Doctor concerned with health care law

Breaking news and expert analysis on legal and compliance issues

[Back To Home][Back To Archives]

From Health Law Daily, July 26, 2017

Major changes to home health PPS proposed for 2019

By Kayla R. Bryant, J.D.

Payment rates under the home health prospective payment system (HH PPS) will increase by 1 percent for calendar year (CY) 2018. In an advance release of a Proposed rule scheduled to publish in the Federal Register on July 28, 2017, CMS also proposedimplementing case-mix methodology refinements and amendments to the Home Health Value-Based Purchasing (HHVBP) model. The rule also outlines a payment system redesign in 2019, which will involve 30-day episodes of care.

Payment rate provisions. Despite the 1 percent increase under the HH PPS, required by section 411(c) of the Medicare Access and CHIP Reauthorization Act (MACRA) for HHAs that submit required quality data, payments to home health agencies (HHAs) would be reduced by 0.4 percent in CY 2018 under the rule, saving about $80 million. The $190 million increase from the payment rate update would be offset by a negative 0.97 percent adjustment to the standardized 60-day episode payment rate. This negative adjustment is comprised of minus 0.9 percent of nominal case-mix growth and the removal of the rural add-on provision. HHAs that do not submit quality data for the Home Health Quality Reporting Program (HHQRP) will be subject to a 2 percentage point market basket percentage decrease.

CMS is statutorily required to target up to but no more than 2.5 percent of total payments as outlier payments. Using preliminary CY 2016 claims data and the proposed CY 2018 payment rates, outlier payments are estimated to make up about 2.47 percent of total HH PPS payments under current methodology. Due to this projection, CMS is not proposing changes to the fixed-dollar loss (FDL) ratio for CY 2018, and will leave the FDL ratio at 0.55 with a loss-sharing ratio of 0.80. The agency found that the current loss-sharing ratio will allow this PPS to remain consistent with high-cost outliers in other Medicare payment systems. CMS noted that there may be a change to the FDL ratio in the upcoming Final rule due to updating the estimates of outlier payments using more current HH PPS data.

Changes for 2019. For periods of care beginning on or after January 1, 2019, the rule proposes a change in the unit of payment, switching from 60-day episodes of care to 30-day episodes. These case-mix methodology refinements are referred to as the home health groupings model (HHGM), and rely on patient information and clinical characteristics to place these shorter episodes of care into payment categories, which CMS believes would improve payment accuracy and access for medically complex cases.

These updates stem from findings issued in a previous report required by section 3131(d) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) that suggested HHAs could be better incentivized to serve patients who do not need therapy services but require skilled nursing care for clinical complex and/or poorly controlled clinical conditions. Under these changes, therapy service use thresholds would be eliminated in order to remove an incentive to provide more therapy visits, a recommendation submitted in the Medicare Payment Advisory Commission’s (MedPAC) March 2017 report to Congress (see MedPAC makes 2018 payment recommendations, March 16, 2017). In addition, an admission source category would be added and six clinical groups would be created. The Low-Utilization Payment Adjustment (LUPA) threshold, used for episodes with four or fewer visits, would be revised in order to be more consistent with 30-day episodes of care. HHGM implementation will require provider education and training, manual revision, and claims processing system changes.

Quality reporting. In order to comply with the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) (P.L. 113-185), which requires post-acute care providers to report standardized patient assessment data and other measures, three new measures are proposed for the HHQRP:

  • changes in skin integrity post-acute care: pressure ulcer/injury;
  • application of percent of residents experiencing one or more falls with major injury; and
  • application of percent of long-term care hospital patients with an admission and discharge functional assessment and a care plan that addresses function.

In determining which measures to add to the HHQRP, CMS reviews measures implemented in other programs and measures endorsed by the National Quality Forum (HQF) for other provider settings. CMS is reviewing reports generated by various agencies on the possibility of adjusting for social risk factors, and is weighing the importance of improving beneficiary outcomes and reducing health disparities while ensuring that provider quality of care of fairly assessed.

HHVBP. HHAs participating in the HHVBP model would have to submit a minimum of 40 completed Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) surveys to receive a performance score for any measures. CMS believes that this policy will better align the HHVBP model with the patient survey star ratings system used for Home Health Compare. The Outcome and Assessment Information Set (OASIS)-based measure, drug education on all medications provided to patient/caregiver during all episodes of care would be removed from the measure set. The proposed rule discusses some measures considered for possible inclusion in future rulemaking.

MainStory: TopStory NewsStory ReimbursementNews CMSNews BillingNews HomeNews PartANews PartBNews PartCNews QualityNews

Back to Top

Health Law Daily

Introducing Wolters Kluwer Health Law Daily — a daily reporting service created by attorneys, for attorneys — providing same-day coverage of breaking news, court decisions, legislation, and regulatory activity.

A complete daily report of the news that affects your world

  • View full summaries of federal and state court decisions.
  • Access full text of legislative and regulatory developments.
  • Customize your daily email by topic and/or jurisdiction.
  • Search archives for stories of interest.

Not just news — the right news

  • Get expert analysis written by subject matter specialists—created by attorneys for attorneys.
  • Track law firms and organizations in the headlines with our new “Who’s in the News” feature.
  • Promote your firm with our new reprint policy.

24/7 access for a 24/7 world

  • Forward information with special copyright permissions, encouraging collaboration between counsel and colleagues.
  • Save time with mobile apps for your BlackBerry, iPhone, iPad, Android, or Kindle.
  • Access all links from any mobile device without being prompted for user name and password.