The CY 2018 Home Health Payment System Rate final rule was published last week and CMS announced the news the industry was hoping to read – “We are not finalizing the implementation of the Home Health Groupings Model (HHGM) in this final rule.”
CMS noted in their comments the desire to work with industry representatives regarding their concerns in changing the unit of payment from 60 days to 30 days in a non-budget neutral manner, along with providing greater transparency in the data to replicate and model the effects on their business.
We finally learned which behavioral factors CMS included in its modeling of the reimbursement impacts. The final rule noted two factors were considered:
- For LUPAs one visit under the proposed HHGM case-mix group thresholds, HHAs would provide an additional visit so the 30-day period of care becomes a non-LUPA; and
- The highest-paying diagnosis code would be listed as primary for clinical grouping assignment
Below are a few other highlights from the final rule related to the Home Health Value Based Purchasing (HHVBP) program, Home Health Quality Reporting Program (HHQRP) and the changing HH PPS case-mix weights (CMW).
Under HHVBP, starting with Performance year 3 (January 2018), the OASIS based measure “Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of Care” is being removed as an applicable measure. Additionally, a minimum of 40 HHCAHPS surveys (up from 20) will be required to receive a performance score for any of the five HHCAHPS measures used in calculating the Total Performance Score (TPS).
Under HHQRP for CY 2020, CMS finalized their intent to replace the “Pressure Ulcer New or Worsened with Changes in Skin Integrity” measure with "Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury" as well as add two new measures:
- "Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)"
- "Percent of Residents Experiencing One or More Falls with Major Injury”
CMS also finalized the removal of 235 data elements from 33 current OASIS items (down from 36) and chose to only adopt the IMPACT assessments relating to Functional Status along with Medical Conditions and Co-morbidities. In order to comply with these new assessments, 17 new OASIS data elements were added to GG0170 along with new OASIS items for Self-Care and Prior Functioning. Collection of these new items will begin for assessments starting in CY 2019 and is available here: OASIS-Items-for-the-CY-2018-HH-PPS-Final-Rule.pdf. This will clearly add to the burden of training staff on the OASIS changes in the upcoming year.
HH PPS Case-mix
Annually since CY 2015, CMS recalibrates the HHRG case-mix weights using the latest available claims and cost data. As part of this process, CMS continues to de-weight the high therapy-based episodes as well as update the scoring methodology for calculating the Clinical and Functional Domains. CY 2018 CMWs decreased an average of 2.2% over CY 2017 with all but 7 of the 153 HHRGs reflecting CMW decreases.
It was notable that three clinical dimensions were re-added that had not been used in the scoring in the past couple of years:
- Prim/Other Dx = Neuro 3-Stroke AND M1810 or M1820 (Dressing upper or lower body) = 1, 2, or 3 (last scored in 2016)
- Prim/Other Dx = Gastro (last scored in 2014)
- M1400 (Dyspnea) = 2, 3, or 4 (last scored in 2016)
One scoring dimension used in CY 2017 received no points for CY 2018:
- Prim/Other Dx = Pulmonary AND M1860 (Ambulation) ≥ 1
To help agencies see where the finalized changes were made, SHP has prepared a PPS Case-Mix Scoring and Thresholds Comparison Guide on how the HHRG scoring is affected, including the mapping and scoring of the new clinical and functional domains. The service domains are not changing at this point.
The industry can breathe a sigh of relief, but the likelihood of an “HHGM-like” reimbursement methodology is very real. The national home care trade associations and large national providers offered a consensus proposal in the week leading up to the release of the final rule. The plan deferred implementation until 2020 along with other provisions, including a Technical Expert Panel to review and participate in designing a new model. We will have to wait and see how much both sides are willing to compromise.