NAHC Submits Comments on CMS Proposed Rule: Case Mix Cut, Value-Based Purchasing, and Quality Measures
September 4, 2015 10:13 AM
The National Association for Home Care & Hospice (NAHC) submitted formal comments on September 3, 2015, to the Centers for Medicare & Medicaid Services regarding its proposed rule that includes the calendar year 2016 Home Health Prospective Payment System (HHPPS) rate update, the Home Health Value-Based Purchasing (VBP) pilot program, and several quality measures for the Home Health Quality Reporting Program. In a letter to CMS, NAHC identified numerous problems with CMS’ proposed rule in each category, and provided specific recommendations to improve the proposed rule.
HHPPS Proposed Case Mix Weight Change Adjustment
NAHC identified several factors that demonstrate CMS’ estimate of “real” and “nominal” case mix change to support its proposed rate reduction is “unreliable.” First, NAHC stated, “CMS did not evaluate any of the 921 variables previously considered in earlier adjustments for years 2012-2014 contemporaneous with the case mix change years in issue. Instead, CMS used its outdated earlier analysis that had applied an evaluation that synchronized the case mix change years under review with the consideration of the level of ‘real’ case mix changes during that same time period.” This is problematic, NAHC stated, because “the historical analyses conducted by CMS demonstrate that the level of ‘nominal’ case mix weight change is not consistent from year to year and had instead, varied greatly.” NAHC stated that CMS’ “reliance on the findings from an unrelated time period is improper to support the proposed two-year adjustment and it is essential that CMS conduct an evaluation of the level of ‘nominal’ change for the specific time period in issue rather than applying an unreliable surrogate.” In addition to the lack of an updated analysis, NAHC stated that the variables evaluated “fall short” of being “reliable indicators.”
Second, NAHC observed that Medicare spending for 2012-2014 has “actually decreased while “nominal” increases in case mix weights should lead to increased spending.” Medicare law indicates that Medicare should only decrease rates if there has been an increase in Medicare home health services spending. Third, CMS failed to account for “what impact any of the case mix weight recalibrations had on the spending that the proposed case mix creep adjustments are intended to address.” NAHC stated that CMS has “recalibrated the case mix adjustment model several times along with rate rebasing, thereby eliminating the effect of any impact from or relevance of previous ‘nominal’ changes in case mix weights.” Fourth, CMS failed to provide “a comprehensive explanation as to why it has not determined that the 2014 rate rebasing effectively eliminated the impact of any alleged nominal case mix weight change that may have occurred in 2012 and 2013.” Fifth, NAHC described a “very unstable financial picture for HHAs and a high risk of care access problems for Medicare FFS, Medicare Advantage, and Medicaid patients alike.” As a result, NAHC stated, CMS should “consider whether to exercise its discretionary authority at this time.”
Following are the recommendations NAHC provided regarding the HHPPS rate reductions:
CMS should withdraw the proposed case mix weight adjustments proposed for 2016 and 2017. No adjustments should be considered until CMS conducts a thorough analysis of real and nominal changes in case mix through evaluation of changes that occurred during the actual years of concern (2012-2014) with respect to the proposed adjustment and any adjustments that might be considered in future years. Such evaluation should analyze any variable that may reasonably explain changes in average case mix weights in addition to those variables considered in earlier analyses.
CMS should provide public notice and an opportunity for comment on any proposed payment rate adjustments with full disclosure of any technical analysis performed by CMS or its contractors prior to implementation.
No case mix weight change adjustment shall be imposed unless it can be demonstrated that Medicare spending on home health services exceeded forecasted spending.
CMS should fully evaluate the impact of case mix weight recalibration and rate rebasing on case mix weight change and publicly disclose such evaluation.
CMS should develop program integrity measures to address provider-specific up-coding as an alternative to across-the-board case mix creep adjustments.
In the event that CMS does not withdraw the proposed adjustments, CMS should hold off on imposing the adjustments until the completion of rate rebasing in 2017. Alternatively, CMS should phase-in the adjustments over a five (5) year period.
