Home Health & Hospice Week

Good news: Project will exclude managed care. Medicaid patients.

Home health agencies' concerns about the coming pay-for-performance demonstration project didn't fall on deaf ears after all.

The Centers for Medicare & Medicaid Services and P4P demonstration contractor Abt Associates have decided to exclude managed care and Medicaid patients from demonstration calculations. That decision comes after listening to HHAs' arguments for the move in a December Open Door Forum on the project.

CMS and Abt originally planned to use outcome-based quality improvement (OBQI) data to compute P4P rankings, Abt's Henry Goldberg told attendees of the National Association for Home Care & Hospice's annual policy conference in Washington, DC.

But after hearing the arguments against including non-Medicare patients, CMS and Abt will compute fee-for-service outcomes separately for the P4P demo, Goldberg revealed in the April 23 session. That means your P4P scores won't match your OBQI-based Home Health Compare figures, experts point out.

The pitch: HHAs have nothing to lose by participating in the P4P demo, Goldberg urged. No agency will lose money by participating--and they could stand to gain a significant amount of money if they do well.

How it will work: CMS and Abt plan to put participating HHAs in two groups--control and treatment. If patients in the treatment group save the Medicare program money overall--on services like hospital stays, doctor visits, durable medical equipment, etc.--participating HHAs will split the money saved.

Downside: If the treatment group patients don't save Medicare any money, there will be no financial rewards. And agencies won't find out whether any money is saved until the first year of the demonstration is over.

CMS and Abt haven't finalized the P4P demo structure yet, however, Goldberg noted. They may also compare the treatment group to patients of HHAs that aren't in the demonstration at all.

Taking overall savings to contribute to P4P rewards is different than most P4P set-ups. Usually programs take a percentage of reimbursement away from providers to form a reward pool and then the winners receive those funds. The home health version is "P4P nice," Goldberg joked--no one's reimbursement is decreased.

Share the wealth: Abt expects many agencies to be P4P winners. CMS and Abt will assign P4P rewards based on each performance measure individually. And they will give rewards for both top performers and most improved, over a certain threshold. "We don't want to reward agencies that start out really, really, really bad and just end up really, really bad," Goldberg told attendees.

Using those rules, 61 percent of agencies in a sample year would have received P4P rewards just for top performance alone, Goldberg said.

Other selling points are that agencies can use P4P success as good publicity and marketing; the demo requires no extra data collection burden since numbers come from submitted OASIS data; and both control and treatment group HHAs will get extra data that could help them improve outcomes, Goldberg said.

"You're going to have P4P sooner or later," Goldberg said. "Why not try it now" with no financial risk? Consider these P4P demo key components when deciding whether to participate:

• Who's enlisted. CMS will soon say where the demonstration will take place. Although the agency and Abt considered offering a nationwide demo, they now plan to run the demo in yet-to-be-announced states in four different regions, Goldberg said. The demo will compare your outcomes to other patients in your region only. Outcomes will also be risk adjusted.

• Who gets rewards. CMS and Abt plan to award the lion's share of the P4P incentives to top performers at 75 percent. Most improved agencies will receive 25 percent of the reward pool.

And they will calculate the rewards by region. That means some regions may see a big reward pool while others have no rewards at all, depending on whether any savings are realized between the treatment and control group patients.

• Time period considered. It's not only outcomes during the home health episode that will count. The P4P time period for calculating outcomes and reward amounts will run 30 days after discharge from home health, Goldberg noted.

• Measures included. Last December, CMS and Abt proposed eight measures for inclusion in the demo. While Goldberg couldn't release the official proposed set of measures at the conference, he did hint that "at least one measure" from the original list won't be on it.

And unfortunately for some, the deleted measure probably won't be the much-criticized ones on hospitalization or emergency room use. Those are a high priority for CMS, Goldberg noted.

Timeline: Watch for CMS to propose the official P4P demonstration structure very soon, Goldberg said. Demonstration details aren't final until the official notice is issued. 

Editor's Note: More P4P information is at www.hhp4pdemo.info.