Home Health & Hospice Week

The Centers for Medicare & Medicaid Services is pushing ahead with plans to publish hospitals' home care referral statistics, and changes to referral practices could be the upshot.

In a rule it calls "Nondiscrimination in Post-Hospital Referral to Home Health Agencies and Other Entities," CMS proposes to collect, maintain and publish information "about hospitals referring Medicare patients to [HHAs] with which the hospitals have a financial interest," it says in the Department of Health and Human Services Semiannual Regulatory Agenda.

CMS plans to take "final action" on the rule in October, the agency notes in the May 27 Federal Register. CMS proposed the rule back in November, where it said it will most likely publish the numbers in January 2004 (see pdf of Eli's HCW, Vol. XI, No. 43, p. 347).

Since CMS proposed the rule, at least one hospital has been cited for its home care referral practices (see pdf of Eli's HCW, Vol. XII, No. 16, p. 122).

If a hospital's referral stats look bad enough, HHAs could see it mend its referral practice ways, predicts consultant Terri Ayer with Ayer Associates in Tuscon, AZ. For example, "where there is obvious, significant bias with referrals going almost exclusively to the hospital-based HHA," a hospital may feel pressured by freestanding HHAs in the area, CMS and/or the public to change.

On the other hand, "in communities where hospitals have made the effort to fairly represent the options, the black and white numbers may end complaints" from freestanding agencies that have unrealistic expectations, Ayer offers.

Making hospitals' stats public is sure to spark a debate over what percentage of self-referrals is acceptable, expects consultant Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas. "What is too much or too high?" Boyd asks.

Freestanding HHAs can't fight the fact that a hospital has a natural, perfectly legal advantage in securing referrals, notes consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD.

Unless patients have had previous experience with an HHA or know someone in the industry, they are likely to go with whomever the hospital recommends, and the hospital is free to recommend its own agency, Sevast points out.

But in those isolated cases where a hospital isn't playing fair, these publicly disseminated numbers may help wronged HHAs bring the problem to light, she acknowledges.

Oversight authorities including CMS, state surveyors, the Joint Commission on Accreditation of Healthcare Organizations, the HHS Office of Inspector General and others may be much more willing to listen to an agency's complaint of patient-steering or cherry picking the most profitable patients if the agency has hard numbers to back it up, Ayer says.

Regulators haven't made much of an effort to prioritize this issue, Boyd notes. But the increased scrutiny made possible by collecting and publishing the numbers could change that focus.

CMS Puts Off COPs - Again

CMS also published its intentions regarding home health conditions of participation in the agenda, pushing the final rule on them back yet one more time to December. The agency first proposed the COP changes more than six years ago.

Due to the drastic changes in the home health industry since 1997, HHAs will need another comment period on the COPs before they become final, experts agree.

Despite the delay, CMS eventually will get the COPs out, Sevast expects. A number of changes that CMS finds important, regarding OASIS and outcome-based quality improvement (OBQI), must be published in them.

And HHAs should find out this month how much CMS will pay them for fiscal year 2004. CMS must publish the new episode and per-visit payment rates by June 28 to meet the Oct. 1 deadline for implementation, the agenda notes.

Oxygen Standards On The Horizon 

CMS wants to propose service standards for suppliers of home oxygen, therapeutic shoes and home nutrition therapy. The standards would "ensure that suppliers are qualified" and would head off fraud and abuse, the agency suggests.

November is the target date for issuing that proposal.

Average wholesale price for drugs covered by Medicare would come under the gun by next month, according to CMS' schedule for an AWP proposed rule in the agenda. If CMS slashes AWP, it must add a separate service component to cover the costs suppliers incur furnishing drugs, the American Association for Homecare insists in a June 4 letter to CMS Administrator Tom Scully.

Physicians receive service payment through the practice expense component of the resource-based relative value system (RBRVS), but suppliers receive no such reimbursement, AAH points out.

And CMS wants better labeling and other distinguishing features for oxygen containers to help avoid "deadly medical gas mix-ups" in which harmful industrial gases are hooked up to patient's oxygen supplies. CMS plans to issue a proposed rule on that matter by February 2004.

Finally, hospices can expect to see their own set of COPs proposed in October, amendments proposed last November finalized in January 2004, and new wage index numbers in August.