[Federal Register Volume 81, Number 128 (Tuesday, July 5, 2016)]
[Proposed Rules]
[Pages 43714-43788]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-15448]
[[Page 43713]]
Vol. 81
Tuesday,
No. 128
July 5, 2016
Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 409 and 484
Medicare and Medicaid Programs; CY 2017 Home Health Prospective Payment
System Rate Update; Home Health Value-Based Purchasing Model; and Home
Health Quality Reporting Requirements; Proposed Rule
Federal Register / Vol. 81 , No. 128 / Tuesday, July 5, 2016 /
Proposed Rules
[[Page 43714]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 409 and 484
[CMS-1648-P]
RIN 0938-AS80
Medicare and Medicaid Programs; CY 2017 Home Health Prospective
Payment System Rate Update; Home Health Value-Based Purchasing Model;
and Home Health Quality Reporting Requirements
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
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SUMMARY: This proposed rule would update the Home Health Prospective
Payment System (HH PPS) payment rates, including the national,
standardized 60-day episode payment rates, the national per-visit
rates, and the non-routine medical supply (NRS) conversion factor,
effective for home health episodes of care ending on or after January
1, 2017. This proposed rule also: Implements the last year of the 4-
year phase-in of the rebasing adjustments to the HH PPS payment rates;
updates the HH PPS case-mix weights using the most current, complete
data available at the time of rulemaking; implements the 2nd-year of a
3-year phase-in of a reduction to the national, standardized 60-day
episode payment to account for estimated case-mix growth unrelated to
increases in patient acuity (that is, nominal case-mix growth) between
CY 2012 and CY 2014; proposes changes to the methodology used to
calculate outlier payments (with regards to payments made under the HH
PPS for high-cost ``outlier'' episodes of care (that is, episodes of
care with unusual variations in the type or amount of medically
necessary care)); proposes changes in payment for Negative Pressure
Wound Therapy (NPWT) performed using a disposable device for patient's
under a home health plan of care; discusses our efforts to monitor the
potential impacts of the rebasing adjustments mandated; includes an
update on subsequent research and analysis as a result of the findings
from the home health study; solicits comments on a potential process
for grouping HH PPS claims centrally during claims processing; and
proposes changes to the Home Health Value-Based Purchasing (HHVBP)
Model, which was implemented on January 1, 2016; and proposes updates
to the Home Health Quality Reporting Program (HH QRP).
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, no later than 5 p.m. on August 26, 2016.
ADDRESSES: In commenting, please refer to file code CMS-1648-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to http://www.regulations.gov. Follow the instructions under
the ``More Search Options'' tab.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-1648-P, P.O. Box 8016,
Baltimore, MD 21244-8016.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-1648-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. For delivery in Washington, DC-- Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A
stamp-in clock is available for persons wishing to retain a proof of
filing by stamping in and retaining an extra copy of the comments
being filed.)
b. For delivery in Baltimore, MD-- Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call (410) 786-7195 in advance to schedule your arrival with one
of our staff members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: For general information about the HH
PPS, please send your inquiry via email to:
[email protected].
For information about the HHVBP Model, please send your inquiry via
email to: [email protected].
Michelle Brazil, (410) 786-1648 for information about the HH
quality reporting program.
Lori Teichman, (410) 786-6684, for information about HHCAHPS.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received at http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. EST. To schedule an appointment to view public comments,
phone 1-800-743-3951.
Table of Contents
I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Costs and Benefits
II. Background
A. Statutory Background
B. System for Payment of Home Health Services
C. Updates to the Home Health Prospective Payment System
III. Proposed Provisions of the Home Health Prospective Payment
System
A. Monitoring for Potential Impacts--Affordable Care Act
Rebasing Adjustments
B. Proposed CY 2017 HH PPS Case-Mix Weights
C. Proposed CY 2017 Home Health Rate Update
1. Proposed CY 2017 Home Health Market Basket Update
[[Page 43715]]
2. Proposed CY 2017 Home Health Wage Index
3. Proposed CY 2017 Annual Payment Update
D. Payments for High-Cost Outliers Under the HH PPS
1. Background
2. Proposed Changes to the Methodology Used To Estimate Episode
Cost
3. Proposed Fixed Dollar Loss (FDL) Ratio
E. Proposed Payment Policies for Negative Pressure Wound Therapy
Using a Disposable Device
F. Update on Subsequent Research and Analysis Related to Section
3131(d) of the Affordable Care Act
G. Update on Future Plans to Group HH PPS Claims Centrally
During Claims Processing
IV. Proposed Provisions of the Home Health Value-Based Purchasing
(HHVBP) Model
A. Background
B. Smaller- and Larger-Volume Cohorts
C. Quality Measures
D. Appeals Process
E. Discussion of the Public Display of Total Performance Scores
V. Proposed Updates to the Home Health Care Quality Reporting
Program (HHQRP)
A. Background and Statutory Authority
B. General Considerations Used for the Selection of Quality
Measures for the HH QRP
C. Policy for Retaining HH QRP Quality Measures Adopted for
Future Payment Determination
D. Process for Adoption of Changes to HH QRP Measures
E. HH QRP Quality, Resource Use, and Other Measures for CY 2018
Payment Determination and Subsequent Years
1. Proposal To Address the IMPACT Act Domain of Resource Use and
Other Measures: MSPB-PAC HH QRP
2. Proposal To Address the IMPACT Act Domain of Resource Use and
Other Measures: Discharge to Community--Post Acute Care Home Health
Quality Reporting Program
3. Proposal To Address the IMPACT Act of 2014 Domain of Resource
Use and Other Measures: Potentially Preventable 30-Day Post-
Discharge Readmission Measure for Post-Acute Care Home Health
Quality Reporting Program.
4. Proposal To Address the IMPACT Act Domain of Medication
Reconciliation: Drug Regimen Review Conducted With Follow-Up for
Identified Issues-Post-Acute Care Home Health Quality Reporting
Program.
F. HH QRP Quality Measures and Measure Concepts Under
Consideration for Future Years
G. Form Manner and Timing of OASIS Data Submission and OASIS
Data for Annual Payment Update
1. Regulatory Authority
2. Home Health Quality Reporting Program Requirements for CY
2017 Payment and Subsequent Years
3. Previously Established Pay-for-Reporting Performance
Requirement for Submission of OASIS Quality Data
4. Proposed Timeline and Data Submission Mechanisms for Measures
Proposed for the CY 2018 Payment Determination and Subsequent Years
5. Proposed Timeline and Data Submission Mechanisms for the CY
2018 Payment Determination and Subsequent Years for New HH QRP
Assessment-Based Quality Measure
6. Data Collection Timelines and Requirements for the CY 2019
Payment Determinations and Subsequent Years
7. Proposed Data Review and Correction Timeframes for Data
Submitted Using the OASIS Instrument
H. Public Display of Quality Measure Data and Opportunity for
Providers To Review and Correct Data and Information to be Made
Public
I. Mechanism for Providing Feedback Reports to HHAs
J. Home Health Care CAHPS[supreg] Survey (HHCAHPS)
1. Background and Description of HHCAHPS
2. HHCAHPS Oversight Activities
3. HHCAHPS Requirements for the CY 2017 APU
4. HHCAHPS Requirements for the CY 2018 APU
5. HHCAHPS Requirements for the CY 2019 APU
6. HHCAHPS Requirements for the CY 2020 APU
7. HHCAHPS Reconsideration and Appeals Process
8. Summary
VI. Collection of Information Requirements
VII. Response to Comments
VIII. Regulatory Impact Analysis
IX. Federalism Analysis
Regulations Text
Acronyms
In addition, because of the many terms to which we refer by
abbreviation in this proposed rule, we are listing these abbreviations
and their corresponding terms in alphabetical order below:
ACH LOS Acute Care Hospital Length of Stay
ADL Activities of Daily Living
APU Annual Payment Update
BBA Balanced Budget Act of 1997, Pub. L. 105-33
BBRA Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of
1999, (Pub. L. 106-113)
CAD Coronary Artery Disease
CAH Critical Access Hospital
CBSA Core-Based Statistical Area
CASPER Certification and Survey Provider Enhanced Reports
CHF Congestive Heart Failure
CMI Case-Mix Index
CMP Civil Money Penalty
CMS Centers for Medicare & Medicaid Services
CoPs Conditions of Participation
COPD Chronic Obstructive Pulmonary Disease
CVD Cardiovascular Disease
CY Calendar Year
DM Diabetes Mellitus
DRA Deficit Reduction Act of 2005, Pub. L. 109-171, enacted February
8, 2006
FDL Fixed Dollar Loss
FI Fiscal Intermediaries
FISS Fiscal Intermediary Shared System
FR Federal Register
FY Fiscal Year
HAVEN Home Assessment Validation and Entry System
HCC Hierarchical Condition Categories
HCIS Health Care Information System
HH Home Health
HHA Home Health Agency
HHCAHPS Home Health Care Consumer Assessment of Healthcare Providers
and Systems Survey
HH PPS Home Health Prospective Payment System
HHRG Home Health Resource Group
HHVBP Home Health Value-Based Purchasing
HIPPS Health Insurance Prospective Payment System
HVBP Hospital Value-Based Purchasing
ICD-9-CM International Classification of Diseases, Ninth Revision,
Clinical Modification
ICD-10-CM International Classification of Diseases, Tenth Revision,
Clinical Modification
IH Inpatient Hospitalization
IMPACT Act Improving Medicare Post-Acute Care Transformation Act of
2014 (Pub. L. 113-185)
IRF Inpatient Rehabilitation Facility
LEF Linear Exchange Function
LTCH Long-Term Care Hospital
LUPA Low-Utilization Payment Adjustment
MEPS Medical Expenditures Panel Survey
MMA Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, Pub. L. 108-173, enacted December 8, 2003
MSA Metropolitan Statistical Area
MSS Medical Social Services
NQF National Quality Forum
NQS National Quality Strategy
NRS Non-Routine Supplies
OASIS Outcome and Assessment Information Set
OBRA Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-2-3,
enacted December 22, 1987
OCESAA Omnibus Consolidated and Emergency Supplemental
Appropriations Act, Pub. L. 105-277, enacted October 21, 1998
OES Occupational Employment Statistics
OIG Office of Inspector General
OT Occupational Therapy
OMB Office of Management and Budget
MFP Multifactor productivity
PAMA Protecting Access to Medicare Act of 2014
PAC-PRD Post-Acute Care Payment Reform Demonstration
PEP Partial Episode Payment Adjustment
PT Physical Therapy
PY Performance Year
PRRB Provider Reimbursement Review Board
QAP Quality Assurance Plan
RAP Request for Anticipated Payment
RF Renal Failure
RFA Regulatory Flexibility Act, Pub. L. 96-354
RHHIs Regional Home Health Intermediaries
[[Page 43716]]
RIA Regulatory Impact Analysis
SAF Standard Analytic File
SLP Speech-Language Pathology
SN Skilled Nursing
SNF Skilled Nursing Facility
TPS Total Performance Score
UMRA Unfunded Mandates Reform Act of 1995
VBP Value-Based Purchasing
I. Executive Summary
A. Purpose
This proposed rule would update the payment rates for home health
agencies (HHAs) for calendar year (CY) 2017, as required under section
1895(b) of the Social Security Act (the Act). This would reflect the
final year of the 4-year phase-in of the rebasing adjustments to the
national, standardized 60-day episode payment rate, the national per-
visit rates, and the NRS conversion factor finalized in the CY 2014 HH
PPS final rule (78 FR 72256), as required under section 3131(a) of the
Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148),
as amended by the Health Care and Education Reconciliation Act of 2010
(Pub. L. 111-152) (collectively referred to as the ``Affordable Care
Act'').
This proposed rule would update the case-mix weights under section
1895(b)(4)(A)(i) and (b)(4)(B) of the Act and includes a reduction to
the national, standardized 60-day episode payment rate in CY 2017 of
0.97 percent, to account for case-mix growth unrelated to increases in
patient acuity (nominal case-mix growth) between CY 2012 and CY 2014
under the authority of section 1895(b)(3)(B)(iv) of the Act. With
regards to payments made under the HH PPS for high-cost ``outlier''
episodes of care (that is, episodes of care with unusual variations in
the type or amount of medically necessary care), this rule proposes
changes to the methodology used to calculate outlier payments under the
authority of section 1895(b)(5) of the Act. Also, in accordance with
section 1834(s)(1) of the Act, as amended by the Consolidated
Appropriations Act of 2016 (Pub. L. 114-113), this rule proposes
changes in payment for Negative Pressure Wound Therapy (NPWT) performed
using a disposable device for patient's under a home health plan of
care for which payment would otherwise be made under section 1895(b) of
the Act. This proposed rule also discusses our efforts to monitor for
potential impacts of the rebasing adjustments mandated by section
3131(a) of the Affordable Care Act, provides an update on subsequent
research and analysis as a result of the findings from the home health
study required by section 3131(d) of the Affordable Care Act, and
provides and update and solicits comments on a process to group HH PPS
claims centrally during claims processing. Additionally, this rule
proposes changes to the HHVBP Model, in which Medicare-certified HHAs
in certain states are required to participate as of January 1, 2016,
under the authority of section 1115A of the Act; and proposes changes
to the home health quality reporting program requirements under the
authority of section 1895(b)(3)(B)(v)(II) of the Act.
