Home Health & Hospice Week

Program expected to go nationwide as early as 2018.

The 2016 HH PPS final rule contains a few minor changes to Value-Based Purchasing, but the program will proceed mostly as proposed in less than two months.

Same: The final rule released Oct. 29 sticks to the timeline of beginning VBP data collection in January for payment adjustments applied in 2018. The Centers for Medicare & Medicaid Services rebuffs calls for a delay. “We expect that competing HHAs will begin transforming delivery patterns as soon as this model is implemented,” CMS says in the rule published in the Nov. 5 Federal Register.

Don’t be surprised to see CMS take VBP nationwide by 2018, says financial expert Pat Laff with Laff Associates in Hilton Head Island, S.C. When CMS piloted the prospective payment system, it implemented the program a mere two years later. The same is likely with VBP.

Same: The final rule also confirms the “Nervous Nine” pilot states for VBP, notes Melinda Gaboury with Healthcare Provider Solutions on her website. Those states are Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee.

“The model will apply to all Medicare-certified HHAs in each of the selected states, which means that all HHAs in the selected states will be required to compete,” CMS emphasizes in the rule.

The agency is requiring all HHAs in the pilot states to compete so that there is no selection bias, agencies are representative of the national population, and the amount of data gathered is meaningful, it says.

CMS dismisses concerns about getting hit with both VBP and the Comprehensive Care Joint Replacement Model at the same time. “HHAs located in the MSAs included in the proposed CJR Model will not be excluded from the HHVBP Model,” CMS determines. “HHAs are not participants in the proposed CJR Model. As proposed, hospitals are the participants. Home health payments for beneficiaries participating in the proposed CJR are not subject to alteration under that model. As proposed, only the hospital payments are at risk.”

Different: Scores of commenters protested the overly large risk pool for VBP, ranging from 5 to 8 percent (see Eli’s HCW, Vol. XXIV, No. 34). But CMS makes only a slight change to the amount at stake, starting lower and ramping up more gradually — 3 percent for CY 2018 (based on 2016 data), 5 percent for CY 2019, 6 percent for 2020; 7 percent for CY 2021 and 8 percent for CY 2022, according to the rule.

“Testing high financial incentives is necessary to motivate improvements in quality and patient satisfaction,” CMS maintains in the rule. But “providing some additional leeway for HHAs to ensure compliance with the model is important,” the agency admits. The new, more gradual timeline “will provide HHAs more time to become familiar with the operation of the model before applying the higher percentage payment adjustments in later years,” the agency concludes.

Remember, “only HHAs that provide very poor quality of care, relative to the cohort they compete within, would be subject to the highest downward payment adjustments,” CMS insists. In the future, CMS may update payments based on VBP data more frequently and closer to the data’s collection, the agency suggests in the rule.

Different: CMS also agrees to remove five of the originally proposed 29 measures used for VBP’s calculations (see box, p. 309, for final measures included). “More narrowly focusing the starter set of measures being tested in the HHVBP Model may increase the likelihood of HHA success,” CMS acknowledges in the rule.

CMS has also proved open to reducing the number of process measures as agencies have urged. “Placing an emphasis on outcome measures over process measures determines performance in a way most meaningful to patients,” the agency says.

The five removed measures are Timely Initiation of Care (NQF0526), Pressure Ulcer Prevention and Care (NQF0538), Multifactor Fall Risk Assessment Conducted for All Patients who can Ambulate (NQF0537), Depression assessment conducted (NQF 0518), and Adverse Event for Improper Medication Administration and/or Side Effects (New Measures).

CMS rejects arguments to drop the vaccination measures from the VBP set. “The measurements related to vaccination are not connected to whether a patient does or does not receive the vaccinations,” the agency points out. “Patients are free to decline vaccinations and competing HHAs are not financially penalized for the patient’s choice.”

Stabilization Arguments Fruitless

CMS shoots down the many suggestions to include measures that address stabilization as well as improvement (see Eli’s HCW, Vol. XXIV, No. 36).

“While we considered using some of the stabilization measures for this model, we found that in contrast to the average HHA improvement measure scores which ranged from 56- to 65-percent, the average HHA stabilization measure scores ranged from 94- to 96-percent,” CMS explains. “Using measures where the average rates are nearly 100- percent would not allow for meaningful comparisons between competing HHAs on the quality of care delivered.”

“We … do not expect any access issues for beneficiaries that have more maintenance needs because HHAs would not know whether the benefi- ciary has restorative or maintenance needs until the HHA initiates the episode of care and conducts the necessary assessments,” CMS maintains in the rule.

However, “we are sensitive to this issue and will closely monitor whether HHVBP Model-specific measures have the potential to impact beneficiaries that require skilled care to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition,” CMS says. “If necessary, we will use future rulemaking if we determine that this issue has a meaningful detrimental effect on payments of those HHAs that provide more maintenance care. In addition, we are currently working on the development of valid and reliable stabilization measures that may be incorporated into the HHVBP Model in the future.”

Note: See the final rule at www.gpo.gov/fdsys/pkg/FR-2015-11-05/pdf/2015-27931.pdf.