Home Health & Hospice Week

The Medicare home health proposed payment rule for 2024 doesn’t stop at calling for a Value-Based Purchasing baseline year change; it also floats a major swap of the elements used to score agencies under the model — and thus a potentially big change to providers’ reimbursement.

Background: The Centers for Medicare & Medicaid Services wants to remove five VBP measures and replace them with three different measures, and then reweight them, summarizes the rule published in the July 10 Federal Register (see details in HHHW by AAPC, Vol. XXXII, No. 24-25).

In particular, CMS proposes replacing the two Total Normalized Composite Measures (for Self-Care and Mobility) with the Discharge Function Score (DC Function) measure and replacing the OASIS-based Discharge to Community (DTC) measure with the claims-based Discharge to Community-Post Acute Care (DTC-PAC) Measure for HHAs.

HHAs have a lot to say about the new DC Function measure in their comment letters.

A very few commenters, including the American Occupational Therapy Association, VNS Health, and Aegis Therapies, offer support ranging from conditional to outright. But the lion’s share of letter-writers have a bone to pick with CMS on the issue — or an entire skeleton.

For instance: The American Hospital Association has “serious doubts about the utility of this measure if it were to undergo the evaluation by a [consensus-based entity],” AHA’s Ashley Thompson says in the trade group’s letter. Even if CMS adopts the measure into its Home Health Quality Reporting Program as proposed, “we strongly urge the agency to hold off on adopting this measure into a pay-for-performance program until we have better information about whether the measure gleans information as intended,” Thompson says.

“We do not support the DC Function measure into VBP until home health agencies have sufficient data on their performance and ability to strateg[ize] improvements if applicable,” agrees Jake Krilovich with the Home Care Alliance of Massachusetts in the trade group’s letter. “We are questioning the accuracy of the measure for stabilized patients, as well as its ability to account for patients that change payer during an HH episode,” Krilovich tells CMS.

And the weighting for the DC Function measure, at 20 percent for the larger-volume cohort and 28.571 percent for the smaller, “seems extreme for patients that are often at a stage in disease progress but are not ready to elect hospice,” suggest execs Jenn Ofelt, Christy Pinkley, and Cathy Simmons with UnityPoint at Home. “Ultimately, this measure may promote cherry-picking of patients, resulting in the home health benefit not being realized for highly acute and/or chronic patients that are extremely sick and in increased total cost of care as symptoms exacerbate requiring higher levels of care,” they caution.

Many questions still surround the measure, says Amedisys Inc. CEO Richard Ashworth in the chain’s comment letter. For example, certain patients are supposed to be excluded from the DC Function calculation, but there is no information as of yet on how that will be accomplished — “OASIS responses for the cognitive assessment … diagnosis codes on the claim … other provider diagnosis codes” or something else, Ashworth asks CMS.

And circumstances outside of an agency’s control can penalize them with this measure. “A patient may request discharge early, plan to move to a different care location, or some other change that may limit the patient’s ability to improve,” Ashworth points out.

Amedisys is also concerned about the penalty when patients switch payers. “Home health providers should not be penalized for following OASIS data collection procedures when a patient has simply chosen to change from one payer to another,” Ashworth insists.

Untried: The DC Function measure “has not been evaluated in the home health setting” and “includes a limited set of self-care items,” the National Association for Home Care & Hospice summarizes in its comment letter.

PPH Proposal Poses Problems

CMS also calls for replacing the claims-based Acute Care Hospitalization During the First 60 Days of Home Health Use and the Emergency Department Use without Hospitalization During the First 60 Days of Home Health measures with the claims-based Potentially Preventable Hospitalization (PPH) measure.

Reminder: HHAs received their first Care Compare preview reports containing PPH data in July and those stats will go up in this month’s refresh (see HHHW by AAPC, Vol. XXXII, No. 31).

The measure has some pros. Unlike the previous ACH and ED measures, it at least acknowledges “that not all hospitalizations or ED visits while a patient is under home health services can be mitigated or prevented,” Amedisys’ Ashworth notes.