B. Summary of the Major Provisions
As required by section 3131(a) of the Affordable Care Act, and
finalized in the CY 2014 HH PPS final rule (78 FR 77256, December 2,
2013), we are implementing the final year of the 4-year phase-in of the
rebasing adjustments to the national, standardized 60-day episode
payment amount, the national per-visit rates and the NRS conversion
factor in section III.C.3. The rebasing adjustments for CY 2017 will
reduce the national, standardized 60-day episode payment amount by
$80.95, increase the national per-visit payment amounts by 3.5 percent
of the national per-visit payment amounts in CY 2010 with the increases
ranging from $1.79 for home health aide services to $6.34 for medical
social services, and reduce the NRS conversion factor by 2.82 percent.
In addition, in section III.C.3 of this rule, we are implementing a
reduction to the national, standardized 60-day episode payment rate in
CY 2017 of 0.97 percent to account for estimated case-mix growth
unrelated to increases in patient acuity (that is, nominal case-mix
growth) between CY 2012 and CY 2014. This reduction was finalized in
the CY 2016 HH PPS final rule (80 FR 68624). Section III.A of this
proposed rule discusses our efforts to monitor for potential impacts
due to the rebasing adjustments mandated by section 3131(a) of the
Affordable Care Act.
In the CY 2015 HH PPS final rule (79 FR 66072), we finalized our
proposal to recalibrate the case-mix weights every year with more
current data. In section III.B.1 of this rule, we are recalibrating the
HH PPS case-mix weights, using the most current cost and utilization
data available, in a budget neutral manner. In section III.C.1 of this
rule, we propose to update the payment rates under the HH PPS by the
home health payment update percentage of 2.3 percent (using the 2010-
based Home Health Agency (HHA) market basket update of 2.8 percent,
minus 0.5 percentage point for productivity), as required by section
1895(b)(3)(B)(vi)(I) of the Act, and in section III.C.2 of this rule,
we propose to update the CY 2017 home health wage index using more
current hospital wage data. In section III.D, we are proposing to
revise the current methodology used to estimate the cost of an episode
of care to determine whether the episode of care would receive an
outlier payment. The methodology change includes calculating the cost
of an episode of care using a cost-per-unit calculation, which takes
into account visit length, rather than the current methodology that
uses a cost-per-visit calculation. In section III.E of this proposed
rule, as a result of the Consolidated Appropriations Act of 2016 (Pub.
L. 114-113), we are proposing changes in payment for when Negative
Pressure Wound Therapy (NPWT) is performed using a disposable device
for a patient under a home health plan of care and for which payment is
otherwise made under the HH PPS. In section III.F of this rule, we
provide an update on our recent research and analysis pertaining to the
home health study required by section 3131(d) of the Affordable Care
Act. Finally, in section III.G of this proposed rule, we provide an
update and solicit comments on a process for grouping the HH PPS claims
centrally during claims processing.
In section IV of this rule, we are proposing the following changes
to the HHVBP Model implemented January 1, 2016. We propose to remove
the definition for ``starter set''; propose to revise the definition
for ``benchmark''; propose to calculate benchmarks and achievement
thresholds at the state level; propose a minimum requirement of eight
HHAs in a cohort; propose to increase the time frame for submitting New
Measure data; propose to remove four measures from the set of
applicable measures; propose to adjust the reporting period and
submission date for one of the New Measures; propose to add an appeals
process that includes the existing recalculation process; and we are
providing an update on the progress towards developing public reporting
of performance under the HHVBP Model.
This proposed rule also proposes updates to the Home Health Quality
Reporting Program in section V, including the adoption of four new
quality measures, the removal of a number of measures, data submission
requirements, and data review and correction policies.
C. Summary of Costs and Transfers
[[Page 43717]]
Table 1--Summary of Costs and Transfers
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Provision description Costs Transfers
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CY 2017 HH PPS Payment Rate Update....... .............. The overall economic impact of the HH PPS payment
rate update is an estimated -$180 million (-1.0
percent) in payments to HHAs.
CY 2017 HHVBP Model...................... .............. The overall economic impact of the HHVBP Model
provision for CY 2018 through 2022 is an estimated
$378 million in total savings from a reduction in
unnecessary hospitalizations and SNF usage as a
result of greater quality improvements in the HH
industry. As for payments to HHAs, there are no
aggregate increases or decreases to the HHAs
competing in the model.
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II. Background
A. Statutory Background
The Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33, enacted
August 5, 1997), significantly changed the way Medicare pays for
Medicare HH services. Section 4603 of the BBA mandated the development
of the HH PPS. Until the implementation of the HH PPS on October 1,
2000, HHAs received payment under a retrospective reimbursement system.
Section 4603(a) of the BBA mandated the development of a HH PPS for
all Medicare-covered HH services provided under a plan of care (POC)
that were paid on a reasonable cost basis by adding section 1895 of the
Act, entitled ``Prospective Payment For Home Health Services.'' Section
1895(b)(1) of the Act requires the Secretary to establish a HH PPS for
all costs of HH services paid under Medicare.
Section 1895(b)(3)(A) of the Act requires the following: (1) The
computation of a standard prospective payment amount, to include all
costs for HH services covered and paid for on a reasonable cost basis,
and that such amounts be initially based on the most recent audited
cost report data available to the Secretary; and (2) the standardized
prospective payment amount is to be adjusted to account for the effects
of case-mix and wage levels among HHAs.
Section 1895(b)(3)(B) of the Act requires an annual update to the
standard prospective payment amounts by the HH applicable percentage
increase. Section 1895(b)(4) of the Act governs the payment
computation. Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act
require the standard prospective payment amount to be adjusted for
case-mix and geographic differences in wage levels, respectively.
Section 1895(b)(4)(B) of the Act requires the establishment of an
appropriate case-mix change adjustment factor for significant variation
in costs among different units of services.
Similarly, section 1895(b)(4)(C) of the Act requires the
establishment of wage adjustment factors that reflect the relative
level of wages, and wage-related costs applicable to HH services
furnished in a geographic area compared to the applicable national
average level. Under section 1895(b)(4)(C) of the Act, the wage-
adjustment factors used by the Secretary may be the factors used under
section 1886(d)(3)(E) of the Act.
Section 1895(b)(5) of the Act gives the Secretary the option to
make additions or adjustments to the payment amount otherwise paid in
the case of outliers due to unusual variations in the type or amount of
medically necessary care. Section 3131(b)(2) of the Patient Protection
and Affordable Care Act of 2010 (the Affordable Care Act) (Pub. L. 111-
148, enacted March 23, 2010) revised section 1895(b)(5) of the Act so
that total outlier payments in a given year would not exceed 2.5
percent of total payments projected or estimated. The provision also
made permanent a 10 percent agency-level outlier payment cap.
In accordance with the statute, as amended by the BBA, we published
a final rule in the July 3, 2000 Federal Register (65 FR 41128) to
implement the HH PPS legislation. The July 2000 final rule established
requirements for the new HH PPS for HH services as required by section
4603 of the BBA, as subsequently amended by section 5101 of the Omnibus
Consolidated and Emergency Supplemental Appropriations Act (OCESAA) for
Fiscal Year 1999, (Pub. L. 105-277, enacted October 21, 1998); and by
sections 302, 305, and 306 of the Medicare, Medicaid, and SCHIP
Balanced Budget Refinement Act (BBRA) of 1999, (Pub. L. 106-113,
enacted November 29, 1999). The requirements include the implementation
of a HH PPS for HH services, consolidated billing requirements, and a
number of other related changes. The HH PPS described in that rule
replaced the retrospective reasonable cost-based system that was used
by Medicare for the payment of HH services under Part A and Part B. For
a complete and full description of the HH PPS as required by the BBA,
see the July 2000 HH PPS final rule (65 FR 41128 through 41214).
Section 5201(c) of the Deficit Reduction Act of 2005 (DRA) (Pub. L.
109-171, enacted February 8, 2006) added new section 1895(b)(3)(B)(v)
to the Act, requiring HHAs to submit data for purposes of measuring
health care quality, and links the quality data submission to the
annual applicable percentage increase. This data submission requirement
is applicable for CY 2007 and each subsequent year. If an HHA does not
submit quality data, the HH market basket percentage increase is
reduced by 2 percentage points. In the November 9, 2006 Federal
Register (71 FR 65884, 65935), we published a final rule to implement
the pay-for-reporting requirement of the DRA, which was codified at
Sec. 484.225(h) and (i) in accordance with the statute. The pay-for-
reporting requirement was implemented on January 1, 2007.
The Affordable Care Act made additional changes to the HH PPS. One
of the changes set out in section 3131 of the Affordable Care Act was
an amendment to section 421(a) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173,
enacted on December 8, 2003) as amended by section 5201(b) of the DRA.
Section 421(a) of the MMA, as amended by section 3131 of the Affordable
Care Act, requires that the Secretary increase, by 3 percent, the
payment amount otherwise made under section 1895 of the Act, for HH
services furnished in a rural area (as defined in section 1886(d)(2)(D)
of the Act) with respect to episodes and visits ending on or after
April 1, 2010, and before January 1, 2016. Section 210 of the Medicare
Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10)
amended section 421(a) of the MMA to extend the rural add-on for 2 more
years. Section 421(a) of the MMA, as amended by section 210 of the
MACRA, requires that the Secretary increase, by 3 percent, the payment
amount otherwise made under section 1895 of the Act, for HH services
provided in a
[[Page 43718]]
rural area (as defined in section 1886(d)(2)(D) of the Act) with
respect to episodes and visits ending on or after April 1, 2010, and
before January 1, 2018.
Section 2(a) of the Improving Medicare Post-Acute Care
Transformation Act of 2014 (the IMPACT Act) (Pub. L. 113-185, enacted
on Oct. 6, 2014) amended Title XVIII of the Act, in part, by adding a
new section 1899B, which imposes new data reporting requirements for
certain post-acute care (PAC) providers, including HHAs. Under section
1899B(a)(1) of the Act, certain post-acute care (PAC) providers
(defined in section 1899B(a)(2)(A) of the Act as HHAs, SNFs, IRFs, and
LTCHs) must submit standardized patient assessment data in accordance
with section 1899B(b) of the Act, data on quality measures required
under section 1899B(c)(1) of the Act, and data on resource use, and
other measures required under section 1899B(d)(1) of the Act. The Act
also requires the Secretary to specify these measures insofar as they
are respect to certain domains no later than the applicable specified
application date that applies to each domain. The specific specified
application dates that apply to each PAC provider type and domain are
described in section 1899B(a)(2)(E) of the Act.
B. System for Payment of Home Health Services
Generally, Medicare makes payment under the HH PPS on the basis of
a national standardized 60-day episode payment rate that is adjusted
for the applicable case-mix and wage index. The national standardized
60-day episode rate includes the six HH disciplines (skilled nursing,
HH aide, physical therapy, speech-language pathology, occupational
therapy, and medical social services). Payment for non-routine supplies
(NRS) is no longer part of the national standardized 60-day episode
rate and is computed by multiplying the relative weight for a
particular NRS severity level by the NRS conversion factor (See section
II.D.4.e). Payment for durable medical equipment covered under the HH
benefit is made outside the HH PPS payment system. To adjust for case-
mix, the HH PPS uses a 153-category case-mix classification system to
assign patients to a home health resource group (HHRG). The clinical
severity level, functional severity level, and service utilization are
computed from responses to selected data elements in the OASIS
assessment instrument and are used to place the patient in a particular
HHRG. Each HHRG has an associated case-mix weight which is used in
calculating the payment for an episode.
For episodes with four or fewer visits, Medicare pays national per-
visit rates based on the discipline(s) providing the services. An
episode consisting of four or fewer visits within a 60-day period
receives what is referred to as a low-utilization payment adjustment
(LUPA). Medicare also adjusts the national standardized 60-day episode
payment rate for certain intervening events that are subject to a
partial episode payment adjustment (PEP adjustment). For certain cases
that exceed a specific cost threshold, an outlier adjustment may also
be available.
C. Updates to the Home Health Prospective Payment System
As required by section 1895(b)(3)(B) of the Act, we have
historically updated the HH PPS rates annually in the Federal Register.
The August 29, 2007 final rule with comment period set forth an update
to the 60-day national episode rates and the national per-visit rates
under the HH PPS for CY 2008. The CY 2008 HH PPS final rule included an
analysis performed on CY 2005 HH claims data, which indicated a 12.78
percent increase in the observed case-mix since 2000. Case-mix
represents the variations in conditions of the patient population
served by the HHAs. Subsequently, a more detailed analysis was
performed on the 2005 case-mix data to evaluate if any portion of the
12.78 percent increase was associated with a change in the actual
clinical condition of HH patients. We examined data on demographics,
family severity, and non-HH Part A Medicare expenditures to predict the
average case-mix weight for 2005. We identified 8.03 percent of the
total case-mix change as real, and therefore, decreased the 12.78
percent of total case-mix change by 8.03 percent to get a final nominal
case-mix increase measure of 11.75 percent (0.1278 * (1 - 0.0803) =
0.1175).
To account for the changes in case-mix that were not related to an
underlying change in patient health status, we implemented a reduction,
over 4 years, to the national, standardized 60-day episode payment
rates. That reduction was to be 2.75 percent per year for 3 years
beginning in CY 2008 and 2.71 percent for the fourth year in CY 2011.
In the CY 2011 HH PPS final rule (76 FR 68532), we updated our analyses
of case-mix change and finalized a reduction of 3.79 percent, instead
of 2.71 percent, for CY 2011 and deferred finalizing a payment
reduction for CY 2012 until further study of the case-mix change data
and methodology was completed.
