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

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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

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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!

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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

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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

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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

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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

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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

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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

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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

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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.

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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