Home Health & Hospice Week

Commenters take aim at rushed implementation, money at stake.

Commenters on the 2022 home health proposed rule have lots of suggestions for how Medicare can do better, starting with Value-Based Purchasing.

Reminder: In its proposed rule, the Centers for Medicare & Medicaid Services states its aim to expand VBP nationwide starting Jan. 1, 2022. Data collected next year would fuel a +/-5 percent payment adjustment in 2024 based on national cohorts for bigger and smaller home health agencies. (See more program details in HCW by AAPC, Vol. XXX, No. 24-25.)

VBP was one of the most commented-on provisions in the rule, with many of the 200-plus comment letters touching on the expansion. In particular, lots of HHAs and their representatives urged CMS to rethink its quick Jan. 1 implemen­tation, for a variety of reasons.

University of Pittsburgh Medical Center Home Healthcare “agrees with national expansion of HH VBP,” President Paula Thomas says in the Seven Fields, Pennsylvania-based agency’s comment letter. “However, we request CMS to consider the impact of the ongoing Public Health Emergency (PHE) and recent COVID surge when deciding to expand … in January 2022,” Thomas tells CMS.

“Extenuating circumstances surrounding caring for COVID patients limits resources that may otherwise be focused on quality projects, staff education and monitoring of these projects,” Thomas continues. “We encourage CMS to extend the expansion of VBP until January 2023 while our nation continues to work through the challenges of this PHE,” she says.

“It is important to provide more opportunity to educate agencies on HHVBP and to allow them time to prepare for this major change before implementing it nationwide,” urges Cheryl Foster, Director of North Kansas City Hospital Home Health, in her letter.

Laura Friend with the West Virginia Council of Home Care Agencies suggests a one-year delay for another reason — "in order to avoid relying on an outdated benchmark year,” Friend notes in her letter. In the rule, CMS proposes using a 2019 base year because 2020 data will be skewed by COVID.

“Using 2019 as a baseline year for the model inherently means comparing pre-COVID-19, pre-PDGM performance to performance in a very different environment,” Friend cautions. “Alternatively, using 2020 data would create its own challenges, given the emergence of COVID-19.”

A delay also would give agencies “more time to successfully prepare for the model’s implementation,” Friend adds.

Bottom line: “CMS should consider extending the start date for an expanded HHVBP to provide HHAs with sufficient time to institute operational reforms that would fuel success under the program,” the National Association for Home Care & Hospice urges in its comment letter.

VBP Arbitrarily Creates Haves, Have-Nots

Another area popular for comment was the amount of reimbursement at stake for VBP results.

Reminder: In its model, CMS started out adjusting HHAs’ payment rates +/-3 percent and extended that up to +/-8 percent in the model’s fifth, canceled year. In the proposed rule, CMS suggests a +/-5 percent adjustment based on VBP results from the start.

“To ensure that my agency has time to become familiar with the operation of the model, I request that CMS reduce the maximum payment adjustment from +/- 5 percent to +/- 3 percent in CY2024,” says physical therapist Marcie Ganson, Director of Rehabilitation Services & Fitness, Health, & Wellness at the Mason District Hospital in Havana, Illinois.

“During the demonstration rollout, risk was increased as agencies gained experience in the demonstration,” points out Joy Cameron, associate vice president of public policy with Humana, in her comment letter. “We would recommend that this implementation have a ramp-up period to provide time for investment and implementation, much like that that was seen in the Hospital and Skilled Nursing Facility rollouts,” Cameron tells CMS.

“The Hospital Value-Based Purchasing Program was statutorily mandated to start the withhold at 1 percent and gradually increase it to 2 percent over five years. The Skilled Nursing Facility Value-Based Purchasing Program was statutorily mandated to maintain a 2 percent withhold,” Cameron recounts. “We are concerned about the significant amount at risk in the initial year when most HHAs were not involved in this program. Experience under the demonstration has shown that it takes time and a substantial investment in resources to develop the capabilities to track performance metrics and succeed under this program,” she says.

Bottom line: “In comparison to other VBP programs, the proposed 5 percent withhold seems high,” Cameron judges. “We recommend starting with a lower withhold and gradually scaling up the risk under the demonstration over time.”

The specific percentage isn’t the only problem with the reward/punishment reimbursement style.

“As currently constructed,” HH VBP “is inherently unfair,” blasts one anonymous commenter. “This process often unfairly penalizes programs that provide cost savings to Medicare.”

How: “The HHVBP program takes dollars from the bottom half of agencies and provides to the top half; this creates the potential for an endless loop where the higher scoring agencies are given funds to reinvest in outcome performance, which would suggest future improvements,” the commenter criticizes. “Meanwhile, the lower half agencies would continue to be penalized even if they continue to produce savings for Medicare,” they say. “This seems unfair.”

Commenters also fault the distribution of adjustments. “Because performance is modeled on a bell curve, a large percentage of HHAs crowd the top of the curve and skew results. It is extremely difficult and sometimes arbitrary to score within the top decile (or the lowest decile), which is where monetary rewards live,” blasts UnityPoint at Home execs Margaret VanOosten, Jenn Ofelt, and Cathy Simmons. “For the remainder of the HHAs, most HHAs fall in the middle of the curve, receive a neutral impact for implementing program requirements, and are not truly incentivized to make significant or even incremental change,” says the Iowa health system-based agency says in its comment letter.

“CMS should re-evaluate whether the current structure adequately incentivizes HHAs to change behavior,” say VanOosten, Ofelt, and Simmons. UnityPoint at Home participated in the nine-state VBP demonstration, they point out.

The anonymous commenter makes a similar point: the “45th percentile of performers may differ barely from one in the 55th percentile,” they say.

Note: The proposed rule is at www.govinfo.gov/content/pkg/FR-2021-07-07/pdf/2021-13763.pdf.