CMS Reveals Pay Changes for Home Health Agencies
Home health agencies can look forward to a 0.7 percent reduction in Medicare payments in the 2017 Medicare home health prospective payment system (HH PPS).
This amounts to a $130 million savings for the agency, but it’s hard to explain: the Centers for Medicare & Medicaid Services (CMS) said the estimated decrease reflects the effects of the 2.5 percent home health payment update percentage ($450 million increase); the rebasing adjustments to the national, standardized 60-day episode payment rate, the national per-visit payment rates, and the non-routine medical supplies (NRS) conversion factor (an impact of -2.3 percent or a $420 million decrease); and the effects of the -0.97 percent adjustment to the national, standardized 60-day episode payment rate to account for nominal case-mix growth, for an expected impact of -0.9 percent (a $160 million decrease).”
Beneficiaries must need intermittent skilled nursing or therapy services, and be homebound and under the care of a physician. Covered services include skilled nursing, home health aide, physical therapy, speech-language pathologists, occupational therapy, medical social service, and medical supplies. Home health agencies are paid a national, standardized 60-day episode payment for most covered home health services, adjusted for case-mix and area wage differences. There are a lot beneficiaries — 3.4 million — and many home health agencies — 11,400. This cost Medicare $18.2 billion in 2015.
The HH PPS final rule is one of several rules for calendar year 2017 that reflect a broader Administration-wide strategy to create a healthcare system that results in better care, smarter spending, and healthier people. Provisions in these rules are helping to move our health-care system to one that values quality over quantity and focuses on reforms such as achieving better health outcomes, preventing disease, helping patients return home, helping manage and improve chronic diseases, and fostering a more efficient and coordinated healthcare system.
Payment Policy Provisions
Rebasing the 60-day Episode Rate
The Affordable Care Act (ACA) directs CMS to apply an adjustment to the national, standardized 60-day episode rate and other applicable amounts to reflect factors such as changes in the number of visits in an episode, the mix of services in an episode, the level of intensity of services in an episode, the average cost of providing care per episode, and other relevant factors. CMS must phase-in any adjustment over a four-year period, in equal increments, not to exceed 3.5 percent of the amount (or amounts) as of the date of the enactment of the ACA (CY 2010).
In this final rule, CMS would complete the final year of the four-year phase-in of the rebasing adjustments to the HH PPS payment rates. As finalized in the CY 2014 final rule, the CY 2017 rebasing adjustment to the national, standardized 60-day payment rate is -$80.95. The overall impact due to the rebasing adjustments is estimated to be a 2.3 percent decrease in HH PPS payments for CY 2017. As noted above, and further below, this is offset by the home health payment update percentage, which would increase overall HH PPS payments in CY 2017 by 2.5 percent.
Updates to Reflect Case-Mix Growth
CMS will implement a 0.97 percent reduction to the national, standardized 60-day episode rate in CY 2017 to account for nominal case-mix growth from 2012 to 2014 (prior to rebasing). CY 2017 will be the second year of the three-year phase-in of the reduction to account for nominal case-mix growth. The -0.97 percent adjustment to the national, standardized 60-day episode payment rate to account for nominal case-mix growth results in an estimated decrease in HH PPS payments for CY 2017 of -0.9 percent.
Negative Pressure Wound Therapy (NPWT)
The Consolidated Appropriations Act, 2016, requires a separate payment to be made to HHAs for NPWT using a disposable 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. As described in the Consolidated Appropriations Act, 2016, the separate payment amount for an applicable disposable device will be set equal to the amount of the payment that would otherwise be made under the Medicare Hospital Outpatient Prospective Payment System (OPPS).
Change in Methodology and the Fixed-Dollar Loss (FDL) Ratio Used to Calculate Outlier Payments
CMS finalized the proposal to change the methodology used to calculate outlier payments, moving from a cost per visit approach to a cost per unit approach (1 unit = 15 minutes). This approach more accurately reflects the cost of an outlier episode of care, and thus better aligns outlier payments with episode costs than the cost-per-visit approach. In addition, CMS finalized the proposal to increase the FDL ratio from 0.45 to 0.55 to ensure outlier payments do not exceed 2.5 percent of total payments for CY 2017, as required by the Social Security Act.
CMS has also updated the HH PPS payment rates by the home health payment update percentage of 2.5 percent, as required by the Social Security Act.
Home Health Quality Reporting Program (HH QRP) Update
Section 2(a) of the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) requires the public reporting of data on HHAs, Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), and Long-Term Care Hospitals (LTCHs) quality measures and data on resource use and other measures. The act also requires the HHS Secretary to modify PAC assessment instruments to provide for the submission and comparison of standardized, and interoperable, patient assessment data on quality measures.