“By removing these two measures in favor of one that is more likely to reflect whether HH agencies are providing proper management and care as well as clear discharge instructions and referrals, CMS can better assess quality of care for the purposes of the HH VBP program,” AHA’s Thompson allows.

But the indicators CMS uses to determine what is potentially preventable may not sync with the home health setting, AHA cautions. And it fails to include as risk adjustment factors certain social determinants of health (SDOH) that are predictive of hospital and ED says.

On another front, “UnityPoint at Home is concerned that the PPH measure will penalize HHAs for patients with progressive disease states and for outcomes that are beyond the control of the HHA,” the hospital-based chain says. “Although not a new measure, the PPH measure is challenging for patients with complex needs, who have chronic conditions that are subject to exacerbation,” they tell CMS.

Impact: “Because the PPH measure is weighted at 26 percent for large-volume cohorts and 37.143 percent for smaller-volume cohorts, it promotes cherry picking, leaving patients with chronic conditions requiring monitoring and more intensive services without needed in-home support and services and forced to seek care in a high-cost setting, which elevate[s] total cost of care,” UnityPoint warns.

And “the challenge for the home health provider is determination of the billing from the Acute Care Hospital and if a hospitalization will be classified as a Potentially Preventable Hospitalization,” Ashworth points out. “The lack of clearly and timely knowledge of a PPH stay impedes the home health provider’s ability to recognize and react in a timely manner to understand their PPH performance and take steps to mitigate PPH stays in the future.”

What’s The Rush?

For all of the new VBP QMs, HHAs just need time to adjust to them before they are used as payment factors, many commenters implored.

“Agencies have spent significant resources on quality improvement, working to improve the items currently in the HHVBP model,” emphasizes Kathy Messerli with the Minnesota Home Care Association in the trade group’s comment letter. “Continually moving the goalpost adds a significant administrative burden for agencies and making an astronomical amount of changes at one time is simply setting agencies up for failure,” she argues.

If the VBP proposals are finalized, “only two out of seven total existing OASIS-based and claims-based measures are proposed to remain,” exclaims UnityPoint. “The shift is significant and will undoubtedly alter the HHVBP model.”

Massive change is negative because “continual revisions to measures and the magnitude of changes to the measure set itself frustrates our providers and staff,” UnityPoint relates. It also “undermines their confidence in Medicare quality programs particularly those tied to value and financial incentives.”

CMS should keep in mind that “upon each revision, EMR software is updated, tested, and implemented; policies, practices and decision support tools are reviewed and revised accordingly; and staff are trained and re-educated related to the new measure,” UnityPoint reviews. “For administrative staff this includes collection, management, and reporting; and for direct care staff this includes coaching on documentation of outcomes and demonstrating improved patient outcomes.”

CMS estimates HHAs would first see their new measure data in October 2024. “These proposed changes devalue the great progress and focus we have made and does not allow providers to prepare for the new measures eight months into the baseline year,” points out Clarisse Torres in Idaho. “We have worked hard to focus on the current measures, and now CMS is pulling the rug out from under us mid-year,” Torres protests in her comment letter.

“Penn Medicine at Home urges CMS to allow more home health agencies to gain more experience in the expanded home health value-based purchasing (VBP) model before implementing the changes it has proposed to the model in 2025,” urge’s PMH’s Joan Doyle in the hospital-based agency’s comment letter. “CMS has proposed new measures and changes to existing measures with just months left before the beginning of a new performance year and so many providers have just recently entered the VBP model for the first time,” Doyle observes.

“We appreciate that CMS designated 2022 as a pre-implementation year and we request that CMS offer the same kind of runway in 2024 to test these changes before 2027 payment amounts are put at risk in 2025,” Doyle says. “For much of the nation including Pennsylvania, 2023 was truly the first year of participating in the model and we are not prepared to begin shifting practices and measure expectations just two years later, in 2025,” she tells CMS.

“CMS proposals for such dramatic changes is genuinely concerning since CMS would have had limited, if any, data on HHAs’ performance in the expanded HHVBP program when the proposals were written,” NAHC also points out.

Stay tuned: See what VBP changes CMS settles on in the home health 2024 final rule expected around the end of this month.