PRMR Final MUC Recommendation Spreadsheet

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people affected by serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

We appreciate the intent of this measure to capture the family and caregiver experience of end of life for their loved one. Yet, there are some inherent questions and challenges within this measure that have yet to be addressed.

First, the mode of survey delivery continues to be redundant and antiquated. While telephonic and mail surveys were the center point in the past, yet most consumer families and caregivers are now internet-literate and prefer this mode to any other mode of communication. It is unclear what the intent and timeline will be for delivery of the survey through the online mode. Secondly, while there is an adjustment that is integrated in the methodology for case-mix, yet the time lag also depends on factors like survey receipt, bereavement impact and certain pother variable that are not factored into the case-mix adjustment calculation. Thirdly, we recognize that the primary common diagnosis amongst hospice patients has undergone a shift in the past few years, due to COVID-19 impact and pother population based factors. We seek clarification as to how the shift in primary terminal diagnoses will impact predictive ability of measure scores. Finally, the complex (and sometimes compound) language of the survey instrument renders lack of interest for response. Would suggest clarification as to how health literacy principles have been factored into development of the update survey measure. We invite the measure developers to address prior comments provided related to the currently existing family and caregiver survey during development of new measures.

In the description of the proposed measures, the CAHPS® Hospice survey is described as a 39-item questionnaire while currently the CAHPS® Hospice survey is a 47-item questionnaire.  I recommend that we support the reduction in CAHPS® survey items, as this has been a frequent request from our members.  In comments received, one member reported that the current survey is “too long and hard for the caregiver to assess” and should be “shortened and to the point.”  Another stated that “the survey has too many questions.” 

There is not currently a Care Preferences domain included in the CAHPS® survey. We suggest the inclusion of these two items, which would provide important data to hospice organizations on their teams ability to meet patient needs and preferences.

NHPCO appreciates the opportunity to provide comments and brings forward challenges and ideas that include hospice provider feedback.

The Defeat Malnutrition Today coalition appreciates the opportunity to submit a comment in support of the proposal to adopt the Global Malnutrition Composite Score (GMCS) for all adults ages 18 or older in the FY2023 MUC List (MUC2023-114).

We commend CMS for considering for inclusion in its payment programs the Global Malnutrition Composite Score for all adults ages 18 or older (MUC2023-114), which is a publicly supported measure that benefits patients, families, and caregivers across all demographic groups—as well as the healthcare system at large. This is a great opportunity to be more inclusive and identify malnutrition and food insecurity earlier. 

In its recent committee meeting, the Pre-Rulemaking Review (PRMR) committee identified areas for consideration with corresponding conditions for expansion of the GMCS to include all adults ages 18 and over, including increase involvement of more patient groups in further work in this measure. Defeat Malnutrition Today is a coalition of over 120 members, committed to defeating older adult malnutrition across the continuum of care. We speak for a diverse alliance of stakeholders and organizations, including caregiver and patient groups such as the National Alliance for Caregiving, Caregiver Action Network, SAGE - Services and Advocacy for GLBT Elders, and Alzheimer’s Foundation of America. We can speak to engagement of groups like our members the National Hispanic Council on Aging, The National Caucus and Center on Black Aging, and the National Indian Council on Aging. We had opportunities to engage as the initial measure was developed and discuss the measure with our members.

As we previously commented, research showing the importance of identifying, diagnosing, and treating malnutrition at all ages continues to grow and early identification of malnutrition can allow for healthy aging. Further, the relationship between malnutrition and food insecurity and its effects on health equity has been proven to be of importance and continues to be studied. The GMCS mirrors the well-established clinical workflows of RDNs in the provision of malnutrition care to adults in the acute care setting, and this measure captures data on the high-quality malnutrition care already being provided by RDNs. Most hospital inpatient screening policies include rescreening if the initial screen is negative for malnutrition risk to capture those who may hospital-acquired malnutrition. The existing GMCS eCQM for 65+ was one of the first quality reporting programs focused on nutrition care or malnutrition performance measures It has been extensively tested and shown that adopting evidence-based malnutrition care best practices is associated with reduced costs and improved patient outcomes.

