Home Health Rate Update for CY2018

Home Health Rate Update for CY2018

Home Health Rate Update for CY2018

CMS projects that Medicare payments to HHAs in CY 2018 would be reduced by 0.4 percent, or $80 million, based on the proposed policies.

The proposed decrease reflects the effects of:

  • a 1 percent home health payment update percentage ($190 million increase);
  • a -0.97 percent adjustment to the national, standardized 60-day episode payment rate to account for nominal case-mix growth for an impact of -0.9 percent ($170 million decrease); and
  • the sunset of the rural add-on provision ($100 million decrease).

Home Health Value Based Purchasing Demonstration

CMS has proposed the following changes to the Home Health Value Based Purchasing (HHVBP) program:

  • to amend the definition of “applicable measure” to specify that the HHA would have to submit a minimum of 40 completed surveys for Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) measures to a performance score for any of the HHCAHPS measures, and
  • For performance year (PY) 3 and subsequent years remove the Outcome and Assessment Information Set (OASIS) -based measure - Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of Care

Applicable Measure

Under the current guidelines for the HHVBP program, a minimum of 20 HHCAHPS completed surveys is necessary for scores to be generated for the HHCHPS quality measures included in the HHAs Total Performance Score.

Separately, for the Patient Survey Star Ratings on HH Compare, CMS requires a minimum of 40 completed HHCAHPS surveys. They do this for stars to have enough variation to minimize random variations but also provide star ratings for as many HHAs as possible.

CMS proposes to align the Patient Survey Star Ratings system and the HHVBP model to provide standard measures, and they propose that HHVBP HHCAHPS measures use 40 (rather than 20) completed surveys.

CMS did analyze the impact on participating HHAs using 40, (rather than 20) HHCAHPS scores.

Their data suggest that achievement thresholds would not change more than =_1.1%, with the largest changes happening in “willingness to recommend the agency” in AZ and NE. Benchmarks had a greater potential for change, ranging down to -3.2% (with NE, AZ, FL being most impacted).

Overall, the proposed change is expected to result in a limited percent change in the average statewide TPS for large-volume HHAs, ranging from -0.4 through +2.2%.

HHAs should look at their interim performance reports (IPRs) which analyzed 40 HHCAHPS surveys across both large and small cohorts in determining quality measure scores. The IPRs will be reissued using 20 more HHCHAPS scores for these same time periods so that HHAs can compare. HHAs will get concurrent IPRs in July 2017 and Annual TPS and payment adjusted reports in August 2017. These concurrent reports will show both the 20 and the 40 survey results and what that does to quality scores.

Currently HHA must generate performance scores on at least 5 applicable measures and if an HHA does not have a minimum of 20 episodes of care to generate a performance score on at least 5 measures, that HHA would not be included in the comparison or have a payment adjustment percentage calculated. Now, “applicable measures” will be those for which an HHA has provided a minimum of 20 HH episodes of care per year for the Oasis-based measures, 20 HH episodes per year for the claims-based measure, or 40 completed surveys for the HHCAHPS measures.

If finalized, this would apply to the calculation of the benchmark and achievement thresholds and the calculation of performance scores for all Model years, beginning with PY one. HHAs will still need to generate scores on 5 applicable measures to participate.

Home Health Grouping Model – in 2019

In 2019 CMS is proposing the most significant change in home health payment since the implementation of the HHPPS. It has scheduled implementation of the new payment system for episodes beginning on and after January 1, 2019. The new system maintains the same basic principle of paying a percentage of a national average payment amount based on a set of weighted patient characteristics. It also continues to include adjustments for low utilization (LUPA), partial episodes(PEP), and outliers. But the length of the episode is reduced to 30 days and the methodology used to determine the percentage adjustment (still called a HHRG or Home Health Resource Group) is substantially changed. Most notable among the changes is the elimination of therapy visits as a factor. It also adjusts HHRGs through entirely different set of scored categories, including differentiating between admissions from the community vs. institutions. The new unit of payment based on a 30-day episode vs. the current 60-day episode under HHPPS implicitly changes the dynamics of the payment system. Although new, the methodology is somewhat less complex than the current HHPPS and is represented simply in the graphic below:

See figure 5.

As was shown in the National CMS Teleconference on Home Health Payment Refinement on January 18th, 2017.

The Abt Technical Report upon which the HHGM model is based may be found at: https://downloads.cms.gov/files/hhgm%20technical%20report%20120516%20sxf.pdf

It is important to note that any PPS system is both an imperfect predictor of use that is then applied to a national average payment for services. That results in significant variation between actual costs and payments both for individual patients and individual agencies. The goal of any PPS is to achieve a system which, on average, pays adequately for the care needed by patients in an agency with an average case mix distribution and that is provided by providers of average efficiency. Thus, the impact of this change in this PPS payment methodology on any one agency will inevitably vary widely to the degree that it deviates from the averages.

Key Characteristics of the HHGM’s Home Health Resource Groups (HHRGs):

  • There will be 144 Home Health Resource Groups that determine the percentage of a standardized 30-day standardized, national payment rate that incorporates consideration of average agency resource use and costs, including those for non-routine medical supplies.
  • The group is determined by:
  • Whether the patient is admitted from community or from an institution (hospital or NF).
  • Whether the patient is in first 30-day episode or a continuing episode.
  • Patient placement into one of 6 broad clinical categories determined by the primary diagnosis.
  • Patient placement in one of 3 broad functional levels based on OASIS data.
  • Whether there is a relevant comorbidity justifying upward adjustment.

