CMS proposes calendar year 2019 and 2020 payment and policy changes for Home Health Agencies and Home Infusion Therapy Suppliers
On July 2, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1689-P] outlining proposed Calendar Year (CY) 2019 Medicare payment updates and proposed quality reporting changes for home health agencies (HHAs), and proposed case-mix methodology refinements and a change in the home health unit of payment from 60 days to 30 days for CY 2020. This proposed rule also discusses the implementation of temporary transitional payments for home infusion therapy services to begin on January 1, 2019 and includes proposals related to full implementation of the new home infusion therapy benefit in CY 2021.
The proposed rule includes policies that are based on three pillars: empowering patients, increasing competition, and fostering innovation. The focus of the proposed rule is on the patients and their needs, and not on increasing process for process sake. CMS would continue a commitment to shift Medicare payments from volume to value, with continued implementation of the Home Health Value-Based Purchasing Model and the Home Health Quality Reporting Program, as well as a new case-mix adjustment methodology for the Home Health Prospective Payment System (HH PPS) that focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. The proposed rule would also modernize Medicare through innovations in home health and the new home infusion therapy benefit, meaningful quality measure reporting, reduced paperwork, and reduced administrative costs.
CMS encourages comments, questions, or thoughts on this proposed rule and will accept comments until August 31, 2018. The proposed rule can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.
Payment Rate Changes under the HH PPS for CY 201
CMS projects that Medicare payments to HHAs in CY 2019 would be increased by 2.1 percent, or $400 million, based on the proposed policies. The proposed increase reflects the effects of a 2.1 percent home health payment update percentage ($400 million increase); a 0.1 percent increase in payments due to decreasing the fixed-dollar-loss (FDL) ratio in order to pay no more than 2.5 percent of total payments as outlier payments (a $20 million increase); and a -0.1 percent decrease in payments due to the new rural add-on policy mandated by the Bipartisan Budget Act of 2018 for CY 2019 ($20 million decrease). The new rural add-on policy requires CMS to classify rural counties into one of three categories based on: 1) high home health utilization 2) low population density and 3) all others. Rural add-on payments for CYs 2019 through 2022 vary based on counties’ category classification.
Modernizing the HH PPS Case-mix Classification System and Promoting Patient-Driven Care
The Bipartisan Budget Act of 2018 requires a change in the unit of payment under the HH PPS, from 60-day episodes of care to 30-day periods of care, to be implemented in a budget neutral manner on January 1, 2020. Also for 2020, Congress mandated that Medicare stop using the number of therapy visits provided to determine payment, because therapy thresholds encourage volume over value and does not acknowledge that all patients aren’t the same, and some patients have complex needs that don’t involve a lot of therapy.
The proposed Patient-Driven Groupings Model, or PDGM, removes the current incentive to overprovide therapy, and instead, is designed to reflect our focus on relying more heavily on clinical characteristics and other patient information to allow payments to more closely coincide with patients’ needs. Using patient characteristics to place home health periods of care into meaningful payment categories is more consistent with how home health clinicians differentiate between home health patients in order to provide needed services. The improved structure of this proposed case-mix system would move Medicare towards a more value-based payment system that puts the unique care needs of the patient first while also reducing the administrative burden associated with the HH PPS.
To support an assessment of the effects of the proposed PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY 2019 HH PPS proposed and final rules. The Home Health Claims-OASIS LDS file can be requested by following the instructions on the following CMS website: https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/Data-Disclosures-Data-Agreements/DUA_-_NewLDS.html, and a file layout will be available.
Additionally, CMS will make available agency-level impacts and a report to congressional committees regarding a technical expert panel’s insights on the proposed PDGM, as well as an interactive Grouper Tool that will allow HHAs to determine case-mix weights for their patient populations. These materials are available on the HHA Center webpage at https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html
The Use of Remote Patient Monitoring under the Medicare Home Health Benefit
CMS is proposing to define remote patient monitoring in regulation for the Medicare home health benefit and to include the cost of remote patient monitoring as an allowable cost on the HHA cost report. Studies note that remote patient monitoring has a positive impact on patients as it allows patients to share more live-time data with their providers and caregivers, which will lead to more tailored care and better health outcomes. CMS believes that by defining remote patient monitoring and including such costs as allowable costs on the HHA cost report could encourage more HHAs to adopt the technology.