We fully support CMS including this measure in the 2024 Hospital Inpatient Quality Reporting Program, given the overarching burden that malnutrition has on patients and the healthcare system. Thank you for considering our comments. Please let us know if we can provide you with any further information. You may reach me at [email protected]

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people affected by serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

We appreciate the intent of this measure to capture the family and caregiver experience of end of life for their loved one. Yet, there are some inherent questions and challenges within this measure that have yet to be addressed.

First, the mode of survey delivery continues to be redundant and antiquated. While telephonic and mail surveys were the center point in the past, yet most consumer families and caregivers are now internet-literate and prefer this mode to any other mode of communication. It is unclear what the intent and timeline will be for delivery of the survey through the online mode. Secondly, while there is an adjustment that is integrated in the methodology for case-mix, yet the time lag also depends on factors like survey receipt, bereavement impact and certain pother variable that are not factored into the case-mix adjustment calculation. Thirdly, we recognize that the primary common diagnosis amongst hospice patients has undergone a shift in the past few years, due to COVID-19 impact and pother population based factors. We seek clarification as to how the shift in primary terminal diagnoses will impact predictive ability of measure scores. Finally, the complex (and sometimes compound) language of the survey instrument renders lack of interest for response. Would suggest clarification as to how health literacy principles have been factored into development of the update survey measure. We invite the measure developers to address prior comments provided related to the currently existing family and caregiver survey during development of new measures.

In the description of the proposed measures, the CAHPS® Hospice survey is described as a 39-item questionnaire while currently the CAHPS® Hospice survey is a 47-item questionnaire.  I recommend that we support the reduction in CAHPS® survey items, as this has been a frequent request from our members.  In comments received, one member reported that the current survey is “too long and hard for the caregiver to assess” and should be “shortened and to the point.”  Another stated that “the survey has too many questions.” 

MUC List Measure

Care Setting

PAC-LTC Committee

PAC-LTC Measures

CAHPS Hospice Survey Hospice Team Communication

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people affected by serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

We appreciate the intent of this measure to capture the family and caregiver experience of end of life for their loved one. Yet, there are some inherent questions and challenges within this measure that have yet to be addressed.

First, the mode of survey delivery continues to be redundant and antiquated. While telephonic and mail surveys were the center point in the past, yet most consumer families and caregivers are now internet-literate and prefer this mode to any other mode of communication. It is unclear what the intent and timeline will be for delivery of the survey through the online mode. Secondly, while there is an adjustment that is integrated in the methodology for case-mix, yet the time lag also depends on factors like survey receipt, bereavement impact and certain pother variable that are not factored into the case-mix adjustment calculation. Thirdly, we recognize that the primary common diagnosis amongst hospice patients has undergone a shift in the past few years, due to COVID-19 impact and pother population based factors. We seek clarification as to how the shift in primary terminal diagnoses will impact predictive ability of measure scores. Finally, the complex (and sometimes compound) language of the survey instrument renders lack of interest for response. Would suggest clarification as to how health literacy principles have been factored into development of the update survey measure. We invite the measure developers to address prior comments provided related to the currently existing family and caregiver survey during development of new measures.

In the description of the proposed measures, the CAHPS® Hospice survey is described as a 39-item questionnaire while currently the CAHPS® Hospice survey is a 47-item questionnaire.  I recommend that we support the reduction in CAHPS® survey items, as this has been a frequent request from our members.  In comments received, one member reported that the current survey is “too long and hard for the caregiver to assess” and should be “shortened and to the point.”  Another stated that “the survey has too many questions.” 

If the intent of the proposed measure is that this item would replace the five existing CAHPS® Hospice Care Training items, then we recommend its inclusion. This revision eliminates the word “training” and replaces it with “teach,” which has been a frequent recommendation from provider organizations. In comments received, it was indicated that CAHPS® training questions routinely score lower than national averages despite extensive staff education, which may be due to the use of the word training itself. Hospice caregivers often mistake “training” for formal education, and do not understand that it can refer to any teaching provided by the hospice team.

NHPCO appreciates the opportunity to provide comments and brings forward challenges and ideas that include hospice provider feedback.

