Home Health & Hospice Week

Small providers somewhat nervous about cohort revamp proposal.

Home health agencies in the nine Value-Based Purchasing states won’t know how they compare with their peers until they get their final performance reports in January. But hopefully a proposed change will make those rankings more fair for small providers.

Recap: Currently, “the HHVBP Model compares a competing HHA’s performance on quality measures against the performance of other competing HHAs within the same state and size cohort.

Within each of the nine selected states, each competing HHA is grouped to either the smaller-volume cohort or the larger-volume cohort,” the Centers for Medicare & Medicaid Services explained in the Prospective Payment System proposed rule released June 27. “When there are too few HHAs in the smaller-volume cohort in each state (such as when there are only one or two HHAs competing within a smaller-volume cohort in a given state) to compete in a fair manner, the HHAs [are] included in the larger-volume cohort for purposes of calculating the [Total Performance Score] and payment adjustment percentage without being measured on HHCAHPS.”

The problem: CMS found that “the benchmark values for the smaller-volume cohorts varied considerably more from state-to-state than the benchmark values for the larger-volume cohorts,” it said. The problem appeared to be that the cohorts were too small. The result could be that “HHAs in the smaller-volume cohorts could be required to meet performance standards that are greater than the level of performance that HHAs in the larger-volume cohorts would be required to achieve.”

The solution: “We are proposing to calculate the benchmarks and achievement thresholds at the state level rather than at the smaller and largervolume cohort level for all model years, beginning with CY 2016,” CMS said in the proposed rule.

Providers and their reps were mostly happy with this change. “We agree with CMS’s assessment that agencies in smaller-volume cohorts may be forced to meet standards inconsistent with largervolume cohort HHAs, unfairly punishing agencies in the smaller-volume cohorts,” said chain Interim Healthcare in its comment letter.

“Changing to a single State cohort for the selection of shared benchmark and threshold values was very important,” Jim Kazmer, Director of Analytics at Wilmington, Mass.-based software company HealthWyse, said in his comment letter. “The small cohort sample sizes were just too small to be representational and reliable.”

The Visiting Nurse Associations of America wants more, however. “We encourage CMS to annually monitor and report the differential impact of unified state-level benchmarks and achievement thresholds by the smaller- and larger-volume cohorts to ensure that this policy does not produce unintended consequences,” VNAA said in its comment letter.

For the proposed change to require at least eight home health agencies in a smaller-volume cohort, VNAA wants CMS to “continually monitor the impact of this proposal on agencies and provide annual updates on how small agencies perform,” it urged. “Specifically, we request a comparison of how smaller-volume cohorts in all states would compare if included in the larger-volume cohort.”

The VBP program’s state-based structure does have downsides, pointed out the Association for Home Care & Hospice of North Carolina and South Carolina. “State-based comparisons set up a competitive environment that is contrary to the nature of quality improvement efforts,” the trade group pointed out in its comment letter.