In the CY 2012 HH PPS final rule (76 FR 68526), we updated the 60-
day national episode rates and the national per-visit rates. In
addition, as discussed in the CY 2012 HH PPS final rule (76 FR 68528),
our analysis indicated that there was a 22.59 percent increase in
overall case-mix from 2000 to 2009 and that only 15.76 percent of that
overall observed case-mix percentage increase was due to real case-mix
change. As a result of our analysis, we identified a 19.03 percent
nominal increase in case-mix. At that time, to fully account for the
19.03 percent nominal case-mix growth identified from 2000 to 2009, we
finalized a 3.79 percent payment reduction in CY 2012 and a 1.32
percent payment reduction for CY 2013.
In the CY 2013 HH PPS final rule (77 FR 67078), we implemented a
1.32 percent reduction to the payment rates for CY 2013 to account for
nominal case-mix growth from 2000 through 2010. When taking into
account the total measure of case-mix change (23.90 percent) and the
15.97 percent of total case-mix change estimated as real from 2000 to
2010, we obtained a final nominal case-mix change measure of 20.08
percent from 2000 to 2010 (0.2390 * (1 - 0.1597) = 0.2008). To fully
account for the remainder of the 20.08 percent increase in nominal
case-mix beyond that which was accounted for in previous payment
reductions, we estimated that the percentage reduction to the national,
standardized 60-day episode rates for nominal case-mix change would be
2.18 percent. Although we considered proposing a 2.18 percent reduction
to account for the remaining increase in measured nominal case-mix, we
finalized the 1.32 percent payment reduction to the national,
standardized 60-day episode rates in the CY 2012 HH PPS final rule (76
FR 68532).
Section 3131(a) of the Affordable Care Act also required that,
beginning in CY 2014, we apply an adjustment to the national,
standardized 60-day episode rate and other amounts that reflect factors
such as changes in the number of visits in an episode, the mix of
services in an episode, the level of intensity of services in an
episode, the average cost of providing care per episode, and other
relevant factors. Additionally, we were required to phase in any
adjustment over a 4-year period in equal increments, not to exceed 3.5
percent of the amount (or amounts) as of the date of enactment of the
Affordable Care Act, and fully implement the rebasing adjustments by CY
2017. The statute specified that the maximum rebasing adjustment was to
[[Page 43719]]
be no more than 3.5 percent per year of the CY 2010 rates. Therefore,
in the CY 2014 HH PPS final rule (78 FR 72256) for each year, CY 2014
through CY 2017, we finalized a fixed-dollar reduction to the national,
standardized 60-day episode payment rate of $80.95 per year, increases
to the national per-visit payment rates per year as reflected in Table
2, and a decrease to the NRS conversion factor of 2.82 percent per
year. We also finalized three separate LUPA add-on factors for skilled
nursing, physical therapy, and speech-language pathology and removed
170 diagnosis codes from assignment to diagnosis groups in the HH PPS
Grouper. In the CY 2015 HH PPS final rule (79 FR 66032), we implemented
the 2nd year of the 4 year phase-in of the rebasing adjustments to the
HH PPS payment rates and made changes to the HH PPS case-mix weights.
In addition, we simplified the face-to-face encounter regulatory
requirements and the therapy reassessment timeframes.
Table 2--Maximum Adjustments to the National Per-Visit Payment Rates
[Not to exceed 3.5 percent of the amount(s) in CY 2010]
------------------------------------------------------------------------
Maximum
2010 National per- adjustments per
visit payment year (CY 2014
rates through CY 2017)
------------------------------------------------------------------------
Skilled Nursing................... $113.01 $3.96
Home Health Aide.................. 51.18 1.79
Physical Therapy.................. 123.57 4.32
Occupational Therapy.............. 124.40 4.35
Speech-Language Pathology......... 134.27 4.70
Medical Social Services........... 181.16 6.34
------------------------------------------------------------------------
In the CY 2016 HH PPS final rule (80 FR 68624), we implemented the
3rd year of the 4-year phase-in of the rebasing adjustments to the
national, standardized 60-day episode payment amount, the national per-
visit rates and the NRS conversion factor (as outlined above).
In the CY 2016 HH PPS final rule, we also recalibrated the HH PPS
case-mix weights, using the most current cost and utilization data
available, in a budget neutral manner, and finalized reductions to the
national, standardized 60-day episode payment rate in CY 2016, CY 2017,
and CY 2018 of 0.97 percent in each year to account for estimated case-
mix growth unrelated to increases in patient acuity (that is, nominal
case-mix growth) between CY 2012 and CY 2014. Finally, we continued to
apply the payment increase of 3 percent for HH services provided in
rural areas (as defined in section 1886(d)(2)(D) of the Act) to
episodes or visits ending before January 1, 2018.
III. Proposed Provisions of the Home Health Prospective Payment System
A. Monitoring for Potential Impacts--Affordable Care Act Rebasing
Adjustments
1. Analysis of FY 2014 HHA Cost Report Data
As part of our efforts in monitoring the potential impacts of the
rebasing adjustments finalized in the CY 2014 HH PPS final rule (78 FR
72293), we continue to update our analysis of home health cost report
and claims data. In the CY 2014 HH PPS final rule, using 2011 cost
report and 2012 claims data, we estimated the 2013 60-day episode cost
to be $2,565.51 (78 FR 72277). In that final rule, we stated that our
analysis of 2011 cost report data and 2012 claims data indicated a need
for a -3.45 percent rebasing adjustment to the national, standardized
60-day episode payment rate each year for 4 years. However, as
specified by statute, the rebasing adjustment is limited to 3.5 percent
of the CY 2010 national, standardized 60-day episode payment rate of
$2,312.94 (74 FR 58106), or $80.95. We stated that given that a -3.45
percent adjustment for CY 2014 through CY 2017 would result in larger
dollar amount reductions than the maximum dollar amount allowed under
section 3131(a) of the Affordable Care Act of $80.95, we were limited
to implementing a reduction of $80.95 (approximately 2.8 percent of the
standardized payment amount for CY 2014) to the national, standardized
60-day episode payment amount each year for CY 2014 through CY 2017.
In the CY 2015 HH PPS final rule, (79 FR 66032-66118) using 2012
cost report and 2013 claims data, we estimated the 2013 60-day episode
cost to be $2,485.24 (79 FR 66037). Similar to our discussion in the CY
2014 HH PPS final rule, we stated that absent the Affordable Care Act's
limit to rebasing, in order to align payments with costs, a -4.21
percent adjustment would have been applied to the national,
standardized 60-day episode payment amount each year for CY 2014
through CY 2017.
In the CY 2016 HH PPS proposed rule (80 FR 39846-39866), using 2013
cost report and 2013 claims data, we estimated the 2013 60-day episode
cost to be $2,402.11 (80 FR 39846). Similar to our discussion in the CY
2014 HH PPS final rule and the CY 2015 HH PPS final rule, we stated
that absent the Affordable Care Act's limit to rebasing, in order to
align payments with costs, a -5.02 percent adjustment would have been
applied to the national, standardized 60-day episode payment amount
each year for CY 2014 through CY 2017.
For this proposed rule, we analyzed 2014 HHA cost report data and
2014 HHA claims data to determine whether the average cost per episode
was higher using 2014 cost report data compared to the 2011 cost report
and 2012 claims da006used in calculating the rebasing adjustments. To
determine the 2014 average cost per visit per discipline, we applied
the same trimming methodology outlined in the CY 2014 HH PPS proposed
rule (78 FR 40284) and weighted the costs per visit from the 2014 cost
reports by size, facility type, and urban/rural location so the costs
per visit were nationally representative according to 2014 claims data.
The 2014 average number of visits was taken from 2014 claims data. We
estimate the cost of a 60-day episode in CY 2014 to be $2,373.87 using
2014 cost report data (Table 3). Our latest analysis of 2014 cost
report and 2014 claims data suggests that an even larger reduction (-
5.30 percent) than the reduction described in the CY 2014 HH PPS final
rule (-3.45 percent) or the reductions described in the CY 2015 HH PPS
final rule and the CY 2016 HH PPS proposed rule (-4.21 and -5.02
percent,
[[Page 43720]]
respectively) would have been needed in order to align payments with
costs. The decrease in the estimated 60-day episode cost from $2,402.11
in CY 2013 to $2,373.87 in CY 2014 was due to both a lower average cost
per visit for skilled nursing and home health aide services in 2014
compared to 2013 and lower average number of visits for skilled nursing
and home health aide services per episode in 2014 compared to 2013.
Table 3--2014 Estimated Cost per Episode
----------------------------------------------------------------------------------------------------------------
2014 Average 2014 Average
Discipline costs per number of 2014 60-Day
visit visits episode costs
----------------------------------------------------------------------------------------------------------------
Skilled Nursing................................................. $128.68 9.09 $1,169.70
Home Health Aide................................................ 56.59 2.19 123.93
Physical Therapy................................................ 155.90 5.18 807.56
Occupational Therapy............................................ 153.69 1.30 199.80
Speech-Language Pathology....................................... 166.98 0.26 43.41
Medical Social Services......................................... 210.48 0.14 29.47
-----------------------------------------------
Total....................................................... .............. 18.16 2,373.87
----------------------------------------------------------------------------------------------------------------
Source: FY 2014 Medicare cost report data and 2014 Medicare claims data from the standard analytic file (as of
June 30, 2015) for episodes (excluding low-utilization payment adjusted episodes and partial-episode-payment
adjusted episodes) ending on or before December 31, 2014 for which we could link an OASIS assessment.
2. Analysis of CY 2015 HHA Claims Data
In the CY 2014 HH PPS final rule (78 FR 72256), some commenters
expressed concern that the rebasing of the HH PPS payment rates would
result in HHA closures and would therefore diminish access to home
health services. In addition to examining more recent cost report data,
for this proposed rule we examined home health claims data from the
first 2 years (CY 2014 and CY 2015) of the 4-year phase-in of the
rebasing adjustments (CY 2014 through CY 2017), the first calendar year
of the HH PPS (CY 2001), and claims data for the 3 years before
implementation of the rebasing adjustments (CY 2011-2013). Preliminary
analysis of CY 2015 home health claims data indicates that the number
of episodes decreased by 3.8 percent from 2013 to 2014, and decreased
by 1.7 percent from 2014 to 2015. In addition, the number of home
health users that received at least one episode of care decreased by
2.95 percent between 2013 and 2014, and decreased slightly by 0.5
percent from 2014 to 2015.The number of FFS beneficiaries has remained
the relatively constant between 2013 and 2015. Between 2013 and 2014
there appears to be a net decrease in the number of HHAs billing
Medicare for home health services of 1.6 percent, and a continued
decrease of 2.7 percent from 2014 to 2015. We note that in CY 2015
there were 2.9 HHAs per 10,000 FFS beneficiaries, which is still
markedly higher than the 1.9 HHAs per 10,000 FFS beneficiaries before
the implementation of the HH PPS methodology in 2001. The number of
home health users, as a percentage of FFS beneficiaries, has been
decreasing since 2011, from 9.2 percent to 8.7 percent in 2015. We
would note that preliminary FFS data on per-enrollee hospital and
skilled nursing facility discharges and days indicates that there was a
decrease in hospital discharges of approximately 0.7 percent and a
decrease in SNF days of approximately 0.9 percent in CY 2015. Any
decreases in hospital discharges and skilled nursing facility days
could, in turn, impact home health utilization as those settings serve
as important sources of home health referrals.
Table 4--Home Health Statistics, CY 2001 and CY 2011 Through CY 2015
--------------------------------------------------------------------------------------------------------------------------------------------------------
2001 2011 2012 2013 2014 2015
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of episodes...................................... 3,896,502 6,821,459 6,727,875 6,708,923 6,451,283 6,340,932
Beneficiaries receiving at least 1 episode (Home Health 2,412,318 3,449,231 3,446,122 3,484,579 3,381,635 3,365,512
Users).................................................
Part A and/or B FFS beneficiaries....................... 34,899,167 37,686,526 38,224,640 38,505,609 38,506,534 38,592,533
Episodes per Part A and/or B FFS beneficiaries.......... 0.11 0.18 0.18 0.17 0.17 0.16
Home health users as a percentage of Part A and/or B FFS 6.9% 9.2% 9.0% 9.0% 8.8% 8.7%
beneficiaries..........................................
HHAs providing at least 1 episode....................... 6,511 11,446 11,746 11,889 11,693 11,381
HHAs per 10,000 Part A and/or B FFS beneficiaries....... 1.9 3.0 3.1 3.1 3.0 2.9
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: National claims history (NCH) data obtained from Chronic Condition Warehouse (CCW)--Accessed on May 14, 2014 and August 19, 2014 for CY 2011, CY
2012, and CY 2013 data; accessed on May 7, 2015 for CY 2001 and CY 2014 data, and accessed on April 7, 2016 for CY 2015 data Medicare enrollment
information obtained from the CCW Master Beneficiary Summary File. Beneficiaries are the total number of beneficiaries in a given year with at least 1
month of Part A and/or Part B Fee-for-Service coverage without having any months of Medicare Advantage coverage.
Note(s): These results include all episode types (Normal, PEP, Outlier, LUPA) and also include episodes from outlying areas (outside of 50 States and
District of Columbia). Only episodes with a through date in the year specified are included. Episodes with a claim frequency code equal to ``0''
(``Non-payment/zero claims'') and ``2'' (``Interim--first claim'') are excluded. If a beneficiary is treated by providers from multiple states within
a year the beneficiary is counted within each state's unique number of beneficiaries served.
In addition to examining home health claims data from the first 2
years of the implementation of rebasing adjustments required by the
Affordable Care Act and comparing utilization in those years (CY 2014 &
CY 2015) to the 3 years prior to
[[Page 43721]]
and to the first calendar year following the implementation of the HH
PPS (CY 2001), we subsequently examined trends in home health
utilization for all years starting in CY 2001 and up through CY 2015.
