Home Health & Hospice Week

Improvement emphasis is disservice.

Lack of stabilization measure inclusion in Medicare’s Home Health Value-Based Purchasing demonstration is a major failing, and it’s going to end up costing the program.

That was the message of many of the 86 commenters who submitted feedback on the Centers for Medicare & Medicaid Services’ 2017 Home Health Prospective Payment System proposed rule published in July. CMS is expected to issue the final rule within a few weeks.

Under VBP, the Total Performance Score (TPS) used to rank agencies and determine payment bonuses and penalties “currently favors rehabilitation home health agencies over chronic care home health agencies,” said Jim Kazmer, Director of Analytics at Wilmington, Mass.-based software company HealthWyse. “This is due to the focus on improvement measures and the exclusion of stabilization measures. Agencies with a higher proportion of rehabilitation patients than chronic disease patients have a higher likelihood of better performance in improvement measures.”

Specifically, VBP “incentivize[s] agencies to take on patients who are capable of demonstrating improvement over time in: 1.) ambulation-locomotion, 2.) bed transferring, 3.) bathing, and 4.) dyspnea,” said Matthew Hubbard in his comment letter.

“We continue to be concerned about the lack of recognition that stabilization is a reasonable clinical goal for some home health patients, and that rewarding only improvement creates a disincentive to care for frail elderly who are less likely to improve,” warned Amedisys Inc. in its comment letter. “A more reasonable goal is to help seniors remain in their homes, whether that is achieved through improvement or stabilization,” the chain said.

“The performance measures do not reflect the patient population served under the Medicare home health benefit as the outcome measures focus on a patient’s clinical improvement and do not address patients with chronic illnesses, deteriorating neurological, pulmonary, cardiac, and other conditions, and some with terminal illness,” the National Association for Home Care & Hospice criticized in its comment letter. “The Medicare home health benefit is not limited to individuals who can show improvement in their clinical condition. If it were, it would disserve the millions of aging beneficiaries afflicted with incurable chronic conditions or terminal illnesses.”

“The focus on improvement measures may trigger discrimination in patient admissions that creates barriers to care for patients with chronic conditions or terminal illness,” the trade group warned.

“The value of including stabilizations measures in HHVBP is readily apparent as it aligns the program with the Medicare home health benefit. Doing so would send a valid message to home health stakeholders that CMS recognizes the scope of the benefit and the population it serves.”

Risk Adjustment Not Enough

In theory, risk adjustment should equalize agencies, Kazmer noted. But risk adjustment accuracy is sorely lacking (see related story, this page).

“A more direct solution is to modify the Total Performance Score calculation to incorporate stabilization outcome measures as well as improvement outcome measures,” Kazmer urged. “In this way, the methodology would be directly measuring chronic care performance instead of indirectly adjusting for its absence (through risk adjustment).”

Bottom line: “Inclusion of stabilization measures in TPS would directly reduce case mix bias in TPS,” Kazmer maintained. “The exclusion of stabilization measures is a direct form of bias. I doubt that this bias is intentional.”