Home Health & Hospice Week

Enough with the case mix reshuffling, commenters tell CMS.

Another payment year’s start will mean another round of uncertainty about how Medicare will reimburse you for your patients.

Reminder: In the 2015 HH PPS final rule, “we finalized a policy to annually recalibrate the HH PPS case mix weights — adjusting the weights relative to one another — using the most current, complete data available,” the Centers for Medicare & Medicaid Services noted in the 2017 Home Health Prospective Payment System proposed rule issued in June.

UnityPoint at Home based in Urbandale, Iowa, “is concerned that case mix payment adjustments continue to jeopardize home health agencies already experiencing small profit margins,” the two-state chain said in its comment letter on the proposed rule. “These adjustments continue to incentivize higher therapy utilization,” UnityPoint maintained.

“HHAs that continue to focus on high quality care and providing only reasonable and necessary home health services continue to see decreases in profit margins resulting in the inability to reinvest in the infrastructure needed to continue to improve quality and patient satisfaction,” UnityPoint told CMS. “Ultimately, we believe that these adjustments will result in fewer HHAs and lessen consumer choice in seeking quality home health options.”

The National Association for Home Care & Hospice took CMS to task in its comment letter for using a 15-minute time component in this year’s case mix recalibration. While the outlier calculation revamp based on the 15-minute time units may be more noticeable, the time component also affects case mix, the trade group noted in its letter.

“NAHC generally agrees that reforming case mix weights and the standards for determining whether an episode of care qualifies for outlier payment are positive steps in bring[ing] accuracy and improved sophistication into the payment methodology,” according to the letter. But “the proposals here include a flawed concept that can trigger discrimination in care access for certain patient populations as a result of inadequate reimbursement,” the trade group said.

“That flaw is the use of 15 minute increments/units of care at uniform levels of value as proxies for costs in both the proposed outlier reforms and case mix weight recalibrations,” NAHC explained. “CMS’s proposal uses a single weighted 15-minute time unit in the case mix weight recalibrations. As a result, those

HHRGs that involve shorter than average visits end up with a lower case mix weight than should be due. Likewise, higher than appropriate case mix weights is assigned to HHRGs with higher than average units of care in the visits.”

The resulting reduced weights in the clinical and functional dimensions will have a “significant adverse impact” on the ability of an HHA to care for patients with the following resource-intensive conditions:

• diabetes;
• heart disease;
• neurological diagnoses (including their associated functional deficit combination);
• blood disorder;
• dyspnea;
• diagnosis combinations; and
• general reductions to skin, wound and ulcer diagnoses.

“We strongly urge CMS to restore justified scoring and weights to ensure that care for patients with these chronic conditions are properly reimbursed,” NAHC said in its letter.

Note: You can see the proposed revised clinical and functional dimension thresholds in in Table 7, and the new proposed case mix weights in Table 9 of the proposed rule at https://www.federalregister.gov/d/2016-15448.