The Table representing the 144 new payment groups is found as Table 42 of the proposed rule presently calculated based on the best data available at the time the rule was prepared. These values will be adjusted based on the best data available prior to 2019 implementation. They will also be adjusted in subsequent years much like has been done under the current PPS system.

Specific Guidance on Resource Groupings:

  • There are 6 Clinical Groupings: Musculoskeletal Rehab, Neuro Rehab, Complex Nursing Interventions, Wound, Behavioral Health, and MMTA (Medication Management, Teaching and Assessment.) Comments are invited on these categories.
  • If the primary diagnosis is insufficient to establish a Clinical Grouping because it is vague, not associated with home care or otherwise appears irrational, the claim will be rejected as “questionable” and returned to the provider correction.
  • Secondary diagnoses will be used to determine whether a comorbidity adjustment is warranted, not to categorize questionable primary diagnoses. The comorbidity system includes 116 total subcategories of comorbidities in 13 body system categories: heart disease, respiratory disease, circulatory disease and blood disorders, cerebral vascular disease, gastrointestinal disease, neurological disease and associated conditions, endocrine disease, neoplasm, genitourinary and renal disease, skin disease, musculoskeletal disease or injury, behavioral health, and infectious disease.
  • There are 3 Functional Categories: Low, Medium, and High. They are based on scoring the following OASIS Items: M1800 Grooming, M1810 Current Ability to Dress Upper Body, M1820 Current Ability to Dress Lower Body, M1830 Bathing, M1840 Toilet Transferring, M1850 Transferring, M1860 Ambulation/Locomotion, and M1032 (M0133 in OASIS C1) Risk of Hospitalization. There is a detailed rational for the inclusion or exclusion of various OASIS items in the proposed rule. Table 36 and 37 describe the point scoring of the OASIS items and classification break points into the Low, Medium, and High Functional Groupings.
  • Definitions of what constitutes an “Initial Episode” reflects current timing rules under HHPPS.
  • Definition of “admission from institution” follows current guidance. However, new occurrence codes will be made available so that this data can come from home health agency final claim rather than waiting for notification to CMS systems based on institutional claims. Retroactive adjustment would be made based on claims records if the home health report of an institutional admission proves unsubstantiated.

The proposed rule contains very detailed data and rationale that explain the choices that have been made and supporting data for each of the new variables that are included or have been excluded from the new payment system. These are based in part on advice from the home health industry in technical advisory groups informing the contractor developing the system, ABT Associates.

LUPA Significant Changes Related to the HHGM:

  • LUPAs (Low Utilization Payment Adjustments) will still be paid but with the shorter episode, the break point for LUPAs will no longer be 4 visits but a number of visits 4 or less based on the specific HHRG. (Table 40).

Key Payment System Characteristics that currently will not be changed:

  • RAPs (Requests for Anticipated Payment) requiring a NOI (Notice of Admission) will still be paid in 2019 at the current 60/40 percentage but CMS is seeking input on whether they are still needed with the shorter 30-day episodes. It notes that other providers, like Hospice, are fine with 30-day payment cycles and do not submit NOIs or receive RAPs.
  • PEPs (Partial Episode Payments) will still be calculated and paid but now as a percentage of the 30-day payment vs. the 60-day payment.
  • Outliers will still be paid according to current methodology using 2019 rates of payment.
  • Initial Episodes will still qualify for an add-on payment.
  • CMS still plans to adjust the new payment system each year based on data reflecting home health agency shifts in utilization.
  • Face to Face, Advanced Beneficiary Notice (ABN), and Home Health Change of Care Notice (HHCCN) requirements continue.

Impacts:

  • Although CMS projects that the shifts in total home health payments driven by HHGM system in 2019 will cause significant reduction of 4.3% ($950 million) in overall payments in 2019 compared to the current system, it proposes to NOT budget neutralize the new system as it has done in prior payment refinements but rather keep those savings. CMS does offer an opportunity to comment on whether to phase this lack of budget neutrality in over two years instead of taking the entire hit in 2019. It rejects a longer phase-in.
  • Of course, the impact of this payment system will vary widely among agencies and even the overly generalized CMS impact tables (Table 55 in the proposed rule) show that some broad classes of providers will show positive gains even without budget neutrality and losses will range from minimal to significant. Only an agency-specific simulation will show the actual impact on any specific agency.
  • In general, rural providers do better than urban, agencies that rely less on therapy vs. nursing in their overall case mix do better

Home Health Quality Reporting Program

CMS has proposed the following changes to the to the Quality Reporting Requirements:

See table 45 for the proposed elements to be removed from OASIS 1/1/19.

  • the replacement of one quality measure,
  • the adoption of two new quality measures,
  • the reporting of standardized patient assessment data in five categories described under the IMPACT Act,
  • Functional status, such as mobility and self-care at admission
  • Cognitive function
  • Special services, treatments and interventions such as the need for ventilator use, dialysis, chemotherapy, central line placement, and total parenteral nutrition
  • Medical conditions and co-morbidities
  • Other categories deemed necessary and appropriate by the Secretary
  • data submission requirements,
  • exception and extension requirements, and
  • reconsideration and appeals procedures.

Further, they are soliciting comments on:

  • The application of NQF measures developed for one care setting to be applied to home health care.
  • Social risk factors most appropriate for reporting stratified measure scores a and potential risk adjustment

Resources:

Proposed rule (https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-15825.pdf?utm_campaign=pi%20subscription%20mailing%20list&utm_source=federalregister.gov&utm_medium=email ).

CMS’ fact sheet on the proposed rule - https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-25.html.

Grouper files and related scoring assistance for the HHGM are on the CMS website at: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

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