Eli's Rehab Report

The home care industry seems united in its rejection of proposal to drop 'close to' proviso.

The harried home care industry is already under significant pressure thanks to the therapy reassessment requirements. Now it is caught between having to say goodbye to reimbursement and limiting patient access to therapy if the PPS proposals go unchanged, come Jan.1.

Old way: Currently, when beneficiaries receive more than one type of therapy in a home health episode, the therapist's reassessment visit "need only be 'close to' the 13th and 19th visits," the Centers for Medicare & Medicaid Services reiterates in the home proposed rule published in the July 13 Federal Register.

New way: CMS proposes "to revise the regulations ... to clarify that in cases where the patient is receiving more than one type of therapy, qualified therapists could complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and the 17th, 18th, or 19th visit for the required 19th visit reassessment," the agency says in the rule. These visit ranges match the ones CMS allows when the patient is in a rural area or has other documented circumstances outside the therapist's control that prevent the reassessment visit from occurring exactly on the 13th or 19th visit.

CMS has proposed this change because it has received repeated questions about what "close to" means under the current requirements. "We recognize the industry's need for additional guidance [and will] provide more precise guidance," the agency says in the rule.

Reassessments Weigh Heavily On HHAs With Little Benefit

The home care industry seems united in its rejection of this proposal, based on the 133 comments filed on the proposed rule. The comment period closed Sept. 5.

"The proposed changes to the timing of the required therapy assessment for multidisciplinary cases can result in substandard care for our home care patients," warns Family Home Care in Washington State. "We would either end up being out of compliance with the rule or we would have to provide visits at a schedule different than ordered by MD and indicated by their needs," the provider says in its comment letter. "This is not in the patient's best interest."

Current therapy reassessment requirements already have added burden, caused scheduling problems and increased cost to home health agencies, notes HealthEast Home Care in St. Paul, Minn. Thanks to the requirements that took effect last year, agencies have to spend more money on clinical and clerical time, software changes, audits, and non-covered visits, HealthEast notes in its comment letter. And they encounter more scheduling problems.

"I understand that this change is being proposed to provide more precise guidance to the industry regarding multi-disciplinary scenarios," says Alice Black with Meditech in Atlanta. "But I think that by being more precise you have actually made the rule more restrictive."

Unintended consequence: "CMS will pose undue hardships on home health agencies and therapists to comply in instances where patients are receiving other services that prohibit them from being able to receive therapy on their planned visit," argues the Home Care Alliance of Massachusetts in its comments. The specific visit ranges may limit patient access to therapy services, which "may result in further deterioration or loss of progression in the patient's condition, HCAM says.

For example: "A patient with cancer receiving chemotherapy may experience significant side effects associated with their treatments that leave them physically incapable of tolerating the planned visit in which the functional reassessment would be completed," explains the American Physical Therapy Association in its comment letter. "Therefore, with the current policy of 'close to,' the therapists could plan to complete the functional reassessments the week before the patient's chemotherapy which may fall on the patient's 10th therapy visit and still remain compliant with the functional reassessment requirement. If the proposed policy is finalized, therapists and HHAs would lose this flexibility."

Reasons for missing an assessment visit are often out of a therapist's control, notes the Hospital and Health System Association of Pennsylvania. When visits are missed due to patient or family cancellations, unplanned hospitalizations, weather, or other reasons, "the result is non-coverage of late assessment visits despite the fact that patients needed and received covered services," HAP adds.

The proposal "will create roadblocks to the delivery of care in accordance with patient needs and physician orders, and present a scheduling nightmare for HHAs," HAP stresses. "To ensure compliance, HHAs will need to manipulate visit schedules and services to patients simply to meet assessment requirements since timing of visits depends not only on the frequency of each therapy discipline, but also on the point that each started in the aggregated therapy visit count."

Waste: "The proposed changes could frequently result in interrupted or unnecessary care for the patient," says commenter Suzanne Clark in Massachusetts. "This is not in the best interest of the patient and provides an unneeded burden on home care agencies."

Small and rural HHAs and their patients will be most vulnerable to the negative effects of this change, APTA cautions. Those types of providers often "do not possess sophisticated EHRs or electronic software, but instead still rely on a paper-based system to record and document therapy visits," the trade group relates. These HHAs already have limited resources to provide therapy services to patients. "The adoption of this policy will only exacerbate their existing patient access issues," APTA stresses.

"In rural communities or areas where speech language pathologists are in short supply, the proposed ... requirements will be a burden and a challenge for agency compliance," agrees the Ohio Council for Home Care & Hospice.

Many commenters provide CMS with specific visit scheduling scenarios that would make the visit ranges unworkable and impact patients' access to care.

Bottom line: "The therapy assessment schedule already creates unnecessary regulatory burden and is particularly cumbersome in the case of multiple therapy patients," the Visiting Nurse Associations of America notes. This change would intensify that problem.

Too Many Assessments

Some commenters questioned the need for all the reassessments that come from the new requirements. In one scenario, a patient receiving physical and occupational therapy could be reassessed during eight out of 20 visits, notes All About Home Care in Texas. That would include initial evals, 30-day evals, and evals on the 13th and 19th visit for each discipline.

"I don't think patients are benefiting from time of evaluation as much as the time for therapy," the agency rep comments. The "focus should be on treating patients and not evaluating only."

"Patients themselves are getting frustrated from these evaluations," the agency adds.

"Patients with the most intense therapy needs where all three therapy disciplines are involved have the greatest likelihood to exceed the thresholds for therapy visits," points out the American Occupational Therapy Association in its comment letter. "These patients typically do not experience enormous change in a short amount of time." Thus, frequent evaluations are duplicative. However, documentation would need to show "strong support" for such patients with complex needs, AOTA acknowledges.

Keep The Status Quo At Least

Many commenters addressing this topic urge CMS to keep the status quo and allow the "close to" timing for reassessment visits in multi-discipline cases. Keep the "current (regulatory) language that the assessment can be done close to the 13th and 19th visit," exhorts VNA of Medical Park in West Virginia.

But other stakeholders want CMS to go even farther in fixing the multi-discipline therapy assessment problem.

For example: "AOTA recommends that CMS base therapy reassessment requirements for complex patients on calendar days rather than number of visits to allow therapists to put the patients' needs first while still meeting CMS requirements for reassessment," the trade group says.

In fact, a good way to streamline therapy reassessment for all patients is to tie the reassessments to time points instead of visit numbers, multiple commenters advise. CMS should "remove the requirement that the functional reassessment be completed by the 13th and 19th visit and simply return to its previous policy," which required reassessment every 30 days, APTA notes. Linking reassessments "to arbitrary visits associated with the payment thresholds is problematic."

Another suggestion: CMS should require therapy disciplines to perform reassessments during their second and fourth week of treatment of the patient, and the final week of the episode, says OCHCH.

Commenters, along with the rest of the industry, will have to wait and see if CMS takes their advice when the final rule comes out. CMS expects to issue the rule in November, it has said.

Note: The 2013 PPS proposed rule is at www.gpo.gov/fdsys/pkg/FR-2012-07-13/pdf/2012-16836.pdf.