THE ISSUES

While evidence already confirms that home healthcare is a cost effective care setting with positive clinical outcomes for patients, the Partnership is working to further improve quality and access for the patients we serve.

PATIENT DRIVEN GROUPINGS MODEL

In July, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the Home Health Prospective Payment System, which includes a newly proposed payment model called Patient-Driven Groupings Model (PDGM).

The newly proposed payment model incorporates minimal changes from previously proposed reforms (HHGM) introduced in 2017, which were broadly opposed and not finalized by CMS. In essence, the PDGM proposal is basically the HHGM proposal with minor modifications.

The Partnership supports CMS’ efforts to reform the home health prospective payment system to more accurately align payment with patient characteristics, quality, and to remove utilization-based incentives. However, despite a fruitful dialogue with providers and the Technical Expert Panel (TEP) this year, CMS did not incorporate critical policy recommendations from the TEP’s Final Report into the CY 2019 home health proposed payment rule.

We have the following concerns about PDGM as proposed:

  • Significant cuts, based on mere assumptions, would destabilize home health services and create clear risks for access to home health care for Medicare beneficiaries.
  • The program creates arbitrary winners and losers among home health agencies, with more than half expected to experience significant Medicare reductions.
  • As we have seen through previous payment models, assumption-based rate reductions could lead to a drop in the use of home health services.
  • CMS has provided no rationale for its current behavioral assumption rate cuts.

The Partnership would support bipartisan legislative solutions that:

  1. Requires Medicare to institute rate adjustments only after behavioral changes actually occur, basing any behavioral adjustment on real “observed evidence.”
  2. Ensures Medicare budget neutrality but requires the phase-in of any necessary rate increases or decreases to be no greater than 2% per year to limit the risk of disruption in care.

HOME HEALTH GROUPINGS MODEL

In 2017, the Centers for Medicare & Medicaid Services' (CMS) Home Health Prospective Payment System (HHPPS) Proposed Rule for CY 2018 included the implementation of the Home Health Groupings Model (HHGM), a payment reform approach that would dramatically alter Medicare payment for skilled home health services. In the development of this payment approach, CMS did not solicit comment or seek industry input in the development of this proposed policy.

The HHGM would overhaul the current Medicare payment system in a non-budget neutral manner. Under HHGM, Medicare payments would be based on patient characteristics instead of care needs, and distributed based on location of providers rather than their quality of service. This would cause uneven payment distribution, as high-quality providers in certain areas could face disproportionate cuts. Furthermore, the geographic disparity would have the greatest effect on seniors living in rural, smaller areas.

On November 1, 2017, CMS announced its decision to not finalize the proposed HHGM in the HHPPS Final Rule for CY 2018. The Partnership looks forward to working collaboratively with CMS and the home health stakeholder community to address the significant flaws in the HHGM, and anticipates that CMS will do so in the year ahead.

FACE TO FACE REQUIREMENT

Under current Medicare policy, a patient needing home healthcare must have a documented face-to-face (F2F) encounter with a physician to certify his or her eligibility for services. The intent is to ensure patients are receiving care in the appropriate setting, but overly complicated and burdensome regulatory requirements result in unintended consequences like care delays or complete denial of skilled home healthcare services.

Data show tens of thousands of claims have been denied for care that is medically necessary and appropriate. While many of these claims are overturned on appeal, the initial denials make it difficult for home healthcare agencies to provide continued, uninterrupted care.

Legislation is being developed by leaders in Congress that would streamline the existing face-to-face documentation rules to reduce the paper work burden on physicians and home health agencies and inappropriate care denials. The legislation would allow for home health agencies to prepare documents for physician review and eliminate duplicative documentation for beneficiaries who have been discharged from a hospital or a post-acute care facility.

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