“ Placing HOME at the center - PowerPoint Presentation

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“Placing HOME at the centerof health care delivery”

HHPPS Overview

Joy Cameron

August 3, 2017Slide2

Overview

CY2018 HHPPSRate

Home Health Value Based Purchasing

Home Health Quality Reporting Program

Home Health Groupings ModelAdvocacyResourcesSlide3

CY2018 Home Health RateCMS projects that Medicare payments to HHAs in CY 2018 would be reduced by 0.4 percent, or $80 million, based on the proposed policies.

The proposed decrease reflects the effects of:

a 1 percent home health payment update percentage ($190 million increase);

a -0.97 percent adjustment to the national, standardized 60-day episode payment rate to account for nominal case-mix growth for an impact of -0.9 percent ($170 million decrease); and

the sunset of the rural add-on provision ($100 million decrease).Slide4

Home Health Value-Based Purchasing Demo

Effective January 1, 2016, the new model is in effect in nine states:

MA, MD, NC, FL, WA, AZ, IA, NE, TNSlide5

Current Value Based Purchasing Measures

Quality of Care

Improvement in ambulation

Improvement in bed transferring

Improvement in bathing Improvement in dyspnea Discharged to community

Improvement in pain with activity

Improved management of oral medications

Influenza immunization received for current flu season

Pneumococcal vaccine ever received

Drug education on all medications provided to the patient/caregiver

Patient Experience

Care of patients

Communication between providers and patients

Specific care issues

Overall rating of home health care Willingness to recommend the agencyAgency Reported MeasuresInfluenza vaccination coverage for home health personnelHerpes zoster (shingles) vaccination ever received by patient Advance care planning

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CY2018 Proposed Changes to HHVBP

Move to 40 surveys from 20 surveys Proposed Program Year 3 change:

Remove the Outcome and Assessment Information Set (OASIS) -based measure - Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of CareSlide7

CY2018 Proposed Changes to HHQRP

the replacement of one quality measure,the adoption of two new quality measures,

the reporting of standardized patient assessment data in five categories described under the IMPACT Act,

Functional status, such as mobility and self-care at admission

Cognitive functionSpecial services, treatments and interventions such as the need for ventilator use, dialysis, chemotherapy, central line placement, and total parenteral nutritionMedical conditions and co-morbiditiesOther categories deemed necessary and appropriate by the Secretarydata submission requirements,

exception and extension requirements, and

reconsideration and appeals procedures.Slide8

CY2018 Proposed Changes to HHQRPFurther, they are soliciting comments on:

The application of NQF measures developed for one care setting to be applied to home health care.

Social risk factors most appropriate for reporting stratified measure scores a and potential risk adjustmentSlide9

Home Health Groupings Model

Proposed to begin 1/1/19The new system maintains the same basic principle of paying a percentage of a national average payment amount based on a set of weighted patient characteristics. Includes:

adjustments for low utilization (LUPA),

partial episodes(PEP), and

outliers. The new unit of payment based on a 30-day episode vs. the current 60-day episode under HHPPSMethodology used to determine the percentage adjustment (still called a HHRG or Home Health Resource Group) is substantially changed. Elimination of therapy visits as a factor.

It also adjusts HHRGs through entirely different set of scored categories,

including differentiating between admissions from the community vs. institutions. Slide10

Key Characteristics of HHGMThere will be 144 Home Health Resource Groups that determine the percentage of a standardized 30-day standardized, national payment rate that incorporates consideration of average agency resource use and costs, including those for non-routine medical supplies.

The group is determined by:

Whether the patient is admitted from community or from an institution (hospital or NF).

Whether the patient is in first 30-day episode or a continuing episode.

Patient placement into one of 6 broad clinical categories determined by the primary diagnosis.Patient placement in one of 3 broad functional levels based on OASIS data.Whether there is a relevant comorbidity justifying upward adjustment.Slide11

Specific Guidance on Resource Grouping

The comorbidity system includes 116 total subcategories of comorbidities in 13 body system categories: heart disease,

respiratory disease,

circulatory disease and blood disorders,

cerebral vascular disease, gastrointestinal disease, neurological disease and associated conditions, endocrine disease, neoplasm, genitourinary and renal disease,

skin disease,

musculoskeletal disease or injury,

behavioral health, and

infectious disease.Slide12

Specific Guidance on Resource Grouping

There are 6 Clinical Groupings: Musculoskeletal Rehab,

Neuro Rehab,

Complex Nursing Interventions,

Wound, Behavioral Health, and MMTA (Medication Management, Teaching and Assessment.) If the primary diagnosis is insufficient to establish a Clinical Grouping because it is vague, not associated with home care or otherwise appears irrational, the claim will be rejected as “questionable” and returned to the provider correction.Secondary diagnoses will be used to determine whether a comorbidity adjustment is warranted, not to categorize questionable primary diagnoses.

