Home Health & Hospice Week

Medicare Advantage will make HHAs’ lives difficult in even more ways under the new payment model.

Delayed benchmarks and unfair exclusion of improve-ment due to a baseline year move is a big Value-Based Purchasing mess, but it’s not the program’s only one.

Medicare Advantage has wreaked havoc with many aspects of home health agencies’ existence, and VBP isn’t immune.

“When a Medicare beneficiary switches from a Medicare Advantage (MA) plan to Fee-for-Service Medicare, [the Centers for Medicare & Medicaid Services] requires the agency complete a new Start of Care (SOC) OASIS,” the National Association for Home Care & Hospice explains in its comment letter on the 2023 proposed rule. “Although CMS’ policy does not require a discharge OASIS from the previous payer, without completing the discharge OASIS, the SOC OASIS for the MA plan does not have an assessment necessary to complete the quality episode. Failure to discharge from the MA plan could negatively impact the agency’s Quality Assessment Only metric,” NAHC continues. “Therefore, HHAs will complete a discharge OASIS assessment with payer changes, creating a premature discharge from the agency, with a resulting artificial quality episode.”

Impact: “The resulting quality measures for the artificial quality episode typically reflect little or no improvement in the outcome measures; negatively impacting the agency’s overall quality measure scores,” NAHC tells CMS. “HHAs increasingly have had concerns with how this has negatively impacted their star ratings and HH QRP program.” Under VBP, ”agencies that have high numbers of patients in MA plans, and subsequent payer changes, are at greater risk for negative impacts,” NAHC warns.

Relatedly, “high occurrences of beneficiary payer changes from one MA plan to another MA plan” is a problem, NAHC adds. “In these situations, agencies are faced with varying plan guidance for submission of start of care and discharge assessments. Often, agencies must unwillingly utilize the Discharge/Readmit process to meet the plan requirements when switching from one MA plan to another. This creates an even larger number of artificial quality episodes, therefore, creating additional negative impact on star ratings and HHVBP measures,” NAHC details.

Result: “Nationwide cohorts in the Expanded HHVBP program could place agencies in high MA saturation areas at an unfair disadvantage,” the trade group cautions. Even if this wasn’t much of a problem in the initial nine-state VBP pilot, “there may have been less variation within those state cohorts than will be seen in a nationwide cohort for comparison,” NAHC expects.

CMS “should exclude patients who have transferred from Medicare fee-for-service to a Medicare Advantage Plan … from Outcome Measures and Value-based Purchasing,” urges Neil Pruitt Jr. of PruittHealth in his comment letter.

Other VBP issues raised in the comment letters include:

• Shared savings. NAHC urges CMS to “provide a ‘shared savings’ element wherein HHAs that reduce Medicare spending through performance improvement share in the estimated $3.4 billion in expected savings to the Medicare program,” its letter says. That “would further incentivize [PI] as well as fairly address the weakness in the HHVBP model that leads to financial penalties to HHAs that contribute to Medicare savings, but still fall in the bottom half of performance in comparison to other HHAs,” NAHC notes.

“In the CY 2022 rulemaking, CMS chose not to address this recommendation on the basis that it had not proposed a ‘shared savings’ element to the design,” the trade group points out. “However, proposed rulemaking is intended to refine and improve policy proposals. The NAHC recommendation was offered for that purpose,” NAHC pushes.

• Unwanted incentives. HHAs with a high proportion of clinically complicated beneficiaries are likely to be financially penalized under the HHVBP, notes LeadingAge’s Katy Barnett in the trade group’s comment letter. Agencies can “simply dump or avoid beneficiaries with complicated conditions to improve their performance” and “access to care with complicated clinical and functional conditions can become problematic,” Barnett warns CMS.