Home Health Value-Based Purchasing (VBP) Pilot Program
NAHC expressed its support for “exploration of innovative payment models such as VBP.” However, the VBP proposal presented by CMS “does not meet appropriate design standards in several respects.” The primary shortcoming in design standards, NAHC stated, is the “significant amount of payment that is put at risk (5-8%) over the five year term of the pilot. This level is far in excess of any Medicare VBP demonstration, pilot, or full program to date.” Furthermore, NAHC’s forecasts indicate that by 2022 when the VBP pilot reaches an 8% risk, 69.31% of HHAs will be paid less than the cost of care. As a result, “even a very small amount at risk will change behaviors and achieve performance improvements.”
A second problem with the program is the requirement “that each year, some HHAs must be penalized, regardless of their performance or performance improvement.” By the fifth year, this would include HHAs “whose performance equals or exceeds the average baseline performance, many of which had received bonus payments in previous years.” Third, NAHC expressed concern about the performance measures proposed by CMS. “Of greatest concern is that these measures do not reflect the patient population served under the Medicare home health benefit as the outcome measures focus on a patient’s clinical improvement and do not address patient’s with chronic illnesses, deteriorating neurological, pulmonary, cardiac, and other conditions, and some with terminal illness.” Instead, NAHC stated that “CMS should balance the improvement measures with stabilization measures. Agencies should be judged and awarded on the number of patients who remain stable and avoid decline in their functional and clinical status.”
NAHC also stated concerns about the complexity of the program. “The measures should be limited to a select set that are most meaningful for patients and best reflect quality home health care. In addition, fewer measures would allow agencies to better focus on areas that impact quality of care within their agency.” NAHC further expressed concern about the use of OASIS items that are not quality related, as well as the implementation date of January 1, 2016. “The proposed rule is not likely to be finalized until on or about November 1, 2015, giving HHAs in the affected 9 states a mere 60 days to take all the steps needed to make VBP a success for the organization (or to avoid the financial disaster that could occur).”
Following are the recommendations NAHC provided regarding VBP:
CMS should modify its proposal to establish a home health VBP with 5-8% of payment at stake. Instead, the VBP should include no more than 1-2% at risk for any provider as that level is sufficient to trigger desired behavioral change without creating too high a risk of impacting care access and depriving HHAs of sufficient resources to support performance improvement.
CMS should convene a VBP Measure Consensus Panel made up of home health clinical experts and other stakeholders to develop VBP measures that have broad-based support, relevance, and efficacy, consistent with the principles outlined above, prior to the implementation of any home health VBP program.
CMS should establish access to real time data and information on the impact of VBP in the pilot states with primary focus on changes in utilization, OASIS and HHCAPS data reporting, access to care, admission practices, compliance with Conditions of Participation, inpatient discharge planning practices, and quality of care outcomes. The data and information should be made available to the public as soon as practicable.
CMS should establish a VBP Management and Monitoring Team with representatives from home health stakeholders to act as a sounding board for any potential VBP changes and to monitor VBP’s impact on care access and quality.
Any HHVBP program should provide a reasonable lead time for affected providers to adjust their practices to maximize operational improvements and patient outcomes. A minimum of 6 months to a year is necessary to achieve those ends.
HH QRP Quality Measures and Measures under Consideration for Future Years
NAHC expressed concerns about several proposed quality measures for the Home Health Quality Reporting Program (HHQRP) that cannot be captured by OASIS. “The implementation of these proposed measures will require additions or modifications to the OASIS assessment or the introduction of a new assessment tool for home health patients,” NAHC stated.
Following are the recommendations NAHC provided regarding the HHQRP Quality Measures:
NAHC urges CMS to employ a transparent process for measure development that allows for multiple avenues for stakeholder input.
NAHC also recommends that CMS give due consideration to the burden involved for home health agencies when developing new quality measures. CMS should balance the addition of new quality measures with the eliminating older measures that are currently part of the HHQRP.
The full letter is available here.
CMS must consider the NAHC comments along with any others submitted in developing the final rule. That final rule is expected to be released in late October or early November as it must be issued at least 60 days prior to its January 1, 2016 effective date.
NAHC has enlisted congressional support in the House and Senate to convince CMS to back off the rate cuts and to revise the Value-Based Purchasing proposal. See previous NAHC Report article here.