Figure 1, displays the average number of visits per 60-day episode of
care and the average payment per visit. While the average payment per
visit has steadily increased from approximately $116 in CY 2001 to $166
for CY 2015, the average total number of visits per 60-day episode of
care has declined, most notably between CY 2009 (21.7 visits per
episode) and CY 2010 (19.8 visits per episode), which was the first
year that the 10 percent agency-level cap on HHA outlier payments was
implemented. As noted in section II.C, we also implemented a series of
reductions to the national, standardized 60-day episode payment rate to
account for increases in nominal case-mix, starting in CY 2008. The
reductions to the 60-day episode rate were: 2.75 percent each year for
CY 2008, CY 2009, and CY 2010; 3.79 percent for CY 2011 and CY 2012;
and a 1.32 percent payment reduction for CY 2013. Figure 2 displays the
average number of visits by discipline type for a 60-day episode of
care and shows that while the number of therapy visits per 60-day
episode of care has increased steadily, the number of skilled nursing
and home health aide visits have decreased, between CY 2009 and CY
2015. Section III.F describes the results of the home health study
required by section 3131(d) of the Affordable Care Act, which suggests
that the current home health payment system may discourage HHAs from
serving patients with clinically complex and/or poorly controlled
chronic conditions who do not qualify for therapy but require a large
number of skilled nursing visits. The home health study results seem to
be consistent with the recent trend in the decreased number of visits
per episode of care driven by decreases in skilled nursing and home
health aide services evident in Figures 1 and 2.
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As part of our monitoring efforts, we also examined the trends in
episode timing and service use over time. Currently, the first two 60-
day episodes of care are considered ``early'' and third or later 60-day
episodes of care are considered ``late'', as long as there is no more
than a 60-day gap in care between one episode and the next.
Specifically, we examined the percentage of early episodes with 0 to 19
therapy visits, late episodes with 0 to 19 therapy visits, and episodes
with 20+ therapy visits from CY 2008 to CY 2015. In CY 2008, we
implemented refinements to the HH PPS case-mix system. As part of those
refinements, we added additional therapy thresholds and differentiated
between early and late episodes for those episodes with less than 20+
therapy visits. Table 5 shows that the percentage of early and late
episodes from CY 2008 to CY 2015 has remained relatively stable over
time. There has been a slight decrease in the percentage of early
episodes with 0 to 19 therapy visits from 65.9 percent in CY 2008 to
59.8 percent in CY 2015 and a slight increase in the percentage of late
episodes with 0 to 19 therapy visits from 29.5 percent in CY 2008 to
33.5 percent in CY 2015. From CY 2014 to CY 2015, there was a slight
decrease in the percentage of early and late episodes with 0 to 19
therapy visits and there was a slight increase in the percentage of
episodes with 20+ therapy visits. In 2015, the case-mix weights for the
third and later episodes of care with 0 to 19 therapy visits decreased
as a result of the CY 2015 recalibration of the case-mix weights.
Despite the decreases in the case-mix weights for the later episodes,
the percentage of later episodes with 0 to 19 therapy visits did not
change substantially.
[[Page 43723]]
Table 5--Home Health Episodes by Episode Timing, CY 2008 Through CY 2015
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of
early % of early Number of late % of late
episodes episodes episodes episodes Number of % of episodes
Year All episodes (excluding (excluding (excluding (excluding episodes with with 20+
episodes with episodes with episodes with episodes with 20+ visits visits
20+ visits) 20+ visits) 20+ visits) 20+ visits)
--------------------------------------------------------------------------------------------------------------------------------------------------------
2008.................................... 5,423,037 3,571,619 65.9 1,600,587 29.5 250,831 4.6
2009.................................... 6,530,200 3,701,652 56.7 2,456,308 37.6 372,240 5.7
2010.................................... 6,877,598 3,872,504 56.3 2,586,493 37.6 418,601 6.1
2011.................................... 6,857,885 3,912,982 57.1 2,564,859 37.4 380,044 5.5
2012.................................... 6,767,576 3,955,207 58.4 2,458,734 36.3 353,635 5.2
2013.................................... 6,733,146 4,023,486 59.8 2,347,420 34.9 362,240 5.4
2014.................................... 6,616,875 3,980,151 60.2 2,263,638 34.2 373,086 5.6
2015.................................... 6,340,931 3,789,676 59.8 2,123,485 33.5 427,770 6.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: National claims history (NCH) data obtained from Chronic Condition Warehouse (CCW)--Accessed on April 7, 2016.
Note(s): Only episodes with a through date in the year specified are included. Episodes with a claim frequency code equal to ``0'' (``Non-payment/zero
claims'') and ``2'' (``Interim--first claim'') are excluded.
We also examined trends in admission source for home health
episodes over time. Specifically, we examined the admission source for
the ``first or only'' episodes of care (first episodes in a sequence of
adjacent episodes of care or the only episode of care) from CY 2008
through CY 2015 (Figure 3). The percentage of first or only episodes
with an acute admission source, defined as episodes with an inpatient
hospital stay within the 14 days prior to a home health episode, has
decreased from 38.6 percent in CY 2008 to 33.9 percent in CY 2015. The
percentage of first or only episodes with a post-acute admission
source, defined as episodes which had a stay at a skilled nursing
facility (SNF), inpatient rehabilitation facility (IRF), or long term
care hospital (LTCH) within 14 days prior to the home health episode,
slightly increased from 16.5 percent in CY 2008 to 18.1 percent in CY
2015. The percentage of first or only episodes with a community
admission source, defined as episodes which did not have an acute or
post-acute stay in the 14 days prior to the home health episode,
increased from 37.4 percent in CY 2008 to 41.9 percent in CY 2015. Our
findings on the trends in admission source are consistent to MedPAC's
as outlined in their 2015 Report to the Congress.\1\ However, MedPAC
examined admission source trends from 2002 up through 2013 and
concluded that ``there has been tremendous growth in the use of home
health for patients residing in the community, episodes not preceded by
a prior hospitalization. The high rates of volume growth for these
types of episodes, which have more than doubled since 2001, suggest
there is significant potential for overuse, particularly since Medicare
does not currently require any cost sharing for home health care.''
---------------------------------------------------------------------------
\1\ Medicare Payment Advisory Commission (MedPAC), ``Report to
the Congress: Medicare Payment Policy''. March 2015. P. 214.
Washington, DC. Accessed on 4/21/2016 at http://medpac.gov/documents/reports/march-2015-report-to-the-congress-medicare-payment-policy.pdf?sfvrsn=0.
---------------------------------------------------------------------------
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We will continue to monitor for potential impacts due to the
rebasing adjustments required by section 3131(a) of the Affordable Care
Act and other policy changes in the future. Independent effects of any
one policy may be difficult to discern in years where multiple policy
changes occur in any given year.
B. Proposed CY 2017 HH PPS Case-Mix Weights
In the CY 2015 HH PPS final rule (79 FR 66072), we finalized a
policy to annually recalibrate the HH PPS case-mix weights--adjusting
the weights relative to one another--using the most current, complete
data available. To recalibrate the HH PPS case-mix weights for CY 2017,
we will use the same methodology finalized in the CY 2008 HH PPS final
rule (72 FR 49762), the CY 2012 HH PPS final rule (76 FR 68526), and
the CY 2015 HH PPS final rule (79 FR 66032). Annual recalibration of
the HH PPS case-mix weights ensures that the case-mix weights reflect,
as accurately as possible, current home health resource use and changes
in utilization patterns.
To generate the proposed CY 2017 HH PPS case-mix weights, we used
CY 2015 home health claims data (as of December 31, 2015) with linked
OASIS data. These data are the most current and complete data available
at this time. We will use CY 2015 home health claims data (as of June
30, 2016) with linked OASIS data to generate the CY 2017 HH PPS case-
mix weights in the CY 2017 HH PPS final rule. The process we used to
calculate the HH PPS case-mix weights are outlined below.
Step 1: Re-estimate the four-equation model to determine the
clinical and functional points for an episode using wage-weighted
minutes of care as our dependent variable for resource use. The wage-
weighted minutes of care are determined using the CY 2014 Bureau of
Labor Statistics national hourly wage plus fringe rates for the six
home health disciplines and the minutes per visit from the claim. The
points for each of the variables for each leg of the model, updated
with CY 2015 home health claims data, are shown in Table 6. The points
for the clinical variables are added together to determine an episode's
clinical score. The points for the functional variables are added
together to determine an episode's functional score.
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In updating the four-equation model for CY 2017, using 2015 home
health claims data (the last update to the four-equation model for CY
2016 used CY 2014 home health claims data), there were few changes to
the point values for the variables in the four-equation model. These
relatively minor changes reflect the change in the relationship between
the grouper variables and resource use between CY 2014 and CY 2015. The
CY 2017 four-equation model resulted in 110 point-giving variables
being used in the model (as compared to the 124 variables for the CY
2016 recalibration). There were ten variables that were added to the
model and 24 variables that were dropped from the model due to the
absence of additional resources associated with the variable. Of the
variables that were in both the four-equation model for CY 2016 and the
four-equation model for CY 2017, the points for 37 variables increased
in the CY 2017 four-equation model and the points for 38 variables
decreased in the CY 2017 4-equation model. There were 25 variables with
the same point values.
Step 2: Re-defining the clinical and functional thresholds so they
are reflective of the new points associated with the CY 2017 four-
equation model. After estimating the points for each of the variables
and summing the clinical and functional points for each episode, we
look at the distribution of the clinical score and functional score,
breaking the episodes into different steps. The categorizations for the
steps are as follows:
Step 1: First and second episodes, 0-13 therapy visits.
Step 2.1: First and second episodes, 14-19 therapy visits.
Step 2.2: Third episodes and beyond, 14-19 therapy visits.
Step 3: Third episodes and beyond, 0-13 therapy visits.
Step 4: Episodes with 20+ therapy visits.
We then divide the distribution of the clinical score for episodes
within a step such that a third of episodes are classified as low
clinical score, a third of episodes are classified as medium
[[Page 43728]]
clinical score, and a third of episodes are classified as high clinical
score. The same approach is then done looking at the functional score.
It was not always possible to evenly divide the episodes within each
step into thirds due to many episodes being clustered around one
particular score.\2\ Also, we looked at the average resource use
associated with each clinical and functional score and used that as a
guide for setting our thresholds. We grouped scores with similar
average resource use within the same level (even if it meant that more
or less than a third of episodes were placed within a level). The new
thresholds, based off of the CY 2017 four-equation model points are
shown in Table 7.
---------------------------------------------------------------------------
\2\ For Step 1, 62% of episodes were in the medium functional
level (All with score 14).
For Step 2.1, 71.0% of episodes were in the low functional level
(Most with score 6).
For Step 2.2, 83.2% of episodes were in the medium functional
level (Most with score 2 or 3).
For Step 3, 51.3% of episodes were in the medium functional
level (Most with score 10).
For Step 4, 54.4% of episodes were in the medium functional
level (Most with score 6).
TABLE 7--CY 2017 Clinical and Functional Thresholds
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1st and 2nd Episodes 3rd+ Episodes All episodes
----------------------------------------------------------------------------------------------------------------------------------------
0 to 13 therapy visits 14 to 19 therapy visits 0 to 13 therapy visits 14 to 19 therapy visits 20+ therapy visits
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Grouping Step:......................................... 1......................... 2.1....................... 3........................ 2.2...................... 4.
Equation(s) used to calculate points: (see Table 6).... 1......................... 2......................... 3........................ 4........................ (2&4).
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dimension Severity...........
level..............
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
,s,nClinical.................. C1................. 0 to 1.................... 0 to 1.................... 0........................ 0 to 1................... 0 to 3.
C2................. 2 to 3.................... 2 to 7.................... 1........................ 2 to 9................... 4 to 17.
C3................. 4+........................ 8+........................ 2+....................... 10+...................... 18+.
Functional.................... F1................. 0 to 13................... 0 to 7.................... 0 to 6................... 0........................ 0 to 2.
F2................. 14........................ 8 to 13................... 7 to 10.................. 1 to 11.................. 3 to 6.
F3................. 15+....................... 14+....................... 11+...................... 12+...................... 7+.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Step 3: Once the clinical and functional thresholds are determined
and each episode is assigned a clinical and functional level, the
payment regression is estimated with an episode's wage-weighted minutes
of care as the dependent variable. Independent variables in the model
are indicators for the step of the episode as well as the clinical and
functional levels within each step of the episode. Like the four-
equation model, the payment regression model is also estimated with
robust standard errors that are clustered at the beneficiary level.
Table 8 shows the regression coefficients for the variables in the
payment regression model updated with CY 2015 home health claims data.
The R-squared value for the payment regression model is 0.4919 (an
increase from 0.4822 for the CY 2016 recalibration).
