Speeches & Testimony

Pew Comments: Proposed Home Health Prospective Payment System Rate

On Sept. 4, The Pew Charitable Trusts submitted comments to the Centers for Medicare & Medicaid Services regarding its proposed update to the Home Health Prospective Payment System.

The comments supported the inclusion of quality measures for advance care plans in the home health value-based purchasing model as an important step toward improving care near the end of life.

Read Pew’s full comments

September 4, 2015

Mr. Andy Slavitt
Acting Administrator, Centers for Medicare & Medicaid Services
Department of Health and Human Services
200 Independence Ave. SW
Washington, DC 20201

Submitted electronically via http://www.regulations.gov/

RE: CMS-1625-P: Medicare and Medicaid Programs; CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements

Dear Acting Administrator Slavitt:

Thank you for the opportunity to comment on the 2016 Home Health Prospective Payment System proposed rule. The Pew Charitable Trusts supports the inclusion of the Advance Care Directive Quality Measure in the Proposed Home Health Value-Based Purchasing Model.

The Pew Charitable Trusts is an independent, non-profit research and public policy organization. The Trusts’ project to improve end-of-life care advances policies that help people make informed decisions about their treatment preferences, improve the documentation of these preferences, and hold health care providers accountable for honoring patient wishes and delivering high-quality care. Additionally, the project highlights innovative ways of providing care to seriously ill people and their families as they near the end of their lives.

Americans near the end of life rarely have conversations about where they wish to die, the care they prefer to receive, and who they want to make decisions for them when needed, despite the many proven benefits to patients and their families. For example, a recent study of patients with advanced cancer found that only 27 percent of patients had discussed end-of-life issues with their oncologist, and most had never discussed pain management with any doctor.1 Because these conversations have not occurred, many people receive aggressive treatments in the intensive care unit and ultimately die in the hospital when they would have preferred to die in their own home. Additionally, family members struggle to make decisions for dying patients and experience stress, guilt, and regret when they are not confident that they know their loved one’s wishes.2

Rigorous research has demonstrated many benefits to people who participate in advance care planning (ACP). Individuals are more likely to have their end-of-life wishes known and respected,3 and patients and families are more satisfied with the care they receive after having these conversations with their doctors.4 Furthermore, patients are less likely to receive unwanted aggressive medical treatments in their last weeks of life,5 are less likely to die in the hospital or intensive care unit,6,7 and are more likely to enroll in hospice8—comprehensive care that supports patients and their families in the final phase of a terminal illness with a focus on comfort and quality of life.

Pew is pleased to see that the proposed value-based purchasing model includes the National Quality Forum (NQF)-endorsed advance care planning quality measure (NQF# 0326). The measure would assess whether home health agencies participating in the value-based program had documented an advance care plan or surrogate decision-maker in the medical record for patients 65 years of age or older or recorded that advanced care planning was discussed and the patient declined to provide an advanced care plan or designate a surrogate. This measure is currently in use in the Physician Quality Reporting System (PQRS) and in hospitals under Meaningful Use Stage 2 as a Menu Objective.

Increasing the use of quality measures for care near the end of life is critical to improving the care given at that time. Since Medicare home health users are significantly more likely to be in poor health than other Medicare beneficiaries, ACP is particularly relevant for this population.9 Documenting a patient’s advance care plan—or that the patient did not wish to provide one—is an important first step in improving advance care planning and end-of-life care. Many measurement models, such as NQF Preferred Practices for Palliative and Hospice Care Quality, The Assessing Care of Vulnerable Elders, and The PEACE Project, include documentation of an ACP as a quality measure.

We support the inclusion of the advance care directive quality measure in the home health value-based purchasing model as an important step towards advancing the needs and wishes of Medicare beneficiaries and improving care near the end of life.

If you have any questions, or need any further assistance, please do not hesitate to contact me at 202-540-6761 or jrising@pewtrusts.org.


Josh Rising, MD
Director, Health Care Programs
The Pew Charitable Trusts


1 Jennifer W. Mack et al., “End-of-Life Discussions Among Patients with Advanced Cancer: A Cohort Study,” Annals of Internal Medicine 153, no. 3 (2012): 4–5, doi: 10.7326/0003-4819-156-3-201202070-00008.
2 David Wendler and Annette Rid, “Systematic Review: The Effect on Surrogates of Making Treatment Decisions for Others,” Annals of Internal Medicine 154, no. 5 (2011): 344, doi: 10.7326/0003-4819-154-5-201103010-00008.
3 Karen M. Detering et al., “The Impact of Advance Care Planning on End-of-Life Care in Elderly Patients: Randomized Controlled Trial,” BMJ 340 (2010): 4–5, doi: 10.1136/bmj.c1345.
4 Detering et al., “The Impact of Advance Care Planning,” 4–5.
5 Joan M. Teno et al., “Association Between Advance Directives and Quality of End-of-Life Care: A National Study,” Journal of the American Geriatrics Society 55, no. 2 (2007): 192, doi: 10.1111/j.1532-5415.2007.01045.x.
6 Rhea A. Stein et al., “Randomized Controlled Trial of a Structured Intervention to Facilitate End-of-Life Decision Making in Patients With Advanced Cancer,” Journal of Clinical Oncology 31, no. 27 (2013): 3406, doi: 10.1200/JCO.2011.40.8872.
7 Detering et al., “The Impact of Advance Care Planning,” 4–5.
8 Lauren H. Nicholas et al., “Regional Variation in the Association Between Advance Directives and End-of-Life Medicare Expenditures,” Journal of the American Medical Association 306, no. 13 (2011): 1451, doi: 10.1001/jama.2011.1410.
9 Avalere, Home Health Chartbook: Prepared for the Alliance for Home Health Quality and Innovation,” (presentation, November 2014).

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