Home health update for Medical Services Committee - Mason

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HOME HEALTH UPDATE
PPS REFORM RESEARCH; NEW COPS
NASL Conference February 7, 2017
Sherill Mason
Mason Advisors LLC
NASL 2017 Winter Conference

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BACKGROUND
• The home health PPS has not been significantly revised since it took effect in
2000
• Much as in SNFs, payments are based on
• The degree of functional impairment of a person
• Clinical complexity
• Volume of therapy visits
• The payment system has been criticized as having a perverse incentive to
over-utilize therapy while not paying enough for clinically complex care
• CMS engaged a contractor to study PPS and in December, 2016 the
contractor released a detailed technical report
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CURRENT HOME HEALTH PPS
• Today, home health agencies are reimbursed for 60 day episodes of care
• Agencies are reimbursed separately for non-routine medical supplies as well as
disposable negative pressure wound therapy devices
• There is no limit to the number of episodes a person can receive, but the
average number of episodes per beneficiary is 1.9
• There is no copayment or deductible
• The first two 60 day episodes are considered “early” and are reimbursed at
higher rates than “late” episodes
• There are 153 different HHRGs
• HHRGs are determined based on information from the OASIS
• Payments for episodes with four or fewer visits are considered LUPAs and are
reimbursed on a per-visit basis
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HHGM MODEL
• The Home Health Grouping Model (HHGM) would eliminate therapy
thresholds in determining payments
• HHGM would group episodes into clinical groups that describe the purpose
of the episode
• HHGM would use OASIS and non-OASIS items in the case mix system
• HHGM measures resource use using a cost-per-minute approach, combining
the non-routine supply payment with the episode payment
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HHGM MODEL
• Under HHGM there would be two 30 day periods within each 60 day episode
• Only the first 30 day period would be considered “early,” receiving a higher
reimbursement rate than “late” periods
• Admission source would be a factor in rates, with admissions from institutional
settings reimbursed at higher rates than admissions from the community
• There would be six clinical groupings, including:
• Musculoskeletal rehabilitation
• Neuro/stroke rehabilitation
• Wounds
• Medication management, teaching and assessment (MMTA)
• Behavioral health
• Complex nursing interventions
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HHGM MODEL
• There would be two or three functional levels
• For patients in the behavioral health or musculoskeletal rehab categories, there
would be two levels, low or high
• For patients in other clinical groups, functional levels would be low, medium and
high
• There would be two comorbidity adjustment groups, including yes or no,
based on secondary diagnoses
• In total, there would be 128 possible different payment groups
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RESEARCH FINDINGS; ADDITIONAL DETAIL
• A wide variation exists in the length of episodes
• Variation is related to the admission source and the reason for receiving home health
• The average length of an episode was 46.1 days
• Admissions from the community had an average length of 49.1 days
• Admissions with a hospital stay within 7 days prior to admission had average stays for 37.8 days, but
varied by DRG
• LEJRs had an average length of 23.7 days
• The following OASIS items are used in the model to determine functional status
• M1800: Grooming
• M1810: Current ability to dress upper body
• M1820: Current ability to dress lower body
• M1830: Bathing
• M1840: Toilet transferring
• M1850: Transferring
• M1860: Ambulation and locomotion
• M1032: Risk for hospitalization
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HHGM MODEL DETAIL
• Abt created 13 broad clinical categories with 116 subcategories to determine
comorbidity adjustments. These include
• Heart disease (11)
• Respiratory disease (9)
• Circulatory disease and blood disorders (12)
• Cerebral vascular disease (4)
• Gastrointestinal disease (9)
• Neurological and associated conditions (11)
• Endocrine disease (6)
• Neoplasms (24)
• Genitourinary and renal disease (5)
• Skin disease (5)
• Musculoskeletal disease or injury (5)
• Behavioral health (11)
• Infectious diseases (4)
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IMPACT ON PAYMENT RATES
• The average 30 day payment under today’s PPS and HHGM would be the
same at $1,519.22
• The new model pays more at the lower-center of distribution and less for the
upper portion of distribution
• For example, payments for the 50 th percentile would be $1,325.18 under current
PPS vs. $1,435.43 under HHGM
• Payments for the 95 th percentile would be $2,767.26 under current PPS and
$2,476.01 under HHGM
• On average, facility-based HHAs would see a 15% increase while
freestanding would see a decline of -1.5%
• Non-profits would see an average increase of 12.9% while for-profits would
see an average decline of -4.7%
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PAYMENTS FOR THERAPY EPISODES WOULD
DECLINE IN FAVOR OF COMPLEX NURSING
EPISODES
• Episodes without therapy would see average increases of 25%, while therapy
episodes would see an average decline of -10%
• Episodes with admissions from institutional settings would see average
increases of 29.5%, while episodes with admissions from the community
would decline an average of -15%
• Episodes falling into the Behavioral Health category would have reduced
payments of 10%
• Episodes in the Wound category would have increased payments of 25% to
nearly 30% while Complex Nursing Intervention episodes would have
average increases of 14% to 18%, depending on the degree of functional
impairment
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HOME HEALTH
Conditions of Participation
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NEW COPS ARE HERE
• On January 9, 2017, CMS released the final rule revising the home health
conditions of participation for the first time in 20 years
• The new CoPs become effective July 13, 2017
• The estimated cost to providers for the first year of implementation is $293.3M,
and $290.1M per year thereafter
• It is possible the new administration will review the rule and could either cancel
or delay implementation
• Overall, the industry response was neutral to positive
• NAHC published an excellent cross-walk on their website
www.nahc.org
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NEW COPS
• Much of the work done on the CoPs was to re-organize existing CoPs in a more
sensible manner
• Certain items were updated to reflect current technology
• On a broad basis, the CoPs are more patient-directed than before
• Requirements were added to communicate in the patient’s primary or preferred
language; the patient has a right to participate in the development of the plan of
care, including receiving a copy of the plan and receiving all services included in
the plan of care
• The CoP requiring HHAs that provide outpatient therapy to meet all of the related
conditions and health and safety requirements was changed from a CoP to a
standard
• Rather than having separate standards for therapists and nurses, skilled professionals
are grouped together in their responsibilities related to assessment, development
and updating plans of care, the provision of services, counseling and education,
preparing clinical notes, participating in QAPI and communicating with physicians
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QUESTIONS?
Thank you so much!
Sherill Mason, Principal, Mason Advisors LLC smason@masonadvisors.com
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