Literature Review

CMS memo hints at what hospices can expect under Special Focus ProgramMcKnight's Home Care; by Adam Healy; 10/8/24Hospices subjected to Special Focus Program (SFP) scrutiny will undergo frequent surveys, and noncompliant providers may face termination from the Medicare program, according to the Centers for Medicare & Medicaid Services. Under the SFP, hospices will receive surveys no less than every six months, and follow-ups may be needed, CMS said in a memo to state hospice survey agencies. Hospices that are found to have condition-level deficiencies will be required to complete appropriate enforcement remedies, which include suspension of payment, civil money penalties, directed plans of correction, directed in-service training or termination, according to CMS’ state operations manual. Hospices that have completed two SFP surveys within 18 months, have zero uncorrected condition-level deficiencies and zero pending immediate jeopardy or condition-level complaints may graduate from the SFP, CMS said. However, any hospice that does not comply with all of CMS’ requirements within the necessary timeframes may be considered for termination.

Medicare Advantage is 'jeopardizing' rural hospitals, execs sayBecker's Hospital CFO Report; by Alan Condon; 10/2/24Medicare Advantage is "failing patients" and "jeopardizing" Nebraska hospitals, according to a survey of 92 member hospitals from the Nebraska Hospital Association. MA provides health coverage to more than 55% of the nation's older adults, about 33.8 million people, but some hospitals and health systems are ending their contracts with MA plans over administrative challenges that include excessive prior authorization denial rates and slow payments from insurers. "Medicare Advantage challenges the future of critical access hospitals due to lower reimbursement rates, slower or denied payments, and increased administrative burdens," Jed Hansen, executive director of the Nebraska Rural Health Association, said during an Oct. 2 virtual meeting with hospital leaders. "Without changes to MA, our rural hospitals may be forced to cut staff and services, further harming patient care. Over time, some of our rural hospitals may be forced to close altogether."

Medicare Advantage Value-Based Insurance Design Model Calendar Year 2025 Model Participation CMS Newsroom; Fact Sheet; 9/27/24 The Centers for Medicare & Medicaid Services (CMS) is announcing the Calendar Year (CY) 2025 participants in the Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model. As part of the VBID Model, MA plans offer additional supplemental benefits and/or reduced cost sharing (in some cases to zero). MA plans participating in the VBID Model may also use reward and incentive programs. ... For CY 2025, the VBID Model has 62 participating Medicare Advantage Organizations (MAOs) testing the model in 48 states, D.C., and Puerto Rico through 967 plan benefit packages (PBPs). All 62 participating MAOs prepared Health Equity Plans on how they will address potential inequities and disparities in access, outcomes, and/or enrollee experience of care as it relates to their participation in the VBID Model. 

HopeHealth CMO: Hospice rules for ‘unrelated care’ getting stricter Hospice News; by Jim Parker; 9/25/24 Dr. Ed Martin began working in hospice in 1987 after hearing families talk about their experiences with those services. Today, he is chief medical officer of Rhode Island-based HopeHealth. The more than 50-year-old nonprofit organization also serves parts of Massachusetts. Martin recently spoke about the complicated issue of care that is deemed “unrelated” to a patient’s terminal diagnosis at the National Hospice and Palliative Care Organization’s Annual Leadership Conference in Denver. Hospice News sat down with Martin at the conference to discuss how he and his organization are addressing the matter of unrelated care, as well as the efficacy of requirements for an addendum to the election statement. [Click on the title's link to continue reading this interview.]

CMS: Kidney Care Choices Model boosted home-based dialysis, but more data needed Hospice News; by Holly Vossel; 9/23/24 The Center for Medicare & Medicaid Innovation’s (CMMI) Kidney Care Choices (KCC) Model demonstration has increased utilization of dialysis in the home and has fostered greater clinician training in addressing related conditions. However, more time and data are needed to evaluate the reimbursement model’s impact on quality and cost, according to the first annual model evaluation report from the U.S. Centers for Medicare & Medicaid Services (CMS). The report includes the agency’s analysis of KCC model results during the first performance year since its launch on Jan. 1, 2022. Having this reimbursement path available could ease pressures for palliative care patients making decisions about their serious illness care options.

East Lansing caregiver sentenced for role in freezing death of elderly womanOIG press release; 9/17/24Colleen Kelly O’Connor, 58, of East Lansing, was sentenced to two years of probation with the first 6-months in jail by Judge Cori E. Barkman of the 29th Circuit Court in Clinton County for her role in the death of an 82-year-old woman in December 2022, announced Michigan Attorney General Dana Nessel. O’Conner was convicted in June by a Clinton County jury of one count of Vulnerable Adult Abuse — Second Degree. The victim, who was under O’Connor’s care at Vista Springs Imperial Park at Timber Ridge, an assisted living facility in Clinton County, died of exposure after being left unsupervised. O’Connor was also ordered to pay $1,115.00 in restitution to the daughter of the victim... During the very early morning hours of December 23, 2022, O’Connor twice observed the victim attempt to go outside without appropriate attire into a blizzard with single-digit temperatures, subzero windchill, and blowing and drifting snow. As a caregiver, O’Connor recklessly failed to act to prevent the victim from going outdoors into the storm, resulting in her death. A snowplow driver found the victim in the parking lot around 7 a.m., partially buried in snow.

