Home Health & Hospice Week

CMS encourages hospitals to highlight quality, cost info for referrals.

The new discharge planning requirements for home health agencies aren’t the only ones affecting home care providers. Hospital provisions in the rule will impact HHAs, too.

The discharge planning final rule published in the Sept. 30 Federal Register specifies that hospitals “must include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides.”

Pay attention: “HHAs must request to be listed by the hospital as available,” the new regulatory language at 482.43 instructs. “This list must only be presented to patients for whom home health care post-hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation,” the Centers for Medicare & Medicaid Services says in the rule.

The proposed rule gave rise to worries about hospitals steering patients to their own HHAs — the same type of worries that have plagued agencies since the Balanced Budget Act of 1997 required hospitals to provide such a list. “Some commenters expressed concern that the proposed requirements may lead to hospital steering, with some commenters expressing concern that certain hospitals may employ tactics to purposely channel patients to other providers or suppliers within their medical system or under common ownership,” the final rule notes.

CMS dismisses those concerns, noting that hospitals and other providers must comply with fraud and abuse laws, Stark self-referral laws, and anti-kickback laws. “Hospitals, HHAs and CAHs will be in compliance … if they present objective data on quality and resource use measures specif­ically applicable to the patient’s goals of care and treatment preferences, taking care to include data on all available PAC providers, and allowing patients and/or their caregivers the freedom to select a PAC provider of their choice,” CMS maintains. “Providers will have to document all such interactions in the medical record.”

Plus: Hospitals must “inform the patient and/or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services, while not specifying or otherwise limiting the qualified providers or suppliers that are available to the patient,” the rule adds.

Remember, “compliance with these requirements will be assessed through on-site surveys by CMS, state survey agencies, and [accrediting organi­zations] and … purposeful patient steering (that is, directing patients and/or their caregivers to PAC providers that do not align with the patient’s goals of care and treatment preferences) could lead to a determination of provider noncompliance with the requirements in this rule,” CMS stresses.

Another help: The rule also finalizes a proposal aimed at patient steering problems. The hospital discharge plan “must identify any HHA or SNF to which the patient is referred in which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare,” the new regulations read.

CMS gives hospitals some leeway on how to handle the requirement, however, by not requiring “a specific form or manner in which the hospital must disclose financial interest. The hospital could simply highlight or otherwise identify those entities in which a financial interest exists directly on the HHA and SNF lists or the hospital could choose to maintain a separate list of those entities in which a financial interest exists,” according to the rule.

That vagueness makes some agencies worry that hospitals will be able to get away with steering patients to their own agencies.

But hospitals should at least have an incentive to guide their patients toward some sort of home health setting, notes Chad Mulvaney with the Healthcare Financial Management Association. “Providing patients and their families with cost and quality data about the post-acute providers available so they can make an informed choice has been shown to reduce costs and improve outcomes,” Mulvaney points out in online analysis.

In fact, data from Medicare’s Bundled Payments for Care Improvement initiative show “the lion’s share of savings … came from reduced unnecessary utilization of institutional settings of post-acute care (both by replacing discharges to skilled nursing facilities (SNFs) with discharge to home with home health and by reducing the number of days in a SNF when an institutional stay is needed),” Mulvaney says.

Unfortunately, “a hospital can comply with the rule, but still keep the lion’s share of the referrals,” judges attorney Robert Markette Jr. with Hall Render in Indianapolis. “This is not because the hospitals are intentionally steering patients, but simply due to an agency being affiliated with the hospital.”

It’s natural for the patient to go with the hospital’s agency if they’ve been satisfied with their experience at the hospital itself. “If I don’t know any of the agencies, but I feel that the hospital took good care of me, I am going to almost certainly pick the agency that has the hospital’s name,” Markette relates.

This rule doesn’t prohibit practices like hospitals placing their agency at the top of their referral list, Markette adds.

Your HH Compare Stats Matter

Like for HHAs (see story, p. 280), the rule finalizes a requirement for hospitals to “assist patients, their families, or the patient’s represen­tative in selecting a post-acute care provider by using and sharing data … on quality measures and data on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.”

Expect this: HFMA urges hospitals to use “cost and quality data” for this purpose. “Although hospitals participating in alternative payment models … have long had the ability to provide patients with this type of information to help guide patient decision-making, some organizations have been hesitant to do so due to CMS’s longstanding requirement that providers also not interfere or influence patient choice,” Mulvaney says. “However, this final rule should help clarify that and allow more providers to succeed in these programs in the near term.”

Highlighting the quality and cost information should “reduce Medicare spending … as Medicare patients choose higher-value PAC providers,” Mulvaney predicts.