Home Health & Hospice Week

Calculation should weight initial visit unit heavier, commenters urge.

How much would your non-visit resources count under Medicare’s proposed change to the outlier payment calculation? Not much.

So complained multiple commenters on the 2017 Home Health Prospective Payment System proposed rule CMS published in the July 5 Federal Register. In the new policy, the Centers for Medicare & Medicaid Services plans to use 15-minute visit units to calculate whether an episode qualifies for an outlier payment and how much that payment will be (see related story, p. 296).

Many home health agencies and their representatives expressed support for outlier payment reform. But most were highly critical of the 15- minute visit counting strategy. The methodology totally misses out on significant costs to the agency.

“Each visit, regardless of duration, involves fixed costs associated [with] review of the patient’s plan of care and notes from the last visit as a standard of practice; as well as transportation to and from the home, and related visit documentation,” explained Interim HealthCare in its comment letter.

In rural areas, those transportation costs can be significant. The Visiting Nurse Associations of America “is concerned that the proposed adjustment based on hours of care could potentially limit home health providers in small and/or rural areas who provider short but necessary visits but travel a great deal of time to serve that patient,” the trade group said in its comment letter.

“Regardless of whether shorter or longer visits are required for medically complex patients, the majority of the care provided occurs outside of the home through activities like care coordination, communication with physicians and other providers, communication and collaboration with community resources, scheduling of care to be provided, documenting the care that is provided that is not able to be documented in the home, transporting lab results, communicating with the interdisciplinary team that is required to care for these patients and so on,” said one Texas commenter. “Why are these activities and the time and expense incurred in doing them properly and effectively not taken into account? Are home health providers merely agencies made up of clinicians who drive from home to home and spend various amounts of time with each patient or are we a critical part of the value continuum that allows patients to remain in their homes (where they prefer to be for as long as they can safely do so) and out of costly institutional care — both costly acute care stays and longer term nursing home settings?”

Front-loaded: “HHA resource utilization is highest at the beginning of each patient encounter,” HealthSouth explained to CMS. “We therefore have serious concerns with the proposal to weight each 15-minute unit the same when, in reality, the time at the beginning of a patient encounter is significantly more resource-intensive than time later in the encounter. The beginning portion of an encounter contains service initiation, patient assessment, and the beginning of any specified treatment — all activities that generate the majority of a home health clinician’s or aide’s workload during an individual encounter.”

Like many other commenters, the Mayo Clinic urged CMS to “refine the proposed policy to give greater weight to the initial 15-minute units to ensure such fixed costs are accurately reimbursed.” HealthSouth also urged CMS to consider adding weight to the last unit of care to cover postvisit costs “such as patient follow-up, care coordination with other providers/professionals, scheduling, transportation, and lab drop-offs.”

Why The Rush?

Multiple commenters urged CMS to take more time coming up with a suitable reform strategy for outliers.

“The proper weighting can be determined through a combination of cost report analyses and sample testing,” suggested the National Association for Home Care & Hospice in its letter.

Time should “not be equated to the patient’s acuity or the need for an experienced and competent clinician caring for an unstable patient who is being supported in the least costly environment, their residence,” said Interim. CMS should “further analyse the data presented with regard to patient acuity

before the proposed methodology is adopted to mitigate the possible negative impact on unstable patients now able to remain at home.” Amedisys Inc. offered to serve on a Technical Expert Panel on the issue.