MUC List Measure

Care Setting

PAC-LTC Committee

PAC-LTC Measures

CAHPS Hospice Survey Hospice Team Communication

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people affected by serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

We appreciate the intent of this measure to capture the family and caregiver experience of end of life for their loved one. Yet, there are some inherent questions and challenges within this measure that have yet to be addressed.

First, the mode of survey delivery continues to be redundant and antiquated. While telephonic and mail surveys were the center point in the past, yet most consumer families and caregivers are now internet-literate and prefer this mode to any other mode of communication. It is unclear what the intent and timeline will be for delivery of the survey through the online mode. Secondly, while there is an adjustment that is integrated in the methodology for case-mix, yet the time lag also depends on factors like survey receipt, bereavement impact and certain pother variable that are not factored into the case-mix adjustment calculation. Thirdly, we recognize that the primary common diagnosis amongst hospice patients has undergone a shift in the past few years, due to COVID-19 impact and pother population based factors. We seek clarification as to how the shift in primary terminal diagnoses will impact predictive ability of measure scores. Finally, the complex (and sometimes compound) language of the survey instrument renders lack of interest for response. Would suggest clarification as to how health literacy principles have been factored into development of the update survey measure. We invite the measure developers to address prior comments provided related to the currently existing family and caregiver survey during development of new measures.

In the description of the proposed measures, the CAHPS® Hospice survey is described as a 39-item questionnaire while currently the CAHPS® Hospice survey is a 47-item questionnaire.  I recommend that we support the reduction in CAHPS® survey items, as this has been a frequent request from our members.  In comments received, one member reported that the current survey is “too long and hard for the caregiver to assess” and should be “shortened and to the point.”  Another stated that “the survey has too many questions.” 

If the intent of the proposed measure is that this item would replace the five existing CAHPS® Hospice Care Training items, then we recommend its inclusion. This revision eliminates the word “training” and replaces it with “teach,” which has been a frequent recommendation from provider organizations. In comments received, it was indicated that CAHPS® training questions routinely score lower than national averages despite extensive staff education, which may be due to the use of the word training itself. Hospice caregivers often mistake “training” for formal education, and do not understand that it can refer to any teaching provided by the hospice team.

NHPCO appreciates the opportunity to provide comments and brings forward challenges and ideas that include hospice provider feedback.

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people experiencing serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

The measure, while capturing the intent of timely reassessment of pain symptoms, is unclear as to the process, tools and implementation.

Timely assessment of pain symptoms is best done in a measurable or comparative manner, suported by standardized (and/or) consistent pain assessment tools. 

It bears clarification whether telephonic pain reassessment will be included in measure compliance. If so, does the telephonic reassessment focus on beneficiary interaction, or also include family/ caregiver interaction. Would also clarification of measure compliance actions when beneficiary is semi-conscious or not in conscious state (active dying process, pain management outcomes, etc).

Reassessment of pain and other symptoms is often a process that is undertaken and included in the assessment and interactions of all interdisciplinary group (IDG) team members. Does this measure identify specifically which IDG members are expected to engage in timely reassessment (may also depend on instrument used) and whether the care plan update would need to follow usual course or requires additional or different elements?

The measure as described in committee comments “derives information from the clinicians providing care, which means they make determinations based on their perceived impact of the pain the patient is experiencing.” While this may be a useful measure, it is difficult to support its inclusion without more information regarding the  outcome measures that HOPE will include for patient pain assessment.  Members report that pain assessments are routinely completed on admission and within one to two calendar days of reported pain as a standard of care, but we don’t have enough information regarding what this clinician-centric assessment of pain impact would entail and to what extent the patient and family would be included in providing their own input as to the impact of the patient’s pain.  Would there be a corresponding measure that would also include timely reassessment of pain itself, or only of clinician-reported pain impact?

NHPCO appreciates the opportunity to provide comments and brings forward challenges and ideas that include hospice provider feedback.

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people experiencing serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

The measure, while capturing the intent of timely reassessment of pain symptoms, is unclear as to the process, tools and implementation.

Timely assessment of pain symptoms is best done in a measurable or comparative manner, suported by standardized (and/or) consistent pain assessment tools. 

It bears clarification whether telephonic pain reassessment will be included in measure compliance. If so, does the telephonic reassessment focus on beneficiary interaction, or also include family/ caregiver interaction. Would also clarification of measure compliance actions when beneficiary is semi-conscious or not in conscious state (active dying process, pain management outcomes, etc).

