CMS seeks answers on palliative care utilization trends and spending

The US Centers for Medicare & Medicaid Services (CMS) is seeking answers from the palliative care community, including some regarding utilization patterns and out-of-hospital expenditures.

The recently proposed palliative care payment rule for 2024 contained a Base reimbursement rate of 2.8% increase as well as provisions intended to support program integrity. Additionally, it included a wealth of data and information requests that could hint at future rulemaking or other action.

“This proposed rule is full of some very interesting statistics and numbers that CMS has released,” Howard Young, a partner at law firm Morgan Lewis, told Hospice News. “It’s somewhat different from previous years where, for example, it was much more to the point of knowing what their proposed rates would be similar to and some focus on health equity. I do not want to say that there was no RFI component, but this year, it caused a lot of ink to flow.

A key set of data relates to the use of Continuing Home Care (CHC), General Inpatient Care (GIP), and Inpatient Respite Care (IRC).

CMS in 2020 rebased the payment rates for the four levels of palliative care with the aim of improving access and better aligning reimbursement for these services with the costs of providing them. In doing so, the agency expected a corresponding increase in usage which, to date, has not materialized.

“We intended to rebase these rates to adequately cover the costs of providing these more intensive levels of care to ensure that hospices have access to the providers needed to comply with the hospices Conditions of Participation (CoP) and promote patient access to all levels of care,” CMS said in the proposed rule. “Despite rebasing payment rates for higher levels of care, there still remains a high percentage of hospices that provide little or no CHC, IRC or GIP.”

In fiscal year 2022, routine home care accounted for 98.8% of palliative care days and 93.7% of payments, representing only modest increases from the previous decade.

A major contributing factor is that many hospices do not actually provide the three highest levels of acuity care, despite federal requirements to do so, according to CMS. As many as 72.2% of hospices reported no HCC cases in the last fiscal year, for example.

The agency also noted differences in usage patterns between for-profit and non-profit hospices. CMS data shows that for-profit organizations were less likely to provide PIGs in 2022, while non-profit organizations accounted for the lion’s share of those who did not report HCC cases.

A number of factors can potentially influence these utilization rates, according to Young.

“One of the reasons may be COVID-19. Getting patients out of their homes into a facility during COVID was particularly challenging. I’m not sure they considered that,” Young said. “The second is simply the effect of the audits. If you’re a hospice that doesn’t provide a lot of GIP or not a lot of ongoing home care, and you start to provide a lot more of it, you’re probably putting yourself at a much higher risk of being selected for an audit.

Review of the use of the GIP has been ongoing for a number of years, dating back to 2013 reports from the Office of Inspector General of the US Department of Health and Human Services.

Although CMS does not have rules that set a limit on the length of GIP stay, Medicare Administrative Contractors (MAC) have pursued palliative care audits related to stays longer than seven days.

These factors can have a “chilling effect” on these three levels of care, according to Mollie Gurian, vice president of home and home and community services policy at LeadingAge.

“CMS needs to help encourage the use of inpatient palliative care, and they can do that by not putting the people who issue the GIP in a pay-and-chase situation, which is where they find themselves. right now,” Gurian told Hospice News. “And then CMS finds them through their contractors for claims, which has a chilling effect. They raise rates, and then they basically ask for money by auditing people.

The conundrum of “untied care”

CMS is also looking to learn more about the factors contributing to the increase in non-hospital expenses for patients who have chosen the benefit. That price rose in fiscal 2022, topping $1.4 billion, the agency reported. This includes items and services covered by Medicare Parts A, B, and D.

Non-hospital expenses for Parts A and B in particular reached $883 million last year, a 28.9% increase from fiscal 2019.

“Recipients receiving palliative care services from for-profit hospices had, on average, 60% higher non-palliative spending per day than non-profit hospice recipients,” CMS said in the language of Rule.

Medicare’s Terms of Participation (CoP) allow healthcare providers to receive payments for services and items considered unrelated to a hospitalized patient’s terminal illness and associated conditions.

Although permitted, payments outside of the Medicare Hospice Benefit should be “exceptional, unusual and rare,” according to CMS, which has historically taken the position that essentially all care necessary for a terminally ill patient should be covered by the service.

Between 2010 and 2019, Medicare paid a total of $6.6 billion to non-hospital providers for services provided to palliative care recipients, according to a report from the Office of Inspector General (OIG) of the US Department of Health and Human Services.

These rising costs led to a recommendation from the OIG that CMS investigate whether palliative care reimbursement reform is needed to resolve duplicate payments.

Although the vast majority of the time the hospice is not the organization billing for these services, these practices and the regulatory response affect them nonetheless. Again, this often takes the form of audits.

CMS drew particular attention to Part D expenditures not related to palliative care, which reached $623 million in 2022, up from $493 million in fiscal year 2019. Critical issues include questions on maintenance medications. For years, HMCs and palliative care providers have grappled with when these drugs should be considered “palliative” versus “curative.”

“They specifically call it maintenance drugs. Sometimes, for example. continuing your diabetes treatment can really help even if it’s not the primary diagnosis,” Katy Barnett, Director of Home Care and Palliative Care Operations and Policy at LeadingAge. “If it suddenly had pre-clearance requirements, there might be a barrier there. People can say, ‘I’d rather not go to hospice. I don’t want to give this up,’ even though that really helps them at the end of life.”

CMS, under the proposed rule, is now seeking additional information from vendors to explain why these expenses are occurring.

For example, the agency asked if hospice enrollment policies could be perceived as restrictive for recipients who may need more expensive end-of-life care, such as blood transfusions, chemotherapy, radiation therapy, or radiation therapy. dialysis, or those who need a “higher intensity”. level of palliative care.

Another potential consideration may be the impact of the addendum to the Hospices Election Statement that CMS introduced in 2021, which required hospices to provide families – upon request – with a list of services that would not be covered by the service. However, at this time, no data is publicly available regarding how often families make these requests or how often hospices provide them.

The issue here is not just bureaucratic. Patients and families often accrue out-of-pocket expenses for items and services that are not covered by the palliative care benefit. In total, these costs reached $197 million for Part A and Part B services in fiscal year 2022.

As CMS tries to get these issues under control, there are concerns that over time this could also trigger audits.

“The fact that CMS reports on a lot of statistics asking the industry to weigh in,” Young said. “I think it’s important to keep in mind with the industry that there’s a pretty high likelihood that we’ll also see an increase in audit activity in non-hospital spending.”