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C-TAC Regulatory Comments Pose an Avenue for Change

By: Joanna George, C-TAC Policy Intern

The Centers for Medicare & Medicaid Services (CMS) is required to post all proposed regulations for a 60-day public comment period before finalizing them. As an advocate for individuals with serious illness, C-TAC comments on pertinent proposed rules to promote high quality, comprehensive, and person-and-family-centered care.

Recently, CMS finalized two important rules and addressed or acknowledged C-TAC’s comments in those final rules:

Skilled Nursing Facility (SNF) Finalized Rule FY 2022

 Quality Measures under Consideration for Future Years:

In this section on potential future measures for the SNF quality program, C-TAC encouraged CMS to incorporate frailty assessments, which was generally acknowledged. (These assessments are not yet required in most Medicare programs due to concerns about provider burden, but C-TAC consistently advocates for doing so on the patient’s behalf.) Also acknowledged was C-TAC’s support for shared decision making and patient-reported outcomes as additional measure concept areas: “One commenter stressed the importance of patient-reported outcomes since they determine outcomes based on information obtained directly from patients, and therefore provide greater insight into patients’ experience of the outcomes of care. Another commenter echoed that and stated that patients and caregivers are the best sources of information reflecting the totality of the patient experience”.

Hospice Finalized Rule FY 2022

Hospice Conditions of Participation- Workforce

C-TAC offered support for the proposed changes in hospice aid training and encouraged CMS to permanently extend and standardize similar staffing flexibilities utilized during the COVID-19 pandemic. Specifically, C-TAC noted the potential to alleviate workforce shortages by expanding the nursing supervisory roles in this proposed rule to include licensed practical nurses in addition to registered nurses. This would provide further staffing flexibility for hospices. This comment was specifically acknowledged by CMS however, the rule was finalized as proposed with no addition of nurse supervisory options. C-TAC also advocated for the permanency of routine home care telehealth flexibility even though this is something that will need a legislative change for CMS to enact.  

Hospice Quality Reporting Program

Based on the required information technology system changes, C-TAC advised CMS to extend their timeframe for the transition from the seven “Hospice Item Set process measures” to the proposed Hospice Care Index (HCI) by two years and to provide hospices with additional time to process this data internally before it is publicly posted. C-TAC also expressed concern that one of the new Index measures placing focus on live discharges could potentially exacerbate the current trend towards patients enrolling in hospice only in the last few days of life. In response, CMS restated their intent to provide hospices with access to preview reports before publicly reporting HCI and stated that the description, rationale, exclusion criteria and other metrics provided in the final rule should equip commentators to replicate the indicators, thresholds and points earned with their own data. They therefore finalized the rule as proposed without our suggested changes.

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey and Star Ratings

When C-TAC expressed the concern of its hospice members regarding the tendency for current Star rating methodologies to force ratings into a traditional bell curve, which might mathematically alter the performances of some hospices, CMS cited that “analyses of existing CAHPS Hospice Survey data demonstrate that hospices with high scores would overwhelmingly receive 4 and 5 stars” while “clustering methodology assigns cut points by minimizing differences within star categories and maximizing differences across star categories. This methodology does not force a set number of hospices into each star category. Using a benchmark rather than the clustering approach represents a major shift from our current practice. The current methodology has been successful for other provider types. We do not believe it is necessary to drastically change our methodology for the CAHPS Hospice Survey.” However, CMS does plan to address the concern from C-TAC and other commenters towards public interpretation of star ratings with further information on the Care Compare website- including explanations to mitigate smaller hospices being penalized by misinterpretation of an absence of star ratings.

To view C-TAC’s full comments, visit our regulatory webpage here.

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