Home Health & Hospice Week

Providers still waiting on key info.

On the eve of implementation, home health agencies are readying new policies and procedures while urging Medicare to release more details about the Value-Based Purchasing model that takes effect Jan. 1.

Hopefully agencies “have already been doing what they need to do, which is provide the highest quality care in a cost-saving setting,” notes Marie Fredette of the Arizona Association for Home Care, in that VBP pilot state. “January 1st isn’t when they will begin doing things differently,” Fredette tells Eli. “It’s when the measurement under the model begins.”

HHAs should have started tightening up their quality improvement procedures and outcomes when the Centers for Medicare & Medicaid Services announced last year, in the 2015 final rule, that VBP was slated for January 2016 implementation, emphasizes consultant Pat Laff with Laff Associates in Hilton Head Island, S.C. On one hand: “This is an opportunity for home health to really shine and we embrace it,” declares Ann Horton with the Maryland-National Capital Homecare Association. “Maryland home health agencies are ready for this challenge and eager to show our value and role in transforming healthcare across the United States,” Horton says. “Our industry is ready to step up to the plate and focus on quality of patient care,” says Bobby Lolley with the Home Care Association of Florida. “Our community dedicates each day to servicing patients in need and providers certainly welcome reform that puts patients at the center of the healthcare system.”

HHAs have been educating themselves on the program, state association heads report. For example, attending webinars focused on VBP data, notes Pat Kelleher with the Home Care Alliance of Massachusetts. The Nebraska Home Care Association has been working with members on preparations, says NHCA’s Janet Seelhoff.

On the other hand: “We are all still in a learning phase about the program and how it will impact agencies in our state and/or access to care,” says Doris Visaya with the Home Care Association of Washington.

It’s difficult for agencies to feel fully prepared when so many details of the program are still unknown. “CMS has not clarified all of the details yet, so we are still waiting to find out what the rules of engagement will be in this program,” Horton observes.

HHAs Impatient For VBP Details

For example: HHAs want information on what benchmarks CMS will use to determine whether agencies will receive a reward, stay even, or lose money under the program. Or even just a projected date when CMS will release that information, Lolley says.

HHAs also hope to soon find out exactly what population CMS will use to determine VBP scores. “The Home Health Compare star rating system uses all OASIS submissions and claims data for Medicare and non-Medicare enrollees on OASIS data,” Lolley explains. VBP is supposed to use data from Medicare enrollees only, “but CMS hasn’t decided if it will be Medicare enrollees in just Fee for Service or also Medicare enrollees in Medicare Advantage as well,” Lolley says.

Result: “This puts home health agencies at a state of ignorance in terms of where they stand in comparison to other agencies in the state and where their own performance will be,” Lolley tells Eli.

“Agencies look at the star rating in Home Health Compare to get a clue, but those won’t be fully accurate.”

HHAs also hope to soon learn how much technical assistance CMS and its VBP contractor, The Lewin Group, will provide under the program, Kelleher says. State associations will be looking “to fill in those gaps.”

“I would like to see CMS get the complete package of information and details out to the agen-cies and state associations as soon as possible,”

Horton says. Then state associations can plan events and target training topics accordingly.

Too Many Measures, Too Much Risk

As the program kicks off, agencies in VBP states wish CMS had listened to more suggestions from commenters on the 2016 proposed rule. For example, many commenters urged the agency to trim the number of quality measures used in VBP.

CMS did cut five measures, but there are still 24 measures agencies must grapple with under the program (see Eli’s HCW, Vol. XXIV, No. 39). That includes three brand new measures that pilot agencies must report via a new portal system.

“We are particularly concerned that efforts to collect new measures will divert staff time needed to work on performance improvement,” Kelleher worries.

Pilot agencies also want to see the risk pool reduced. CMS originally proposed a pool rising from 5 to 8 percent over five years. Many commenters vociferously protested a risk pool that large, in comparison to 1-2 percent for hospital VBP (see Eli’s HCW, Vol. XXIV, No. 34).

In response, CMS made the risk pool increase more gradual, starting at 3 percent. But it still will rise to 8 percent in the fifth year of the program.

“We still believe that 3-8 percent at risk is way too high when one factors in all the other cuts in reimbursement that a homecare provider has to deal with these days,” Lolley insists. “Home health providers in the Sunshine State are certainly weary of continued risk of reimbursement cuts, including the case mix creep cuts.”

Florida providers also wish they weren’t the only “large Medicare population state” to be in the pilot, Lolley relates.

Agency Closures Loom On The Horizon

The first year of VBP is likely to put agencies on a big learning curve, particularly since many of the final details are still unreleased. The year’s biggest challenge “will be getting all the agencies in our state on board, informed and educated about the program,” Horton predicts. “Training is costly and not all agencies have the funds to pay for conferences and trainings. We are looking for as many free and low-cost training opportunities as we can find.” And “first years always have challenges in both implementation and unintended consequences,” Fredette cautions.

Delayed impact: Remember, pilot agencies won’t see the payment effects of their VBP scores until 2018.

HHAs in pilot states can’t stick their heads in the sand, experts caution. “History shows us that major changes in payment methodology do lead to closures,” Horton says.

“Any business has potential to be at risk in the face of a change to their revenue stream,” Fredette acknowledges.

The rub: It won’t even necessarily be poor quality agencies that are forced to close, Lolley expects. “Under this new model, the amount of your reimbursement isn’t just dictated based on how your agency performs, but also how it performs compared to those in your area,” he points out. “So even if everyone is delivering care with high patient quality, there will still be losers.”

Do this: Actively engaging in education and preparation activities will be key to surviving under the system, experts urge (see story, this page).

Note: Read about the VBP program in the final rule at www.gpo.gov/fdsys/pkg/FR-2015-11-05/pdf/2015-27931.pdf. See CMS’s HH VBP website at https://innovation.cms.gov/initiatives/home-healthvalue-based-purchasing-model.