Home Health & Hospice Week

Access issues loom if pay reform isn't budget neutral, expert warns.

The home health industry's tooth-and-nail fight to head off the disastrous Home Health Groupings Model has succeeded - at least in the short term.

Late Nov. 1, the Centers for Medicare & Medicaid Services posted the 2018 Home Health Prospective Payment System final rule. Much to home health agencies' delight, CMS said on its website that it "is not finalizing the implementation of the Home Health Groupings Model (HHGM) in this final rule. The agency received many comments from the public that it would like to take into further consideration."

The vast majority of the proposed rule's 1,350 commenters vehemently opposed the payment model which would have stripped nearly $1 billion from Medicare home health spending in its first year alone and eliminated therapy utilization from the case mix adjustment system altogether. Numerous lawmakers also weighed in, sending CMS Administrator Seema Verma and then-HHS Secretary Tom Price letters urging the agency to delay the program and to solicit more industry input on revising it. CMS maintains in the final rule that "commenters were generally supportive of the concept of revising the HH PPS case-mix methodology to better align payments with the costs of providing care."

But, it does admit that "commenters included technical comments on various aspects of the proposed case-mix adjustment methodology under the HHGM and were most concerned about the proposed change in the unit of payment from 60 days to 30 days and such change being proposed for implementation in a non-budget neutral manner. Commenters also stated their desire for greater involvement in the development of the HHGM and the need for access to the necessary data in order to replicate and model the effects on their businesses."

While CMS withdrew its HHGM proposal for the time being, it did follow through on a common request from commenters: elaborating on the behavioral assumptions it used in modeling HHGM's impact. One assumption was "for LUPAs one visit under the proposed HHGM case-mix group thresholds, HHAs would provide an additional visit so the 30-day period of care becomes a nonLUPA." In other words, episodes one visit shy of the LUPA threshold would commonly see a visit added on, compared to current utilization.

The other assumption was that "the highest paying diagnosis code would be listed as primary for clinical grouping assignment," according to the rule.

The HHGM withdrawal also means CMS will be walking back its proposal "to add two current OASIS-C2 items, M1033 and M1800, at the [followup] time point or to remove collection of eight current OASIS-C2 integumentary status items at the FU time point," the final rule notes.

Watch For Ghost Of HHGM In 2018

HHAs' efforts to lobby against the HHGM change, particularly bipartisan support garnered from members of Congress, may have weighed heavily in favor of CMS and the Office of Management and Budget nixing the proposal for 2019, believes Dave Macke, Director of Reimbursement Services with VonLehman & Co. in Ft. Wright, Kentucky.

Fifty senators from both sides of the aisle sent letters to HHS and CMS urging an HHGM delay, and in the House 179 representatives did likewise, notes the National Association for Home Care & Hospice, ElevatingHOME, and the Partnership for Quality Home Healthcare in a joint statement about the rule.

Some industry unity seems to have gone a long way on this matter. "I don't know that the omission of HHGM from the 2018 payment rule happens without a unified effort of the national trade associations, state trade associations, and all providers of all sizes," observes finance expert Mark Sharp with BKD in Springfield, Missouri. "The collaborative effort was refreshing to see for the sake of the industry. Kudos to the leaders on all fronts."

Agencies may be particularly relieved that OMB resisted the "money grab" of HHGM's severe budget cut, Macke notes.

"I'm glad to see ... CMS is willing to do more research and get stakeholder involvement" in future payment reform, Macke tells Eli.

Stay tuned: But agencies must keep a close eye on CMS's activities surrounding HHGM to head off another drastically unfavorable proposal.

View this year's rule "as a postponement and not a cancellation," urges Tom Boyd, VP of Reimbursable Services with Simione Healthcare Consultants in Rohnert Park, California. "Look for it to be back for 2020, with some modifications as advocated by the home health care associations."

While "a battle may have been won with the delay, the war will likely continue on HHGM," Sharp agrees. "I hope this delay is a sign that CMS is ready to welcome stakeholders to the table in the development of any new payment model, and that sufficient amounts of homework is done to understand true impacts of any new payment model."

NAHC, ElevatingHOME and PQHHC expressed appreciation for the delay and eagerness to work with CMS on the next iteration of payment reform.

Vital: Sharp hopes to see payment reform go budget-neutral in the next go-round. "The home health industry has seen the federal base rates decreased by nearly 15 percent over a seven-year period," Sharp tells Eli. "While the industry has been amazing in its ability to pivot to reduce the impact of these cuts, I don't know how much more they could absorb without closures and access to care issues."

Note: See the 258-page final rule at https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-23935.pdf. Stay tuned to future issues of Eli's Home Care Week for more details and analysis of the rule's provisions.