Home Health & Hospice Week

Value-Based Purchasing rules may alter how acquisitions go down.

Medicare is getting to training in earnest for the Expanded Home Health Value-Based Purchasing Model, dropping four new VBP resources plus new OASIS-E materials.

In recent days, the Centers for Medicare & Medicaid Services has issued the Expanded HHVBP Model Guide (49 pages), the May issue of its HHVBP Newsletter (four pages), An Overview: Risk Adjustment Process and Use in the Expanded HHVBP Model (eight pages), and Instructions for Accessing the Achievement Thresholds and Benchmarks in iQIES (two pages), not to mention the threshold and benchmarks themselves. On the OASIS-E side, CMS has issued the Draft OASIS-E Guidance Manual (356 pages) and the updated OASIS-E tool (32 pages) (see related OASIS-E story, p. 138).

The new materials generally cover information CMS has already issued in various places including the 2022 final rule, February webinar, Frequently Asked Questions updated last month, earlier newsletters, and elsewhere. However, it’s worth noting these important points either introduced or reinforced in the guide:

• PPH. Experts have been wondering if the new quality measure for hospitalization and emergency department use may slide into 2023 VBP usage, instead of waiting until 2024.

Reminder: In the 2022 home health final rule, CMS finalized that the Home Health Within Stay Potentially Preventable Hospitalization (PPH) measure will replace the Acute Care Hospitalization and Emergency Department measures in the HH Quality Reporting Program effective January 2023. While HHQRP implementation is set for next year, VBP still has the ACH and ED measures in place for that timeframe, with PPH slated to replace them in 2024.

The new guide doubles down on that timeline. “Beginning with the CY 2023 HH QRP, the Home Health Within Stay Potentially Preventable Hospitalization (PPH) measure will replace the ACH and ED Use measures,” CMS acknowledges in the guide. “However, the PPH measure is not included in the expanded HHVBP Model quality measure set for the CY 2023 performance year/CY 2025 payment year.”

Still, to know for sure, HHAs should wait and see what the 2023 proposed rule holds when CMS issues it in June or July, industry veterans suggest.

• CHOW. Buyers will have one more factor to consider when analyzing potential acquisitions and how to structure them — how VBP adjustments for that agency will be affected. “CMS determines an HHA’s baseline year by the HHA’s Medicare-certification date,” the guide explains. “If a change in ownership (CHOW) results in the use of a new CCN, neither the baseline nor the performance year score will transfer to the new CCN,” CMS spells out. However, “if the agency continues to use the same CCN, then the baseline and the performance year scores transfer to the new owners,” the guide says.
• Small cohorts and CAHPS. The guide affirms CMS’ intention to form a sizeable larger-volume cohort and a much smaller smaller-volume cohort for VBP competition. The larger-volume group will have 60 or more unique beneficiaries in the calendar year prior to the performance year, while the smaller-volume group will have 59 or less. In 2019, that would have broken down to about 7,084 HHAs in the larger-volume cohort and 485 HHAs in the smaller-volume cohort.

Overall, OASIS-based measures account for 35 percent of an agency’s Total Performance Score (TPS) under VBP, claims-based measures comprise 35 percent, and CAHPS-based measures make up the remaining 30 percent. However, “many of the smaller-volume HHAs may not receive a score on the HHCAHPS survey-based measures … while most of the larger-volume cohort HHAs would be scored on the full set of applicable measures,” the guide highlights.

How it will work: “If an HHA is missing all measures from one measure category” — OASIS, claims, or CAHPS — “the weights for the remaining two measure categories are redistributed so that the proportional contribution remains consistent with the original weights,” CMS explains in the guide. “These redistributed measure categories sum to one hundred percent (100%) of the HHA’s TPS,” the agency says.

“For example, if an HHA has sufficient data for claims-based and OASIS-based measures but not HHCAHPS survey-based measures, then the OASIS-based and claims-based measures each count for fifty percent (50%),” the manual details. “If two (2) measure categories are missing, the remaining category is weighted at one hundred percent (100%).”

Questions are still outstanding regarding the cohort sorting as well. “Are they looking at provider numbers, tax ID numbers, or what?” asks Julianne Haydel with Haydel Consulting Services and The Coders in Baton Rouge, Louisiana. Large chains “have multiple small agencies, but they have the same corporate resources available to them as larger agencies,” Haydel notes.

• Measure dates vary. Don’t expect each measure in VBP to draw data from the same time period. “It is important to note that [the Interim Performance Report] data collection periods differ among the types of measures and there are varying lengths of differences in data availability by measure category,” CMS points out in the guide.

For example, for the first IPR expected in July 2023, “data include OASIS-based measure data for twelve (12) months ending 3/31/2023 (performance data covering 4/1/2022 through 3/31/2023), while for the claims-based and HHCAHPS survey-based measures, data includes twelve (12) months ending 12/31/2022 (performance data covering 1/1/2022 – 12/31/2022),” the guide illustrates.

• Measure numerators and denominators. With 12 VBP quality measures to keep track of, including two composite measures comprised of six and three OASIS M items, respectively, knowing exactly what goes into the calculation — and what doesn’t — can be a challenge.

In the guide, CMS provides a handy chart in Appendix B that spells out what goes into the numerator and denominator for each measure, as well as a link to further measure specs.

For example, for the Acute Care Hospitalization measure, which is worth 75 percent of the claims-based category, the numerator includes the “number of home health stays for patients who have a Medicare claim for an unplanned admission to an acute care hospital in the 60 days following the start of the home health stay,” according to the guide. The denominator includes the “number of home health stays that begin during the 12-month observation period. A home health stay is a sequence of home health payment episodes separated from other home health payment episodes by at least 60 days.”

• Holism. Wise agencies will do well to keep the bigger picture in mind.

“A central driver of the Model’s quality measure set is to have a broad, high impact on care delivery and support priorities to improve health outcomes, quality, safety, efficiency, and experience of care for patients,” CMS explains in the guide. “The expanded Model quality measures strive to encompass a holistic view of the patient beyond a particular disease, functional status, state, or care setting.”

Note: The Expanded HHVBP Model Guide is at https://innovation.cms.gov/media/document/hhvbp-exp-model-guide.