Education, Care Coordination Key to Preventing Unnecessary Revocations of the Hospice Benefit 

Hospice News | By Jim Parker

Revocations of the hospice benefit can have serious adverse effects on patients and families, as well as providers. Understanding the causes and repercussions of these incidents can help operators prevent them, when appropriate.

Live discharges can occur for a number of reasons, including the patient or family changing their minds about receiving hospice care, or the patient improves and no longer needs those services. A patient may choose to resume curative treatment, or they might move out of the hospice’s service area.

In some cases, a frightened patient or a patient in crisis may call an ambulance or visit and emergency room, prompting revocation of the Medicare Hospice Benefit in order to receive hospital care.

Causes of Revocations

When it comes to revocations, fear and a lack of education about hospice are often significant factors, Sara Sprague, manager of clinical quality improvement, for Providence Hospices of Orange County in California, said at the National Hospice and Palliative Organization’s (NHPCO) Annual Leadership Conference.

“Families don’t fully understand hospice and the scope of hospice, what it provides. There’s also a lack of clarity on disease progression and prognosis, caregiver burden, distress, or difficult to manage symptoms,” Sprauge said at the conference. “You also have caregivers’ reluctance to administer morphine, and the response time of the hospice when compared to 911, and the family’s difficulty in accepting the patient’s own mortality. What’s interesting here when you look at these items is that some of them are within the control of hospice.”

About 15.4% of patients who were discharged from hospice in 2020 did so while they were still alive, according to NHPCO. Of those, 5.7% were due to revocations, and 2.2% transferred to a different hospice.

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Flu Cases Climbing as We Return to a More 'Typical' Season

WebMD Health News | Damian McNamara, MA

In what looks like a return to a typical pre-pandemic flu season, cases nationwide continue to slowly climb this fall, national infectious disease expert and pharmacy data shows. 

Flu is still nothing to mess with, and officials are promoting the flu activity results as a reminder for people to get their flu shots as soon as possible – before an expected peak early next year.

Seasonal influenza activity is increasing in most parts of the country, primarily in the South Central, Southeast, and West Coast regions, the CDC said in updated numbers released Monday. In the prior week, the number of lab tests positive for the flu was up 3%, and the number of outpatient visits for respiratory illness was up 2.9%.

Numbers from a national pharmacy chain shows the same overall slow increase in cases and the highest flu activity across the southern United States.As of Nov. 4, 2023, Puerto Rico, Mississippi, and Louisiana had the most flu activity, the 2023-2024 Walgreens Flu Index shows.

"At this time, it is very low activity. There's not much of a flu season yet," said Pedro Piedra, MD, a professor of molecular virology and microbiology at Baylor College of Medicine in Houston.

The major virus circulating now is respiratory syncytial virus (RSV) and not influenza. "But that doesn't mean that the flu is not going to come. Viruses come in waves," Piedra said. "Until then, this is the best time to be vaccinated and to be getting prepared for the flu season."

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Industry Still in Shock Following Release of Home Health Final Rule

McKnight’s Home Care | By Adam Healy
 
Home health and hospice providers are still reeling from the release of last week’s home health rule. The regulation slapped home health providers with more Medicare cuts and finalized a Special Focus Program for hospices based on what providers believe is a flawed algorithm.
“It’s a punch in the gut, really, for providers,” Katie Smith Sloan, president and CEO of LeadingAge, said to McKnight’s Home Care Daily Pulse in a press conference at LeadingAge’s annual meeting. “And it’s really baffling to me that you can have an administration that says we need to support our older adults, we need to provide quality care, and yet we can cut reimbursement.”
 
The rule, released last Wednesday, included a permanent behavioral adjustment of -2.89%, prompting outcry from providers and advocates for the home health industry. These cuts came atop a permanent rate reduction of 3.925% this year, and many organizations like LeadingAge believe it may be too much for agencies to handle.
 
“It further squeezes the home health providers out there who are already struggling with workforce issues, increased costs,” Sloan said. “I have no idea what the thought process is. They clearly have done a disservice.”
 
How the cuts were implemented may unevenly affect providers of different sizes, markets or types, LeadingAge’s experts also said. 
 
“Doing it in aggregate means you’re treating all people equally,” Mollie Gurian, vice president of home based and HCBS policy at LeadingAge, said in an interview with McKnight’s Home Care Daily Pulse at the meeting. “Even whether their margins are 30% or whether their margins are 2% or negative. And it’s going to cause closures.”
 