Maryland to drop Kaiser as Medicaid administrator Becker's Hospital CFO Report; by Jakob Emerson; 9/23/24 Maryland will drop Kaiser Permanente as a Medicaid managed care organization in 2025. "After some lengthy contract negotiations, the [Maryland] Department of Health has elected not to enter into a contract with Kaiser and we are working to ensure a seamless transition of those enrollees to other health plans," MDH's deputy secretary of healthcare finance, told local radio station WYPR on Sept. 20. ... "If we are not able to participate in Medicaid, it would interrupt the highest-rated care and coverage of our more than 113,000 Medicaid members in Maryland in 2025," a spokesperson for Kaiser told Becker's. "We will continue to work with the Maryland Department of Health so we can continue serving this community for decades to come." According to WYPR, the state will renew its existing managed care contracts, which includes Aetna, CareFirst BCBS, UnitedHealthcare, Elevance Health's Wellpoint, Jai Medical Systems, Maryland Physicians Care, MedStar Family Choice and Priority Partners.

New revised Medicaid Fraud Control Unit performance standardsOIG press release on X; 9/19/24HHS-OIG published revised Medicaid Fraud Control Unit (MFCU) performance standards. The standards provide helpful guidance to MFCUs in their operations and assist HHS-OIG in overseeing MFCUs. Read the performance standards here: https://direc.to/fj2o. 

Most frequent CMS citations in 2024 Becker's Clinical Leadership; by Paige Twenter; 9/19/24 Similar to 2023, hospitals are most frequently cited for deficiencies in patient rights, according to CMS data obtained by Becker's.  So far this year, CMS accrediting agencies have conducted nearly 2,760 surveys at U.S. hospitals. Of those surveys, more than 6% have resulted in a citation over a patient's right to receive care in a safe setting. Here are the 25 most common citations as of Sept. 15, according to data from CMS' Quality and Certification Oversight Reports: 

What are the Medicare respite care guidelines? Medical News Today; by Amy McLean; 9/18/24 Medicare Part A and Medicare Advantage may cover respite care as part of hospice care coverage. A person will usually need to pay 5% of the Medicare-approved amount for respite care. Respite care allows the carer to take a short amount of time off from caring for an individual. If the Medicare beneficiary spends this time in a medical facility, Medicare will likely cover the cost of the stay. [Click on the title's link to read on] ... to learn more about Medicare coverage for respite care, including what it means and what costs may be involved.

CMS submits 75,000 pages to federal court to justify nursing home staffing mandate McKnights Long-Term Care News; by Kimberly Marselas; 9/15/24 The Department of Health and Human Services filed more than 75,000 pages of rule-making records with a federal court Friday, beginning its formal defense of its controversial nursing home staffing mandate. The submission of the administrative record is the first significant advance in the case since the American Health Care Association brought its challenge to the minimum staffing standard in late May. The Texas Health Care Association, three Texas providers and LeadingAge are also part of the case. In another development, District Court for the Northern District of Texas Judge Matthew Kacsmaryk on Sept. 10 agreed to fold in a separate federal challenge against the staffing mandate filed by the state of Texas. He noted that the two cases “share common questions of law or fact, consist of similar parties, the same claims, and [have] the same relief sought.”

More home health providers sunset relationships with largest Medicare Advantage players Home Health Care News; by Andrew Donlan; 9/13/24 Essentia Health--a regional nonprofit health system with a substantial home health arm--announced this week that it will no longer serve as an in-network provider for UnitedHealth Group. ... Dr. Cathy Cantor, Essentia’s chief medical officer for population health, said in a statement ... “The frequent denials and associated delays negatively impact our ability to provide the timely and appropriate care our patients deserve. This is the right thing to do for the people we are honored to serve.” Headquartered in Duluth [MN], Essentia Health provides care across Minnesota, Wisconsin and North Dakota. Its network includes about 15,000 employees, 14 hospitals, 78 clinics, six long-term care facilities, six assisted living and independent living facilities, and much more. It also has a robust home health and hospice business. The company has informed patients that it will no longer serve as an in-network provider for the above-mentioned MA payers beginning Jan. 1. ... Sanford Health, a health system based in Sioux Falls, South Dakota, announced a similar plan this week. 

Medicare Advantage bonus payments decline for first time since 2015Becker's Payer Issues; by Rylee Wilson; 9/11/24Bonus payments to Medicare Advantage plans will decline by around 8% in 2024 compared to 2023, according to a report from KFF. The analysis, published Sept. 11, found bonus payments to MA plans will decline by around $1 billion to $11.8 billion in 2024. Although this was the first decline since 2015, the $11.8 billion in payments will still exceed amounts for every year from 2015 to 2022. The number of bonus payments will decline because of temporary policies in place during the COVID-19 pandemic increased star ratings for some plans, according to KFF. When the policies ended, some plans took a hit in bonus payments. CMS pays Medicare Advantage plans bonus payments for achieving a star rating of four or higher.