Home Health & Hospice Week

CMS, MedPAC reps get an earful

Government representatives weren't the only ones doing the talking at the National Association for Home Care & Hospice's annual policy conference in Washington, DC.

Conference attendees took the opportunity to air their grievances with the Centers for Medicare & Medicaid Services and the Medicare Payment Advisory Commission during the question-and-answer portions of sessions given by CMS and MedPAC reps.

Providers and their advocates took aim at MedPAC's profit margin figures for home health agencies. MedPAC used a projected 14.7 percent Medicare margin as justification for recommending a rate freeze in 2007 for HHAs (see Eli's HCW, Vol. XV, No. 9).

MedPAC's profit margin analysis and rate freeze recommendation were a major influence on Congress passing an HHA rate freeze for this year, CMS' Laurence Wilson noted in his session.

"Profit margins are grossly overstated," consultant Pat Laff told MedPAC staffer Sharon Bee Cheng in her session on pay for performance. Big-ticket items such as telemedicine costs don't show up in those figures, argued Laff, with Laff Associates in Hilton Head, SC.

One Visiting Nurse Association director told Cheng that her VNA has been forced to reduce staff because of the pay cuts sparked by the profit margin figures. Many providers aren't being represented fairly to Congress with those margins, she insisted.

Chen responded that MedPAC reports note the wide variety of profit margins within the industry, and that providers should talk to policymakers about what is allowable on the cost report.

P4P Problems Proliferate

HHAs had a host of criticisms of possible P4P models. Chief among them is that a P4P system will reduce access to care for chronically ill patients. "Who will take those patients?" one HHA official asked.

Providers also had concerns about paying agencies enough to encourage their P4P participation, OASIS accuracy and sensitivity, how long CMS would withhold the reward pool after it's collected from providers, and how agencies on tight budgets would obtain training to improve outcomes under P4P.

Providers voiced these concerns to CMS:

• ABNs. One agency exec asked if there was any way to secure changes to the overly burdensome advance beneficiary notice that is set to take effect in June (see Eli's HCW, Vol. XV, No. 8).

The sheer number of ABNs agencies are supposed to hand out is ridiculous, Laff tells Eli. Requiring an ABN every time care is reduced could mean multiple ABNs per episode, he warns.

• Medicare Advantage. Provider complaints about Medicare managed care plans are legion. Medicare Advantage plans are severely restricting services for home health patients, protested Kristy Wright, CEO of the VNA of Western Pennsylvania. And on the VNA's highest-paid MA contract, it still loses $50 per visit because MA per-visit costs are higher than Medicare visit costs, she said.

Patients enrolled in MA plans "are getting a different Medicare benefit," agreed session moderator Mary St. Pierre with NAHC.

Major problems have arisen because home health patients thought they were signing up for Part D prescription drug plans only and instead ended up in full MA plans, said Jean Macdonald with the Indiana Association for Home and Hospice Care. It's not fair to beneficiaries, Macdonald stressed.

Home care providers are concerned about MA plans' marketing tactics, St. Pierre added.

CMS staffers are "sensitized" to the issue, Wilson promised. However, they may not have much control over things like home health utilization guidelines for individual plans, he noted.

• CBSAs. Some of the wage index changes made in the new Core Based Statistical Area classifications "just seem to be wrong," one Georgia agency rep maintained. He asked how to get CBSA errors fixed.

CMS can't offer wage index reclassification to HHAs like it can to hospitals because it isn't allowed under statute, Wilson maintained.

• Los Angeles fraud. An L.A. County Home Health Council representative protested the difficulty of getting paid for L.A. HHAs who get on CMS' "mysterious list" for fraud in the area. After a RAP already pays, HHAs get their claims denied with no chance for appeal and have to give back the RAP money, the rep said.

There are "huge home health fraud issues" in the L.A. area, CMS' Marie Casey acknowledged. She urged affected providers to work with the CMS regional office to get help if they are targeted unfairly for medical review and denials.