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Your CHAP on-the-go source for news + policy review, innovation, interviews with thought leaders, and the top trends in community-based care.The views expressed by the authors, hosts, and guests are their own, and their appearance on the program does not imply an endorsement of them or any entity they represent. Views and opinions expressed by CHAP employees are those of the employees and do not necessarily reflect the organization's view.
CHAPcast by CHAP - Community Health Accreditation Partner
The FY 2025 Hospice Wage Index Rule: Insights From NAHC and NHPCO
Take a first look at the Fiscal Year 2025 Hospice Wage Index Rule with the unparalleled insights of industry authorities Katie Wehri (NAHC) and Patrick Harrison (NHPCO). Our conversation slices through the complexity to deliver a focused commentary on what this proposed rule signifies for hospice care providers, highlighting the rule's unexpected early release and the notable absence of anticipated program integrity proposals. We delve into the ramifications of the missing measures and the adaptability required in the wake of this development. The advent of the HOPE assessment tool is scrutinized as it transitions from a patient-centric assessment to a pivotal data collection asset, with an eye on the nuances of its rollout.
The hospice community stands at the precipice of change with the Medicare Advantage hospice component sunset within the VBID model by CMS. We dissect the repercussions of this pivot from earlier value-based system inclinations and emphasize the balance between cautious optimism and the realities of the evolving healthcare system. The episode also honors the dedication of hospice workers amid workforce tribulations and increased CMS scrutiny, championing a dual focus on patient care and compliance. We invite our listeners to deepen their engagement with this critical dialogue by leveraging resources such as NHPCO and NAHC, and by partaking in informative webinars that illuminate the path ahead. Your involvement and feedback are the heartbeat of our community, and we're thankful for every clinician's commitment to excellence in hospice care.
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Hi there, I'm Jennifer Kennedy, the lead for Compliance Standards and Quality at CHAP, and welcome to our CHAPcast.
Speaker 1:Today we're going to be talking about the Fiscal Year 2025 Hospice Wage Index Rule.
Speaker 1:This is in proposed format and, while we're not going to bring you through each and every detail of the rule because you can get that out there in various posts that have come out from my respective guests today and actually Chap did put out an overview or a summary of the rule as well but what we're going to do here today is to really, you know, do like a quick snapshot of takeaways from these very talented hospice experts in the hospice regulatory and compliance space that will help you get a different kind of perspective on this particular rule. So I am so pleased to be joined by my colleagues and friends today Katie Weary, who is the Vice President of Regulatory Affairs, quality and Compliance at the National Association for Home Care and Hospice, and Patrick Harrison, who is the Senior Director of Regulatory and Compliance at the National Hospice and Palliative Care Organization. Welcome to both of you. I'm so happy to have you back in the saddle in the chap cast saddle to tackle what we're going to talk about today.
Speaker 2:Well, thanks for having us, Jennifer. It's always great to sit down and have a discussion with you and Patrick.
Speaker 3:And Jennifer appreciate the opportunity. It's great to be here today with you. I know.
Speaker 1:So let's get down to brass tacks and talk about some hospice, should we?
Speaker 1:I always say, I love the smell of the Federal Register in the morning. I love it. So I was actually pretty surprised to see when this rule did post. I was expecting it to post maybe at the end of the month Usually it's Friday at a 4 o'clock posting time but when it did pop out late on a Thursday it did kind of take me by surprise. You know, I was a little unaware. But of course, as both of you know, what we do is we see that rule and pop it right open and we say, oh, what's the page count? That's not bad. Or oh my God, that's pretty bad.
Speaker 2:That's exactly right, and it was a little bit of a surprise this year, just because you know we're looking all the time to see when it leaves the Office of Management and Budget, and it didn't leave until right before it posted. So it was a little bit of a surprise but honestly I'm grateful that it was a Thursday and not a Friday.
Speaker 1:Yeah, absolutely.
Speaker 2:I agree.
Speaker 1:Yeah, and you know I saw it. Of course, when I saw it, as you and Patrick probably did, you know it was posted on the public inspection desk first, and now it is, as of April 4th, made its way to the Federal Register proper. So you know, I really want to hear from you. As I said, we're not going to like go through the whole rule, you know, do an account of everything that's in it. But I wanted to know from you and let's start with Patrick what was your number one takeaway from this proposed rule.