Table 8--Payment Regression Model
------------------------------------------------------------------------
New payment
Variable description regression
coefficients
------------------------------------------------------------------------
Step 1, Clinical Score Medium........................... $25.75
Step 1, Clinical Score High............................. 60.84
Step 1, Functional Score Medium......................... 71.60
Step 1, Functional Score High........................... 108.83
Step 2.1, Clinical Score Medium......................... 53.35
Step 2.1, Clinical Score High........................... 129.94
Step 2.1, Functional Score Medium....................... 11.54
Step 2.1, Functional Score High......................... 67.03
Step 2.2, Clinical Score Medium......................... 33.94
Step 2.2, Clinical Score High........................... 188.53
Step 2.2, Functional Score Medium....................... 0.31
Step 2.2, Functional Score High......................... 63.34
Step 3, Clinical Score Medium........................... 9.35
Step 3, Clinical Score High............................. 95.01
Step 3, Functional Score Medium......................... 56.44
Step 3, Functional Score High........................... 88.01
Step 4, Clinical Score Medium........................... 76.63
Step 4, Clinical Score High............................. 261.74
Step 4, Functional Score Medium......................... 22.89
Step 4, Functional Score High........................... 73.10
Step 2.1, 1st and 2nd Episodes, 14 to 19 Therapy Visits. 498.19
Step 2.2, 3rd+ Episodes, 14 to 19 Therapy Visits........ 515.73
Step 3, 3rd+ Episodes, 0-13 Therapy Visits.............. -73.96
Step 4, All Episodes, 20+ Therapy Visits................ 906.64
Intercept............................................... 393.43
------------------------------------------------------------------------
Source: CY 2015 Medicare claims data for episodes ending on or before
December 31, 2015 (as of December 31, 2015) for which we had a linked
OASIS assessment.
Step 4: We use the coefficients from the payment regression model
to predict each episode's wage-weighted minutes of care (resource use).
We then divide these predicted values by the mean of the dependent
variable (that is, the average wage-weighted minutes of care across all
episodes used in the payment regression). This division constructs the
weight for each episode, which is simply the ratio of the episode's
predicted wage-weighted minutes of care divided by the average wage-
weighted minutes of care in the sample. Each episode is then aggregated
into one of the 153 home health resource groups (HHRGs) and the ``raw''
weight for each HHRG was calculated as the average of the episode
weights within the HHRG.
Step 5: The raw weights associated with 0 to 5 therapy visits are
then
[[Page 43729]]
increased by 3.75 percent, the weights associated with 14-15 therapy
visits are decreased by 2.5 percent, and the weights associated with
20+ therapy visits are decreased by 5 percent. These adjustments to the
case-mix weights were finalized in the CY 2012 HH PPS final rule (76 FR
68557) and were done to address MedPAC's concerns that the HH PPS
overvalues therapy episodes and undervalues non-therapy episodes and to
better align the case-mix weights with episode costs estimated from
cost report data.\3\
---------------------------------------------------------------------------
\3\ Medicare Payment Advisory Commission (MedPAC), Report to the
Congress: Medicare Payment Policy. March 2011, P. 176.
---------------------------------------------------------------------------
Step 6: After the adjustments in step 5 are applied to the raw
weights, the weights are further adjusted to create an increase in the
payment weights for the therapy visit steps between the therapy
thresholds. Weights with the same clinical severity level, functional
severity level, and early/later episode status were grouped together.
Then within those groups, the weights for each therapy step between
thresholds are gradually increased. We do this by interpolating between
the main thresholds on the model (from 0-5 to 14-15 therapy visits, and
from 14-15 to 20+ therapy visits). We use a linear model to implement
the interpolation so the payment weight increase for each step between
the thresholds (such as the increase between 0-5 therapy visits and 6
therapy visits and the increase between 6 therapy visits and 7-9
therapy visits) are constant. This interpolation is identical to the
process finalized in the CY 2012 HH PPS final rule (76 FR 68555).
Step 7: The interpolated weights are then adjusted so that the
average case-mix for the weights is equal to 1.0000.\4\ This last step
creates the proposed CY 2017 case-mix weights shown in Table 9.
---------------------------------------------------------------------------
\4\ When computing the average, we compute a weighted average,
assigning a value of one to each normal episode and a value equal to
the episode length divided by 60 for PEPs.
Table 9--Proposed CY 2017 Case-Mix Payment Weights
----------------------------------------------------------------------------------------------------------------
Clinical and functional levels
Payment group Step (episode and/or (1 = low; 2 = medium; 3 = Proposed CY
therapy visit ranges) high) 2017 weights
----------------------------------------------------------------------------------------------------------------
10111............................ 1st and 2nd Episodes, 0 to 5 C1F1S1 0.5972
Therapy Visits.
10112............................ 1st and 2nd Episodes, 6 C1F1S2 0.7322
Therapy Visits.
10113............................ 1st and 2nd Episodes, 7 to 9 C1F1S3 0.8671
Therapy Visits.
10114............................ 1st and 2nd Episodes, 10 C1F1S4 1.0021
Therapy Visits.
10115............................ 1st and 2nd Episodes, 11 to C1F1S5 1.1370
13 Therapy Visits.
10121............................ 1st and 2nd Episodes, 0 to 5 C1F2S1 0.7059
Therapy Visits.
10122............................ 1st and 2nd Episodes, 6 C1F2S2 0.8224
Therapy Visits.
10123............................ 1st and 2nd Episodes, 7 to 9 C1F2S3 0.9389
Therapy Visits.
10124............................ 1st and 2nd Episodes, 10 C1F2S4 1.0554
Therapy Visits.
10125............................ 1st and 2nd Episodes, 11 to C1F2S5 1.1719
13 Therapy Visits.
10131............................ 1st and 2nd Episodes, 0 to 5 C1F3S1 0.7624
Therapy Visits.
10132............................ 1st and 2nd Episodes, 6 C1F3S2 0.8835
Therapy Visits.
10133............................ 1st and 2nd Episodes, 7 to 9 C1F3S3 1.0045
Therapy Visits.
10134............................ 1st and 2nd Episodes, 10 C1F3S4 1.1255
Therapy Visits.
10135............................ 1st and 2nd Episodes, 11 to C1F3S5 1.2466
13 Therapy Visits.
10211............................ 1st and 2nd Episodes, 0 to 5 C2F1S1 0.6363
Therapy Visits.
10212............................ 1st and 2nd Episodes, 6 C2F1S2 0.7787
Therapy Visits.
10213............................ 1st and 2nd Episodes, 7 to 9 C2F1S3 0.9210
Therapy Visits.
10214............................ 1st and 2nd Episodes, 10 C2F1S4 1.0634
Therapy Visits.
10215............................ 1st and 2nd Episodes, 11 to C2F1S5 1.2057
13 Therapy Visits.
10221............................ 1st and 2nd Episodes, 0 to 5 C2F2S1 0.7450
Therapy Visits.
10222............................ 1st and 2nd Episodes, 6 C2F2S2 0.8689
Therapy Visits.
10223............................ 1st and 2nd Episodes, 7 to 9 C2F2S3 0.9928
Therapy Visits.
10224............................ 1st and 2nd Episodes, 10 C2F2S4 1.1167
Therapy Visits.
10225............................ 1st and 2nd Episodes, 11 to C2F2S5 1.2406
13 Therapy Visits.
10231............................ 1st and 2nd Episodes, 0 to 5 C2F3S1 0.8015
Therapy Visits.
10232............................ 1st and 2nd Episodes, 6 C2F3S2 0.9300
Therapy Visits.
10233............................ 1st and 2nd Episodes, 7 to 9 C2F3S3 1.0584
Therapy Visits.
10234............................ 1st and 2nd Episodes, 10 C2F3S4 1.1868
Therapy Visits.
10235............................ 1st and 2nd Episodes, 11 to C2F3S5 1.3153
13 Therapy Visits.
10311............................ 1st and 2nd Episodes, 0 to 5 C3F1S1 0.6896
Therapy Visits.
10312............................ 1st and 2nd Episodes, 6 C3F1S2 0.8431
Therapy Visits.
10313............................ 1st and 2nd Episodes, 7 to 9 C3F1S3 0.9967
Therapy Visits.
10314............................ 1st and 2nd Episodes, 10 C3F1S4 1.1502
Therapy Visits.
10315............................ 1st and 2nd Episodes, 11 to C3F1S5 1.3038
13 Therapy Visits.
10321............................ 1st and 2nd Episodes, 0 to 5 C3F2S1 0.7983
Therapy Visits.
10322............................ 1st and 2nd Episodes, 6 C3F2S2 0.9334
Therapy Visits.
10323............................ 1st and 2nd Episodes, 7 to 9 C3F2S3 1.0685
Therapy Visits.
10324............................ 1st and 2nd Episodes, 10 C3F2S4 1.2036
Therapy Visits.
10325............................ 1st and 2nd Episodes, 11 to C3F2S5 1.3387
13 Therapy Visits.
10331............................ 1st and 2nd Episodes, 0 to 5 C3F3S1 0.8548
Therapy Visits.
10332............................ 1st and 2nd Episodes, 6 C3F3S2 0.9944
Therapy Visits.
10333............................ 1st and 2nd Episodes, 7 to 9 C3F3S3 1.1341
Therapy Visits.
10334............................ 1st and 2nd Episodes, 10 C3F3S4 1.2737
Therapy Visits.
10335............................ 1st and 2nd Episodes, 11 to C3F3S5 1.4133
13 Therapy Visits.
[[Page 43730]]
21111............................ 1st and 2nd Episodes, 14 to C1F1S1 1.2720
15 Therapy Visits.
21112............................ 1st and 2nd Episodes, 16 to C1F1S2 1.4503
17 Therapy Visits.
21113............................ 1st and 2nd Episodes, 18 to C1F1S3 1.6287
19 Therapy Visits.
21121............................ 1st and 2nd Episodes, 14 to C1F2S1 1.2884
15 Therapy Visits.
21122............................ 1st and 2nd Episodes, 16 to C1F2S2 1.4719
17 Therapy Visits.
21123............................ 1st and 2nd Episodes, 18 to C1F2S3 1.6554
19 Therapy Visits.
21131............................ 1st and 2nd Episodes, 14 to C1F3S1 1.3676
15 Therapy Visits.
21132............................ 1st and 2nd Episodes, 16 to C1F3S2 1.5480
17 Therapy Visits.
21133............................ 1st and 2nd Episodes, 18 to C1F3S3 1.7283
19 Therapy Visits.
21211............................ 1st and 2nd Episodes, 14 to C2F1S1 1.3481
15 Therapy Visits.
21212............................ 1st and 2nd Episodes, 16 to C2F1S2 1.5366
17 Therapy Visits.
21213............................ 1st and 2nd Episodes, 18 to C2F1S3 1.7251
19 Therapy Visits.
21221............................ 1st and 2nd Episodes, 14 to C2F2S1 1.3645
15 Therapy Visits.
21222............................ 1st and 2nd Episodes, 16 to C2F2S2 1.5582
17 Therapy Visits.
21223............................ 1st and 2nd Episodes, 18 to C2F2S3 1.7518
19 Therapy Visits.
21231............................ 1st and 2nd Episodes, 14 to C2F3S1 1.4437
15 Therapy Visits.
21232............................ 1st and 2nd Episodes, 16 to C2F3S2 1.6342
17 Therapy Visits.
21233............................ 1st and 2nd Episodes, 18 to C2F3S3 1.8247
19 Therapy Visits.
21311............................ 1st and 2nd Episodes, 14 to C3F1S1 1.4573
15 Therapy Visits.
21312............................ 1st and 2nd Episodes, 16 to C3F1S2 1.6952
17 Therapy Visits.
21313............................ 1st and 2nd Episodes, 18 to C3F1S3 1.9330
19 Therapy Visits.
21321............................ 1st and 2nd Episodes, 14 to C3F2S1 1.4738
15 Therapy Visits.
21322............................ 1st and 2nd Episodes, 16 to C3F2S2 1.7168
17 Therapy Visits.
21323............................ 1st and 2nd Episodes, 18 to C3F2S3 1.9597
19 Therapy Visits.
21331............................ 1st and 2nd Episodes, 14 to C3F3S1 1.5530
15 Therapy Visits.
21332............................ 1st and 2nd Episodes, 16 to C3F3S2 1.7928
17 Therapy Visits.
21333............................ 1st and 2nd Episodes, 18 to C3F3S3 2.0326
19 Therapy Visits.
22111............................ 3rd+ Episodes, 14 to 15 C1F1S1 1.2970
Therapy Visits.
22112............................ 3rd+ Episodes, 16 to 17 C1F1S2 1.4670
Therapy Visits.
22113............................ 3rd+ Episodes, 18 to 19 C1F1S3 1.6370
Therapy Visits.
22121............................ 3rd+ Episodes, 14 to 15 C1F2S1 1.2974
Therapy Visits.
22122............................ 3rd+ Episodes, 16 to 17 C1F2S2 1.4779
Therapy Visits.
22123............................ 3rd+ Episodes, 18 to 19 C1F2S3 1.6584
Therapy Visits.
22131............................ 3rd+ Episodes, 14 to 15 C1F3S1 1.3873
Therapy Visits.
22132............................ 3rd+ Episodes, 16 to 17 C1F3S2 1.5611
Therapy Visits.
22133............................ 3rd+ Episodes, 18 to 19 C1F3S3 1.7349
Therapy Visits.
22211............................ 3rd+ Episodes, 14 to 15 C2F1S1 1.3454
Therapy Visits.
22212............................ 3rd+ Episodes, 16 to 17 C2F1S2 1.5348
Therapy Visits.
22213............................ 3rd+ Episodes, 18 to 19 C2F1S3 1.7242
Therapy Visits.
22221............................ 3rd+ Episodes, 14 to 15 C2F2S1 1.3458
Therapy Visits.
22222............................ 3rd+ Episodes, 16 to 17 C2F2S2 1.5457
Therapy Visits.
22223............................ 3rd+ Episodes, 18 to 19 C2F2S3 1.7455
Therapy Visits.
22231............................ 3rd+ Episodes, 14 to 15 C2F3S1 1.4358
Therapy Visits.
22232............................ 3rd+ Episodes, 16 to 17 C2F3S2 1.6289
Therapy Visits.
22233............................ 3rd+ Episodes, 18 to 19 C2F3S3 1.8220
Therapy Visits.
