NAHC Submits Formal Comments on Medicare Proposal to Bundle Payments for Joint Replacement Services
September 11, 2015 10:57 AM
On Tuesday, September 8, the National Association for Home Care & Hospice (NAHC) submitted comments to the Centers for Medicare & Medicaid Services (CMS) on its proposal to establish a pilot program that “bundles” payments for lower hip and knee joint replacements (see previous NAHC Report article here for a summary of the proposed rule). In a letter to CMS Acting Administrator Andy Slavitt, NAHC called the proposed rule a “positive step,” and also provided a number of comments and recommendations to improve it. “With the significant growth in joint replacement services, innovative approaches to care and the financing of that care should be explored thoroughly,” NAHC stated. “At the same time, we support CMS’s recognition that innovations be approached carefully to ensure that there are no unintended adverse consequences. In line with such caution, NAHC offers the following comments that are intended to constructively improve the proposal.”
NAHC submitted the following comments and recommendations:
The proposal requires that the hospitals and other physicians included in the Comprehensive Care for Joint Replacement (CCJR) Model provide notice to beneficiaries regarding their freedom to choose any qualified provider, a list of the post-acute care options, an explanation of the CCJR model, and proposed cost-sharing and quality information. NAHC expressed support for the proposal’s protection of the beneficiary’s right to choose the course of care and provider. However, NAHC provided several revisions for CMS to strengthen the proposed beneficiary protection:
Revise the timing of the required notice to the beneficiary to a point prior to admission to an anchor hospitalization. NAHC noted that, “by the time a patient is admitted to a hospital, the course of action as well as the likely path of post-acute care may have already been designed.” Instead, notice should be provided prior to admission. NAHC stated: “The notice can be provided by the admitting physician regardless of whether that physician is participating in CCJR Sharing. Alternatively, since the surgery is generally elective, the hospital involved can convey the notice prior to admission once the surgery is scheduled.”
Devise a model notice regarding freedom of choice, including an explanation of the CCJR model and all of the care provider types that are included in the bundle. Such a model notice, NAHC stated, will “achieve a level of accuracy and consistency that will not occur with individual notice formats and contents devised by each hospital.”
Institute a “structured monitoring program to ensure compliance with the patient notice requirements,” including: A) Submission of any model notice format and content to the monitoring entity in advance of its use; B) Certification of assurances of compliance by the hospital/physician; C) Auditing of compliance within the first 30-60 days of implementation of CCJR; D) Annual auditing of compliance thereafter.
Access to Care
While “a payment model that financially rewards a hospital for reducing care costs has the potential to create barriers to care access,” NAHC expressed support for the CMS proposal to “monitor compliance” and “integrate the QIOs [Quality Improvement Organizations] into the process as an entity available to handle beneficiary complaints” in order to protect beneficiaries’ access to care. NAHC provided additional recommendations for CMS to protect access to care:
Provide appeal rights to any Medicare beneficiary comparable to those appeal rights available to Medicare Advantage enrollees. While adverse payment determinations are subject to appeal under the usual Fee-for-Service (FFS) rules, the potential for adverse care decisions exists in the CCJR model. Given that beneficiaries may face care steering that is counter to their interests, appeal rights are the best mechanism to protect those interests.
Establish a structured auditing system to monitor providers for compliance with the patient-centered care planning expected in the model. Such audits should be conducted by an outside party and should occur in the early stages of the new model and periodically thereafter.
Inform CCJR patients of the hotlines available to convey grievances on care at each level of service during the episode.
Provider Participation and Payment
In addition to supporting the proposal’s allowance for all Medicare-qualified providers to participate in the program’s post-hospital services along with the beneficiary’s freedom to choose a provider, NAHC expressed support for “maintaining the existing payment model for provider services along with direct provider payment. In addition, the payment reforms intended with the CCJR model are best managed through a shared-savings, payment reconciliation approach for both the episode initiators and other participants.” Furthermore, NAHC stated its support for “continuing the existing Medicare coverage standards for home health services and hospice care” with the “exceptions noted in regulatory waivers” (see “Regulatory Waivers” below).
