Home Health & Hospice Week

Therapy is likely on its way out as a payment factor, regardless of HHGM's fate.

A united effort by the often-splintered home care industry seems to have succeeded in scuttling the dreaded Home Health Groupings Model in the 2018 HH PPS final rule, but experts are betting that won't be the last you see of the payment reform plan.

The Centers for Medicare & Medicaid Services said it "wasn't finalizing" the HHGM proposal when it issued the final rule Nov. 1 (see Eli's HCW, Vol. XXVI, No. 39). But if you look closely, CMS also took pains to make clear it was not officially withdrawing HHGM, which was the target of most of the 1,350 comment letters CMS received on the proposed rule.

"It is unclear whether HHGM is truly dead or just delayed," notes Washington, D.C.-based healthcare attorney Elizabeth Hogue. "It seems possible that [HHGM] has just gone dormant and may rear its ugly head at a later date."

What will happen with HHGM is anyone's guess at this point, agrees Robert Markette Jr., attorney with Hall Render in Indianapolis. CMS says it "received many comments from the public that it would like to take into further consideration."

"While the industry got at least a temporary gift during National Home Care and Hospice Month, it's too early to celebrate [HHGM's] demise," Hogue says.

On one hand: CMS and its contractor Abt Associates have spent a lot of time and resources developing HHGM, so CMS "salvaging" the model with some tweaks to address the points that most concerned commenters is at least somewhat likely, Markette says.

In the final rule, CMS notes that "commenters were most concerned about the proposed change in the unit of payment from 60 days to 30 days and such change being proposed ... in a nonbudget neutral manner." They also wanted a seat at the table for payment reform development and more access to support data used in the process.

Markette wouldn't be surprised to see a new HHGM proposal that omits the switch to 30-day payment cycles, but keeps the elimination of therapy utilization from the PPS case mix system. Various bodies including the Medicare Payment Advisory Commission, Government Accountability Office, and HHS Office of Inspector General are all critical of using therapy visits to help set HH PPS rates.

But if CMS does cut therapy utilization as a case mix factor, it will have to find another way to incorporate consideration for therapy costs into the payment system, Markette believes. A great number of the comment letters on the proposed rule were from therapists stressing this point and arguing for therapy's cost-saving value in home care.

A new payment reform model "must recognize that therapy is a legitimate part of home health... that keeps patients out of the hospital," Markette tells Eli.

On the other hand: HHGM was begun under the Obama administration, and the Trump administration may take this opportunity to scrap the initiative and start over with something else entirely, Markette offers. With Administrator Seema Verma heading up CMS, the agency might choose to go in an entirely different direction considered more "innovative," he adds.

In the CMS release announcing the final rule, Verma says "it will take additional time to further engage with stakeholders to move towards a system that shifts the focus from volume of services to a more patient-centered model. CMS will take the comments submitted on the proposed rule into further consideration regarding patients' needs that strikes the right balance in putting patients first."

Do this: In either scenario, HHAs probably "need to prepare for a shift of payment incentives for therapy toward higher utilization of SN and HHA disciplines," predicts consultant Anna Doyle with Laff Associates in Hilton Head Island, South Carolina.

Even if providers aren't ready to take concrete steps toward payment reform prep yet, "all agencies should remain alert regarding this matter until such time as CMS releases additional information," urges consulting firm The Health Group in Morgantown, West Virginia.

Don't Let CMS Off The Hook

Regardless of future rulemaking, HHAs now can celebrate that they "dodged payment reform ... that would have eviscerated the industry," Markette cheers.

And "what is definitely worth celebrating is that the deletion of HHGM in the final rule is likely a result of action taken by the industry," Hogue says. "Just an outstanding effort that truly made a difference."

In a statement, NAHC calls the HHGM delay "a clear victory for the home health community that took action to stop the rule from becoming final. NAHC thanks everyone who has fought this good fight with us."

The sheer volume of comments on the proposed rule (1,350 letters) may have surprised CMS, and certainly got its attention, Markette says. The resulting success should remind HHAs to use their voice and comment on important rules and initiative going forward, he urges.

Watch out: If CMS's attention to budget neutrality when announcing HHGM's deletion from the final rule is any indication, the agency may pursue payment reform without accompanying cuts in the future. If that's the case, Markette exhorts HHAs to be just as vocal in submitting feedback to CMS on vital payment system changes.

Investors seemed to be one sector celebrating the news from Medicare. Stocks in publicly traded home care companies rose sharply on news of HHGM's delay.

Stats: Before and after the rule's announcement, Louisville, Kentucky-based Almost Family Inc.'s stock price rose from $40.40 per share to $53.95 (36 percent increase); Lafayette, Louisianabased LHC Group's stock price rose from $65.31 to $72.07 (10 percent increase); Baton Rouge, Louisiana-based Amedisys Inc.'s stock price rose from $46.45 to $58.49 (26 percent increase); Kindred Healthcare Inc. (with Kindred at Home, formerly Gentiva) rose from $5.85 to $8.40 (49 percent); and Birmingham, Alabama-based Health-South Inc. (with Encompass Home Health) rose from $45.34 to $49.36 (9 percent). However, some of those stock prices fell again after rising.