Home Health & Hospice Week

Accuracy will place heavy burden on agencies.

One step in the HHGM case mix process is going to lead to increased hospitalizations, heavier administrative burdens, and potential access issues, warned multiple commenters on the HH PPS proposed rule for 2018.

In the Home Health Prospective Payment System proposed rule published in the July 28 Federal Register, the Centers for Medicare & Medicaid Services sets out step one of the Home Health Groupings Model case mix system; classify 30-day episodes into four categories based on timing and source of admission - Community Early, Community Late, Institutional Early, Institutional Late.

That involves determining the patient's admission source, CMS explains. During a 14-day lookback period, patients who were admitted to an inpatient acute care hospital, skilled nursing facility, inpatient rehabilitation facility, or long-term care hospital will qualify as "institutional" sources of admission. Patients who come from another setting are "community" sources of admission.

CMS rejected using admission source as a case mix factor when it revamped PPS in 2008. So why make the change now?

In the proposed rule, CMS cites multiple research studies demonstrating that post-institutional stay patients have higher resource needs.

Data crunching by CMS backs up that assertion, the agency contends. HHA claims data from 2016 shows that for 30-day periods, "institutional admissions have significantly higher average resource use at $2,165.06 compared with community admissions at $1,393.10, a difference of $771.96."

Also, admission source did not perform well as a resource use indicator in the current case mix system. But in HHGM, it apparently performs better.

Community Cases Will See Sharp Pay Drop

Many of the 1,350 commenters on the rule disagreed with CMS's proposal to use admission source as a case mix factor.

Impact: Aegis Therapies in Texas said "for patients with comparable values in other groups ... the admission source can be a 20 percent difference in reimbursement," according to its comment letter.

That doesn't square with the company's experience. "CMS ... ignores the fact that the largest percentage of home health patients ... arrive at home care from community settings, rather than being discharged from an institutional setting," the company said. "Many of our community patients have multiple comorbidities and high care needs."

"The institution of the admission source designation is also going to impact agencies in a very disproportionate way," Aegis continued.

"Those agencies who have focused on supporting the community to age in place are going to suffer significantly in this model as opposed to their counterpart who has focused on institutional settings."

Advocacy group ElevatingHOME told CMS that "community referrals, currently 60 percent of all Medicare home health episodes, experience the most severe payment reductions" under HHGM. Paying HHAs significantly less for community-admitted patients "creates a perverse incentive for agencies to move away from serving patients from the community and will limit access for these beneficiaries," ElevatingHOME predicted.

From Medicare's perspective, that may be all well and good to reduce home care spending. But "reduced access to home-based care will likely result in an increase in emergency department visits, an increase in hospital admissions, and increased use of higher cost institutional care for patients who could otherwise have pre-acute conditions successfully managed in the home," ElevatingHOME warned.

"Inpatient settings would become the primary patient referral target and community referral sources may find a less enthusiastic HHA community," cautioned the National Association for Home Care & Hospice in its letter. Innovative programs aimed at curbing hospitalizations for at-risk beneficiaries also will be stymied.

Bottom line: The institution/community case mix factor "may disincentivize HH providers from accepting patients from the community, which could lead to increased hospitalizations and access issues," said national chain Kindred at Home in its letter.

Multiple commenters urged CMS to drop the case mix factor altogether. "Devaluing the community admission is an unintended consequence of this NPRM, and counter to the triple aim of keeping patients healthier, improving quality, and lowering the overall cost of care," Aegis said.

"A beneficiary's care should be based on clinical diagnosis and their need for services," maintained Pinnacle Senior Care in Michigan. "No payment incentives, or disincentives, should drive home health delivery determinations and therefore access to care, based on the referral source."

Kindred "recommends that more analysis be conducted on this payment adjustment given the high probability that other case-mix adjustments adequately account for differences in payments more accurately than admission source," the company said.