Speaker 3:So, jennifer, that is a great question and I'll be perfectly honest, I'm going to cheat a little bit in my response. Okay, I'm going to say my key takeaway for what was in the rule and what was not in the rule, and let me begin by first stating what I think was surprising to me as to what was not in the rule, and that was any program integrity proposals. We all know that there's hospice is a space where we actually are seeing fraud occurring. The NHPC, nac and the combined national associations worked very diligently and aggressively to protect and preserve the quality and integrity of the hospice benefit in response to some of the concerns we've seen out there about this fraud and we saw some provisions last year come out about this and given the pressure and given the scrutiny right now, it was very surprising not to see anything there. Possibly may see something yet in the home health rule later this year, but just it was interesting to see at 4.15 pm on Thursday nothing there popped out in the rule.
Speaker 3:Getting more to your question as to what kind of our key takeaway was in the hospice rule, there's a lot of things but really in terms of the key takeaway was, I think, the hope assessment and I. There's a lot of items there that are obviously important and I don't think Hope's proposal is surprising, but it is interesting to see this come out. We finally have something here. We have finally something we can see, given the previous years of discussion, working groups and listening sessions that have been put together to help inform this assessment, and I say assessment there purposefully, this assessment and I say assessment there purposefully and it's interesting given how this started really as a patient assessment tool, we've now moved away from that in the role more to a data collection instrument, which is interesting.
Speaker 3:Another thing I'll flag is a timing here. The fact sheet for the proposed rule indicated that this assessment or this tool would go into effect in fiscal year 2025. If you actually look in the rule, it says on or after October 1, 2025, which is technically fiscal year 2026. So just in terms of timing there, it's going to be interesting and very important for providers to take a look at that and prepare for what's coming next important for providers to take a look at that and prepare for what's coming next.
Speaker 1:Yeah, you know the HOPE tool stood out to me because you know I've been waiting with bated breath to see what that draft tool looks like. And you know it's very timely, patrick, because my colleague Kim Skehan and I recorded a webinar for the NHPCO Interdisciplinary Conference on getting ready for the HOPE assessment and I think we said in there we predict that it's going to post in this, you know upcoming rulemaking and poof, there it was. So I agree with you. Not too surprising, katie. Number one standout in the rule.
Speaker 2:And to pick just one, that was difficult I know, Absolutely stand out in the role and to pick just one, that was difficult. I agree with everything that Patrick has said so far and definitely I was very intrigued with the hope and wanted to learn a little bit more about that. But I think the other part to this is the RFI, or the request for information on the high intensity, pallensity palliative care services and really what's happening. There is a telltale sign that CMS is looking at changing the payment structure for hospice. They're asking specifically is there maybe another payment methodology that we need to be looking at here in addition to the hospice per diem rate? That's going to help cover this, and I think that's great. We have so many hospices that find it's incredibly difficult to cover some of these high intensity services and they have to limit the number of patients they can take with that, and it's also a sign that CMS is looking at how hospices operate and what is our healthcare system today and modernizing the hospice benefit a bit, and I think that's great.
Speaker 1:Did you feel, katie, when you read that, like I got like this, my back neurons were tingling like, oh, palliative care. We're thinking about palliative care here, even though it's not expressly said in in that text. You know, it seems like they're. You know, with the MM. I'm sorry, I'm thinking it's Friday and we're recording this on a Friday, and sometimes my neurons are a little fried by Friday.
Speaker 1:But you know the demo that we had, you know, over several years to test palliative care to me. There was something in there that said to me oh you know, maybe they're taking some of that outcome of data to think about how they would, as you mentioned, reconstruct not only the payment but maybe reconstruct the benefit a little bit.
Speaker 2:I definitely think that CMS is looking at the benefit as a whole and ways that they can improve and expand upon what is already existing. As far as palliative care itself is concerned, I think this RFI from CMS, as well as the way that they're approaching palliative care, is to incorporate palliative care concepts into already existing programs. They're looking at seriously ill individuals and really expanding that palliative care, making sure that all programs cover it, which is really what is intended. In palliative care it's not specific to a time frame or to a particular diagnosis. So I think that part is great. But I agree with you. Hearkening back to the Medicare Care Choices model and other models under CMMI, you know they're definitely recognizing that our health care system today needs to expand in its payment structure to match the types of care that people are receiving.
Speaker 1:Yeah, and their wishes for that care. I couldn't agree with you more, katie. I've been a hospice nurse for a long time and I had the absolute honor to be included in the 2020 St Christopher's Palliative Care Nursing Project and talk to nurses all over the globe, and it's palliative care meaning seriously ill till you take your last breath, and that's the continuum. And I would love to see the US sort of move in terms of clinical care to something like that, as a model for sure.
Speaker 2:Definitely.
