Summary of Public Comments Responses RD 8-7

CMS Response to Public Comments Received for CMS-10390

The Centers for Medicare and Medicaid Services (CMS) received comments related to CMS- 10390 from a hospice provider and a state association for hospice and palliative care. This is the reconciliation of the comments.

Comment:

The Centers for Medicare and Medicaid Services (CMS) received comment from a hospice provider recommending that the on-line entry site be structured similar to the voluntary reporting design to allow for revision of entered data before submission.

The commenter also recommended that, before any additional hospice quality measures are implemented, the administrative burden of collecting and reporting/submitting data be tested against reality in a group of varied hospices. This would be the most effective manner of gaining insight into the true burden for providers.

Response:

CMS appreciates the suggestions and recommendations made by this commenter.

The Hospice web-based data entry tool does provide the capability for the user to enter, save and edit data prior to submitting the NQF #0209 data and the Structural Measure data to CMS. 

CMS agrees that it is important to understand the burden to providers. The burden calculations presented in the PRA package are based on estimates obtained from over 900 hospices during the voluntary reporting period. As a result of the burden estimates obtained during the voluntary reporting period, CMS made changes to reduce burden for the first year of required reporting. CMS will continue to use results of testing for future burden estimates. A study with varied hospices from around the country is currently underway and will yield valuable burden information. CMS will consider the results of this study to inform decisions about quality measures currently under consideration for implementation as part of the Hospice Quality Reporting Program.

Comment:

The Centers for Medicare and Medicaid Services (CMS) received comment from a state association for hospice and palliative care supporting the creation of the Hospice Quality Reporting Program as well as the two quality measures to be reported, but expressing concern that CMS has greatly underestimated the time and cost needed to complete the quality reporting requirements.

• The commenter references EMRs in their comment and expresses concern that many hospices in their state cannot afford EMR systems and that the time estimates and associated costs will increase greatly if a hospice does not have or cannot fully utilize EMRs to gather and submit quality data to CMS.

• The commenter expresses the belief that CMS has underestimated the time associated with staff training and are concerned that education to staff and the cost of ongoing auditing and re-education to staff to ensure appropriate and accurate reporting will drive up the costs.

• The commenter states that not all hospices in the state have the specific jobs noted by CMS and that the jobs CMS listed and the related costs for performing those duties will fall to other hospice staff, potentially adding additional time and costs.

• The commenter also expressed concern that part of the burden to complying with the Quality Reporting Program is following-up with patients in a timely manner to ensure that a beneficiary’s pain is under control, stating that this follow-up may require additional visits to try new ways to address the pain, which may add additional costs and time not accounted for in CMS’ estimates.

Response:

CMS appreciates concern expressed by this commenter but disagrees with the comment that the CMS-10390 underestimates the burdens imposed on hospice providers.

CMS does not suggest the use of EMRs to collect the data required for either of the hospice quality measures nor did CMS use data collection by EMR systems in the burden calculations. The burden calculations for the first year of reporting were based in part on the experiences of over 900 hospices that reported Structural Measure/QAPI data during the Voluntary Reporting Period. Those hospices represented a wide variety of hospices with varying characteristics including size and use of EMRs versus paper charts. In establishing that burden estimate, CMS used data from hospices regarding the time it took them to complete the reporting. As a result of the burden estimates obtained during the voluntary reporting period, CMS made changes to reduce burden for the first year of required reporting.

The NQF #0209 was not collected during the Voluntary Reporting Period. The burden estimate for this measure was based in part on self-report data shared by a group of hospices with varying characteristics all of whom already were collecting and using the NQF #0209 measure.

In calculating burden, CMS did consider time spent training staff who will enter and submit the data as well as time spent learning from the User Guides. These estimates were based on the experience of over 900 hospices that participated in the voluntary reporting of the structural measure as well as the self report of hospices already using the NQF # 0209 measure.

It is true that not all hospices have the same staffing pattern as that displayed in the PRA package, and there will be variations in the level of burden as a result. To the extent possible, these variations were already taken into consideration when the burden estimate was produced. Assumptions made in a burden calculation may or may not exactly represent all of the many variations of hospice provider organizations nationwide. For instance, the use of office support volunteers was not considered ion the burden calculation. CMS will use information about burden during the first year of reporting to inform decisions for the second year of reporting.

Finally, the requirements of reporting the NQF #0209 measure should not interfere with best practices in pain management provided by hospices. Even in the absence of the NQF #0209 requirement, hospices should be providing individualized pain management for each of its patients. This could require intensive follow-up for patients with hard-to-treat pain, and is part of the expected effort a hospice would make to relieve pain and suffering for all patients. Therefore, collecting the NQF #0209 would not add burden to the clinical care processes the hospice would already be providing for patients experiencing pain. Further, the NQF #0209 measure does not require that the follow-up question be asked during an in-person visit; it may be asked over the phone. The NQF #0209 measure does not require that the follow-up question be asked by a nurse.

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