Home Health & Hospice Week

CMS expects agencies providing more therapy visits to see bigger pay cuts under pay reform.

Among the Home Health Groupings Model’s many flaws is its incentive to not furnish therapy to home health patients. So say scores of therapist commenters, many of them with decades of home health experience.

When the Centers for Medicare & Medicaid Services issued the 2018 Home Health Prospective Payment System proposed rule in July, many industry members’ foremost concern with the nearly $1 billion pay cut HHGM would carry in the first year of implementation alone (see commenters feedback on that topic in Eli’s HCW, Vol. XXVI, No. 36). But arguably the second-most referenced topic in the 1,350 comment letters received on the rule was HHGM’s therapy changes.

Now: Currently, part of the PPS case mix system is based on the number of therapy visits provided to patients. The high-therapy episodes particularly have correspondingly high reimbursement rates.

Then: Under HHGM, CMS would eliminate therapy altogether as a PPS case mix factor.

Using therapy utilization as a payment factor has long been a point of contention. “The average number of therapy visits per 60-day episode of care have increased since the implementation of the HH PPS, while the number of skilled nursing and home health aide visits have decreased over the same time period,” CMS points out in the proposed rule published in the July 28 Federal Register.

Further, “the average episode payment by the number of therapy visits for episodes with at least one therapy visit in 2013 increased sharply in therapy provision just over payment thresholds at 6, 7, and 16,” CMS says. According to a study, “the presence of sharp increases in the percentage of episodes just above payment thresholds suggests a response to financial incentives in the home health payment system.”

Similarly, between 2008 and 2013, the Medicare Payment Advisory Commission reported a 26 percent increase in the number of episodes with at least six therapy visits, compared with a 1 percent increase in the number of episodes with five or fewer therapy visits, CMS adds.

And the average share of therapy visits across all 60-day episodes of care increased from 9 percent of all visits in 1997, prior to the implementation of the HH PPS, to 39 percent of all visits in 2015, CMS analysis shows, according to the rule.

MedPAC for years has urged CMS to eliminate therapy from the HH PPS case mix system, as did the Senate Finance Committee when it investigated the matter in 2010. The Senate Finance inquiry “highlighted the abrupt and dramatic responses the home health industry has taken to maximize reimbursement under the therapy threshold models (both the original 10-visit threshold model and under the revised thresholds implemented in the CY 2008 HH PPS final rule),” CMS notes. “Under the HH PPS, the [Senate Finance] report noted that HHAs have broad discretion over the number of therapy visits to provide patients and therefore have control of the single-largest variable in determining reimbursement and overall margins.”

The proposed rule notes that “the HHGM proposal … relies more heavily on clinical characteristics and other patient information (for example, principal diagnosis, functional level, comorbid conditions, admission source, and timing) to place patients into meaningful payment categories, rather than the current therapy driven system. We believe this patient-centered approach is consistent with how clinicians differentiate between home health patients and would improve payment accuracy and access for medically complex cases and not just cases receiving therapy.”

Hospitalizations Will Rise Under HHGM, Commenters Say

According to many therapist industry veterans, CMS is throwing the baby out with the bathwater in the HHGM approach to therapy.

“I am appalled by this proposed rule,” said Clay Watson, Therapy Chair for the Utah Association for Home Care, in his comment letter. “This rule will have incredibly negative impacts on seniors and people with disabilities [and] will effectively deny access to one of the most cost effective interventions in all of CMS,” Watson contended. “Inhome provision of Physical, Occupational and Speech Therapies allows front line treatment that manages risk in your most costly populations. This proposed rule would greatly increase your hospitalization risk, driving health care costs much higher.”

Less therapy provided is going to translate into more hospitalizations for those patients, agreed therapist Mike Black from Utah in his comment letter. That will “be crippling to the Medicare budget and extremely detrimental to the geriatric population.”

“I have been a physical therapist for 24 years and have worked in every type of setting,” Pete Barusic from North Carolina said in his comment letter to CMS. “The last two have been in the home health and currently the patients that are receiving home health are sicker and have more challenges than what I had seen even five to 10 years ago. They are less capable medically to attend outpatient therapy and for those that would normally benefit from short term rehab stay, they no longer qualify. We have seen the trend that elective surgical patients are now being sent home, with a larger majority having multiple comorbidities. They do not fall into the normal classification system and it is not realistic to provide them the same level of services as someone without any other medical issues.”

Result: “This population runs a significantly higher risk of re-hospitalization and infection,” Barusic stresses. “They would benefit from more services, not less.”

The payment reductions for therapy patients will mean those patients have trouble accessing the benefit, many commenters told CMS. Bob Mc-Kneely from Georgia said “I have been a home health physical therapist since 1992. There have been many changes in the payment system for home health, but none have had the negative effect that the current proposal will have to patient care. The inability to provide therapy services to rural areas, the high risk for hospitalization due to decreased level of care, and the increased Medicare dollars spent on those hospitalizations will be crippling to the Medicare budget and extremely detrimental to our senior population.”

This proposal will limit therapy services for patients who are “most vulnerable and have the greatest need for rehabilitation,” warned PT John Werle in Indiana.

“This is a step in the wrong direction,” emphasized a commenter from Your Therapy Source in Texas. “Patients get so little therapy in home health as it is now. To offer less is to offer virtually nothing.”

PT Jason Darling of Sunshine Home Health in Spokane Valley, Washington, agreed CMS is going down the wrong path. “If anything, we should continue to focus on increasing access to home health therapies as we can truly make a difference in one’s ability to stay in their own home longer and in a safe manner, thus avoiding hospitalizations,” Darling argued. “This would especially be true of those hospitalizations that result due to falls (PT and OT can minimize fall risk), aspiration pneumonia (Speech therapy can decrease this risk), and medical complications from weakness/lack of activity due to chronic diseases such as Congestive Heart Failure or Chronic Obstructive Pulmonary Disease. Medicare beneficiaries with these conditions can benefit greatly from the teaching of therapists to improve their functioning and safety, yet the HHGM model would not support their involvement due to the predicted low reimbursement levels.”

Multiple commenters noted that beneficiaries living in rural areas will particularly be vulnerable to therapy access problems under HHGM.

Anticipating some of the arguments against HHGM underpaying for therapy, CMS said in the proposed rule that under the model, “therapy continues to be a valued home health service, as two of the six clinical groups (neuro/stroke rehabilitation and musculoskeletal rehabilitation) under the HHGM reflect instances where therapy would be the primary focus of home health care.”

Agencies will find out whether CMS will heed commenters’ feedback in this area when the agency issues the 2019 HH PPS final rule, expected in early November.

Side note: Removing the therapy thresholds from PPS is one reason CMS is also proposing a 30- day PPS payment period under HHGM, down from the current 60 days. “Without thresholds being used to account for resource use variation, a shorter period of care is needed to reduce the variation and improve the accuracy of the case-mix weights generated under the HHGM. The HHGM’s goodness of fit statistics (for example, R-squared) improve due to reduced resource use variation when a shorter, more constrained time period is examined,” the agency says.

Note: See the 2019 HH PPS proposed rule at www.gpo.gov/fdsys/pkg/FR-2017-07-28/pdf/2017-15825.pdf.