Among the many attempts at explaining the next iteration of a home health payment plan, perhaps the clearest came from a panel discussion featuring two Chief Strategy Officers, Steve Guenthner of LHC Group, and Luke James of Encompass Home Health & Hospice. The session at last month’s Lincoln Health Post Acute 360 conference was moderated by Des Varady, CEO of The Corridor Group.
(Editor’s note: The proposed PPS replacement has become known by one of its provisions, HHGM, for Home Health Grouper Model. However, in its July 2 announcement, CMS is now referring to it as the “Patient-Driven Groupings Model.” Apparently, we have to get used to a new acronym, PDGM, or continue to refer to it as “The CMS 2020 Fiasco.” Click here for the announcement in the Federal Register. See below for the official CMS news release with quotes from administrator Seema Verma.) [This article points to the many possible changes in healthcare at home service delivery and payment–among these: 1) an agreement among the Post-Acute 360 panelists that the “net effect of the 30 day episodes of care will eliminate “therapy as a reimbursement factor, and a more complex diagnosis categorizing system will be to increase hospital admissions and home health agency costs.” More concern were raised among panelists–among these that “SCIC (significant change in condition) episodes might grow out of proportion;” and that the home health industry must agree to undertake coordinated lobbying with CMS about paying for the many changes on the horizon in healthcare at home service delivery. The full text of a news release titled “CMS Takes Action to Modernize Medicare Home Health” appears at the end of this article. Many urls are provided at the end of the articl, too, to describe, according to CMS Admistator Seema Verma, the “redesign of the home health payment system [that]encourages value over volume and removes incentives to provide unnecessary care.”]
The panelists agreed that then net effect of 30-day episodes, the elimination of therapy as a reimbursement factor, and a more complex diagnosis categorizing system will be to increase hospital admissions and home health agency costs. On the most obvious level, with 30-day payment episodes but an expectation that care will continue to be delivered for 60 days, more resources will be needed in each agency’s billing department, an inconvenience for some, a prohibitive cost for others. More subtly, they pointed out, CMS will be watching to see how provider behavior changes in response to new rules, especially with regard to therapy.
“In a footnote on a page somewhere in the 500’s, CMS makes some guesses about how the industry might change behavior to respond to its new payment model,” Guenthner said. “They seem to have an interest in engaging providers to tell them how to adjust the model to compensate.”
Another concern, James added, is that SCIC (significant change in condition) episodes might grow out of proportion. “In designing HHGM,” he explained, “CMS has created six clinical categories. One of them, the lowest reimbursed category, will absorb over half of all home health episodes. One in five episodes will qualify as a ‘questionable encounter,’ which would not be reimbursed at all.”
The example he offered is the common UTI diagnosis. PDGM requires specificity about exactly where the infection lies. That will require multiple unnecessary ED visits, physician-ordered tests, and harmful delays, not to improve — or even change — the treatment, but only to micro-categorize for purposes of billing.
Coordinated lobbying
The Parthership for Quality Home Health Care has been active in trying to get additional qualification about the 30-day payment period and the expectation the 60-day treatment is still expected. NAHC continues its efforts to explain to CMS and to legislators that the changes will reduce the millions in savings home health provides to payers. Providers, supported by academia that “knows good payment policy when they see it,” are pushing CMS to continue to improve the plan prior to the 1/1/20 due date.
They are also insisting that CMS finalize the rule early. “There is no way software vendors and providers can prepare if the rule is not finalized until November of 2019,” the panelists agreed.
By statute, CMS is required to include at least one Technical Expert Panel meeting during the comment period. LHC Group members on the last TEP pushed for a “risk-based grouper model,” reasoning “Shouldn’t a patient at risk have more resources allocated and paid for than a patient with low rehospitalization risk?” The hope is that yet another TEP process will come out of this comment.
How to prepare
Regardless of how the final rule is worded, providers can be certain more cuts will be required. Coding will remain the same, QA will become more difficult, and the luxury of providing extra visits will disappear. The best advice the panel had to offer is to start now to focus on utilization. Learn to build lean care plans. Rely on patient engagement, family assistance, and remote patient monitoring whenever possible, even if all you can afford is daily phone calls. Beef up your assessment and coding processes, get them both right. If you can stabilize a person with multiple chronic conditions in seven visits, there is no reason to continue to do 17, just because that is how you have always done it. (See the article elsewhere in this issue about software to guide care planning efficiency.)