New Home Infusion Therapy Services Temporary Transitional Payment and Home Infusion Therapy Benefit
For CYs 2019 and 2020, as required by section 50401 of the Bipartisan Budget Act of 2018, CMS proposes the implementation of the temporary transitional payment for home infusion therapy services that would begin on January 1, 2019 and end the day before the full implementation of the new home infusion therapy benefit. Section 5012 of the 21st Century Cures Act (Cures Act) creates a new separate Medicare benefit category for coverage of home infusion therapy services including associated professional services for administering certain drugs and biologicals through a durable medical infusion pump, training and education, and remote monitoring and monitoring services effective January 1, 2021. This rule solicits comments on elements of the home infusion therapy benefit. In addition, this rule also proposes health and safety standards for home infusion therapy, an accreditation process for home infusion therapy suppliers and an approval and oversight process for the organizations that accredit home infusion therapy suppliers.
Home Health Quality Reporting Program (HH QRP) Provisions
In furtherance of the Meaningful Measures Initiative and to further align with the policies of other CMS quality reporting programs, CMS is proposing to replace our policy for removing previously adopted HH QRP measures with eight measure removal factors. CMS is also proposing to remove seven quality measures beginning in the CY 2021 HH QRP based upon one of these eight proposed measure removal factors. An update on the implementation of certain provisions of the IMPACT Act is also being provided along with a discussion of accounting for social risk factors in the HH QRP. Lastly, CMS is proposing to update its regulations to clarify that only a portion of OASIS data is used to determine whether an HHA has satisfied the HH QRP reporting requirements for a program year.
Home Health Value-Based Purchasing Model
In the CY 2019 HH PPS proposed rule, in addition to providing an update on the progress towards developing public reporting of performance under the Health Value-Based Purchasing (HHVBP) Model, CMS proposes to refine the HHVBP Model. CMS proposes to remove two Outcome and Assessment Information Set (OASIS)‑based measures, Influenza Immunization Received for Current Flu Season Measure and the Pneumococcal Polysaccharide Vaccine Ever Received, from the set of applicable measures; replace three OASIS-based measures with two proposed composite measures on total change in self-care and mobility; amend how we calculate the Total Performance Scores by changing the weighting methodology for the OASIS-based, claims-based, and HHCAHPS measures; and rescore the maximum amount of improvement points.
Regulatory Burden Reduction
The cost impact related to OASIS item collection as a result of the proposed implementation of the PDGM and proposed changes to the HH QRP as outlined above, are estimated to result in a net $60 million in annualized cost savings for home health agencies, or $5,150 in cost savings per HHA per year beginning in CY 2020.
In an effort to make improvements to the health care delivery system and to reduce unnecessary burdens for physicians, CMS is proposing to eliminate the requirement that the certifying physician estimate how much longer skilled services are required when recertifying the need for continued home health care. This proposal is responsive to industry concerns about regulatory burden reduction and could reduce claims denials that solely result from an estimation missing from the recertification statement. We estimate that this proposal would result in annualized cost savings to certifying physicians of $14 million beginning in CY 2019.
We are also proposing to amend current regulations to align them with current sub-regulatory guidance to allow medical record documentation from the HHA to be used to support the basis for certification of home health eligibility, consistent with the Bipartisan Budget Act of 2018.
These burden reduction efforts would allow providers to spend more time on their chief responsibility: improving the health outcomes of their patients.
Advancing My HealthEData: Request for Information from stakeholders
In addition to payment and policy proposals, CMS is releasing a Request for Information (RFI) to obtain feedback on positive solutions to better achieve interoperability or the sharing of healthcare data between providers. Specifically, CMS is requesting stakeholder feedback through a RFI on the possibility of revising Conditions of Participation related to interoperability as a way to increase electronic sharing of data by providers. This will inform next steps to advance this critical initiative.
In responding to the RFI, commenters should provide clear and concise proposals that include data and specific examples. CMS will not respond to RFI comment submissions in the final rule, but rather will actively consider all input in developing future regulatory proposals or future sub-regulatory guidance.
For additional information about the Home Health Value-Based Purchasing Model, visit https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model.
For additional information about the Home Health Prospective Payment System, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/index.html.For additional information about the Home Health Quality Reporting Program, visit https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Requirements.html
The proposed rule can be viewed at https://www.federalregister.gov/public-inspection.