Reassessment of pain and other symptoms is often a process that is undertaken and included in the assessment and interactions of all interdisciplinary group (IDG) team members. Does this measure identify specifically which IDG members are expected to engage in timely reassessment (may also depend on instrument used) and whether the care plan update would need to follow usual course or requires additional or different elements?

The measure as described in committee comments “derives information from the clinicians providing care, which means they make determinations based on their perceived impact of the pain the patient is experiencing.” While this may be a useful measure, it is difficult to support its inclusion without more information regarding the  outcome measures that HOPE will include for patient pain assessment.  Members report that pain assessments are routinely completed on admission and within one to two calendar days of reported pain as a standard of care, but we don’t have enough information regarding what this clinician-centric assessment of pain impact would entail and to what extent the patient and family would be included in providing their own input as to the impact of the patient’s pain.  Would there be a corresponding measure that would also include timely reassessment of pain itself, or only of clinician-reported pain impact?

NHPCO appreciates the opportunity to provide comments and brings forward challenges and ideas that include hospice provider feedback.

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people experiencing serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

The measure, while capturing the intent of timely reassessment of non-pain symptoms, is unclear as to the process, tools and implementation. Timely assessment of clinical symptoms is best done in a measurable or comparative manner, supported by standardized (and/or) consistent pain assessment tools. 

It bears clarification whether telephonic symptom reassessment will be included in measure compliance. If so, does the telephonic reassessment focus on beneficiary interaction, or also include family/ caregiver interaction. Would also clarify measure compliance actions when beneficiary is semi-conscious or not in conscious state (active dying process, symptom management outcomes, etc).

Reassessment of symptoms is often a process that is undertaken and included in the assessment and interactions of all interdisciplinary group (IDG) team members. Does this measure identify specifically which IDG members are expected to engage in timely reassessment (may also depend on instrument used) and whether the care plan update would need to follow usual course or requires additional or different elements?

Presumably, this measure would be paired with a corresponding timely reassessment of non-pain symptoms outcome measure, but without more information on the proposed contents of the HOPE tool, it is difficult to recommend inclusion of this measure, especially as it is unclear how much the patient and family would be able to contribute perspectives to the non-pain symptom impact clinician determination.

NHPCO appreciates the opportunity to provide comments and brings forward challenges and ideas that include hospice provider feedback.

The National Hospice and Palliative Care Organization (NHPCO) is the nation’s largest membership organization for hospice providers and professionals who care for people experiencing serious and life-limiting illness. NHPCO members provide care in more than 4,000 hospice and palliative care locations and care for over two-thirds of the Medicare beneficiaries served by hospice nationwide. In addition, hospice and palliative care members employ thousands of professionals and volunteers. On behalf of our members, NHPCO appreciates the opportunity to comment on the 2023-2024 Pre-Rulemaking Measure Review (PRMR) results.  

The measure, while capturing the intent of timely reassessment of non-pain symptoms, is unclear as to the process, tools and implementation. Timely assessment of clinical symptoms is best done in a measurable or comparative manner, supported by standardized (and/or) consistent pain assessment tools. 

It bears clarification whether telephonic symptom reassessment will be included in measure compliance. If so, does the telephonic reassessment focus on beneficiary interaction, or also include family/ caregiver interaction. Would also clarify measure compliance actions when beneficiary is semi-conscious or not in conscious state (active dying process, symptom management outcomes, etc).

Reassessment of symptoms is often a process that is undertaken and included in the assessment and interactions of all interdisciplinary group (IDG) team members. Does this measure identify specifically which IDG members are expected to engage in timely reassessment (may also depend on instrument used) and whether the care plan update would need to follow usual course or requires additional or different elements?

Presumably, this measure would be paired with a corresponding timely reassessment of non-pain symptoms outcome measure, but without more information on the proposed contents of the HOPE tool, it is difficult to recommend inclusion of this measure, especially as it is unclear how much the patient and family would be able to contribute perspectives to the non-pain symptom impact clinician determination.

NHPCO appreciates the opportunity to provide comments and brings forward challenges and ideas that include hospice provider feedback.

Please see attachment.