Comments on FY17 Proposed Payment Rule
Legislation | April 23, 2016
LeadingAge comments on the FY17 proposed payment rules for hospice and skilled nursing facilities.
We are pleased with both the 2.05% increase for FY 2017 payments for Hospice and the 2.1% FY 2017 increase for Skilled Nursing.
Hospice
We agree with the proposed quality measure for Hospice: Hospice Visits when Death in Imminent, which is actually comprised of 2 measures.
- One measure is the % of Hospice patients who received a visit by a registered nurse, physician, nurse practitioner or physician assistant in the last 3 days of life.
- The second measure is the % of patients who received at least 2 visits by a medical social work, chaplain, spiritual counselor, licensed practice nurse or hospice aid in the last 7 days of life.
While we concur with the intent of the first measure, we are concerned about the disadvantage rural providers may have in accessing RNs, Doctors, NPs or PAs for in-person visits. The second measure allows for much greater flexibility and allows for visits by Hospice staff that may well better meet the needs and wishes of the patient and family.
We adamantly support consumer information as proposed in the Hospice Compare Web site, but we remain concerned about the eventual evolution to a quality rating system based on a 5-star model. Our experience with the 5 star ratings in nursing homes has shown that there are basic flaws in how they are calculated, how the various star ranking compare between regions, and how confusing they can be to consumers.
We hope that CMS would not repeat the same mistakes in the Hospice 5 star system. For more information, read LeadingAge's take by Peter Notarstefano.
Skilled Nursing Facilities (SNFs)
Regarding the SNF proposed value-based measures, LeadingAge is and always has been, a support of transparency in meaningful, person-centered quality measures and the valuation through payment of high quality services. For more details, visit the Federal Register.
Hospital Readmission
Currently, as part of the Protecting Access to Medicare Act of 2014 (PAMA), SNFs already have a value-based program, included in the FY 2016 ANF PPS final rule of an all-cause, all condition hospital readmission measure. CMS has proposed a new readmission measures for all-condition, risk adjusted potential preventable hospital readmissions for SNFs that would be triggered if there was a SNF admission within 1 day of the proximal hospital discharge, and would include the full 30-days following the hospital admission, even if the patient was discharged into the community.
We support the intent and recognize that this will provide incentives for nursing homes to coordinate with home and community based services following a SNF discharge. We are pleased that the risk adjustment for this measure includes not only diagnoses, but also sociodemographic factors that often play as significant a part in the risk of readmission as do the medical conditions.
We do remain concerned, however, regarding the performance standard and benchmarking for this measure. We would prefer to see testing of this benchmarking model prior to public reporting and to eventual payment penalties and incentives.
Unless this benchmarking is done correctly, the unintended consequence may be that nursing homes have incentives to not accept medically complex, or otherwise high risk patients, thus creating a potential access issue for the most vulnerable groups.
Discharge to Community
This measure we support in concept. It looks at patients who have been discharged and have not had an unplanned readmission to the hospital, nor have died, within the 31 days following discharge, but have remained at “home” with or without home health services.
The propose rule does not specify that risk adjustment would include socio-demographic characteristics, which we believe are critical to include and are strong predictors of “return to community.” In addition, we would ask that “home” be defined as the place the individual calls home, include assisted living, residential care settings or other congregate housing in the community.
Medication Reconciliation
This measure proposes to determine whether or not nursing home providers were responsive to potential or actual clinically significant medication issues when such issues were identified. Medication reconciliation and optimum medication management are critical elements for good care. This measure, however, is potentially vague and not yet adequately tested.
We strongly believe that this measure should first undergo testing prior to the incorporation into a value-based quality measure for reporting.
Medicare Spending per Beneficiary
We have multiple concerns with this measure. There are concerns as to how claims are counted, to which provider they are attributed, and whether it includes valid, meaningful risk adjustment that includes not only diagnostic categories, but function limitations, cognitive impairment and socio-demographic characteristics; all which are known to be linked to total costs of care and services.
For all of these measures we remain concerned about the methodology for eventual incentive payments or penalties, as well as the time lapse between the actual events and the reporting date. If these are truly to be incentives for meaningful quality improvement, providers need a clear link between practice and outcomes. Delays of a year or more provide little direction or meaning to practice changes.