CHRONIC Bill moves through Finance Committee

Senate Finance Committee recently passed the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017. This legislation is the product of several years of work by the committee to improve care for Medicare beneficiaries with chronic illness, whether they are served by traditional fee-for-service, Medicare Advantage plans, or Accountable Care Organizations.

What is most notable for the hospice community is not what’s in the bill, but what is not. Early drafts of this legislative package included a proposal to carve hospice in under the Medicare Advantage program. Thanks to the advocacy efforts of the hospice community, the committee opted not to include a hospice MA carve-in in this legislation.

The bill does, however, include a range of policies aimed at increasing home based care, advancing team based care, expanding innovation and technology, better identifying the chronically ill population, and empowering individuals and caregivers in care delivery. Many provisions in the bill are relevant to distinct provider groups and patient populations, such as ESRD patients or telehealth providers. Others, however, may be of particular interest to hospice and palliative care providers, including provisions that:

  • Extend the Independence at Home program, a physician and nurse-based model that allows seniors with multiple, complex, chronic conditions to receive specialized care at home from a team of providers. Some hospice and palliative care programs have developed relationships with IAH programs.
  • Allow an MA plan to offer a wider array of supplemental benefits to chronically ill enrollees. These supplemental benefits would be required to have a reasonable expectation of improving or maintaining the health or overall function of the chronically-ill enrollee and would not be limited to primarily health related services. This could be an opportunity for providers to work with MA plans to offer community based palliative care services.
  • Require the Government Accountability Office (GAO) to submit a report to Congress to facilitate a comprehensive plan of longitudinal care for a Medicare beneficiary diagnosed with a serious or life-threatening illness. GAO would study the extent to which such services are currently provided to beneficiaries, whether there would be any duplication with existing benefits, and any barriers to hospitals, skilled nursing facilities, hospice programs, home health agencies and other providers working with a Medicare beneficiary to engage in the care planning process. NHPCO would be sure to work with GAO on this important report.

While the Finance Committee passed the bill with unanimous approval, it is unclear whether the bill will find its way to the Senate floor in the near term. Senator Hatch has made clear his intent to keep the bill separate from other bills to repeal and replace the Affordable Care Act. As such, it could take some time for this bill to move through the process. NHPCO and HAN will be sure to carefully monitor and keep our members apprised about the progress of this legislation.

Questions? Comments? Contact the HAN team at

They’re baaaaaack! Week one of the 115th Congress

The 115th Congress was sworn in this past Tuesday and immediately started causing trouble. The first thing the House of Representatives did was take up a rules package that included a provision to gut the Office of Congressional Ethics. Following a campaign season that promised to “Drain the Swamp,” this was an interesting choice for a first vote.

(Photo by Chip Somodevilla/Getty Images)

Needless to say, social media erupted on Tuesday, and thousands of Americans overloaded the Capitol switchboard and servers to complain about the proposed rule. President-elect Trump turned up the heat when he tweeted, “With all that Congress has to work on, do they really have to make the weakening of the Independent Ethics Watchdog, as unfair as it.” Facing the mounting pressure, House Republicans scuttled the proposed rule change, promising to revisit it later, possibly in cooperation with House Democrats.

So why is this important to the hospice community? Well, if nothing else, it demonstrates the importance of paying close attention to the legislative process, and the power that voters can have when they organize and mobilize. In the years before the interwebs, this type of change likely would have slid by, unnoticed by most Americans. You have a voice, you have a mouse, and you have a platform – you can use them to great effect, especially for the hospice community.

So what else have we been up to? Well, the HAN team put out our  What to Expect in 2017 Policy Points Video, prognosticating on what we think will happen over the next few months. A good amount of speculation, but hopefully some good information for you to tuck away. Take the 7 minutes to listen – we think it’ll be worth your time.

We also recently sent a letter to President-elect Trump, introducing him to our community and our key policy priorities. It is a broad-brush overview, but we plan to dive in to the details with his team as they settle into their new positions over the coming months. You can read it here. 

So that’s about it for now. Check back regularly, as we will be posting more about the Trump Administration as we near Inauguration Day and as he assumes the Presidency.

Carrier Pigeons, Red Tape and the Million Dollar Typo.

This past Friday, the HAN team and the NHPCO regulatory team met with CMS leadership to talk about problems that hospices are experiencing with the Notice of Election/Notice of Termination/Revocation (NOD/NOTR) process.

