Changes to the Hospice Quality Reporting Program and Other Measures Development Issues

CMS utilized the FY2022 proposed hospice payment rule to comment heavily on the Hospice Quality Reporting Program (HQRP).  Key provisions are listed below with an opportunity to comment on each.  Please respond to any or all of the questions provided. 
For more information, please consult the NAHC summary of the proposed rule.

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* 1. CMS proposes to eliminate the seven HIS measures from Care Compare no earlier than May 2022 while maintaining the Comprehensive Assessment at Admission measure.  The data would continue to be available in the data catalog. Please provide any concerns/comments your hospice has on this proposal here.

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* 2. CMS is transitioning the HQRP from the QIES ASAP system to the iQIES system.  No specific date was provided for the transition, but CMS indicated notification of the transition will be through subregulatory means (i.e. web page postings, listserv messaging, etc.). Home health migrated to the iQIES in January 2020. Please see the proposed rule summary for more information.

In the following box please let us know how much notification time is reasonable for your hospice, and provide any concerns/comments your hospice has on this transition here.

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* 3. CMS proposes to utilize the following for claims-based measures:
  • Use claims data submitted up to at least 90 days after the last discharge date in the applicable period.  For example, if the last discharge date in the applicable period for a measure is December 31, 2022, for data collection January 1, 2022 through December 31, 2022, the data extract would not be sooner than March 31, 2023.
  • Update the claims-based measures used for the HQRP at least annually.
  • Calculate claims-based scores based on one or more years of data.
Please answer the following questions for this proposal in the box specified.

a.      Does your hospice find the time frame for data extraction reasonable?  If not, what is a more reasonable time frame and why?

b.      Does your hospice believe an annual update of the claims-based measures is reasonable? If not, what is a more reasonable update time frame and why?

c.       Does your hospice believe that using one or more years of data for claims-based measures calculation is reasonable?  If not, why not?

d.      In box d. please provide any additional comments on the claims-based measures.

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* 4. CMS is proposing to add the Hospice Care Index (HCI) measure to the HQRP.  This is a claims-based composite measure through which CMS identifies hospice performance across ten indicators.  CMS would establish a threshold for each indicator above or below which a hospice’s score is determined to be substandard.  CMS would then add scores for the indicators together and establish a threshold for the composite value.  CMS plans to publicly report the HCI no earlier than May 2022 and utilize claims beginning with FY2021. To view the ten indicators and the threshold percentiles, please see the summary of the proposed rule.

a.      Does your hospice support the HCI?

b.      Does your hospice currently collect data on each of the ten indicators?  If yes, for which indicators is data collected?

c.        Does your hospice find the threshold percentiles reasonable?   If not, what would be a reasonable percentile and why?

d.      Would your hospice be ready for public reporting of the HCI no earlier than May 2022?   If not, how much time is necessary for preparation?

e.      Please provide any additional comments on the HCI in box e.

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* 5. The COVID-19 Public Health Emergency (PHE) quality reporting exemptions impact the data available for use for public reporting.  As a result, CMS proposes to utilize only three quarters of Hospice Item Set (HIS) data, as opposed to the usual four quarters of data, for the February 2022 Care Compare refresh and then resume utilizing four quarters of data for subsequent refreshes.  Likewise, CMS proposes to utilize three quarters of post-exemption data, plus five quarters of pre-exemption data for public reporting of the CAHPS Hospice Survey measures for the February 2022 refresh.  For each subsequent refresh CMS proposes to report one more post-exemption quarter of data and fewer pre-exemption quarters of data until eight quarters of post-exemption data is reached in the May 2023 refresh.

Please provide any concerns/comments your hospice has on this proposal in the following box.

