Medicare Compliance & Reimbursement

The time to make changes is now.

Home health agencies’ (HHAs’) payments are at stake if the Centers for Medicare & Medicaid Services (CMS) goes ahead with implementing its pay for performance plans as planned.

Background: CMS announced in the 2015 home health prospective payment system proposed rule, issued on July 1, that it is considering implementing a P4P program, now known as Value-Based Purchasing (VBP), in January 2016.

“As currently envisioned, the HHA VBP model would reduce or increase Medicare payments, in a 5-8 percent range, depending on the degree of quality performance in various measures to be selected,” says the rule published in the July 7 Federal Register.

Prepare for Outcome Changes

Unclear: CMS doesn’t propose specific outcomes measures for use in the VBP model, but that doesn’t mean you should take a “wait and see” approach. Consider the following steps you can take today to help prepare for the future of home health reimbursement.

Assess current outcomes. “It is a little early to know for sure which outcomes CMS will use for the proposed Value-Based Purchasing [model], but providers don’t have to wait for CMS to start making a positive impact,” says Pat Jump with Rice Lake, Wis.-based Acorn’s End Training & Consulting. Pay special attention to outcomes that have the greatest impact on cost to the Medicare system, she advises. “We know for sure that re-hospitalizations have a big impact, as do falls at home. Additionally, we know that issues around medications tend to be costly. Providers need to make sure they are looking at outcomes reports including comparisons with other providers in their area, with outcome averages for their state as well as national statistics.”

Don’t miss: “I don’t have a crystal ball, but if you base assumptions on the importance CMS has placed on hospitalization costs and outcomes that are related to the issues identified in Hospital Compare (since hospitals have already been subject to VBP),” CMS might look at the following outcomes says consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C.:

• Re-hospitalization percent (for same diagnosis as patient was previously hospitalized) 
• Improvement in surgical wounds;
• Percent of patients with heart failure who were treated for heart failure symptoms;
• Percent of patients who received pneumonia vaccine.

Target underperforming outcomes. If your outcome rates are poor by comparison to others, take action to improve them, Jump urges. Look at the top one or two outcomes with the greatest variance from state and national averages and concentrate on improvement in those specific outcomes. Spend at least six months working on interventions for improvement before moving on to other outcomes, she says. Monitor the progress toward improvement on a continuous basis.

4. Work with clinicians. “It is important to get feedback from the clinicians doing the OASIS assessments and ask for specific interventions they believe would have the greatest impact on improvement,” Jump says. “Invariably, poor outcomes are related to lack of understanding regarding how to answer the OASIS data items, including interpretation of the items as well as methods for obtaining the answers (interview vs. observation, for example).”

The best antidote for this lack of understanding is OASIS training, Jump says. “Training that occurs once a year or less frequently than once a year is insufficient. At least some sort of training needs to occur on a continuous basis — perhaps through weekly tips or monthly lunch-and-learn sessions.”