The Special Focus Program for hospices also drew criticism for the algorithm that determines what providers are to be placed on the list. Since the provision was finalized without modification in the rule released last week, LeadingAge has explored ways to delay or prevent the SFP before it goes into effect on Jan. 1, 2024, according to Gurian.
 
“We’ve been strategizing about whether there’s a legislative approach that could help to delay it,” Gurian said. As to whether this possibility could be successful, “Probably not, but it’s worth trying, and I think we have support,” she said.
 
Luckily, CMS left room for further discussion, according to Katy Barnett, director of home care and hospice operations and policy, in an interview with McKnight’s Home Care Daily Pulse.
“There was some language in there after each of the sections finalizing the proposal that they really did clearly think that more conversation would be necessary,” Barnett said.
 
But if implemented, the SFP is expected to create a sort of “chilling effect” among providers, which might steer consumers away from unfairly-targeted hospices. It may not cause providers to halt hospice services, but it could reduce access to quality care, she noted.
 
“I don’t think it necessarily will drive providers out,” Gurian said. “I don’t think people will stop doing hospice because of the existence of a special focus program. But we do think if the wrong providers are identified, it could have a scarlet letter effect that is unfortunate … which would affect access ultimately.”

CMS Finalized Home Health Rules – Hospices Significantly Impacted

The Health Group

[CMS] finalized the Home Health Prospective Payment System Rate Update which includes many provisions impacting hospices. The following provider enrollment regulations were finalized:

• § 424.502 Definitions. Revises the definition of managing employee to include Hospice and SNF Medical Director and Administrator.
• § 424.518 Screening levels for Medicare providers and suppliers.  Revised to accommodate PHE waiver for fingerprint based criminal background checks for newly enrolled high-risk providers, including hospices.
• § 424.527 Provisional period of oversight. Codifies who is subject to a provisional period of oversight and the effective date, including hospices.
• § 424.530 Denial of enrollment in the Medicare program.  Reapplication bar changed to 10 years from 3 years. A provider or supplier that is currently subject to a reapplication bar may not order, refer, certify, or prescribe Medicare-covered services, items, or drugs, and Medicare will not pay for services ordered.
• § 424.540(a)(1) change the 12-month time frame to 6 months for deactivations related to non-billing, including hospices.
• § 424.550 Prohibitions on the sale or transfer of billing privileges. Applies the 36-month rule to hospice providers.

Additionally, the Hospice Special Focus Program ("SFP”) will proceed with implementation in 2024.  SFP is a program intended to identify hospices as poor performers. Selected hospices will be subjected to increased oversight, and they must successfully complete the SFP program or be terminated from the Medicare program.

The final rule essentially gave no consideration to comments made to the proposed rule and all proposed provisions were finalized as proposed.  While many provisions in the final rule will increase costs incurred by hospices to comply, the implications associated with SFP are most concerning. The final rule did not address any recommendations on delaying the implementation of SFP or how the SFP could be improved, including:

• Scaling the survey data by hospice size,
• Accounting for the large number of hospices that do not have reportable HCI scores or data for the 4 CAHPS measures,
• Reducing the weight given to CAHPS data in the SFP algorithm,
• Providing transparency into exactly how SFP hospices will be chosen from the list of bottom 10% performers,
• Providing SFP hospices with technical assistance to support quality improvement,
• Going back to the SFP TEP to address technical shortcomings of the proposed design, and
• Giving hospices a preview period so they could better understand their SFP scores before the program was fully implemented.

By implementing the SFP using a flawed algorithm, underlying criteria for selecting hospices for SFP will be based on:

• Survey reports with Condition-Level Deficiencies (“CLDs”),
• CMS Medicare data sources from the Hospice Quality Reporting Program (“HQRP”), and
• Medicare claims and Consumer Assessment of Healthcare Providers and Systems (“CAHPS”) Hospice Survey.

The process, as outlined, will fail to identify hospices most appropriate for additional oversight and support, and risk reducing access to higher-quality care by directing patients and families to hospices that perform most poorly relative to health and safety requirements.  Even CMS, in the final rule concludes, “The final SFP algorithm is designed as an initial step in identifying poor quality indicators.”

More detailed information will be provided on the final rule and hospice implications with further in-depth review, including addressing the practical implications of the changes.  The entire rule is available here.

The provisions of the final rule impacting hospices will be discussed at our conference next week in Ft. Lauderdale.  Details are available here.