Hospice have been mindful of happenings in the nation’s capital in recent weeks as federal agencies prepare extensive revisions to survey and regulatory enforcement processes, a vaccine mandate for health care workers and the release of additional Provider Relief Funds.
The U.S. Centers for Medicare & Medicaid Services (CMS) inserted provisions into the Fiscal Year 2022 proposed rule for home health agencies, pursuant to the HOSPICE Act. If made final, the new regulations would require multidisciplinary survey teams, prohibit surveyor conflicts of interest and update the surveyor training process. The rule would also create a Special Focus Program (SFP) with the power to impose enforcement remedies against hospices with poor survey performance.
Accreditors would also have to require their surveyors to undergo the same training programs as those affiliated with Medicare state agencies, which would be updated if this rule were made final. The new training program would emphasize quality of care, according to CMS.
The White House also recently announced that COVID-19 vaccines would be mandatory for health care workers. While many providers hailed this decision as a critical step to protect their employees, patients and families, they also worry about potential turnover or associated costs.
Hospice News sat down with National Hospice & Palliative Care Organization (NHPCO) President and CEO Edo Banach to discuss these initiatives.
NHPCO in its comments on the proposed rule encouraged CMS to consider a matrix approach to the SFP to avoid placing undue weight on any one citation. What would such an approach look like?
It’s important to sort of understand the evolution here. This stems from a report that the [U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG)] and subsequent legislation that we worked on collaboratively with Congress, the HOSPICE Act. We don’t want to set up a system where providers essentially have a “gotcha” relationship with their surveyors, so that any single citation could lead to an inability to continue participating in the Medicare program. As written, the rules read that way. There is a suspension of payments, potentially, for any violation.
We’re recommending a suspension of payments only for new admissions, and only as a last resort, when the hospice has an Immediate Jeopardy finding. Immediate Jeopardy is really severe. This is an entity that really shouldn’t be participating, but most violations aren’t of that nature. We want to make sure that there is an ability for the hospice to work with a surveyor to address whatever it is they feel is a concern without necessarily shutting down the whole operation.
That would essentially align the hospice oversight regime with those for nursing homes, home health and everything else. We don’t want to go further than that. We should all be aligned.
Regarding NHPCO’s support for the provisions related to surveyor training, are there particular areas on which some of this training should focus?
It’s important that the surveyors are consistently trained. There are some surveyors that work for accrediting organizations, and there are some surveyors that work for the various state agencies. Right now, there is a vast difference between surveyors that work for different state agencies or accreditors. What we’re seeking to do, especially for providers that work in multiple states, is provide a little more consistency when it comes to the oversight that they can expect anywhere that they do business.
Revised training would be to level the playing field with regard to the responsibilities of the surveyors. The OIG report was not simply saying to give providers a slap on the wrist. OIG was actually saying we’ve got a problem with respect to CMS, the oversight of hospice and the contractors carrying out the Conditions of Participation. The problem is not simply provider behavior. The problem is also oversight.
[The HOSPICE Act] and subsequently this rule seeks to create that level playing field among the various states and accreditors so that providers — and at the end of the day, consumers — know what they can expect.
CMS had proposed a subset of the hospices would be selected to participate in the SFP. Based on state priorities, what are some of your concerns about that language?
We’re talking about a federal program with federal Conditions of Participation, what we’re going for is consistency between the various states. Sometimes this is also overseen not by a state, but by The Joint Commission or a different accreditation organization. We have an issue with anything that would cause there to be inconsistency and lack of clarity for both the providers and for the consumers.
We have recommended establishing a Technical Expert Panel (TEP) to discuss the hospice Special Focus Program. This is something that has very important implications. The TEP would be responsible for working with CMS on the continued rollout of the hospice SFP, and also consumer-facing survey deficiency reports. There has to be a way for the provider community and for the consumers to provide feedback to CMS in some organized way. That’s what the TEP would do.
Turning to the vaccine mandate, do you foresee challenges for providers in terms of implementation?
We are concerned about providers’ ability to find sufficient staff. This is a problem that we’re seeing across our sector. Actually, a lot of sectors across the nation are seeing this. Some of that does have to do with vaccine hesitancy and concerns about taking the vaccine.
We are attuned to and concerned about the impact of any vaccine mandates on providers and staff. We have been watching over the last year-and-a-half situations where individuals who are not vaccinated are spreading disease to other people. We believe that there is a public health imperative to make sure that people who serve folks, especially in the home, are not spreading disease from one home to the other. We’ve felt that as much as we’re concerned about providers.
We could not support any policy that would potentially spread disease from home to home. That said, we have been very clear with the administration about the fact that any mandate would have to come along with additional Provider Relief Funds. We were instrumental in getting a billion dollars of funding for the hospice sector in the CARES Act, and any vaccine requirement would have to come along with additional support. It does cost money, and it could cost even more to make sure that we can stem the loss of individuals who work for our members.
How costly are these vaccine programs for hospices?
It’s unclear, and it depends on what you call costly. First of all, it’s quite clear that providers are finding themselves having to provide bonuses and additional payments to their staff in order to retain them. This is a very trying time.
Second, there are additional costs for hospices during the pandemic, the [personal protective equipment (PPE)] costs, the home testing costs, and just the compliance costs, including compliance with Provider Relief Funds. Those all have to be built into the cost of doing business. It’s not simply the direct impact of a vaccine mandate.
There’s also a cost in having individuals who are not vaccinated get sick, because what we’re talking about here are mostly self-insured employers who are paying for the cost of any illness that their employees might have. It’s one of the reasons why we at NHPCO also have a vaccine mandate for folks who work here.
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