bereavement counseling
• L596
– (1) - Bereavement counseling. The hospice must:
• (iii) Ensure that bereavement services reflect the needs of
the bereaved.
• (iv) Develop a bereavement plan of care that notes the
kind of bereavement services to be offered and the
frequency of service delivery.
63
L596 deficiency examples
• Bereavement files in the survey sample failed
to contain a bereavement reassessment or
bereavement plan of care for the deceased
patients’ family
– Hospice agency policy required bereavement
assessment/intervention within 10 days of the
death
64
MEDICARE/MEDICAID
FRAUD AND ABUSE
Compliance plans
• Vigilance is required about compliance activities
• Compliance with:– Medicare Hospice Conditions of Participation
– Other hospice regulations
– Claims submission requirements
– Eligibility requirements
– Requirements for continued eligibility
• Compliance plan should include:– Specific timeframes for internal audits of agency practices
– Protocol for reviewing processes that may be out of compliance with current laws and regulations.
3/22/2012
12
Risk areas for hospice fraud and abuse
• Eligibility
– Does this patient meet the eligibility requirements
for admission to the hospice program?
– Does the documentation support eligibility?
• Site of care
– Do the patients in nursing facilities meet the
eligibility requirements for hospice?
– Is the length of stay appropriate, or were those
patients admitted “too early” for hospice care?
Risk areas for hospice fraud and abuse
• Level of care
– Does the level of care match the patient’s
symptom management concerns or family need
for respite?
– Is General Inpatient care appropriate and
documented in the medical record?
• Claims submission
– Are the dates of service, Q-codes for location of
care, and levels of care accurate?
Audits Increasing
• Recovery Audit Contractors
• Medicaid Integrity Contractors
• Zone Program Integrity Contractors
• All active in hospice
• More providers and more states involved LEADERSHIP INTO THE FUTURE
Leadership in the future….
• Jim Collins – “Great by Choice”
• Why do some companies thrive in uncertainty,
even chaos and others do not?
Findings…..
• Leaders…– Not more risk taking, more visionary, more creative
– More disciplined, more empirical, more paranoid
• Innovation….– Innovation by itself is not the solution
– More important – ability to scale innovations, to blend creativity with discipline
• Leading in a fast world....– Fast decisions and fast actions…sure way to get killed
• Great companies – Changed less in reaction to radically changing world