Speaker 1:So let me come back to you, patrick Now, given what we're seeing here in this proposed rule and knowing what we know about when it you know many of the things that went into contact, contact went into effect rather on January 1st. As you mentioned program integrity, we had many program integrity items go into effect January 1st. What do you see, or what will what in your crystal globe, patrick? Would you say the hospice landscape looks like for the balance of 2024, going into early 25?
Speaker 3:That's a great question, jennifer, and actually one I get all the time now, and my response is actually to adopt the old sailors of Dodge here Red skies at night, sailors delight, red skies in the morning, sailors warning. And I think the question right now is is it morning or night?
Speaker 1:Yeah.
Speaker 3:And there are definitely strong clouds on the horizon and there's going to be some turbulent waters ahead that we're going to have to navigate through this next year, and there's a couple of things I really want to highlight that I think is going to be important for us to be cognizant of as we come to this new hospice landscape. A couple of things here, first of which is the Hospice Special Focus Program here, first of which is the hospice special focus program. We know this was finalized in last year's home health role and we know CMS has indicated that hospices selected for the special focus program will be identified in November this year. The special focus program just for the listeners here is a program that was authorized under statute that is intended to address hospices that have substantially failed to meet Medicare program requirements. There's been some discussions around that and back in with the 2022 home health rule, there were some initial proposals there that CMS openly did not finalize. At that time. There was a technical expert panel and then we saw in the 2024 home health final rule, cms actually proposed and finalized the methodology for the special focus program, or SFP, as you may hear me refer to on this podcast.
Speaker 3:We are concerned about the methodology that CMS has selected in identifying those hospices and we are concerned that will not effectively identify hospices who may not be providing care at a level they should be and, more importantly, it may end up actually steering beneficiaries away from hospices to potentially even poor performing hospices, and that's something we're very concerned about. Given that announcement, we know that CMS will identify those hospices for the special focus program itself, but CMS will also identify the bottom 10% of hospices nationwide under that methodology and that can have significant ramifications for the industry going forward. Other items I want to highlight here as well, and there's a lot. I can spend just an hour on this question alone, but I won't do that to our listeners today.
Speaker 1:I know we could talk for hours, right.
Speaker 3:The other item I want to highlight here is VBID and the value-based insurance design model. As we all know, traditionally Medicare is carved out of Medicare Advantage and there has been a hospice component of the value-based insurance design model that's been in effect since 2021. Indicated that hospice component would be sunset at the end of this year, which is a very stark contrast from the signaling that we were receiving from the agency even in January, where, at that time, we had a request for information indicating that CMS planned to allow Medicare Advantage organizations to require the enrollees to only receive receive hospital services from in-network providers. And given that shift in the plans to really move towards this value-based system and in recognition that our nation is going with Medicare Advantage, it was a little bit surprising to see CMS's decision in that area.
Speaker 1:Yeah, it was. I think a lot of people are surprised but they're going shoo. But I don't think we should go shoo just yet, honestly, right.
Speaker 3:Absolutely, and I always say cautious optimism. But it's are gone, but not forgotten it's. We don't. We know it's being sunset. We're not, yeah sure, and I'm frankly not even sure the CMS knows yet what we're going to be looking for. Yeah, I agree, yeah.
Speaker 1:I agree for sure. All right, Katie, let's come over to your crystal ball. And what is your crystal ball saying for hospice landscape?
Speaker 2:Well, definitely agree with Patrick. We're not sure exactly how cloudy and stormy things are going to be, but I definitely think we're kind of looking at hospice warning as opposed to Sailor's delight here. And as you talk about VBID and like you both said, we cannot just say, oh, it's all gone, we don't need to worry about it anymore.
Speaker 2:Cms is focused on value-based care and they're also focused on prior authorization. How exactly hospice fits in there, I think they don't know, and that's why we saw a change in VBID. But thinking about those goals that CMS has with value-based purchasing and prior authorization and where hospice is today, in the recent past, and where there's really you know, you know a flame actually under CMS is related to program integrity. And could some of CMS's goals for value-based purchasing and prior authorization, combined with program integrity, bring something very new to hospices, like a review choice demonstration where they're having a review of the record before payment is made to make sure that this patient is eligible? I think that is a definite possibility and we need to consider what CMS might be doing that's innovative and different than what we've heard about for hospices in the past or what we've even thought was a realm of possibility for hospices in the past, or what we've even thought was a realm of possibility for hospices in the past.
Speaker 1:Yeah, I agree, Katie. I think everything and anything is on the table at this point with the amount of scrutiny that is happening. So, katie, let's stick with you. What is the number one action that you think providers should be taking, like, let's say, right now?