22311............................ 3rd+ Episodes, 14 to 15 C3F1S1 1.5659
Therapy Visits.
22312............................ 3rd+ Episodes, 16 to 17 C3F1S2 1.7676
Therapy Visits.
22313............................ 3rd+ Episodes, 18 to 19 C3F1S3 1.9692
Therapy Visits.
22321............................ 3rd+ Episodes, 14 to 15 C3F2S1 1.5664
Therapy Visits.
22322............................ 3rd+ Episodes, 16 to 17 C3F2S2 1.7785
Therapy Visits.
22323............................ 3rd+ Episodes, 18 to 19 C3F2S3 1.9906
Therapy Visits.
22331............................ 3rd+ Episodes, 14 to 15 C3F3S1 1.6563
Therapy Visits.
22332............................ 3rd+ Episodes, 16 to 17 C3F3S2 1.8617
Therapy Visits.
22333............................ 3rd+ Episodes, 18 to 19 C3F3S3 2.0671
Therapy Visits.
30111............................ 3rd+ Episodes, 0 to 5 C1F1S1 0.4850
Therapy Visits.
30112............................ 3rd+ Episodes, 6 Therapy C1F1S2 0.6474
Visits.
30113............................ 3rd+ Episodes, 7 to 9 C1F1S3 0.8098
Therapy Visits.
30114............................ 3rd+ Episodes, 10 Therapy C1F1S4 0.9722
Visits.
30115............................ 3rd+ Episodes, 11 to 13 C1F1S5 1.1346
Therapy Visits.
30121............................ 3rd+ Episodes, 0 to 5 C1F2S1 0.5706
Therapy Visits.
30122............................ 3rd+ Episodes, 6 Therapy C1F2S2 0.7160
Visits.
30123............................ 3rd+ Episodes, 7 to 9 C1F2S3 0.8614
Therapy Visits.
30124............................ 3rd+ Episodes, 10 Therapy C1F2S4 1.0067
Visits.
30125............................ 3rd+ Episodes, 11 to 13 C1F2S5 1.1521
Therapy Visits.
30131............................ 3rd+ Episodes, 0 to 5 C1F3S1 0.6186
Therapy Visits.
30132............................ 3rd+ Episodes, 6 Therapy C1F3S2 0.7723
Visits.
30133............................ 3rd+ Episodes, 7 to 9 C1F3S3 0.9261
Therapy Visits.
30134............................ 3rd+ Episodes, 10 Therapy C1F3S4 1.0798
Visits.
[[Page 43731]]
30135............................ 3rd+ Episodes, 11 to 13 C1F3S5 1.2336
Therapy Visits.
30211............................ 3rd+ Episodes, 0 to 5 C2F1S1 0.4992
Therapy Visits.
30212............................ 3rd+ Episodes, 6 Therapy C2F1S2 0.6684
Visits.
30213............................ 3rd+ Episodes, 7 to 9 C2F1S3 0.8377
Therapy Visits.
30214............................ 3rd+ Episodes, 10 Therapy C2F1S4 1.0069
Visits.
30215............................ 3rd+ Episodes, 11 to 13 C2F1S5 1.1761
Therapy Visits.
30221............................ 3rd+ Episodes, 0 to 5 C2F2S1 0.5848
Therapy Visits.
30222............................ 3rd+ Episodes, 6 Therapy C2F2S2 0.7370
Visits.
30223............................ 3rd+ Episodes, 7 to 9 C2F2S3 0.8892
Therapy Visits.
30224............................ 3rd+ Episodes, 10 Therapy C2F2S4 1.0414
Visits.
30225............................ 3rd+ Episodes, 11 to 13 C2F2S5 1.1936
Therapy Visits.
30231............................ 3rd+ Episodes, 0 to 5 C2F3S1 0.6328
Therapy Visits.
30232............................ 3rd+ Episodes, 6 Therapy C2F3S2 0.7934
Visits.
30233............................ 3rd+ Episodes, 7 to 9 C2F3S3 0.9540
Therapy Visits.
30234............................ 3rd+ Episodes, 10 Therapy C2F3S4 1.1146
Visits.
30235............................ 3rd+ Episodes, 11 to 13 C2F3S5 1.2752
Therapy Visits.
30311............................ 3rd+ Episodes, 0 to 5 C3F1S1 0.6292
Therapy Visits.
30312............................ 3rd+ Episodes, 6 Therapy C3F1S2 0.8165
Visits.
30313............................ 3rd+ Episodes, 7 to 9 C3F1S3 1.0039
Therapy Visits.
30314............................ 3rd+ Episodes, 10 Therapy C3F1S4 1.1912
Visits.
30315............................ 3rd+ Episodes, 11 to 13 C3F1S5 1.3786
Therapy Visits.
30321............................ 3rd+ Episodes, 0 to 5 C3F2S1 0.7149
Therapy Visits.
30322............................ 3rd+ Episodes, 6 Therapy C3F2S2 0.8852
Visits.
30323............................ 3rd+ Episodes, 7 to 9 C3F2S3 1.0555
Therapy Visits.
30324............................ 3rd+ Episodes, 10 Therapy C3F2S4 1.2258
Visits.
30325............................ 3rd+ Episodes, 11 to 13 C3F2S5 1.3961
Therapy Visits.
30331............................ 3rd+ Episodes, 0 to 5 C3F3S1 0.7628
Therapy Visits.
30332............................ 3rd+ Episodes, 6 Therapy C3F3S2 0.9415
Visits.
30333............................ 3rd+ Episodes, 7 to 9 C3F3S3 1.1202
Therapy Visits.
30334............................ 3rd+ Episodes, 10 Therapy C3F3S4 1.2989
Visits.
30335............................ 3rd+ Episodes, 11 to 13 C3F3S5 1.4776
Therapy Visits.
40111............................ All Episodes, 20+ Therapy C1F1S1 1.8071
Visits.
40121............................ All Episodes, 20+ Therapy C1F2S1 1.8389
Visits.
40131............................ All Episodes, 20+ Therapy C1F3S1 1.9087
Visits.
40211............................ All Episodes, 20+ Therapy C2F1S1 1.9136
Visits.
40221............................ All Episodes, 20+ Therapy C2F2S1 1.9454
Visits.
40231............................ All Episodes, 20+ Therapy C2F3S1 2.0152
Visits.
40311............................ All Episodes, 20+ Therapy C3F1S1 2.1709
Visits.
40321............................ All Episodes, 20+ Therapy C3F2S1 2.2027
Visits.
40331............................ All Episodes, 20+ Therapy C3F3S1 2.2725
Visits.
----------------------------------------------------------------------------------------------------------------
To ensure the changes to the HH PPS case-mix weights are
implemented in a budget neutral manner, we then apply a case-mix budget
neutrality factor to the proposed CY 2017 national, standardized 60-day
episode payment rate (see section III.C.3. of this proposed rule). The
case-mix budget neutrality factor is calculated as the ratio of total
payments when the CY 2017 HH PPS case-mix weights (developed using CY
2015 home health claims data) are applied to CY 2015 utilization
(claims) data to total payments when CY 2016 HH PPS case-mix weights
(developed using CY 2014 home health claims data) are applied to CY
2015 utilization data. This produces a case-mix budget neutrality
factor for CY 2017 of 1.0062, based on CY 2015 claims data as of
December 31, 2015.
C. Proposed CY 2017 Home Health Payment Rate Update
1. Proposed CY 2017 Home Health Market Basket Update
Section 1895(b)(3)(B) of the Act requires that the standard
prospective payment amounts for CY 2017 be increased by a factor equal
to the applicable HH market basket update for those HHAs that submit
quality data as required by the Secretary. The home health market
basket was rebased and revised in CY 2013. A detailed description of
how we derive the HHA market basket is available in the CY 2013 HH PPS
final rule (77 FR 67080-67090).
Section 3401(e) of the Affordable Care Act, adding new section
1895(b)(3)(B)(vi) to the Act, requires that, in CY 2015 (and in
subsequent calendar years), the market basket percentage under the HHA
prospective payment system as described in section 1895(b)(3)(B) of the
Act be annually adjusted by changes in economy-wide productivity. The
statute defines the productivity adjustment, described in section
1886(b)(3)(B)(xi)(II) of the Act, to be equal to the 10-year moving
average of change in annual economy-wide private nonfarm business
multifactor productivity (MFP) (as projected by the Secretary for the
10-year period ending with the applicable fiscal year, calendar year,
cost reporting period, or other annual period) (the ``MFP
adjustment''). The Bureau of Labor Statistics (BLS) is the agency that
publishes the official measure of private nonfarm business MFP. Please
see http://www.bls.gov/mfp to obtain the BLS historical published MFP
data.
[[Page 43732]]
Using IHS Global Insight's (IGI) first quarter 2016 forecast, the
MFP adjustment for CY 2017 (the 10-year moving average of MFP for the
period ending CY 2017) is projected to be 0.5 percent. Thus, in
accordance with section 1895(b)(3)(B)(iii) of the Act, we propose to
base the CY 2017 market basket update, which is used to determine the
applicable percentage increase for the HH payments, on the most recent
estimate of the proposed 2010-based HH market basket (currently
estimated to be 2.8 percent based on IGI's first quarter 2016
forecast). We propose to then reduce this percentage increase by the
current estimate of the MFP adjustment for CY 2017 of 0.5 percentage
point (the 10-year moving average of MFP for the period ending CY 2017
based on IGI's first quarter 2016 forecast), in accordance with
1895(b)(3)(B)(vi). Therefore, the current estimate of the CY 2017 HH
payment update is 2.3 percent (2.8 percent market basket update, less
0.5 percentage point MFP adjustment). Furthermore, we note that if more
recent data are subsequently available (for example, a more recent
estimate of the market basket and MFP adjustment), we would use such
data to determine the CY 2017 market basket update and MFP adjustment
in the final rule.
Section 1895(b)(3)(B) of the Act requires that the home health
update be decreased by 2 percentage points for those HHAs that do not
submit quality data as required by the Secretary. For HHAs that do not
submit the required quality data for CY 2017, the home health payment
update would be 0.3 percent (2.3 percent minus 2 percentage points).
2. Proposed CY 2017 Home Health Wage Index
a. Background
Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the
Secretary to provide appropriate adjustments to the proportion of the
payment amount under the HH PPS that account for area wage differences,
using adjustment factors that reflect the relative level of wages and
wage-related costs applicable to the furnishing of HH services. Since
the inception of the HH PPS, we have used inpatient hospital wage data
in developing a wage index to be applied to HH payments. We propose to
continue this practice for CY 2017, as we continue to believe that, in
the absence of HH-specific wage data, using inpatient hospital wage
data is appropriate and reasonable for the HH PPS. Specifically, we
propose to continue to use the pre-floor, pre-reclassified hospital
wage index as the wage adjustment to the labor portion of the HH PPS
rates. For CY 2017, the updated wage data are for hospital cost
reporting periods beginning on or after October 1, 2012 and before
October 1, 2013 (FY 2013 cost report data). We would apply the
appropriate wage index value to the labor portion of the HH PPS rates
based on the site of service for the beneficiary (defined by section
1861(m) of the Act as the beneficiary's place of residence).
b. Updates
Previously, we determined each HHA's labor market area based on
definitions of metropolitan statistical areas (MSAs) issued by the
Office of Management and Budget (OMB). In the CY 2006 HH PPS final rule
(70 FR 68132), we adopted revised labor market area definitions as
discussed in the OMB Bulletin No. 03-04 (June 6, 2003). This bulletin
announced revised definitions for MSAs and the creation of micropolitan
statistical areas and core-based statistical areas (CBSAs). The
bulletin is available online at www.whitehouse.gov/omb/bulletins/b03-04.html.
On February 28, 2013, OMB issued Bulletin No. 13-01, announcing
revisions to the delineations of MSAs, Micropolitan Statistical Areas,
and CBSAs, and guidance on uses of the delineation of these areas. This
bulletin is available online at http://www.whitehouse.gov/sites/default/files/omb/bulletins/2013/b-13-01.pdf. This bulletin states that
it ``provides the delineations of all Metropolitan Statistical Areas,
Metropolitan Divisions, Micropolitan Statistical Areas, Combined
Statistical Areas, and New England City and Town Areas in the United
States and Puerto Rico based on the standards published on June 28,
2010, in the Federal Register (75 FR 37246-37252) and Census Bureau
data.''
While the revisions OMB published on February 28, 2013 are not as
sweeping as the changes made when we adopted the CBSA geographic
designations for CY 2006, the February 28, 2013 bulletin does contain a
number of significant changes. For example, there are new CBSAs, urban
counties that have become rural, rural counties that have become urban,
and existing CBSAs that have been split apart.
In the CY 2015 HH PPS final rule (79 FR 66085 through 66087), we
finalized changes to the HH PPS wage index based on the OMB
delineations, as described in OMB Bulletin No. 13-01. In CY 2015, we
included a one-year transition to those delineations by using a blended
wage index for CY 2015.
The OMB's most recent update to the geographic area delineations
was published on July 15, 2015 in OBM bulletin 15-01. This bulletin is
available online at https://www.whitehouse.gov/sites/default/files/omb/bulletins/2015/15-01.pdf. The revisions to the delineations that affect
the HH PPS are changes to CBSA titles and the addition of CBSA 21420,
Enid, Oklahoma. CBSA 21420 encompasses Garfield County, Oklahoma.
