Home Health & Hospice Week

Eliminating therapy from case mix won’t fix what ails it, commenters say.

The Centers for Medicare & Medicaid Services, the Medicare Payment Advisory Commission, and the Senate Finance Committee, among others, have long been criticizing therapy as a Home Health Prospective Payment System factor due to agencies’ ability to influence the utilization. That may be a valid point, but cutting therapy from PPS case mix won’t be the cure-all many believe, multiple commenters told CMS in their feedback on the 2018 HH PPS proposed rule.

Physical therapist Joseph McLean, the rehabilitation manager at Visiting Nurse and Health Services of Connecticut, laid out the problem in his comment letter. “In the same way these agencies implemented procedures to maximize therapy visits [under current PPS], I feel it will be very likely the same agencies will severely curtail therapy services once the HHGM goes into effect. There is absolutely no incentive in this model for an agency to provide any therapy. If the patient falls into a group that provides lower reimbursement because therapy is not expected to be provided, many agencies will dictate to their therapists that plans of care must be limited.”

The problem applies to “what might be considered a high therapy group” as well, McLean notes. In that case, “the incentive will also be to provide as little therapy as possible. As I’m sure CMS is well aware, therapy is a high-cost service and the less therapy provided to a patient who is expected to have high therapy utilization will mean higher margins for the agency.”

Warning: “The reason CMS originally tied therapy utilization to increased payment was because it was understood that agencies might be tempted not to provide a high-cost service like therapy if they were not paid to do so,” McLean told CMS. “From what I can tell, there is no penalty for not providing therapy to a patient the groupings model expects to have high therapy utilization, which would seem to incentivize agencies to limit therapy as much as possible to maximize their margin.”

The California Hospital Association also expressed concerns “that the reduced reliance on therapy volume for rate determination may lead to provider stinting on therapy,” according to its comment letter. “While we recognize that the patient classification is designed to provide a rate inclusive of necessary physical/occupational therapy or speech/language pathology (SLP) services, it is unclear how HHAs will be held accountable for providing those services.”

Ideally, CMS would use patient outcomes as a check on therapy stinting, through avenues such as Home Health Compare and, to a greater extent, Value-Based Purchasing. CMS may also intend to use medical review to combat such gaming, noted the American Physical Therapy Association in its comment letter.

But “the VBP program is not currently a viable option, as the program is still in its infancy, and it continues to be unclear what impact the program will have on the behavior of HHAs,” APTA contended.

And “we fail to see how medical review is a sufficient option to remedy the consequences associated with delivering inadequate care, as medical review does nothing that would allow care delivery to be modified during the episode,” APTA said.

“How will a reviewer looking at a chart prove that more therapy visits should have been provided?” McLean asked CMS. “This seems like a much higher hurdle to clear than reviewing a current episode and determining a number of therapy visits were not necessary.”

Bottom line: “What checks will the new model have to ensure therapy is provided to patients who need it?” McLean asked. “From where I sit, it looks to me that it will be much easier for agencies to maximize margins under HHGM than it ever was for agencies to maximize reimbursement under PPS.”