Home Health & Hospice Week

PPS rule comments go from 89 last year to 1,350 this year.

If CMS was testing the waters for payment reform with its recent Home Health Groupings Model, the agency may feel burned from the scorching comments it received on its proposal in the 2018 Home Health Prospective Payment System rule.

In July, the Centers for Medicare & Medicaid Services floated an entirely new payment model with some very drastic changes, including elimination of therapy from the case mix system, a major overhaul of the factors used to calculate case mix, shortening payment periods from 60 to 30 days, and more. CMS estimated that home health agencies would see an average 4 percent payment reduction under HHGM, which would strip nearly $950 million from home health spending in its first year, 2019, alone (see Eli’s HCW, Vol. XXVI, No. 27-28).

While HHAs had expected a payment reform proposal after some earlier CMS releases about the model, they were largely blindsided by the model’s extreme changes and severe pay cuts. Accordingly, they used the official rulemaking comment process, which closed Sept. 25, to let CMS have it.

More than 1,350 parties submitted comments on the rule, according to regulations.gov. That is a sharp increase compared to recent years — there were only 89 commenters on the 2017 HH PPS rule last year; 120 commenters on the 2016 HH PPS rule; and 364 commenters on the 2015 HH PPS rule. The majority of this year’s commenters addressed only one issue in their letters — the HHGM proposal.

Many commenters exhibited frustration and anger over HHGM, using words like “death knell” and “nightmare” to describe the proposed change.

“Please do not pass this proposed rule,” said one Florida commenter. “It will destroy all quality home health as we know it.”

Another commenter criticized the HHGM formulation process as “not transparent… [T]here was no input from experienced, quality providers.

Have any of you been on the front lines and in the patient’s homes?” the commenter demanded. “You will be rewarding inefficiency and not high quality, and placing your Medicare population and veterans living in the rural communities at greatest risk.”

“Making payments based on patient characteristics and not care need is absurd. Look at your processes used for characteristics, then you go to the front lines of care and see if it matches up… You are about to change the most efficient, cost effective form of healthcare for many Americans.” Christine Folker from Florida told CMS “as an Administrator of a home health agency and a member of the home health industry for 20 years, I continue to watch the industry be decimated by regulations and burden placed on good providers instead of CMS taking on the bad providers directly.

As an agency that continues to hire more and more staff to keep up with the burden and onslaught of regulations, this change stands to weed out good providers who can no longer afford to be compliant,” she said.

HHGM’s impact “on our elderly patients (your parents and mine) will be devastating. It will negatively affect our economy and the patients that have built this free country,” exclaimed occupational therapist Gaytha Ziegelmeier from Oklahoma.

“These changes feel punitive,” said Lisa Haglund with Sunshine Home Health Care in Spokane, Washington. “The resulting effect will be the closing of many agencies, [a] decrease in resources for our patients, and [an] increase in the utilization of more expensive hospitalizations.”

“This would devastate our industry. Currently our profit margins are very small and we can barely make a living now,” warned Adri Diaz from Florida.

“The purposed changes seem as though they want to obliterate home health agencies and the benefits they provide to the community (especially the aging). I feel the changes would make it impossible to provide the type of services needed to keep people in their homes instead of being in the hospital or rehab and this would just increase health care costs across the board,” said Sandra Sherman from Florida in her comment letter.

“My agency, like many others, struggles with a limited, ever-shrinking margin that limits its services,” said Administrator Karla Jensen in Idaho. “Wound care with the expensive bandages and supplies … tripling while our reimbursement shrinks is bad enough, and now you want to lower our rates and give us more rules that will jeopardize our agency survival,” Jensen told CMS. HHGM will restrict access to care “for beneficiaries who might require expensive institutionalization if denied home health services. Please help us continue to improve upon our clients’ health rather than removing revenue we would devote to this goal.”

“I have worked in home health for many years and have seen decrease after decrease in reimbursement to home health agencies. The people who suffer are the sick and the elderly,” said Michelle Steele in North Carolina. “We as healthcare professionals like to treat our patients like we would treat our family, and it is heartbreaking to feel like you do not have the resources to do so.”

PT Brett Thompson in Utah, who said he has been a home health therapist for 24 years, told CMS “HHGM would not only reduce my ability to provide care, but it would put my and 30+ percent of the other home health companies I know out of business.

We along with nearly every other home health agency of which I’m familiar operate on a net 1-2 percent profit margin. Nursing and therapy rates are up and over the past ten years, our revenue is down by nearly 40 percent. How much of the burden of health care cost reduction does or should one very small part of the industry have to bear?” Thompson asked CMS.

“The HHGM as proposed is bad policy for patients,” publicly traded company Almost Family Inc. told CMS in its letter. “It is a large and inappropriate rate cut that will lead directly to a reduction in services to these highly vulnerable patients when they need it most,” the Louisville-based chain said.

“Our modeling confirms patients with multiple chronic conditions such as COPD, congestive heart failure and stroke victims will experience dramatic reductions in care.”

Industry Is ‘Weary And Disgusted,’ One Commenter Says

Judith MacDonald in Florida told the agency that “the new rules, compounded with the rest of the changes burdening the home health industry by Medicare, will cripple our agency. The Emergency Preparedness deadline is Nov. 15, the new COPs are due in January, never mind cutting off our cash flow while we are making payroll for visits not paid, never mind the additional 2 percent sequestration facing us, ADRs, audits, survey, and the list goes on and on.”

“Medicare has become a large and uncontrolled behemoth with so many moving parts that agencies can hardly keep up with what is going on and do what’s required to keep us in compliance, but then another rule comes down from another direction and we are scrambling to adhere to that,” Mac-Donald said. “Everyone in our industry is totally weary and disgusted.”

“Let’s top it all off with 2 major hurricanes devastating our southeastern and southern boundaries leaving our major cities flooded, no power, businesses crippled, patients with no homes, no power, mold, and crime, and we are expected to still meet CMS deadlines for everything... What about showing the same compassion for agencies that we are showing our victims?” MacDonald asked. “It seems that CMS is more interested in their rules, regulations and deadlines than they are for the beneficiaries and professionals trying to take care of them. Our country and infrastructure are under tremendous pressure to provide for our citizens. It’s time for Medicare to help with solutions instead of compounding the problems,” she urged.

HHGM Needs More Testing

Numerous commenters pointed out HHGM’s untried status. “This model has not been tested or subject to any type of demonstration prior to proposal.

It is an extremely new, complex system, and there are many unanswered questions surrounding the model,” said physical therapist John Werle from Indiana.

It was hard for agencies to even start to guess at how HHGM will affect them in order to comment, many providers complained. “The grouper modeling tool proposed by CMS was only released with this proposed rule, making it all but impossible to fully interpret during the short comment period,” said Banner Health in Gilbert, Arizona. HHGM is a “radical shift in how home health services are reimbursed.”

Multiple commenters accused CMS and its HHGM proposal of having a bias against small community providers. “If this goes through, I know that thousands of small businesses will close down, leaving only the corporate giants with private equity funds backing their operations,” Diaz said in her letter.

Note: See the proposed rule at www.gpo.gov/fdsys/pkg/FR-2017-07-28/pdf/2017-15825.pdf.