Home Health & Hospice Week

Will you qualify for the nationwide smaller or larger cohort?

The Value-Based Purchasing program is expanding na-tionwide, and it will change how home health agencies are paid. Agencies need to get a firm grasp of the specifics as soon as possible to make sure they are ready for the reimbursement-impacting change by its proposed Jan. 1 launch date.

For example: HHAs will be compared to other agencies in their cohort to determine VBP rankings. The Centers for Medicare & Medicaid Services plans to form two nationwide cohorts, for “larger- versus smaller-volume” providers, explains the 2022 home health payment proposed rule published in the July 7 Federal Register.

That’s different from the current nine-state model, in which agencies are compared to other agencies only in their state.

“Moving to two nationwide cohorts may create more room for agencies to avoid penalties, because there is a much broader range of participants in the cohort,” expects attorney Robert Markette Jr. with Hall Render in Indianapolis.

Plus: “Using nationwide rather than State/territory-based cohorts in performance comparisons would also be consistent with the Skilled Nursing Facility and Hospital VBP Programs, in addition to the Home Health Compare Star Ratings,” CMS says. And “this option would be the least operationally complex to implement,” it adds.

CMS defines a smaller-volume cohort as “the group of competing HHAs that are exempt from participation in the HHCAHPS survey,” while the larger-volume cohort is “the group of competing HHAs that are participating in the HHCAHPS survey in accordance with § 484.245,” according to the proposed rule. Agencies are eligible for CAHPS exemption when they have fewer than 60 survey-eligible patients in a year, the rule notes.

In 2019, 7,084 HHAs fell within the larger-volume cohort and 485 HHAs fell within the smaller-volume cohort, CMS calculates. “These HHA counts would provide a sufficiently large number of values in each cohort to allow ranking of HHA performance scores and payment adjustment percentages across the range of -5 percent to +5 percent,” CMS maintains.

Read on for more details of the new program:

• CMS is cutting its original Home Health VBP model short by a year so that the nationwide expansion can begin in January 2022, it says in the rule. The nine-state demonstration will end this December, with no more payment adjustments occurring based on the model.
• Nationwide VBP’s first performance year, in which performance data will be collected, will be in 2022, with the data from that year affecting payments up to 5 percent in the first payment year, 2024. “We may make changes to the payment adjustment percentage through rulemaking in future years of the expansion, as additional evaluation data from the HHVBP expanded Model become available,” CMS says in the proposed rule. The 5 percent figure compares to the original nine-state model’s graduated payment rate of 3 to 8 percent over its five-year course. The last year’s 8 percent adjustments, however, were cancelled along with the program to make way for nationwide VBP and due to COVID-19’s impact.
• Data from 2022 will be compared to data from 2019 as the baseline “due to the potentially de-stabilizing effects of the COVID-19 public health emergency (PHE) on quality measure data in CY 2020,” CMS says in the proposed rule. “We may propose to update the baseline year for subsequent years of the expanded Model through future rulemaking,” CMS adds.
• CMS will use a Total Performance Score (TPS) to rank agencies and assign their payment adjustment of up to five percent, negative or positive. The components of the TPS score are (1) a raw quality measure score for each applicable measure during the performance year; (2) an “achievement score” for each applicable measure — a numeric value between 0 and 10 that quantifies an HHA’s performance on a given quality measure compared to other HHAs in the same cohort in the baseline year; (3) an “improvement score” for each applicable measure — a numeric value between 0 and 9, that quantifies an HHA’s performance on a given quality measure compared to its own individual performance in the baseline year (the improvement threshold); (4) a “performance score” for each applicable measure that is the higher of the achievement score or the improvement score; and (5) weighting of each performance score, using each measure’s assigned weight. The performance scores are then summed to generate the HHA’s TPS, CMS explains.
• The claims-based, OASIS assessment-based, and the HHCAHPS survey-based measure categories would be weighted 35 percent, 35 percent, and 30 percent, respectively, and would account for 100 percent of the TPS.
• HHAs shouldn’t have to guess at their VBP performance. “We propose to provide HHAs with their applicable benchmarks and achievement thresholds prior to the start of or during the performance year so that they can be used to set performance targets to guide HHAs’ quality improvement projects,” CMS says in the rule.
• Expanded nationwide VBP will use the same quality measures the current nine-state model uses, at least to start. See the proposed quality measure set in Table 26 at www.govinfo.gov/content/pkg/FR-2021-07-07/pdf/2021-13763.pdf.
• As with the original VBP model, CMS proposes to use two types of reports to provide information on performance and payment adjustments under the expanded HHVBP Model. The Interim Performance Report (IPR) distributed to HHAs quarterly “would contain information on the interim quality measure performance based on the 12 most recent months of data available,” CMS explains. The Annual TPS and Payment Adjustment Report “would be made available to each of the competing HHAs in approximately August of each year preceding the payment adjustment year, expected beginning in August 2023,” CMS says.
• CMS proposes to publicly report performance data for the expanded HHVBP Model beginning with the CY 2022 performance year/CY 2024 payment year. CMS wants to report: benchmarks and achievement thresholds for each small- and large-volume cohort; agencies’ measure results and improvement thresholds; TPS; TPS Percentile Ranking; and payment adjustment for a given year. “We propose to report these data by State, CCN, and agency name through a CMS website” by December 2023, CMS says.