Home Health & Hospice Week

VBP model’s set-up will encourage providers to cherry pick patients, commenters warned.

Commenters on the 2016 PPS rule have listed many flaws in the Value-Based Purchasing pilot proposed for nine states starting Jan. 1. But one of the biggest problems is the dynamic of stabilization versus improvement in the VBP methodology.

Both the VBP model and the recently implemented star rating system on Home Health Compare “put a heavy emphasis on the ability of providers to ‘improve’ the status of the patient,” said PT consultant Cindy Krafft in her comment letter on the 2016 home health prospective payment system proposed rule published in the July 10 Federal Register. “The nurses, therapists, social workers and aides that provide care in the home want to be able to improve the condition and functional ability of every patient, but given the complexity of many of those we serve, our ability to employ skilled care to stabilize the situation and prevent decline (and higher cost care) is invaluable to both the individual and those that love them,” insisted Krafft, of Kornetti & Krafft Health Care Solutions.

“The consistent omission of our data showing stabilization … devalues this important aspect of what we strive for in home health,” Krafft told the Centers for Medicare & Medicaid Services. “In light of the Jimmo v Sebelius decision, the continued emphasis on ‘improvement,’ leaving ‘stabilization’ data inaccessible to our consumers and completely omitted from determining our ‘value’ in demonstration models, does not make sense.”

Cherry picking: With the financial incentives that VBP will bring, “the proposed measures may put too much emphasis on improvement and could incentivize HHAs to choose only patients who can improve,” warned the American Occupational Therapy Association in its comment letter. That would leave “the most vulnerable patients to be eliminated as potential patients for home health care.”

Remember, “many patients require home health services to stabilize or prevent further decline of a condition or functional limitation,” AOTA said. “The settlement in Jimmo v. Sebelius acknowledges that Medicare covers skilled nursing and therapy even if a person’s functional status may not improve. Medicare must cover medically necessary skilled nursing and therapies to maintain a person’s condition or slow deterioration under the Jimmo settlement.”

“Many of the older patients receiving home care have functional limitations that will never improve based on disabilities or chronic illnesses,” explained Karen Alvarez from the pilot state of Florida, in her comment letter. “For these patients maintaining their present functional status with no decline in function is a good outcome for them.”

The proposed VBP model and the star rating methodology favor “agencies that are choosy on which clients they take on,” insisted Diana Taylor in the VBP pilot state of Iowa in her comment letter.

“The agencies taking on the chronic and challenging clients are not rewarded for ‘true care’ keeping them from progressing, keep[ing] chronic clients out of the ER, and keeping them out of the hospital.”

Result: “These agencies that take on clients who by chronic illness cannot improve are going to have their rates cut,” Taylor observed. “Medicare savings comes from managing chronic care,” she said. “True chronic clients do not show many improvements, but the goal to … prevent them from getting worse, identifying early signs or symptoms that takes actual nursing and professional skill … would contain cost of our three most expensive diagnosis in the U.S.”

“Many home health patients will not experience improvement due to the acuity of their condition,” Kindred at Home, which acquired Gentiva this year, stated in its comment letter. “Indeed, HHAs are often called upon to maintain a patient’s condition and slow the decline of their health in order to prevent their reinstitutionalization,” the chain said.

Value-Based Purchasing Ignores One Important Benefit

“CMS continues to under-value stabilization as a legitimate goal of home health services,” criticized chain Amedisys Inc. in its comment letter. “Our ability to stabilize the status of a frail, homebound beneficiary to allow them to remain in their home is … unrecognized in the VBP model. Agencies care for a chronically co-morbid population where often the goal for the patient is to prevent decline.” Agencies have “a significant number of our patients with chronic illness.”

“A deficiency of the group of proposed HHVBP measures is their failure to account for Medicare home health patients for whom home health treatment is specifically prescribed for maintenance, that is, to stabilize or prevent the decline of a condition or functional limitation,” agreed HealthSouth Corp. in its letter. “The Medicare home health benefit is not limited to individuals who can show improvement in their clinical condition. If it were, it would disserve the millions of aging beneficiaries afflicted with incurable chronic conditions or terminal illnesses. While the target outcomes for many home health patients are ones of maintenance, the patient-level HHVBP measures focus only on patient improvement or progress, disregarding successes for patient maintenance.”

“Recent data indicates that the highest per patient Medicare spending on home health services is for patients aged 85 and above,” pointed out the National Association for Home Care & Hospice in its comment letter. “In that patient category, many are afflicted with multiple co-morbidities involving COPD, CHF, Diabetes, and other chronic illnesses.

If this is the primary patient population using home health services, performance measures based on improvement are not very helpful.”

The proposed measures “do not reflect the patient population served under the Medicare home health benefit as the outcome measures focus on a patient’s clinical improvement and do not address patients with chronic illnesses, deteriorating neurological, pulmonary, cardiac, and other conditions, and some with terminal illness,” NAHC said. “This is a shortcoming of the recently unveiled Star Rating system as well and NAHC does not support extending that weakness into a VBP model that will have an even greater impact on home health care delivery.”

Add Stabilization Measures, Commenters Urge

CMS needs to keep the patients in mind when shaping VBP, multiple commenters stressed. “Patients often set goals to stabilize because it is the most realistic and achievable in their current condition,” Amedisys told the agency. “It is important to take into consideration the patient’s perspective when measuring quality. This allows us to move to a more patient-centered approach.”

“Home health agencies should not be penalized because no actual improvement was achieved,” urged Alvarez.

“The time has come to acknowledge the tremendous amount of skill that is required to prevent a complex patient from declining and driving up the overall healthcare cost by reporting stabilization rates for home health to the public (via Home Health Compare), factoring them into the Star Rating system and incorporat[ing] them into the value based purchasing model,” Krafft contended.

“CMS should balance the improvement measures with stabilization measures in the HHVBP,” HealthSouth urged. “In addition to patient improvement, HHAs should also be judged and awarded on the number of patients who remain stable and avoid decline in their functional and clinical status.” CMS should “consider replacing some of the outcome and process measures with stabilization measures in both the VBP pilot and in the Star ratings program,” Amedisys recommended.

Either way: CMS should include “one or more measures that evaluate a patient’s stabilization, or modif[y] existing outcome measures to account for HHAs’ performance in stabilizing and preventing the deterioration of patients,” Kindred said. If CMS doesn’t change the measures, it should at least closely monitor VBP for cherry picking and access problems, multiple commenters advised.

Stay tuned: Whether CMS will incorporate stabilization measures into VBP should be answered by the final rule, which is expected by next month.

Note: See the proposed rule at www.gpo.gov/fdsys/pkg/FR-2015-07-10/pdf/2015-16790.pdf.