Home Health & Hospice Week

Hospital-imposed visit number limits bedevil agencies.

If you haven’t taken steps to partner with hospitals on the new Comprehensive Care for Joint Replacement (CJR) model, you may see your referral stream from them severely impacted.

At the National Association for Home Care & Hospice March on Washington meeting April 4, Centers for Medicare & Medicaid Services Deputy Administrator Sean Cavanaugh highlighted CJR as one of the alternative payment models that CMS is testing. About 30 percent of the country’s population resides in the 67 MSAs where the model is operating, Cavanaugh pointed out.

Watch out: The model applies to hospitals in those 67 metro areas, but it is still likely to affect you even if your agency isn’t in or close to those MSAs. CJR is based on the hospital where the patient received the procedure, not where the patient lives, reimbursement expert M. Aaron Little with BKD in Springfield, Mo., told Eli at the conference. So a patient who travels to a premier hospital in a not-too-close city still will affect that hospital’s bottom line, Little reminds agencies.

After a slow start at the beginning of the year for many hospitals (see Eli’s HCW, Vol. XXV, No. 8), home health agencies are now getting meetings with CJR hospital execs about the lower joint replacement patients affected by the program, conference attendees told Eli.

Under CJR, all Medicare costs for the patients during the hospital stay and 90 days post discharge get counted. If a hospital’s CJR patients’ average cost comes in above a set “target price” issued by the Centers for Medicare & Medicaid Services, CMS will require a repayment. If its average cost comes in below the target, Medicare will pay the hospital an add-on bonus. CMS delayed the repayments until the second year of the model that starts in January 2017, but bonuses will start this year. The “stop-loss” limit for repayments will gradually increase to 20 percent in years 4 and 5 of the model. Hospitals were able to start accessing their target prices in February via the CJR Data Portal, a CMS spokesperson confirms to Eli.

“We expect this incentive to coordinate the services a patient receives before, during, and after surgery [and] will encourage hospitals and clinicians to partner with nursing facilities, home health agencies and other providers of rehabilitation services to provide seamless, high quality care,” CMS said in an April 1 release about the program’s launch.

Good: Hospital executives are recognizing that home health providers can furnish much lower-cost care than skilled nursing facilities after a joint replacement discharge, as long as the patient is stable enough to go home, noted Ed Schulte with Caregivers Home Health in Topeka, Kan. Thus, more joint replacement referrals should come agencies’ way.

Bad: Unfortunately, multiple hospitals are telling HHAs that if they want to keep referrals from that hospital, they must furnish four or fewer visits to their discharged joint replacement patients, attendees told Eli. That’s because the much lower payment for Low Utilization Payment Adjustment (LUPA) episodes will mean a much lower price tag to count toward the hospitals’ average cost figure under CJR.

Worse: Some hospitals are telling agencies that if they fail to deliver just the four LUPA visits to these patients, they won’t lose only CJR patient referrals — they’ll lose all their referrals from that hospital, agency execs said.