Existing hospital discharge planning “has, on occasion, been focused on getting the patient out of the hospital rather than any extended planning relative to post-hospital care.” However, under the CCJR model, “post-hospital care planning takes on a wider and time-extended responsibility” and the “process of discharge planning must evolve if it is to fit the needs in the CCJR model.” Specifically, NAHC recommends that CMS:
Revise hospital discharge rules to incorporate the new responsibilities triggered by a 90-day CCJR episode. The modification of that rule should include a requirement that discharge planning involve an interdisciplinary team that incorporates expertise in all post-acute care capabilities.
Require that the episode initiator ensure the availability of and offer Advance Care Planning discussions, along with the opportunity to complete an advance directive.
Scope of CCJR Post-Hospital Services: Hospice Care
The CMS proposal includes hospice care in the bundle of post-acute care services subject to the CCJR model,but plans to exclude “unrelated” services that are defined as services for “acute clinical conditions not arising from existing episode-related chronic clinical conditions or complications of LEJR surgery; and chronic conditions that are generally not affected by the LEJR procedure or post-surgical care” from the bundle. However, the proposed rule does not include a rationale for differentiating hospice admissions “that are related to or unrelated to the purpose for and consequences of LEJR surgery.” NAHC recommends that CMS:
Disclose in detail its rationale for inclusion of hospice in the CCJR bundle. While the other included services are obviously appropriate, hospice services are unique and have been generally excluded from past bundling innovations.
Provide complete data on CCJR episode hospice spending and utilization to better understand the impact of including hospice in the CCJR bundle.
Establish detailed guidance on how to determine if the post-surgical hospice services are related or unrelated to the joint replacement surgery.
Establish a data acquisition system on hospice use in the final CCJR model.
The proposed rule’s calculation of the Target Price measure that will be applied in determining any shared savings to the hospital episode initiator does not take into account over 900,000 claims from all Medicare provider sectors that are backlogged awaiting assignment to and adjudication by Administrative Law Judges (ALJ). Nor does the process for reconciliation in CCJR shared savings consider the pending ALJ appeals. Regarding the calculation of the Target Price, NAHC provided the following recommendations for CMS:
Include an estimate of the impact of the pending ALJ appeals on the Target Price. It is more reasonable to use an estimate based on historical reversal rates than to adjust the Target Price as appeal decisions are issued.
Include a mechanism in the reconciliation process to take appeal reversal into consideration where claims audits deny post-hospital services coverage in such areas as home health services.
Establish standards to address potential changes in provider specific prospective payment systems.
The proposal includes gainsharing standards that are “needlessly complex.” Therefore, NAHC provided the following comment: “Drop the gainsharing standards. Alternatively, simplify them significantly using deference to the hospital plan as a starting point.”
In addition to the regulatory waivers CMS included in the proposal, NAHC recommends modifications to the waivers as well as additional regulatory waivers for consideration by CMS:
Home Health Services “Homebound” and “Incident to” Services Direct Supervision Requirements.While CMS proposal would waive the “direct supervision” requirement for services “incident to” physician services, it rejects a waiver of the “confined to home” (homebound) requirement for coverage of home health services. However, CMS fails to recognize that the two overlap. NAHC recommends that CMS: 1) Establish a homebound waiver to fit the circumstances described in the “incident to” waiver. 2. Issue a clarification that specifically permits a hospital or community physician or non-physician practitioner to contract with an HHA for home nursing visits under the “incident to” waiver. This clarification should also provide that the Medicare home health agency Conditions of Participation do not apply to such visits.
Telehealth Services. NAHC supports the proposed waivers of the originating site and geographic service area for coverage of telehealth services. NAHC further recommends that CMS “waive the requirements of the telehealth services benefits as proposed along with a waiver of the requirement that such services be performed by physicians or non-physician practitioners and permit the provision of telehealth services by HHAs through licensed clinicians to individuals who are not receiving Medicare-covered home health services.”
Waiver of the physician certification requirements for home health services. “A waiver of the limitation requiring physician certification would permit the patient to maintain the connection with the primary practitioner without the need to insert a new physician into the patient’s care,” NAHC stated.
Waiver of federal antikickback and patient gift rules related to pre-op counseling and home assessments by home health agencies. NAHC stated: “Certain orthopedic surgeons had found that such pre-op services improved the transition of patients to the home following joint replacement surgery, including reduced length of stay at the hospital and improved rehabilitation at home. However, with the OIG concerns set out in the referenced Advisory Opinion, such services have been effectively halted within home health services.”
To read the full letter containing NAHC’s recommendations, please click here.