The comorbidity system includes 116 total subcategories of comorbidities in 13 body system categories: heart disease, respiratory disease, circulatory disease and blood disorders, cerebral vascular disease, gastrointestinal disease, neurological disease and associated conditions, endocrine disease, neoplasm, genitourinary and renal disease, skin disease, musculoskeletal disease or injury, behavioral health, and infectious disease.Slide13

Specific Guidance on Resource GroupingThere are 3 Functional Categories:

Low,

Medium, and

High.

They are based on scoring the following OASIS Items: M1800 Grooming, M1810 Current Ability to Dress Upper Body, M1820 Current Ability to Dress Lower Body,

M1830 Bathing,

M1840 Toilet Transferring,

M1850 Transferring,

M1860 Ambulation/Locomotion, and

M1032 (M0133 in OASIS C1) Risk of HospitalizationSlide14

Specific Guidance on Resource Grouping

“Initial Episode” reflects current timing rules under HHPPS“admission from institution” follows current guidance

However, new occurrence codes will be made available so that this data can come from home health agency final claim rather than waiting for notification to CMS systems based on institutional claims.

Retroactive adjustment would be made based on claims records if the home health report of an institutional admission proves unsubstantiated.Slide15

Significant Changes to LUPAsLUPAs (Low Utilization Payment Adjustments) will still be paid but with the shorter episode:

the break point for LUPAs will no longer be 4 visits but a number of visits 4 or less based on the specific HHRG.

(Table 40)Slide16

Key Characteristics Not Changed by HHGM

RAPs (Requests for Anticipated Payment) requiring a NOI (Notice of Admission) will still be paid in 2019 at the current 60/40 percentage but CMS is seeking input on whether they are still needed with the shorter 30-day episodes. It notes that other providers, like Hospice, are fine with 30-day payment cycles and do not submit NOIs or receive RAPs.

PEPs (Partial Episode Payments) will still be calculated and paid but now as a percentage of the 30-day payment vs. the 60-day payment.

Outliers will still be paid according to current methodology using 2019 rates of payment.

Initial Episodes will still qualify for an add-on payment.CMS still plans to adjust the new payment system each year based on data reflecting home health agency shifts in utilization.Face to Face, Advanced Beneficiary Notice (ABN), and Home Health Change of Care Notice (HHCCN) requirements continue.Slide17

Advocacy

Short window for CMS to consider comments.Consider impact to your individual agency. GIVE FEEDBACK!

Gather comments from agencies and vendors.

Consider a demonstration or voluntary trial.

Slow implementation.August recess visits.Coordinate with ElevatingHOME.Slide18

AdvocacyProposal shifts Medicare home health from a 60-day episode of care payment model to a 30-day episode of care payment model effective January 1, 2019.

This is too big of a change, too quickly and is untested. It shifts an entire health care industry and delivery segment to an untested payment model. There is no precedent for this in any other health care delivery segment.

This change has only been modeled on paper and has never been tested by any agency in any area of the country.

CMS refused numerous requests in the last 12 months to release the information and methodology needed to estimate impact to agencies. Information was first available and released in proposed rule, July 25, 2017.

The new HHGM methodology is a radical shift. For example, it eliminates the therapy visit volume payment determinant in the current model and uses an entirely different case mix model focused on patient characteristics. Slide19

AdvocacyCMS estimates that moving to this model will remove $950 million in Medicare home health payments and asserts it will not impact access to home health care.

After years of rebasing and reductions in payment - despite demand for these services, another cut of this significance will impact access to patients. Many agencies in hard-to-serve areas have very narrow margins that cannot sustain these additional cuts.

Continued payment cuts to home-based care runs counter to the high-quality, patient-preferred care option delivered at a lower cost to Medicare (over institutional based care). Slide20

ResourcesProposed rule (

https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-15825.pdf?utm_campaign=pi%20subscription%20mailing%20list&utm_source=federalregister.gov&utm_medium=email ).

CMS’ fact sheet on the proposed rule -

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-07-25.html

.Grouper files and related scoring assistance for the HHGM are on the CMS website at: https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.htmlSlide21

ResourcesThe

Abt Technical Report upon which the HHGM model is based may be found at:

https://downloads.cms.gov/files/hhgm%20technical%20report%20120516%20sxf.pdf

CMS’ fact sheet on the proposed quality changes:

Proposed Measure Specifications and Standardized Data Elements for the CY 2018 HH PPS Notice of Proposed Rule MakingOASIS 2019 Change Table for CY 2018 HH PPS NPRMProposed OASIS Items for CY 2018 HH PPS NPRMhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html

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