For those just tuning in, a quick recap: hospices must submit an NOE, and have that NOE accepted by the MAC within five days of a patient’s hospice election. The NOE essentially flags that patient in CMS’ common working file, and notifies hospitals, DME providers, and other providers that the patient has elected hospice. By notifying these providers in a timely manner,  unwanted, unnecessary, or costly care is ideally avoided. If an NOE is not submitted and accepted within five days, hospices don’t get paid for those days of care.  So getting those NOEs in on time is a big deal.

cms-august-2016-2Now NOEs are filled out by humans, and humans sometimes make mistakes – like misspelling the patient’s name, or putting the wrong admit date on the form. Unfortunately, CMS has no system for correcting an NOE once it is submitted.  And in many cases, the hospice might not even know there’s a problem until the NOE gets returned from the MAC, sometimes weeks later.

Bored yet?  Confused?  I don’t blame you.  But this is important.  According to a recent NHPCO survey, this policy is costing hospices as much as $20 million.  As one hospice put it, “We lost $100,000 because of this system.  In my area, that’s enough to pay an extra social worker, RN or  two full-time hospice aides.” Long story short, this stuff matters.

Hence, our recent trips up to Baltimore and again to the Humphrey Building this past Friday.  The good news is that CMS was pretty receptive to our concerns, and even brainstormed some potential policy changes while we were there.  The bad news? Well, CMS has some pretty arcane computer systems (I think I saw a carrier pigeon on my way out the door), bureaucracies are not known for their efficiency, and to further complicate things, there’s a Presidential election underway (for those who may not have noticed) meaning that there will be at least some turnover at the senior leadership level at CMS in the next couple months.

That said, we will keep working with CMS to try to find workable solutions to this issue, and to ensure that hospices are not penalized for honest, typographical mistakes.  Stay tuned to this blog for additional updates.

Have you had problems with NOE/NOTR? Let us know in the comments!

Spending at EOL declines with age. Well, duh.

We read a lot of studies here at HAN, and one from the Kaiser Family Foundation crossed my desk this morning titled, “Spending at the End of Life declines with Age.” Of course anything with “end-of-life” in the title is going to get my attention, but what really struck me about this particular article was the reporter’s comment that its findings were “counterintuitive. . . given that the conventional wisdom is that Medicare end-of-life spending is concentrated on its oldest beneficiaries”

But to us, it made perfect sense.  For some reason – maybe it’s the wisdom of the aged – folks in their 80s and 90s seem more willing to ask the question, “What does this treatment mean for me,” and “Would I really forgo quality of life for a few more weeks?”  These questions are either easier to ask – or easier to answer — when you’ve reached your 8th and 9th decade.

In any event, the study was chock-full of interesting tidbits, including the following graph, which determined that spending at end-of-life has declined in recent years.  I know that correlation doesn’t equal causation, but there’s probably at least some connection between this trend and the hospice growth of the 2000s.

Figure 3: The share of total traditional Medicare spending on traditional Medicare beneficiaries who died at some point in the year has declined over time

I also found it interesting that we’re still spending 51% of Medicare dollars on inpatient stays in the last year of life. Unfortunately, the study only breaks it down by decedent/survivor, but does not break down hospice v. non-hospice decedents.  I suspect we’d see significantly lower costs in all categories for hospice decedents.

That all said, I was a political science/theater major, so statistics is not my strong suit. Some of you research braniacs might glean even more from this.  See anything interesting?  Let us know in the comments.

“Assessing Progress in End-of-Life and Serious Illness Care.”


This week, the National Academy of Medicine (NAM) held a meeting on “Assessing Progress in End-of-Life and Serious Illness Care.” The event explored the progress made since the 2014  publication of Dying in America, a comprehensive report about the quality, availability and benefits of comprehensive, patient-centered care for individuals with advanced and serious illness.

At this week’s meeting, dozens of health care leaders, policymakers, consumer organizations, medical societies, and others dissected how much progress has been made in the areas of person-centered care; communication and advance care planning; professional education and development; policy payment reforms; and public education and engagement.

In general, panelists and participants agreed that we’ve made significant progress on many of these issues.  CMMI Director Patrick Conway highlighted CMS’ recent decision to allow physicians to bill for advance care planning services as one area of growth, and also discussed the Medicare Care Choices Model demonstration, which allows hospice-eligible individuals to access both conventional treatment and palliative care.  Other speakers pointed to progress on consumer education and engagement, as well as provider training, but reiterated that much work remains to be done.

For our part, NHPCO continues to support the recommendations of Dying in America, and has put particular emphasis on the need for better advance care planning and concurrent care (notably through our work on the Care Planning Act and the MCCM demonstration), as well as consumer engagement and outreach (through our Moments of Life campaign, We Honor Veterans, and our partnerships to reach out to historically under-served communities).