Home Health & Hospice Week

Suggestion: If CMS won’t keep 2019 as the baseline year, then it should postpone implementation.

If Medicare officials finalize a proposal to slide the Value-Based Purchasing baseline year from 2019 to 2022, it will be bad news for the many home health agencies that have been working diligently to improve their outcomes since then. A multitude of HHAs are imploring CMS to scrap that plan.

Recap: In its 2023 proposed rule released June 17, the Centers for Medicare & Medicaid Services floated a change to the HHA and model baseline years from CY 2019 to CY 2022 (see HCW by AAPC, Vol. XXXI, No. 22-23). The revision would “enable CMS to measure competing HHAs performance on benchmarks and achievement thresholds that are more current,” according to the rule published in the June 23 Federal Register. “More recent data from the CY 2022 time period is more likely to be aligned with performance years’ data under the expanded Model, and provide a more appropriate baseline for assessing HHA improvement for all measures under the Model,” CMS maintained.

If the baseline year moves as proposed, CMS “would anticipate providing HHAs with their final individual improve-ment thresholds in the summer of CY 2023,” the rule said. Bumping that timeline by half a year would be OK, because “this would be consistent with the original HHVBP Model, for which improvement thresholds using CY 2015 data were made available HHAs in the first interim performance report (IPR) in the summer of the first performance year (CY 2016).”

Many providers are pushing back on the proposal in their comments on the rule, which were due by Aug. 16.

“It is very unfair that the proposed final rule is looking to change the Home Health Value Based Purchasing baseline year from 2019 to 2022,” says one anonymous commenter from Wisconsin. “Our agency has been focused throughout all of 2022 in making improvements based on our 2019 scores. Now we are being told that those improvements will actually be held against us (as seen by no longer getting improvement points),” the commenter protests.

“This decision to move baseline years seems like an attempt to financially penalize those agencies that are in the improvement point world, while rewarding those who are in the achievement point world,” the Wisconsin provider tells CMS in its letter. “Your decision to change baseline years is distrustful, and lacks integrity,” the letter accuses.

Multiple HHAs submitted a template-based letter with this message: “My agency has worked hard in 2022 to provide the best care to our patients, your proposal to change the baseline year essentially expunges the hard work I put in as a professional to ensure my patient outcomes were the best. Should this proposal take effect, it would seriously challenge the trust I have with CMS in rolling out complex programs like Value Based Purchasing,” the agencies stress.

“Some agencies have already put time and money in researching their 2019 data and getting groups together to see where improvements are to be focused on,” Rhonda Schreier from Iowa says in her letter.

Bumping the baseline year “will be unfavorable to the pilot states, since those states have already made progress in improving,” points out an anonymous commenter from Washington.

“We had a 71.6 percent increase in our performance scores, yet we only gained 3 percent in our percentile ranking,” Neil Pruitt Jr. of PruittHealth notes in his comment letter. “This large increase reflects the hard work all agencies are doing to improve data collection, outcome measures, and quality measures. Changing the base year will negate much of these efforts, impact quality scores, and disrupt implementation of VBP as the 2022 data from CMS is not yet available,” Pruitt criticizes.

“Changing the baseline year without complete data available to home health agencies in the first six months of their accountability is setting them up for failure,” warns LeadingAge’s Katy Barnett in the trade group’s comment letter.

The rationale CMS cites, that agencies in the VBP pilot received their threshold data six months into the first performance year, doesn’t hold up, Barnett says. “This is an ineffective and harmful comparison,” she blasts. “First, for the original demonstration, the first two years had NO payment adjustment incentive.” In contrast, CMS proposes to hold onto the 5 percent adjustment incentive for the expanded VBP’s first performance year.

“Second, the cohorts in the first demonstration were state-based,” Barnett adds. “In the expanded demonstration, cohorts can include agencies for multiple state[s], which gives agencies from the original nine states an unfair advantage.”

Receiving threshold data well into the performance year was a target for much criticism in the comment letters. “Understanding these targets in advance is important for planning and successfully achieving outcomes warranting bonus payments,” emphasizes Donna Wilhelm with health system Trinity Health, parent of Trinity Health at Home, in the system’s letter.

“This proposal … will prevent home health agencies from knowing what target to try to reach. This is extremely important for agencies to know what areas they need to prioritize,” explains Kay Findlay in Kansas in her letter. This is “a major concern,” she warns.

“CMS cannot have the luxury of getting the information out to agencies when it works for them,” Schreier insists in her letter. HHAs must have that info ahead of time.

“Performance improvement targets should be identified prior to expansion of the program,” maintains Mary Haynor from Wisconsin in her comment letter.

Bottom line: “As agencies have been working diligently to enhance performance over the original baseline year of 2019, we ask CMS to use the original date of 2019,” asks Paula Thomas, President of University of Pittsburgh Medical Center Home Health Care, in the agency’s comment letter. If CMS refuses to consider maintaining the status quo, it should at least “make sure agencies receive their baseline 2022 performance standards prior to the end of 2023 Q1,” Thomas says.

Alternative: If CMS sticks with the move to 2022, it “should delay implementation of the Expanded HHVBP Model until CY2024 due to the proposed six-month delay in providing final Individual Improvement Thresholds, Achievement Thresholds, and Benchmark Data,” LeadingAge recommends.

Don’t Dismiss COVID Effects

One financial expert points out another good reason to avoid 2022 as a base year. “I do not think that any year that could be tainted with COVID-19 consequences should be considered because it could very likely distort ... actual baseline results upon which the HH VBPM is based,” CPA John Reisinger with Innovative Financial Solutions for Home Health says in his comment letter. “A significant portion of the potential population of home health-eligible patients/ beneficiaries were removed from the actual population of home health users, because they chose (or it was decided for them) to not accept home health services that they were otherwise eligible for, for fear of COVID,” Reisinger explains.

“And it is likely these beneficiaries were of a higher-acuity and/ or possessing various comorbidities that made them extremely vulnerable to COVID-19.”

Less acute or complicated PHE-era home health users are likely not “truly representative of what those benchmarks and achievement thresholds would have been sans COVID-19,” Reisinger believes. “If there’s a chance that that is the case (which I believe is very likely) then CMS should NOT change the baseline year to CY 2022,” Reisinger insists in his letter.

Now that HHAs have spoken their piece, they are waiting to see whether CMS has listened when it issues the 2023 final rule expected in late October or early November.

Note: The 84-page proposed rule is at www.govinfo.gov/ content/pkg/FR-2022-06-23/pdf/2022-13376.pdf.