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* 6. CMS proposes to introduce Star Ratings for public reporting of CAHPS Hospice Survey results on the Care Compare or successor websites no sooner than FY 2022.  The calculation and display of the CAHPS Star Rating would be similar to that of other quality reporting programs which means ‘top box’ scores for each of the eight HQRP CAHPS measures would be used and data would be calculated on a bell curve.  Hospices would need to have a minimum of 75 completed surveys for the data to be displayed.  For details on the calculation of the Star Ratings please see the summary of the proposed rule.

a.      Does your hospice routinely have a minimum of 75 completed CAHPS surveys?

b.      FY2023 is the soonest that the CAHPS Hospice Survey Star Rating would appear on Care Compare.  Does your hospice find this time frame sufficient? If not, what is a better time frame and why?

c.       Would your hospice find it beneficial to have Preview Reports available prior to the typical six months before public display of the measure? If yes, how many months before public display is sufficient?

d.      Does your hospice have any concerns/suggestions about the proposed calculation of the Star Rating?  If yes, what are the concerns/suggestions?

e.     Please provide any concerns/suggestions your hospice has on this proposal in box e.

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* 7. The following question relates to a Request for Information (RFIs)/solicitation of feedback from CMS.  There is no proposal associated with this request. 

CMS is seeking feedback on the potential use of Fast Healthcare Interoperable Resources (FHIR) for digital quality measures (dQMs) within the HQRP, aligning where possible with other quality programs. FHIR is an open source standards framework (in both commercial and government settings) created by Health Level Seven International (HL7®) that establishes a common language and process for all health information technology. For more information on the FHIR and dQMs please see the summary of the proposed rule.  Specific questions CMS has are:

a.      What EHR/IT systems do you use and do you participate in a health information exchange (HIE)?

b.      How do you currently share information with other providers and are there specific industry best practices for integrating SDOH (social determinants of health) screening into EHRs?

c.       What ways could CMS incentivize or reward innovative uses of health information technology (IT) that could reduce burdens for post-acute care settings, including but not limited to hospices?

d.      What additional resources or tools would post-acute care settings, including but not limited to hospices and health IT vendors, find helpful to support testing, implementation, collection, and reporting of all measures using FHIR standards via secure application program interfaces (APIs) to reinforce the sharing of patient health information between care settings?

e.      Would vendors, including those that service post-acute care settings, including but not limited to hospices, be interested in or willing to participate in pilots or models of alternative approaches to quality measurement that would align standards for quality measure data collection across care settings to improve care coordination, such as sharing patient data via secure FHIR API as the basis for calculating and reporting digital measures?

f.        What could be the potential use of FHIR dQMs that could be adopted across all QRPs?

g.      Please provide additional concerns/suggestions/comments in box g.

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* 8. The following questions relate to Requests for Information (RFIs)/solicitation of feedback from CMS.  There are no proposals associated with these requests.

CMS is seeking comment on the possibility of expanding measure development, and adding aspects of SPADEs (the standardized patient assessment data elements developed in response to the IMPACT Act for post-acute are) that could apply to hospice and address gaps in health equity in the HQRP.  For more information about this request and CMS’ comments on closing the health equity gap, please see the proposed rule summary.  Specifically, CMS is asking that hospice stakeholders:

a.      Provide recommendations for quality measures or measurement domains that address health equity, for use in the HQRP.

b.      Provide guidance on suggested parts of Social Determinants of Health (SDOH) SPADEs adoption that could apply to hospice in alignment with national data collection and interoperable exchange standards.

c.      Provide feedback on ways CMS can promote health equity in outcomes among hospice patients. Specifically CMS is seeking feedback regarding whether including facility-level (hospice-level) quality measure results stratified by social risk factors and social determinants of health (for example, dual eligibility for Medicare and Medicaid, race) in confidential feedback reports could allow facilities to identify gaps in the quality of care they provide.

d.      Describe methods that hospices use in employing data to reduce disparities and improve patient outcomes, including the source(s) of data used, as appropriate

e.     Describe existing challenges providers encounter for effective capture, use, and exchange of health information, such as data on race, ethnicity, and other social determinants of health, to support care delivery and decision making.