CMS Takes Action to Modernize Medicare Home Health
Action Puts Value Over Volume and Advances MyHealthEData Initiative
WASHINGTON DC – July 2, 2018 – Today, the Centers for Medicare & Medicaid Services (CMS) proposed significant changes to the Home Health Prospective Payment System to strengthen and modernize Medicare, drive value, and focus on individual patient needs rather than volume of care. Specifically, CMS is proposing changes to improve access to solutions via remote patient monitoring technology, and to update the payment model for home health care.
“Today’s proposals would give doctors more time to spend with their patients, allow home health agencies to leverage innovation and drive better results for patients,” said CMS Administrator Seema Verma. “The redesign of the home health payment system encourages value over volume and removes incentives to provide unnecessary care.”
CMS’s proposed changes promote innovation to modernize home health by allowing the cost of remote patient monitoring to be reported by home health agencies as allowable costs on the Medicare cost report form. This is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data is shared among patients, their caregivers, and their providers. Supporting patients in sharing this data will advance the Administration’s MyHealthEData initiative.
As required byd the Bipartisan Budget Act of 2018, this proposed rule would also implement a new Patient-Driven Groupings Model (PDGM) for home health payments. The current system pays for 60-day episodes of care and relies on the number of therapy visits a patient receives to determine payment. The PDGM would eliminate the use of “therapy thresholds” in determining payment and changes the unit of payment to 30-day periods of care. The improved structure would move Medicare towards a more value-based payment system that puts the unique care needs of the patient first while also reducing the administrative burden associated with the HH PPS. The PDGM would be implemented in a budget-neutral manner on January 1, 2020.
The proposed rule also includes information on the implementation of home infusion therapy temporary transitional payments as required by the Bipartisan Budget Act of 2018. In addition, the proposed rule solicits comments on elements of the new home infusion therapy benefit category and proposes standards for home infusion therapy suppliers and accrediting organizations of these suppliers as required by the 21st Century Cures Act.
Physicians who order home health services for their patients would also see administrative burden reduced under this rule. CMS is proposing to eliminate the requirement that the certifying physician estimate how much longer skilled services would be needed when recertifying the need for continuing home health care, as this information is already gathered on a patient’s plan of care.
The proposed rule helps advance the Trump Administration’s Meaningful Measures Initiative. CMS is proposing changes to the Home Health Quality Reporting Program (HH QRP). The cost impact related to updated data collection processes as a result of the proposed implementation of the PDGM and proposed changes to the HH QRP are estimated to result in a net $60 million in annualized cost savings to HHAs, or $5,150 in annualized cost savings per HHA, beginning in CY 2020.
In the proposed rule CMS is releasing a Request for Information to welcome continued feedback on the Medicare program and interoperability. CMS is gathering stakeholder feedback on revising the CMS patient health and safety standards that are required for providers and suppliers participating in the Medicare and Medicaid programs to further advance electronic exchange of information that supports safe, effective transitions of care between hospitals and community providers.
The proposed rule and the Request for Information can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.
The proposed rule announced today is part of a broader effort to put patients over paperwork by improving access to and value of care, and reducing the administrative burden on physicians so that more effective care to patients may be provided. To date, CMS has taken the following notable actions in this year’s rulemaking for Medicare, among others, to advance the Patients Over Paperwork initiative for Medicare beneficiaries:
- The modernizing proposals to advance CMS’ Meaningful Measures Initiative released in five separate fiscal year 2019 proposed rules are projected to save Medicare providers close to four million hours and more than $144 million as they take effect in 2019 and 2020.
- CMS proposed a Patient-Driven Payment Model for the Skilled Nursing Facility Prospective Payment System that ties payment to patients’ conditions and care needs rather than volume of services provided and simplifies complicated paperwork requirements that save facilities approximately $2.0 billion over 10 years.
- CMS finalized a rule that would allow Medicare Advantage plans to offer more tailored plan benefit packages and new types of supplemental benefits.
For a fact sheet on today’s proposed rule, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-02.html
For additional information about the Home Health Prospective Payment System, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/index.html and https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html.
For additional information about the Home Health Value-Based Purchasing Model, visit https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model.
For additional information