In order to address those geographic areas in which there are no
inpatient hospitals, and thus, no hospital wage data on which to base
the calculation of the CY 2017 HH PPS wage index, we propose to
continue to use the same methodology discussed in the CY 2007 HH PPS
final rule (71 FR 65884) to address those geographic areas in which
there are no inpatient hospitals. For rural areas that do not have
inpatient hospitals, we would use the average wage index from all
contiguous CBSAs as a reasonable proxy. For FY 2017, there are no rural
geographic areas without hospitals for which we would apply this
policy. For rural Puerto Rico, we would not apply this methodology due
to the distinct economic circumstances that exist there (for example,
due to the close proximity to one another of almost all of Puerto
Rico's various urban and non-urban areas, this methodology would
produce a wage index for rural Puerto Rico that is higher than that in
half of its urban areas). Instead, we would continue to use the most
recent wage index previously available for that area. For urban areas
without inpatient hospitals, we would use the average wage index of all
urban areas within the state as a reasonable proxy for the wage index
for that CBSA. For CY 2017, the only urban area without inpatient
hospital wage data is Hinesville, GA (CBSA 25980).
The proposed CY 2017 wage index is available on the CMS Web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices.html
3. Proposed CY 2017 Annual Payment Update
a. Background
The Medicare HH PPS has been in effect since October 1, 2000. As
set forth in the July 3, 2000 final rule (65 FR 41128), the base unit
of payment under the Medicare HH PPS is a national, standardized 60-day
episode payment rate. As set forth in 42 CFR 484.220, we adjust the
national, standardized 60-day episode payment rate by a case-mix
[[Page 43733]]
relative weight and a wage index value based on the site of service for
the beneficiary.
To provide appropriate adjustments to the proportion of the payment
amount under the HH PPS to account for area wage differences, we apply
the appropriate wage index value to the labor portion of the HH PPS
rates. The labor-related share of the case-mix adjusted 60-day episode
rate would continue to be 78.535 percent and the non-labor-related
share would continue to be 21.465 percent as set out in the CY 2013 HH
PPS final rule (77 FR 67068). The CY 2017 HH PPS rates would use the
same case-mix methodology as set forth in the CY 2008 HH PPS final rule
with comment period (72 FR 49762) and would be adjusted as described in
section III.C. of this rule. The following are the steps we take to
compute the case-mix and wage-adjusted 60-day episode rate:
(1) Multiply the national 60-day episode rate by the patient's
applicable case-mix weight.
(2) Divide the case-mix adjusted amount into a labor (78.535
percent) and a non-labor portion (21.465 percent).
(3) Multiply the labor portion by the applicable wage index based
on the site of service of the beneficiary.
(4) Add the wage-adjusted portion to the non-labor portion,
yielding the case-mix and wage adjusted 60-day episode rate, subject to
any additional applicable adjustments.
In accordance with section 1895(b)(3)(B) of the Act, this document
constitutes the annual update of the HH PPS rates. Section 484.225 sets
forth the specific annual percentage update methodology. In accordance
with Sec. 484.225(i), for a HHA that does not submit HH quality data,
as specified by the Secretary, the unadjusted national prospective 60-
day episode rate is equal to the rate for the previous calendar year
increased by the applicable HH market basket index amount minus two
percentage points. Any reduction of the percentage change would apply
only to the calendar year involved and would not be considered in
computing the prospective payment amount for a subsequent calendar
year.
Medicare pays the national, standardized 60-day case-mix and wage-
adjusted episode payment on a split percentage payment approach. The
split percentage payment approach includes an initial percentage
payment and a final percentage payment as set forth in Sec.
484.205(b)(1) and (b)(2). We may base the initial percentage payment on
the submission of a request for anticipated payment (RAP) and the final
percentage payment on the submission of the claim for the episode, as
discussed in Sec. 409.43. The claim for the episode that the HHA
submits for the final percentage payment determines the total payment
amount for the episode and whether we make an applicable adjustment to
the 60-day case-mix and wage-adjusted episode payment. The end date of
the 60-day episode as reported on the claim determines which calendar
year rates Medicare would use to pay the claim.
We may also adjust the 60-day case-mix and wage-adjusted episode
payment based on the information submitted on the claim to reflect the
following:
A low-utilization payment adjustment (LUPA) is provided on
a per-visit basis as set forth in Sec. 484.205(c) and Sec. 484.230.
A partial episode payment (PEP) adjustment as set forth in
Sec. 484.205(d) and Sec. 484.235.
An outlier payment as set forth in Sec. 484.205(e) and
Sec. 484.240.
b. Proposed CY 2017 National, Standardized 60-Day Episode Payment Rate
Section 1895(3)(A)(i) of the Act required that the 60-day episode
base rate and other applicable amounts be standardized in a manner that
eliminates the effects of variations in relative case mix and area wage
adjustments among different home health agencies in a budget neutral
manner. To determine the CY 2017 national, standardized 60-day episode
payment rate, we would apply a wage index standardization factor, a
case-mix budget neutrality factor described in section III.B, a
reduction of 0.97 percent to account for nominal case-mix growth from
2012 to 2014 as finalized in the CY 2016 HH PPS final rule (80 FR
68646), the rebasing adjustment described in section II.C, and the MFP-
adjusted home health market basket update discussed in section III.C.1
of this proposed rule.
To calculate the wage index standardization factor, henceforth
referred to as the wage index budget neutrality factor, we simulated
total payments for non-LUPA episodes using the proposed CY 2017 wage
index and compared it to our simulation of total payments for non-LUPA
episodes using the CY 2016 wage index. By dividing the total payments
for non-LUPA episodes using the proposed CY 2017 wage index by the
total payments for non-LUPA episodes using the CY 2016 wage index, we
obtain a wage index budget neutrality factor of 0.9990. We would apply
the wage index budget neutrality factor of 0.9990 to the proposed CY
2017 national, standardized 60-day episode rate.
As discussed in section III.B of this proposed rule, to ensure the
changes to the case-mix weights are implemented in a budget neutral
manner, we would apply a case-mix weight budget neutrality factor to
the CY 2017 national, standardized 60-day episode payment rate. The
case-mix weight budget neutrality factor is calculated as the ratio of
total payments when CY 2017 case-mix weights are applied to CY 2015
utilization (claims) data to total payments when CY 2016 case-mix
weights are applied to CY 2015 utilization data. The case-mix budget
neutrality factor for CY 2017 would be 1.0062 as described in section
III.B.1 of this proposed rule.
Next, as discussed in the CY 2016 HH PPS final rule (80 FR 68646),
we would apply a reduction of 0.97 percent to the national,
standardized 60-day episode payment rate in CY 2017 to account for
nominal case-mix growth between CY 2012 and CY 2014. Then, we would
apply the -$80.95 rebasing adjustment finalized in the CY 2014 HH PPS
final rule (78 FR 72256), and discussed in section II.C. Lastly, we
would update the proposed payment rates by the proposed CY 2017 HH
payment update percentage of 2.3 percent (MFP-adjusted home health
market basket update) as described in section III.C.1 of this proposed
rule. The proposed CY 2017 national, standardized 60-day episode
payment rate is calculated in Table 10.
[[Page 43734]]
Table 10--Proposed CY 2017 60-Day National, Standardized 60-Day Episode Payment Amount
--------------------------------------------------------------------------------------------------------------------------------------------------------
Proposed CY
Wage index Case-mix Nominal case- CY 2017 Proposed CY 2017 national,
CY 2016 National, standardized 60-day episode budget weights budget mix growth Rebasing 2017 HH standardized 60-
payment neutrality neutrality adjustment (1- adjustment payment update day episode
factor factor 0.0097) payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
$2,965.12......................................... x 0.9990 x 1.0062 x 0.9903 -$80.95 1.023 $2,936.68
--------------------------------------------------------------------------------------------------------------------------------------------------------
The proposed CY 2017 national, standardized 60-day episode payment
rate for an HHA that does not submit the required quality data is
updated by the proposed CY 2017 HH payment update (2.3 percent) minus 2
percentage points and is shown in Table 11.
Table 11--Proposed CY 2017 National, Standardized 60-Day Episode Payment Amount for HHAs That DO NOT Submit the Quality Data
--------------------------------------------------------------------------------------------------------------------------------------------------------
Proposed CY
Wage index Case-mix Nominal case- 2017 HH Proposed CY
CY 2016 National, standardized 60-day episode budget weights budget mix growth CY 2017 payment update 2017 national,
payment neutrality neutrality adjustment (1- Rebasing minus 2 standardized 60-
factor factor 0.0097) adjustment percentage day episode
points payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
$2,965.12......................................... x 0.9990 x 1.0062 x 0.9903 -$80.95 x 1.003 $2,879.27
--------------------------------------------------------------------------------------------------------------------------------------------------------
c. Proposed CY 2017 National Per-Visit Rates
The national per-visit rates are used to pay LUPAs (episodes with
four or fewer visits) and are also used to compute imputed costs in
outlier calculations. The per-visit rates are paid by type of visit or
HH discipline. The six HH disciplines are as follows:
Home health aide (HH aide);
Medical Social Services (MSS);
Occupational therapy (OT);
Physical therapy (PT);
Skilled nursing (SN); and
Speech-language pathology (SLP).
To calculate the proposed CY 2017 national per-visit rates, we
start with the CY 2016 national per-visit rates. We then apply a wage
index budget neutrality factor to ensure budget neutrality for LUPA
per-visit payments and then we increase each of the six per-visit rates
by the maximum rebasing adjustments described in section II.C. of this
rule. We calculate the wage index budget neutrality factor by
simulating total payments for LUPA episodes using the proposed CY 2017
wage index and comparing it to simulated total payments for LUPA
episodes using the CY 2016 wage index. By dividing the total payments
for LUPA episodes using the proposed CY 2017 wage index by the total
payments for LUPA episodes using the CY 2016 wage index, we obtain a
wage index budget neutrality factor of 0.9998. We would apply the wage
index budget neutrality factor of 0.9998 in order to calculate the CY
2017 national per-visit rates.
The LUPA per-visit rates are not calculated using case-mix weights.
Therefore, there is no case-mix weights budget neutrality factor needed
to ensure budget neutrality for LUPA payments. Finally, the per-visit
rates for each discipline are updated by the proposed CY 2017 HH
payment update percentage of 2.3 percent. The national per-visit rates
are adjusted by the wage index based on the site of service of the
beneficiary. The per-visit payments for LUPAs are separate from the
LUPA add-on payment amount, which is paid for episodes that occur as
the only episode or initial episode in a sequence of adjacent episodes.
The proposed CY 2017 national per-visit rates are shown in Tables 12
and 13.
Table 12: Proposed CY 2017 National Per-Visit Payment Amounts for HHAs That DO Submit the Required Quality Data
----------------------------------------------------------------------------------------------------------------
Wage index
CY 2016 per- budget CY 2017 Proposed CY Proposed CY
HH Discipline type visit payment neutrality Rebasing 2017 HH 2017 per-visit
factor adjustment payment update payment
----------------------------------------------------------------------------------------------------------------
Home Health Aide............. $60.87 x 0.9998....... + $1.79........ x 1.023........ $64.09
Medical Social Services...... 215.47 x 0.9998....... + 6.34......... x 1.023........ 226.87
Occupational Therapy......... 147.95 x 0.9998....... + 4.35......... x 1.023........ 155.77
Physical Therapy............. 146.95 x 0.9998....... + 4.32......... x 1.023........ 154.72
Skilled Nursing.............. 134.42 x 0.9998....... + 3.96......... x 1.023........ 141.54
Speech Language Pathology.... 159.71 x 0.9998....... + 4.70......... x 1.023........ 168.16
----------------------------------------------------------------------------------------------------------------
The proposed CY 2017 per-visit payment rates for an HHA that does
not submit the required quality data are updated by the proposed CY
2017 HH payment update percentage (2.3 percent) minus 2 percentage
points and is shown in Table 13.
[[Page 43735]]
Table 13--Proposed CY 2017 National Per-Visit Payment Amounts for HHAs That DO NOT Submit the Required Quality
Data
----------------------------------------------------------------------------------------------------------------
Proposed CY
Wage index 2017 HH
CY 2016 per- budget CY 2017 payment update Proposed CY
HH Discipline type visit rates neutrality Rebasing minus 2 2017 per-visit
factor adjustment percentage rates
points
----------------------------------------------------------------------------------------------------------------
Home Health Aide................ $60.87 x 0.9998 + $1.79 x 1.003 $62.84
Medical Social Services......... 215.47 x 0.9998 + 6.34 x 1.003 222.43
Occupational Therapy............ 147.95 x 0.9998 + 4.35 x 1.003 152.73
Physical Therapy................ 146.95 x 0.9998 + 4.32 x 1.003 151.69
Skilled Nursing................. 134.42 x 0.9998 + 3.96 x 1.003 138.77
Speech Language Pathology....... 159.71 x 0.9998 + 4.70 x 1.003 164.87
----------------------------------------------------------------------------------------------------------------
d. Low-Utilization Payment Adjustment (LUPA) Add-On Factors
LUPA episodes that occur as the only episode or as an initial
episode in a sequence of adjacent episodes are adjusted by applying an
additional amount to the LUPA payment before adjusting for area wage
differences. In the CY 2014 HH PPS final rule, we changed the
methodology for calculating the LUPA add-on amount by finalizing the
use of three LUPA add-on factors: 1.8451 for SN; 1.6700 for PT; and
1.6266 for SLP (78 FR 72306). We multiply the per-visit payment amount
for the first SN, PT, or SLP visit in LUPA episodes that occur as the
only episode or an initial episode in a sequence of adjacent episodes
by the appropriate factor to determine the LUPA add-on payment amount.
