NAHC Submits Comments on CMS Proposed Rule: Outlier Eligibility, Case Mix Weight Recalibration, Value-Based Purchasing, Negative Pressure Wound Therapy and Quality Measures
September 1, 2016 02:26 PM
The National Association for Home Care & Hospice (NAHC) submitted formal comments to the Centers for Medicare & Medicaid Services regarding its proposed rule that includes the calendar year 2017 Home Health Prospective Payment System (HHPPS) rate update along with significant changes in HHRG scoring and weights, a revised standard for outlier episode payments, modifications in the current Home Health Value-Based Purchasing (VBP) pilot program, and several revised quality measures for the Home Health Quality Reporting Program.
In the comments to CMS, NAHC identified numerous concerns with CMS’s proposed rule in each category, and provided specific recommendations to improve the proposed rule.
HHPPS Proposed 2017 Payment Rates
The proposed rule sets the 2017 payment rates in line with the final year of rate rebasing. While, the rebasing action was effectively set in 2014, NAHC explained in its comments that many home health agencies are currently paid less than their costs due to the generalized rate adjustment methodology established by CMS in 2014 for the 4-year phase in of rebasing.
“NAHC remains concerned that the rebasing of payment rates puts access to home care in jeopardy in various parts of the country…It is concerning that the proposed rule continues to reference the relationship between payment rates and average cost since few home health agencies experience “average costs”… No health care delivery infrastructure can continue to meets the needs of a diverse patient population across the widely varying economies throughout the United States if reimbursement is limited to average cost,” NAHC stated in its comments.
The Medicare Payment Advisory Commission (MedPAC), in its comments, maintains that rate rebasing did not cut payment rate enough. NAHC added its concerns about current rates to respond to the MedPAC recommendations. NAHC support its comments with strong data showing the financial outcome of existing rate rebasing showing average Medicare margins approaching zero.
Outlier Reform and Case Mix Weight Recalibration
NAHC notes a significant concern with the proposed changes to outlier payment eligibility determinations and the recalibrated case mix weights. Both suffer from CMS’s attempt to fine tune the system to better reflect cost differences in patient care. The source of the concern is CMS’s proposed use of un-weighted 15 minute service time increments in establishing payments for outliers and case mix weights. In doing so, CMS fails to recognize that service visits have invariable costs that occur regardless of the length of a visit. NAHC comments reference travel time and travel costs as an example. NAHC recommends that CMS rethink its proposal and delay any changes unless it can properly reflect these costs in the 15 minute increments.
Additional concerns highlighted in the NAHC comments involve the changes in the case mix scoring standards that modify the impact of certain diagnosis in the resulting case mix category assignment.
Home Health Value-Based Purchasing (VBP) Pilot Program
The proposed rule offers a series of reforms to the just-started value-based purchasing pilot program. Generally, NAHC comments support the proposed changes.
Specifically, NAHC supports the proposals to:
remove certain measures for the reasons stated in the NPRM;
eliminate smaller- and larger-volume cohorts for purposes of setting performance benchmarks and thresholds (effective in 2016) and use state-level calculation instead;
establish a minimum of eight HHAs in the smaller-volume cohort;
require annual rather than quarterly reporting for the influenza vaccination measure; and
establish an appeals process.
Beyond the proposed refinements to HHVBP, NAHC remains concerned with elements of the original design that remain unchanged. However, the proposed VBP changes do not alter some aspects of the design with which NAHC expressed concerns in the original HHVBP rulemaking, including the amount of payment at risk (3-8%) over the five year term of the pilot. “This level is still far in excess of any Medicare VBP demonstration, pilot, or full program to date,” states NAHC. “[I]t cannot be safely assumed that those providers will have sufficient financial resources to avoid a death spiral caused by a likely permanent reduction in payment. Performance improvement does not happen without adequate financial support. Once an HHA suffers the extreme penalty at risk in the HHVBP (3-8%), it is unlikely that it can afford the necessary changes in its operation to improve its performance and avoid future penalties.”
A central concern with the original design remains as an industry-wide criticism of the program. NAHC states that it “remains concerned that the focus on improvement measures may trigger discrimination in patient admissions that creates barriers to care for patients with chronic conditions or terminal illness.” New concerns have surfaced since the original rule was issued in 2016. Those concerns include CMS’s use of all patient data for a value-based program that is limited to Medicare fee-for-service patients. In addition NAHC explains that the system’s risk adjuster fails to sensibly account for patient variations such that home health agencies with certain patients will get lower scores than deserved.
Proposed Payment Policies for Negative Pressure Wound Therapy Using a Disposable Device
Based on a recent change in the law, CMS proposes a separate payment to a HHA for a disposable NPWT device when furnished on or after January 1, 2017, to an individual who receives home health services for which payment is made under the Medicare home health benefit. The proposal raises a number of questions on how it actually works.
Among the areas needing clarification is the connection between Medicare home health payment and the NPWT payment under Medicare Part B. “Given that disposable device-related NPWT is intended to substitute for DME-related NPWT, the reimbursement consequences should not favor one care method over the other. With the proposed reimbursement standards, there is a high risk that disposable-related NPWT would provide significantly lower reimbursement, well below HHA costs,” states NAHC.
Proposed Updates to the Home Health Quality Reporting Program (HHQRP)
In this area, the opening remark is that “NAHC appreciates CMS’s reevaluation of the home health measure set and agrees with eliminating measures from the HHQRP that are topped out or have limited clinical or quality value. We do encourage CMS, however, to continue developing meaningful measures for inclusion in the HHQRP, particularly stabilization measures.” Thereafter, NAHC gets very specific with the CMS proposals.
CMS proposes to add four new measures that were developed to meet the requirements of the IMPACT Act. These proposed measures are:
MSPB–PAC HH QRP;
Discharge to Community-PAC HH QRP;
Potentially Preventable 30-Day Post-Discharge Readmission Measure for HH QRP; and
Drug Regimen Review Conducted With Follow-Up for Identified Issues-PAC HH QRP
CMS proposes to end the “treatment episode” 60 days after for all episodes except partial episode payments (PEPs). NAHC has concerns regarding the construct of the episode window and episode length for home health patients that are not under a home health plan of care for the entire 60 days (treatment episode). Patients are often discharged from care prior to the end of the 60 day home health episode. Since the treatment period is for the full 60 days, these patients could be under a treatment episode for days, even weeks, where care is not being provided by the agency. In addition, since the associated episode does not end until 30 days after the treatment episode ends, MSPB could include costs that occur months after patients have been discharged from the home health agency’s care. The proposed episode window can unfairly attribute spending for home health patients discharged prior to the end of the 60 day episode.
Also, the risk adjustment model does not include variables for socio-economic/socio-demographic status or caregiver support. Both of these variables are key indicators of an individual’s ability to be discharge to, and remain in the community following a post-acute care stay.
NAHC urges the developers to include in the risk adjustment model variables to address socio-economic status, socio-demographic status, and caregiver support. “NAHC strongly supports the inclusion of socio-demographic status as a variable for risk adjustment. NAHC believes the risk adjustment model should also include variables to address income, caregiver support, and prior PAC stays.”
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 releasedin late October or early November as it must be issued at least 60 days prior to its January 1, 2017effective date.