LeadingAge Responds to Medicare Proposed Rules

Regulation | June 18, 2019 | by Jodi Eyigor, Aaron Tripp

The public comment period for the fiscal year (FY) 2020 Medicare proposed rules for skilled nursing facilities (SNF) and hospice closed on June 18, 2019. LeadingAge filed comments on behalf of our members for each rule that will impact payment and policy beginning on October 1, 2019.

Annually, the Centers for Medicare & Medicaid Services (CMS) releases proposed payment and policy rules that reflect the expected payment update for Medicare reimbursement. If Congress does not supersede existing stature payment updates are based on a formula in current law. That was the case for SNFs with a proposed 2.5% payment update and hospice with a 2.7% payment update for FY 2020. These numbers could change in the final rule, but typically little if at all, based on updated market data.

In addition to payment updates, regulatory and policy changes are often included in the proposed rules. Summaries of the included proposals for the skilled nursing and hospice rules are available on the website. Each touches on reimbursement proposals in addition to the regulatory proposals. Thanks to the input of members and staff analyses we offer the below summaries of our comments on the proposals.

Skilled Nursing Facilities Comments

Wage Index Adjustment

As CMS continues to utilize the hospital wage index in developing the SNF wage index, and changes have been proposed in the Hospital Inpatient Prospective Payment System (IPPS) proposed rule to address wage index disparities between high- and low-wage index hospitals, LeadingAge requests clarification on how those changes would impact the SNF wage index and recommends CMS examine wage index disparities to identify any issues to address relative to SNFs.

Changes Related to the Patient-Driven Payment Model (PDPM)

LeadingAge supports PDPM-related changes such as updating the regulatory text to more accurately reflect terms that will be utilized with the implementation of PDPM and supports the revision of the group therapy definition to reflect services provided to groups of 2 to 6 individuals. CMS proposed a subregulatory process to make non-substantive changes to ICD-10 code mappings and related software and while we support this change, we request clarification on when providers can expect these updates to take place in order to reduce the administrative burden and margin for error associated with unpredictable updates.

Quality Measures

Several changes were proposed for quality measures in both the SNF Quality Reporting Program (QRP) and the SNF Value-Based Payment (VBP) program. We suggest further exploration or development of several of the measures proposed for FY 2022 QRP to ensure that any adopted measures present an accurate picture of care, such as adding qualifiers to questions assessing social determinants of health and conducting a further review of instruments measuring mood status. LeadingAge supports the exclusion of baseline nursing home residents from the QRP discharge to community measure and the name change proposed for the VBP measure related to hospital readmission.

Hospice Comments

Proposed Rebasing of the Continuous Home Care (CHC), Inpatient Respite Care (IRC) and General Inpatient Care (GIP) Payment Rates

LeadingAge supports efforts to have payment rates accurately reflect the costs of providing the traditional, robust hospice model. Every hospice patient will not need all four levels of care. However, a hospice providing all four levels is an indicator of quality and hospices must be prepared in terms of staffing, contracts and other resources, to offer each level according to a patient’s needs.

We have heard from members that they lose money when providing the higher levels of care and often must fundraise and rely on foundations to cover the costs for those with the ability to offer inpatient services on their own. Many hospices do not have their own inpatient facilities and must rely on contracts with other institutions to fulfill the requirements for GIP and IRC. Given this variation, we believe CMS ought to study the redistributive effect of the rebasing proposal since it reduces the routine home care (RHC) rates by 2.71% to meet budget neutrality requirements. This reduction in RHC could disproportionately impact nonprofit hospice providers who will pass through the increased rates for the higher levels of care to partners while absorbing the reduction of RHC rates.

Proposed Election Statement Content Modifications and Proposed Addendum to Provide Greater Coverage Transparency and Safeguard Patient Rights

LeadingAge agrees that it is a critical issue that beneficiaries and their families understand what is included and excluded when they elect the hospice benefit. That said we have concerns and questions about the proposal for the election statement addendum. The burden associated with the proposal is not an accurate representation of the time and resources to complete and maintain the addendum. Additionally, we seek clarification from CMS on aspects of the proposal as the timeframes do not seem practical and there are vagaries about the requirements, including signatures, updates, and sharing the addendum with others. Additional concerns arise for payment implications given the proposal as a condition of payment coupled with the lack of clarity could pose real implementation challenges for the proposal as written.

Request for Information Regarding the Role of Hospice and Coordination of Care at End-of-Life

We believe that any alternative payment approaches for hospice should be designed in thoughtful ways and ensure beneficiary and family access to the critical services offered by nonprofit, community-integrated hospice providers. Given experience from other service providers, our members have a concern that if hospice migrates out of Medicare fee-for-service into other arrangements that payment will not occur promptly which could directly impact cash flow. Additionally, most alternative payment models have had an explicit focus on reducing lengths of stay and costs per beneficiary. This approach does not inherently align with quality end-of-life care by hospice providers.

Next Steps

CMS will review comments and publish their responses in the final rules expected in August. At that time, we will notify members of the release and implications that are scheduled to take effect on October 1, 2019.