Home Health & Hospice Week

Getting docked for things that are out of a home health agency's control is just one of the industry's major concerns about the pay for performance program that may hit sooner than you think.

On Feb. 24, the Centers for Medicare & Medicaid Services held a special Open Door Forum about the home health P4P program, now called value-based purchasing (VBP). The Affordable Care Act, passed last March, requires CMS to issue a report on VBP for home care to Congress in October, noted CMS's John Pilotte in the call.

CMS is still formulating its plan for the report, Pilotte noted. "Your feedback will be valued and help shape what this report ultimately looks like and recommends," he told attendees.

CMS will base its recommendations on factors including the P4P demonstration than ran in 2007 and 2008 (see related story, this page), P4P methods in other industries, and provider feedback, observers expect.

CMS is considering multiple structural issues for a VBP plan, including:

• what measures to include as the basis for performance;
• whether to reward performance based on attainment (high scores), improvement, or both; and
• how to structure payment -- bonuses and penalties for the highest and lowest, recoupments, etc.

Multiple industry callers were adamant that CMS consider an HHA's scope of control over the outcomes used for VBP. CMS will almost surely plan to include hospital readmissions in any VBP structure, based on the previous P4P demonstration and other activities.

"Acute care hospitalization ... is a really difficult multi-faceted experience," one HHA caller told CMS in the forum.

Depending on the patients' condition when discharged and the length of stay, "sometimes we cannot impact those patients that have to go back into the hospital," Ann Brissette of Bronson Home Health Care in Kalamazoo, Mich., said in the call.

CMS needs to base VBP on "something where the agency performance is the driving variable," urged Bob Wardwell with the Visiting Nurse Associations of America. CMS must realize that with some measures, "we're measuring things other than the performance of individual agencies. We're measuring physician behavior, we're measuring hospital behavior, we're measuring the ability of patients to get into hospitals."

Similarly, CMS needs to make sure its risk adjustment procedures are good enough to base payment decisions on, multiple callers urged. Risk adjustment is very important, especially with newly established outcomes, Barbara McCann with Sunrise, Fla.-based chain Interim Healthcare said in the call.

Risk adjustment needs to take many factors into account to accurately adjust for a patient's condition, callers said. Those elements include chronic conditions, payor status ranging from Medicaid dual eligibles to Medicare Advantage, palliative care needs, and other characteristics.

The OASIS tool doesn't necessarily reflect the patient's acuity, warned one caller. You can have a patient with high acuity score "a quite low case mix weight," she said.

CMS's risk adjustment for VBP needs to be "better than 'good enough' and really excellent," urged Wardwell, a former CMS top official. "If we don't have a really sound risk adjustment system ... we're at real risk of exacerbating a problem that already has too many patients in too many areas being left behind ... because they don't have a good prognosis and are going to be costly to care for."

"Many of us do take patients that are more difficult to keep out of the hospital," and the risk adjustment and eventual VBP structure need to compensate for that, urged Val Edison with Iowa Home Health Care in Urbandale.

Bottom line: CMS needs to make sure VBP "is actually measuring differences in performance, not differences in what patients come to our door and are accepted for admission," Wardwell stressed.

Callers were also concerned about very small providers, where isolated incidents can wreck a provider's outcomes.

For example:With the measure for increase in pressure ulcers, "for a small agency, one single event can potentially cause it to be higher than the national average," said Dianne Hansen with Partners in Home Care in Missoula, Mont.

If CMS fails to ensure that it chooses VBP measures in an agency's control that are successfully risk adjusted, it's risking access problems by closing agencies that are already hanging on by a thread in low-access areas.

"I am very, very concerned about sole proprieters ... that are in rural America," one caller told CMS in the forum. "These are agencies that are working at a deficit... Penalties could actually put them out of business and access would be impacted."

Such access problems also could arise if CMS chooses to impose penalties on the lowest performers to pay for bonuses to the highest performers, Mary St. Pierre with the National Association for Home Care & Hospice.said in the forum.

Forum participants seemed united in denouncing any form of recoupments for low performers after the fact. Ideally, CMS could draw funds for the bonuses from savings in the Medicare program, like it did in the demonstration project. But at least CMS could adjust future payment rates or reduce every provider's base payment amount to fund a VBP pool, callers suggested. Like in the P4P demo, most callers agreed that rewards should go to a combination of top performers and improvers.