Home Health & Hospice Week

Lack of stabilization measures, too-big outlier pool remain major problems.

If you were hoping to see some of the Value-Based Purchasing program’s biggest flaws addressed in the 2017 HH PPS final rule, you’ll likely be disappointed.

The Centers for Medicare & Medicaid Services finalizes its VBP proposals without change. They include the mostly supported provisions to:

• Calculate benchmarks and achievement thresholds at the state level rather than the level of the size cohort and revise the definition for “benchmark” to state that benchmark refers to the mean of the top decile of Medicare-certified HHA perform-ance on the specified quality measure during the baseline period calculated for each state;
• Require a minimum of eight HHAs in any size-cohort;
• Increase the timeframe for submitting New Measure data from seven calendar days to 15 calendar days following the end of each reporting period to account for weekends and holidays;
• Remove four measures (Care Management: Types and Sources of Assistance, Prior Functioning ADL/IADL, Influenza Vaccine Data Collection Period, and Reason Pneumococcal Vaccine Not Received) from the set of applicable measures; and
• Adjust the reporting period and submission date for the Influenza Vaccination Coverage for Home Health Personnel measure from a quarterly submission to an annual submission.

These changes are “just fine-tuning,” notes finance and operations consultant Pat Laff with Laff Associates in Hilton Head, S.C.

Appeals Deadline Shortened

In the final rule released Oct. 31, CMS also finalizes its more criticized proposal to implement the recalculation and reconsideration processes, which include shortening the timeframe for submitting recalculation requests from 30 days to 15 days. Some commenters argued that just wasn’t enough time (see Eli’s HCW, Vol. XXV, No. 37).

“We proposed to shorten the timeframe for recalculations and reconsiderations to accommodate the time needed to generate and submit the final data file to the FISS to meet the January payment adjustment implementation date for each model year,” CMS explains in the final rule. “We believe that HHAs’ ability to review their quarterly Interim Performance Reports and submit recalculation requests provides HHAs with a mechanism to address potential errors in advance of receiving the Annual TPS and Payment Adjustment Report and we expect that in many cases, the reconsideration requests would result in a mechanical review of the application of the formulas for the TPS and LEF. We therefore believe that 15 calendar days is a sufficient amount of time to determine whether an appeal is needed, collect supporting data, and submit a recalculation request following the posting of the Annual TPS and Payment Adjustment Reports.”

VBP’s Serious Flaws Remain Uncorrected

But CMS fails to address, or brushes off, the most pressing concerns that agencies presented in their comment letters on the 2017 HH PPS proposed rule: the lack of stabilization measures; the too-large outlier pool that will range up to 8 percent in the program’s final year; the weakness of the program’s risk adjustment; inclusion of managed care and Medicaid patients in the calculations; and public reporting.

For example: CMS says it’s considering public reporting of VBP data in 2019. “We support providing the public with information to make an informed decision when choosing a Medicare-certified HHA,” the rule says, sidestepping issues of whether the data will really be ready for public view.

Medicaid: And CMS notes that “HHAs are informed when the HHAs log into the HHVBP Secure Portal that the Total Performance Score on a set of measures collected via OASIS and HHCAHPS for all patients serviced by the HHA” — including Medicaid and managed care patients. “We have not received any concerns or recalculation requests relating to the scope of quality measure data used to generate these reports.”

Stabilization measures: “The HHVBP Model is designed such that any measures determined to be good indicators of quality will be considered for use in the HHVBP Model in future years and may be added through the rulemaking process,” CMS says, referring readers to the 2016 rule for more discussion of why measures were chosen.

CMS’s Secretiveness Over VBP Backfires

In response to many comments, including from the Medicare Payment Advisory Commission, about setting benchmarks ahead of time, CMS released more information about when and where HHAs in the nine VBP states are receiving their benchmark information.

This clarification is necessary, in part, because CMS is allowing only VBP-participating agencies to log on to its VBP education website and attend educational offerings. Even vendors that must provide VBP-compliant software have been barred from independently accessing HHVBP Connect and the Secure Portal for submitting VBP data.

For example: CMS first issued “initial baseline benchmarks” from 2015 data on HHVBP Connect in February and updated them in April, the rule explains. And CMS issued agencies their own OASIS-based 2016 Quarter 1 benchmarks in July 2016, and HHCAHPS-based benchmarks for the quarter last month.

MedPAC’s and others’ comments about setting VBP benchmarks ahead of time are “outside of the scope of the proposed methodology change in the CY 2017 HH PPS proposed rule,” CMS says.

The VBP changes CMS makes are mostly positive, the National Association for Home Care & Hospice judges in its rule analysis. But “NAHC remains concerned with elements of the original design that remain unchanged such as the amount of payment at risk (3-8 percent) over the five year term of the pilot, the sole use of improvement measures whereas the Medicare patient population includes chronically infirm home health patients, and the inclusion of non-Medicare patient outcomes in a Medicare VBP,” the trade group says.

Heads up: “While CMS is moving forward with a proposed VBP pilot, an effort to legislate VBP in all of post-acute care is going on as well,” NAHC adds. The two governmental forces do not appear to be moving in tandem. “That will make for a very interesting health policy dynamic to see what model prevails ultimately,” NAHC says.