Following opportunities for proposed rule public comment, as well as measure development related technical expert review and public comment and the review by the measures application partnership process, in this final rule and beginning with the CY 2018 payment determination, CMS adopted four measures to meet the requirements of the IMPACT Act. Three of these measures are calculated using Medicare claims. The Total Medicare Spending per Beneficiary – Post Acute Care Home Health Quality Reporting Program (MSPB-PAC HH QRP) measure does not require additional data submission. The fourth measure is assessment-based and is calculated using Outcome and Assessment Information Set (OASIS) data. The various measures are as follows:
- Potentially Preventable 30-Day Post-Discharge Readmission Measure for Post-Acute Care Home Health Quality Reporting Program;
- Total Medicare Spending per Beneficiary – Post Acute Care Home Health Quality Reporting Program (MSPB-PAC HH QRP);
- Discharge to Community- Post Acute Care Home Health Quality Reporting Program; and
- Drug Regimen Review Conducted with Follow-Up for Identified Issues-Post-Acute Care Home Health Quality Reporting Program.
The Home Health Conditions of Participations (CoPs) require HHAs to submit OASIS assessments for quality measurement purposes; submission of OASIS data is also required as a condition of payment. HHAs that do not submit quality measure data to CMS will see a 2.0 percent reduction in their annual payment update (APU). Last year CMS finalized its proposal to require all HHAs to submit both admission and discharge OASIS assessments for a minimum of 90 percent of all patients with episodes of care occurring during the reporting period. CMS is incrementally increasing this compliance threshold from 70 percent to 90 percent over three years, beginning with the reporting period for CY 2017 (July 1, 2015-June 30, 2016).
In 2015, CMS undertook a comprehensive reevaluation of all 81 HH quality measures, some of which are used only in the Home Health Quality Initiative (HHQI), and others which are also used in the HH QRP. The goal of this reevaluation was to streamline the measure set, consistent with Measures Management System (MMS) guidance and in response to stakeholder feedback. This reevaluation included a review of the current scientific basis for each measure, clinical relevance, usability for quality improvement, and evaluation of measure properties, including reportability and variability.
CMS’s measure development and maintenance contractor convened a Technical Expert Panel (TEP) on August 21, 2015, to review and advise on the reevaluation results. Information regarding the TEP’s feedback can be found on their website. As a result of the comprehensive reevaluation, CMS identified 28 HHQI measures that were either “topped out” and/or determined to be of limited clinical and quality improvement value by TEP members. These measure will no longer be included in the HHQI. In addition, based on the results of the comprehensive reevaluation and the TEP input, CMS finalized removal of six process measures from the HH QRP, beginning with the CY 2018 payment determination, because they are “topped out” and no longer have sufficient variability to distinguish between providers in public reporting.
Home Health Value-Based Purchasing Model
In the CY 2016 Home Health Prospective Payment System final rule, CMS finalized its proposal to implement the Home Health Value-Based Purchasing (HHVBP) Model in nine states representing each geographic area in the nation. For all Medicare-certified home health agencies (HHAs) that provide services in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington, payment adjustments will be based on each HHA’s total performance score on a set of measures already reported via OASIS and HHCAHPS for all patients serviced by the HHA, or determined by claims data, plus three new measures where points are achieved for reporting data.
The HHAs in these nine states will have their payments adjusted (upward or downward) in the following manner: a maximum payment adjustment of three percent in CY 2018; a maximum payment adjustment of five percent in CY 2019; a maximum payment adjustment of six percent in CY 2020; a maximum payment adjustment of seven percent in CY 2021; and, a maximum payment adjustment of eight percent in CY 2022.
In the CY 2017 Home Health Prospective Payment System final rule, in addition to providing an update on the progress towards developing public reporting of performance under the HHVBP Model, CMS is finalizing the following changes and improvements related to the HHVBP Model:
- Calculate benchmarks and achievement thresholds at the state level rather than the level of the size-cohort and revise the definition for “benchmark” to state that benchmark refers to the mean of the top decile of Medicare-certified HHA performance on the specified quality measure during the baseline period calculated for each state;
- Require a minimum of eight HHAs in any size-cohort;
- Increase the timeframe for submitting New Measure data from seven calendar days to fifteen calendar days following the end of each reporting period to account for weekends and holidays;
- Remove four measures (Care Management: Types and Sources of Assistance, Prior Functioning ADL/IADL, Influenza Vaccine Data Collection Period, and Reason Pneumococcal Vaccine Not Received) from the set of applicable measures;
- Adjust the reporting period and submission date for the Influenza Vaccination Coverage for Home Health Personnel measure from a quarterly submission to an annual submission; and
- Implement the recalculation and reconsideration processes.