Speaker 2:Right. Well, I think this even relates to kind of what I think is something that will be a challenge for hospices for a while and that is related to the workforce. You know we were seeing some workforce challenges, especially with nursing, prior to the pandemic, and the pandemic has really impacted all of health care. We're seeing vacancy rates in nursing at, you know, 10, 15 percent vacancy rates across all health care providers, upwards of 20, 25 percent. So we know that that will remain a challenge that's going to stay in our landscape and we need to make sure to acknowledge that and figure out how best to deal with that. I think there are some. If we're looking at silver linings, one of the silver linings is that necessity is the father of invention. I think that's how that saying goes and we may see some innovative work that our hospices are doing to address that workforce challenge.
Speaker 2:We've got to continue dealing with the program integrity issues, as we've talked about here. We've got the special focus program. We know that we have the program integrity. All those themes are still going to keep pulling through and while they can't be minimized, they're incredibly important.
Speaker 2:You've got to have folks in your organization who are working on all of those things, and there's a lot to keep your eye on, but what cannot be minimized and, in fact, I think needs to take center stage and I always take this opportunity to remind people of this, and I think, jennifer, you know we've talked about this in some of our other podcasts is that focus on patient care. Absolutely, we absolutely have to make that the center point, and I'm not saying at the expense of all these other things that we've talked about, but you've got to have people in your organization who are championing that focus on patient care and improving quality of care and looking at tools like the HOPE and other tools that are out there. How can we improve the services that we're delivering? And I just think that's a very critical message that we cannot lose.
Speaker 1:Absolutely Katie Patrick. Number one action Absolutely Katie Patrick number one action.
Speaker 3:First off, I agree with Katie 100 percent there. Absolutely Excellent point there. And really that North Star. We need to keep our minds on heads as we move forward through this. Other item I'll mention here is going to be critical, now more than ever, really to be proactive and engaged rather than being reactive. And what I mean by that is actually a couple of things, First of which is it's going to be really important to stay engaged in federal issues, be it congressional, be it regulatory.
Speaker 3:There is a lot happening in the hospice space right now between quality changes, between special focus, program program integrity and otherwise. It's really critical that we are all paying close attention, not just to see what's happening right now, but what's coming down the line and part. One particular component I'd recommend there is, with this rule proposal coming out and obviously this is not the final rule, there may be changes but really HUSP should take a look and understand this HOPE tool and what that's going to mean, how we're going to be measuring, how we're going to be conducting these assessments, because once that's finalized, there are going to be some, I say, challenges and opportunities there to get systems up to date to manage that change In the rule. We also see some significant wage index area changes and among other changes the offices really need to be aware of, because some of those changes could have the impact of changing certain regions' payments For example, your classification from an urban to rural or vice versa, which, if finalized, will have significant implications for payments. We talked earlier about the special focus program.
Speaker 3:Katie talked a bit about the program integrity considerations and these are all things that we really need to be paying close attention to, and I know us policy wonks like to look at these federal rules, and earlier you made the comment, Jennifer, about looking at the Federal Register, and I agree I'm one of those policy nerds there too, but I think it's also important that hospices do the same as well. Another item I'll just mention as part of that piece and I know I'm getting a little long-winded in my response here, Jennifer, so apologies, but part of that engagement, it's important to see where CMS is going and one of the directions that CMS is going is health equity. We know it's one of the agency pillars. We've seen efforts to address disparities and advance equity and various rulemaking proposals and policies throughout the care continuum and as we begin looking at data and looking at how CMS plans to address that within a hospice and productive care lens. To the extent hospices can be part of that conversation, I think it's going to be very critical going forward.
Speaker 1:Yeah, I couldn't agree with you more, patrick, on that.
Speaker 1:In fact, chap is rolling out our health equity standards of excellence later this year because we feel that it is an important, important thing to address and it's extremely timely as well.
Speaker 1:Well, oh my gosh, thank you both for joining me today to give your expert thoughts to our listeners, and I wanted to thank all of you for taking time out of your day to plug into our podcast.
Speaker 1:So, from me and the entire CHAP team, and before I do sign off, there are a couple important things that we would ask you, I think collectively, as Katie, patrick and Jennifer from CHAP today, from chap today, is you know, plug into what knock and nhpco have in terms of their um, their summaries for the final rule that they put out, which are equally excellent um. And also, I know that you will, if you haven't already been, facilitate you will facilitate webinars that produce a summary and an overview for folks to plug into as well. And please, from CHAP, we would love you to leave a review, share the podcast link so that it can make its way to more people who can learn about what is included not only in the hospice rule in proposed format, but what we think the landscape is going to look like in calendar year 2024. And for me and the entire CHAP team, keep your quality needle moving forward, stay safe and well and thanks for all you do. Thank you.
