Home Health & Hospice Week

That lack of access will cost Medicare money.

Commenters’ favorite Home Health Value-Based Pur­chasing topic was how the newly proposed-to-expand payment model treats patients who don’t improve — and why that’s all wrong.

“Since HHVBP was first proposed in 2015, the criteria used to measure HHVBP blatantly discriminate against Medicare beneficiaries with longer-term, chronic conditions who require skilled care but are not expected to improve — patients covered by the Jimmo class action settlement,” accuses Judith Stein with the Center for Medicare Advocacy in her comment letter. (Reminder: The 2013 Jimmo v. Sebelius settlement makes clear that Medicare covers skilled nursing and therapy even when the patient’s condition may not improve.)

“These measure sets are discouraging to patients with Alzheimer’s, ALS, COPD, CP, MS, paralysis, post-stroke, and to many other beneficiaries with longer-term, chronic conditions,” Stein insists.

“CMS has failed to secure meaningful measures in HHVBP for individuals who do not improve, but who need services to maintain their conditions or to slow decline,” Stein declares in the letter. “Instead, HHVBP measures penalize home health agencies when patient improvement is not achieved. Expanding HHVBP will continue and exacerbate the devastating loss of access to necessary home health care that Jimmo beneficiaries have experienced,” she says.

“The HHVBP model has devastated delivery of home care to people who are not expected to improve and expansion of HHVBP will exponentially worsen the problem,” Stein warns. “Since 2015, six years of CMS promising to consider new measures for Jimmo beneficiaries” has amounted to “no progress toward producing such measures in HHVBP,” Stein lambastes. “CMS’s answer is the same each year, as stated in the latest proposed rule, ‘we do not believe [stabilization measures] would allow for meaningful comparisons between competing-HHAs on the quality of care delivered,’” she cites.

“CMS offers nothing further to describe how care for people who need services to maintain or slow decline, critical ‘stabilization measures,’ will ever be incorporated into HHVBP,” Stein blasts.

“Not only does HHVBP discriminate against Jimmo beneficiaries, it creates a ‘survival of the fittest’ mentality among providers,” Stein adds. “The few agencies remaining that are willing to serve all patients, including patients with longer-term, chronic conditions who qualify for coverage, may be financially penalized and/or audited for providing such services,” she warns CMS.

“Our overarching concern about the expanded HHVBP model is the same as what we expressed about the original model, namely maintenance of beneficiary access to home health care,” says AARP in its comment letter. “HHAs may … respond to payment pressure by avoiding beneficiaries whose care is perceived as potentially jeopardizing HHAs’ performance scores, yet those beneficiaries may be the ones having the greatest clinical needs for home health services,” AARP stresses.

It’s not just beneficiary advocates who see this problem. HHAs widely pointed it out when CMS first proposed the VBP model in 2015 (see HCW by AAPC, Vol. XXIV, No. 36).

And they do so again in this round of commenting. “Home health agencies are often dealing with patients with chronic illness for whom stabilization is a positive outcome, but this is not taken into account with the HHVBP model,” Cheryl Foster, Director of North Kansas City Hospital Home Health, says in her comment letter. “I fear that agencies will tend to reject referrals on these patients as they know that they will not likely be able to improve their outcomes, leaving them with few options for the care they need,” Foster says.

“The original HHVBP does not adequately address the value of high-quality home health services for patients with chronic illness or those at the end of life,” points out Lauren Reynolds, founder of At Home Nursing Care Inc. in Encinitas, California. Even with some tweaks from CMS, the expanded model does the same, Reynolds says.

“The current program disincentivizes providers from taking maintenance patients as most measures are based on patient improvement. Successful treatment of a maintenance patient will likely not result in improvement in most of the metrics,” reports Joy Cameron, associate vice president of public policy with Humana, in her comment letter.

Take These Steps, HHAs And Reps Say

To fix these issues, some commenters recommend drastic actions. “HHVBP should be suspended, reviewed for all the reasons previously stated, and not expanded unless and until measure sets account for all patients equally,” Stein urges CMS.

But many HHAs and their representatives suggest the program go ahead, perhaps with a slight delay, with fixes in place.

One option would be more carrot, less stick. “I recommend the model be constructed where the high performing agencies share in the Medicare savings, while those that do not meet this threshold are not penalized,” says one anonymous commenter.

Many providers urge inclusion of quality measures aimed at stabilization. “CMS should establish a Technical Expert Panel (TEP) to evaluate the proposed HHVBP measures to ensure that the measures appropriately consider the full scope of the patient population served with the home health benefit, particularly patients not likely to experience condition improvement,” the National Association for Home Care & Hospice recommends in its comment letter.

“A modified risk adjuster that accounts for this patient population” would also combat the problem, NAHC suggests.

“CMS should develop measures that reward stabilization in patients with chronic and/or unstable conditions,” urges Patricia Kelleher with the Home Care Alliance of Massachusetts in her comment letter.

If CMS can’t manage to include the not-expected-to-improve population, then it should leave them out of VBP altogether, multiple commenters urge.

“Please consider excluding patients that discharge from HH to a hospice,” asks Kimberly Oxendine, Director of Quality and Compliance with HealthKeeperz Inc., in her comment letter. “These patients have declines, which negatively impact HH. However, HHs are admitting these patients to manage hospital transitions, prevent rehospitalizations, care for wounds, meds, etc. during a time that the patient/family are not accepting of hospice,” Oxendine explains.

“Typically, the HH staff are the ones who provide the education to get these patients on the right service line (hospice), but we are affected negatively when we have provided the best care and resources possible,” Oxendine highlights.

Stein suggests a broader exclusion. “If CMS expands HHVBP, CMS should remove all patients with maintenance goals from HHVBP inclusion until all measures, incentives, and disincentives equally reflect their needs and qualifications for Medicare coverage as for those beneficiaries who can improve,” she exhorts. “This alternative is not a solution, and will not make Jimmo beneficiaries any more desirable to home health agencies, but it would not impose affirmative punitive HHVBP measures on agencies for serving patients with longer-term, chronic conditions,” she says.

Note: CMS’ fact sheet about the Jimmo settlement is at www.cms.gov/medicare/medicare-fee-for-service-payment/snfpps/downloads/jimmo-factsheet.pdf.