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
The Centers for Medicare & Medicaid Services (CMS) has finalized the Home Health Prospective Payment System rule, which includes a new payment model called Patient-Driven Groupings Model (PDGM).
The PDGM incorporates minimal changes from previously proposed reforms (HHGM) introduced in 2017, which were broadly opposed and not finalized by CMS. In essence, PDGM 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:
- 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 home health community has been working with bipartisan lawmakers in Congress to develop legislative solutions that will ensure these behavioral-based payment changes are grounded in evidence and observed data.
We support legislation, S.3545 introduced by Senators Collins (R-ME), Stabenow (D-MI) and Nelson (D-FL), S. 3458 introduced by Senators Kennedy (R-LA) and Cassidy (R-LA), and H.R. 6932 introduced by Representatives Ralph Abraham (R-LA), Garrett Graves (R-LA), Scott DesJarlais (R-TN), Vern Buchanan (R-FL), and Terri Sewell (D-AL), which makes the following changes to the home health payment model:
Requires Medicare to institute rate adjustments only after HHA behavioral changes actually occur, basing any behavioral adjustment on real “observed evidence.”
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.
S. 3545 also includes a provision strongly supported by the home health community that would permit the waiving of the homebound regulatory requirement to enable greater flexibility for Medicare beneficiaries in Medicare advantage plans (and waiver programs) to receive home health services.
This legislation is vital to ensure that the Medicare home health benefit is strengthened and secured for the growing number of seniors who depend on it.
Ask Your Lawmakers to Support Vital Home Health Legislation.
- PQHH statement: Home Health Leaders Urge Additional Refinements to Patient Driven Groupings Model Before 2020 Implementation in Response to HHPPS Final Rule
- PQHH statement: Home Health Leaders Applaud Introduction of Senate & House Legislation to Strengthen Medicare Home Health Reforms
- PQHH statement: Home Health Leaders Applaud the Introduction of the Home Health Payment Innovation Act
- One-Pager: CMS’ Proposed Patient Driven Groupings Model
- One-Pager: Co-Sponsor Legislation to Improve Home Health Payment Reform to Protect Services for America’s Seniors
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.