Home Health & Hospice Week

Hospice services will count toward spending.

You’ll be responsible for patients long after discharge, at least in one respect, under a newly adopted quality measure.

Despite industry protest, the Centers for 1Medicare & Medicaid Services finalized the four IMPACT Act-required quality measures as-is in its 2017 Home Health Prospective Payment System final rule. For the new measure “Total Medicare Spending per Beneficiary — Post Acute Care Home Health Quality Reporting Program (MSPB-PAC HH QRP),” CMS retained its proposed 90-day window.

How it will work: “The episode trigger … is defined as the first day of a patient’s home health claim with a HHA,” CMS explains in the rule published in the Nov. 3 Federal Register. “The episode
window is the time period during which Medicare FFS Part A and Part B services are counted towards the MSPB–PAC HH QRP episode.” And that window length, comprised of “treatment” and “associated services” periods, is set by the type of episode:

1. Standard. Non-Low Utilization Payment Adjustment, non-Partial Episode Payment episodes have a treatment period that “begins at the episode trigger (that is, on the first day of the home health claim) and ends after 60 days after the episode trigger,” CMS explains. “The associated services period begins at the episode trigger and ends 30 days after the end of the treatment period,” CMS adds. In other words, the window is 90 days.

2. LUPA. The window for a LUPA episode is the same as for a standard one — 90 days.

3. PEP. For these episodes, “the treatment period begins at the episode trigger (that is, on the first day of the home health claim) and ends at discharge,” according to the rule. The associated services period starts at the episode trigger and ends 30 days after discharge.

To calculate per bene spending, Medicare will add the cost for Medicare Fee For Service Part A and Part B services during the 90-day episode for standard and LUPA categories and varying length episode for the PEP category, CMS says.

Exceptions: CMS did finalize certain exclusions that won’t be counted in the spending, including “planned hospital admissions; management of certain preexisting chronic conditions (for example, dialysis for end-stage renal disease [ESRD] and enzyme treatments for genetic conditions); treatment for preexisting cancers; organ transplants; and preventive screenings (for example, colonoscopy and mammograms),” according to the rule. “Exclusion of such services ... ensures that facilities do not appear more expensive due to these services and do not have disincentives to treat patients with certain conditions or complex care needs.” CMS also excludes from the calculation episodes during which the beneficiary isn’t under Medicare the entire time.

What’s not excluded: The measure “include[s] the Medicare spending for hospice services but risk adjust[s] for them, such that MSPB–PAC HH QRP episodes with hospice are compared to a benchmark reflecting ... episodes with hospice,” CMS says. “We believe that this provides a balance between the measure’s intent of evaluating Medicare spending and ensuring that providers do not have incentives against the appropriate use of hospice services in a patient-centered continuum of care.”

Watch out: Scenarios that will make your MSPB figure skyrocket are when patients who are hospitalized or enter another facility, such as a Skilled Nursing Facility, during the episode window. Commenters on the proposed rule shared plenty of concerns about this measure with CMS — particularly about the 90-day window length.

Criticism #1: Window Length

Short but standard episodes will leave agencies on the hook for spending long after their care of the patient is over, protested Interim Healthcare’s Barbara McCann in the company’s comment letter.

“We are concerned about ending home health episodes at 60 days due to the variation in discharged points prior to the 60th day,” McCann said.

“Many home health patients are discharged with goals met prior to the end of their 60-day episode of care, effectively shortening the ‘treatment period,’” Amedisys Inc. told CMS in its comment letter. “If the associated services period does not begin until day 61, the home health agency is inappropriately held accountable for Medicare spending for a post-discharge period of longer than 30 days.”

Response: The treatment period’s length is 60 days for standard episodes “to reflect that HHAs are paid under the HH PPS at a rate based on a 60-day period as determined by the Home Health Resource Groups (HHRGs), regardless of when the last visit actually takes place,” CMS says. “Defining the ... treatment period based on the relevant Medicare payment policy aligns with the definition of the treatment periods for the other MSPB–PAC measures.”

Criticism #2: Significance

And the measure won’t be very meaningful, industry reps warned. “The amount of Medicare spending per beneficiary … does not have a direct correlation to the quality of care provided by Medicare providers,” the National Association for Home Care & Hospice stressed in its comment letter. “Although MSPB may provide some useful information regarding resource utilization, it should not be used as the sole resource use measure or to draw assumptions on quality of care on its own.”

The figures are even less helpful when comparing across provider types, cautioned the American Physical Therapy Association in its comment letter. “There are significant resource variations across the postacute care settings that need to be adequately addressed before cross-setting comparisons can be achieved,” the trade group insisted.

Response: CMS indicated this is a problem to work on in the future. “We will continue to work towards a more uniform measure across settings as we gain experience with these measures, including further research and analysis about comparability of resource use measures across settings for clinically similar patients, different treatment periods and windows, risk adjustment, service exclusions, and other factors,” the agency says in the final rule.

Criticism #3: Misuse

APTA was also skeptical about CMS’s plans for the measure’s usage. “One MSPB measure, in isolation with the limitations of claims based data, cannot define postacute care,” APTA warned in its comment letter. “Therefore, it is imperative that this measure is used in concert with other measures to more fully define the scope of postacute care services. The final MSPB measure should be used to effectively analyze the necessity of postacute care services and not to merely make payment cuts.”

There are still many other quality measures, CMS takes pains to point out. But “we believe it is important that the cost of care be explicitly measured so that, in conjunction with other quality measures, we can publicly report which HHAs are involved in the provision of high quality care at lower cost,” the agency says.

Criticism #4: Access

This measure might lead to HHAs avoiding patients at high risk of elevated spending levels.

“Using MSPB as a quality measure could negatively impact access to home health care for certain high risk patient populations as providers are incented to avoid ‘high cost’ patients,” NAHC warned.
CMS’s response to the access problem was that risk adjustment will take care of it. “To mitigate the risk of creating incentives for HHAs to avoid medically complex beneficiaries, who may be at higher risk for poor outcomes and higher costs, we have included factors related to medical complexity in the risk adjustment methodology for the ... measure, including an indicator for ESRD,” according to the rule. And excluding certain services also helps avoid access issues, CMS maintains. (For more on risk adjustment problems, see story below).