For example, for LUPA episodes that occur as the only episode or an
initial episode in a sequence of adjacent episodes, if the first
skilled visit is SN, the payment for that visit would be $261.16
(1.8451 multiplied by $141.54), subject to area wage adjustment.
e. Proposed CY 2017 Non-routine Medical Supply (NRS) Payment Rates
Payments for NRS are computed by multiplying the relative weight
for a particular severity level by the NRS conversion factor. To
determine the proposed CY 2017 NRS conversion factor, we start with the
CY 2016 NRS conversion factor ($52.71) and apply the -2.82 percent
rebasing adjustment described in section II.C. of this rule (1--0.0282
= 0.9718). We then update the conversion factor by the proposed CY 2017
HH payment update percentage (2.3 percent). We do not apply a
standardization factor as the NRS payment amount calculated from the
conversion factor is not wage or case-mix adjusted when the final claim
payment amount is computed. The proposed NRS conversion factor for CY
2017 is shown in Table 14.
Table 14--Proposed CY 2017 NRS Conversion Factor for HHAs That DO Submit the Required Quality Data
----------------------------------------------------------------------------------------------------------------
Proposed CY
CY 2017 Proposed CY 2017 NRS
CY 2016 NRS conversion factor Rebasing 2017 HH conversion
adjustment payment update factor
----------------------------------------------------------------------------------------------------------------
$52.71....................................................... x 0.9718 x 1.023 $52.40
----------------------------------------------------------------------------------------------------------------
Using the CY 2015 NRS conversion factor, the payment amounts for
the six severity levels are shown in Table 15.
Table 15--Proposed CY 2017 NRS Payment Amounts for HHAs That DO Submit the Required Quality Data
----------------------------------------------------------------------------------------------------------------
Proposed CY
Relative 2017 NRS
Severity level Points (scoring) weight payment
amounts
----------------------------------------------------------------------------------------------------------------
1........................................... 0................................. 0.2698 $14.14
2........................................... 1 to 14........................... 0.9742 51.05
3........................................... 15 to 27.......................... 2.6712 139.97
4........................................... 28 to 48.......................... 3.9686 207.95
5........................................... 49 to 98.......................... 6.1198 320.68
6........................................... 99+............................... 10.5254 551.53
----------------------------------------------------------------------------------------------------------------
For HHAs that do not submit the required quality data, we begin
with the CY 2016 NRS conversion factor ($52.71) and apply the -2.82
percent rebasing adjustment discussed in section II.C of this proposed
rule (1-0.0282 = 0.9718). We then update the NRS conversion factor by
the proposed CY 2017 HH payment update percentage (2.3 percent) minus 2
percentage points. The proposed CY 2017 NRS conversion factor for HHAs
that do not submit quality data is shown in Table 16.
[[Page 43736]]
Table 16--Proposed CY 2017 NRS Conversion Factor for HHAs That DO NOT Submit the Required Quality Data
----------------------------------------------------------------------------------------------------------------
Proposed CY
2017 HH payment
CY 2017 update Proposed CY
CY 2015 NRS Conversion factor Rebasing percentage 2017 NRS
adjustment minus 2 conversion
percentage factor
Points
----------------------------------------------------------------------------------------------------------------
$52.71....................................................... x 0.9718 x 1.003 $51.38
----------------------------------------------------------------------------------------------------------------
The payment amounts for the various severity levels based on the
updated conversion factor for HHAs that do not submit quality data are
calculated in Table 17.
Table 17--Proposed CY 2017 NRS Payment Amounts for HHAs That DO NOT Submit the Required Quality Data
----------------------------------------------------------------------------------------------------------------
Proposed CY
Relative 2017 NRS
Severity level Points (scoring) weight payment
amounts
----------------------------------------------------------------------------------------------------------------
1........................................... 0................................. 0.2698 $13.86
2........................................... 1 to 14........................... 0.9742 50.05
3........................................... 15 to 27.......................... 2.6712 137.25
4........................................... 28 to 48.......................... 3.9686 203.91
5........................................... 49 to 98.......................... 6.1198 314.44
6........................................... 99+............................... 10.5254 540.80
----------------------------------------------------------------------------------------------------------------
f. Rural Add-On
Section 421(a) of the MMA required, for HH services furnished in a
rural areas (as defined in section 1886(d)(2)(D) of the Act), for
episodes or visits ending on or after April 1, 2004, and before April
1, 2005, that the Secretary increase the payment amount that otherwise
would have been made under section 1895 of the Act for the services by
5 percent.
Section 5201 of the DRA amended section 421(a) of the MMA. The
amended section 421(a) of the MMA required, for HH services furnished
in a rural area (as defined in section 1886(d)(2)(D) of the Act), on or
after January 1, 2006 and before January 1, 2007, that the Secretary
increase the payment amount otherwise made under section 1895 of the
Act for those services by 5 percent.
Section 3131(c) of the Affordable Care Act amended section 421(a)
of the MMA to provide an increase of 3 percent of the payment amount
otherwise made under section 1895 of the Act for HH services furnished
in a rural area (as defined in section 1886(d)(2)(D) of the Act), for
episodes and visits ending on or after April 1, 2010, and before
January 1, 2016.
Section 210 of the Medicare Access and CHIP Reauthorization Act of
2015 (MACRA) (Public Law 114-10) amended section 421(a) of the MMA to
extend the rural add-on by providing an increase of 3 percent of the
payment amount otherwise made under section 1895 of the Act for HH
services provided in a rural area (as defined in section 1886(d)(2)(D)
of the Act), for episodes and visits ending before January 1, 2018.
Section 421 of the MMA, as amended, waives budget neutrality
related to this provision, as the statute specifically states that the
Secretary shall not reduce the standard prospective payment amount (or
amounts) under section 1895 of the Act applicable to HH services
furnished during a period to offset the increase in payments resulting
in the application of this section of the statute.
For CY 2017, home health payment rates for services provided to
beneficiaries in areas that are defined as rural under the OMB
delineations would be increased by 3 percent as mandated by section 210
of the MACRA. The 3 percent rural add-on is applied to the national,
standardized 60-day episode payment rate, national per visit rates, and
NRS conversion factor when HH services are provided in rural (non-CBSA)
areas. Refer to Tables 18 through 21 for these payment rates.
Table 18--Proposed CY 2017 Payment Amounts for 60-Day Episodes for Services Provided in a Rural Area
----------------------------------------------------------------------------------------------------------------
For HHAs that DO submit quality data For HHAs that DO NOT submit quality data
----------------------------------------------------------------------------------------------------------------
Proposed CY Proposed CY
2017 rural Proposed CY 2017 rural
Proposed CY 2017 national, Multiply by the national, 2017 national, Multiply by the national,
standardized 60-day episode 3 percent rural standardized standardized 3 percent rural standardized
payment rate add-on 60-day 60-day add-on 60-day
episode episode episode
payment rate payment rate payment rate
----------------------------------------------------------------------------------------------------------------
$2,936.68..................... x 1.03 $3,024.78 $2,879.27 x 1.03 $2,965.65
----------------------------------------------------------------------------------------------------------------
[[Page 43737]]
Table 19--Proposed CY 2017 Per-Visit Amounts for Services Provided in a Rural Area
--------------------------------------------------------------------------------------------------------------------------------------------------------
For HHAs that DO submit quality data For HHAs that DO NOT submit quality data
--------------------------------------------------------------------------------------------------------------------------------------------------------
Proposed CY Multiply by the Proposed CY Proposed CY Multiply by the Proposed CY
HH Discipline type 2017 per-visit 3 percent rural 2017 rural per- 2017 per-visit 3 percent rural 2017 rural per-
rate add-on visit rates rate add-on visit rates
--------------------------------------------------------------------------------------------------------------------------------------------------------
HH Aide............................................... $64.09 x 1.03 $66.01 $62.84 x 1.03 $64.73
MSS................................................... 226.87 x 1.03 233.68 222.43 x 1.03 229.10
OT.................................................... 155.77 x 1.03 160.44 152.73 x 1.03 157.31
PT.................................................... 154.72 x 1.03 159.36 151.69 x 1.03 156.24
SN.................................................... 141.54 x 1.03 145.79 138.77 x 1.03 142.93
SLP................................................... 168.16 x 1.03 173.20 164.87 x 1.03 169.82
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 20--Proposed CY 2017 NRS Conversion Factors for Services Provided in a Rural Area
----------------------------------------------------------------------------------------------------------------
For HHAs that DO submit quality data For HHAs that DO NOT submit quality
------------------------------------------------------------------------- data
---------------------------------------
Multiply by Proposed CY Multiply by Proposed CY
the 3 2017 rural Proposed CY the 3 2017 rural
Proposed CY 2017 conversion factor percent NRS 2017 percent NRS
rural add- conversion conversion rural add- conversion
on factor factor on factor
----------------------------------------------------------------------------------------------------------------
$52.40....................................... x 1.03 $53.97 $51.38 x 1.03 $52.92
----------------------------------------------------------------------------------------------------------------
Table 21--Proposed CY 2017 NRS Payment Amounts for Services Provided in a Rural Area
----------------------------------------------------------------------------------------------------------------
For HHAs that DO submit For HHAs that DO NOT submit
------------------------------------------------- quality data quality data
---------------------------------------------------------------
Proposed CY Proposed CY
2017 NRS 2017 NRS
Severity level Points (scoring) Relative payment Relative payment
weight amounts for weight amounts for
rural areas rural areas
----------------------------------------------------------------------------------------------------------------
1............................. 0............... 0.2698 $14.56 0.2698 $14.28
2............................. 1 to 14......... 0.9742 52.58 0.9742 51.55
3............................. 15 to 27........ 2.6712 144.16 2.6712 141.36
4............................. 28 to 48........ 3.9686 214.19 3.9686 210.02
5............................. 49 to 98........ 6.1198 330.29 6.1198 323.86
6............................. 99+............. 10.5254 568.06 10.5254 557.00
----------------------------------------------------------------------------------------------------------------
D. Payments for High-Cost Outliers Under the HH PPS
1. Background
Section 1895(b)(5) of the Act allows for the provision of an
addition or adjustment to the national, standardized 60-day case-mix
and wage-adjusted episode payment amounts in the case of episodes that
incur unusually high costs due to patient care needs. Prior to the
enactment of the Affordable Care Act, section 1895(b)(5) of the Act
stipulated that projected total outlier payments could not exceed 5
percent of total projected or estimated HH payments in a given year. In
the July 3, 2000 Medicare Program; Prospective Payment System for Home
Health Agencies final rule (65 FR 41188 through 41190), we described
the method for determining outlier payments. Under this system, outlier
payments are made for episodes whose estimated costs exceed a threshold
amount for each Home Health Resource Group (HHRG). The episode's
estimated cost is the sum of the national wage-adjusted per-visit
payment amounts for all visits delivered during the episode. The
outlier threshold for each case-mix group or Partial Episode Payment
(PEP) adjustment is defined as the 60-day episode payment or PEP
adjustment for that group plus a fixed-dollar loss (FDL) amount. The
outlier payment is defined to be a proportion of the wage-adjusted
estimated cost beyond the wage-adjusted threshold. The threshold amount
is the sum of the wage and case-mix adjusted PPS episode amount and
wage-adjusted FDL amount. The proportion of additional costs over the
outlier threshold amount paid as outlier payments is referred to as the
loss-sharing ratio.
In the CY 2010 HH PPS proposed rule (74 FR 40948), we stated that
outlier payments increased as a percentage of total payments from 4.1
percent in CY 2005, to 5.0 percent in CY 2006, to 6.4 percent in CY
2007 and that this excessive growth in outlier payments was primarily
the result of unusually high outlier payments in a few areas of the
country. In that discussion, we noted that despite program integrity
efforts associated with excessive outlier payments in targeted areas of
the country, we discovered that outlier expenditures still exceeded the
5 percent target in CY 2007 and, in the absence of corrective measures,
would continue do to so. Consequently, we assessed the appropriateness
of taking action to curb outlier abuse. As described in the HH PPS
final rule (74 FR 58080 through 58087), to mitigate possible billing
vulnerabilities associated with excessive outlier payments and adhere
to our statutory limit on outlier payments, we finalized an outlier
policy that included a 10 percent agency-level cap on outlier payments.
This cap was implemented in concert with a reduced FDL ratio of
[[Page 43738]]
0.67. These policies resulted in a projected target outlier pool of
approximately 2.5 percent. (The previous outlier pool was 5 percent of
total home health expenditures). For CY 2010, we first returned the 5
percent held for the previous target outlier pool to the national,
standardized 60-day episode rates, the national per-visit rates, the
LUPA add-on payment amount, and the NRS conversion factor. Then, we
reduced the CY 2010 rates by 2.5 percent to account for the new outlier
pool of 2.5 percent. This outlier policy was adopted for CY 2010 only.
As we noted in the CY 2011 HH PPS final rule (75 FR 70397 through
70399), section 3131(b)(1) of the Affordable Care Act amended section
1895(b)(3)(C) of the Act, and required the Secretary to reduce the HH
PPS payment rates such that aggregate HH PPS payments were reduced by 5
percent. In addition, section 3131(b)(2) of the Affordable Care Act
amended section 1895(b)(5) of the Act by re-designating the existing
language as section 1895(b)(5)(A) of the Act, and revising the language
to state that the total amount of the additional payments or payment
adjustments for outlier episodes may not exceed 2.5 percent of the
estimated total HH PPS payments for that year. Section 3131(b)(2)(C) of
the Affordable Care Act also added subparagraph (B) which capped
outlier payments as a percent of total payments for each HHA at 10
percent.
As such, beginning in CY 2011, our HH PPS outlier policy is that we
reduce payment rates by 5 percent and target up to 2.5 percent of total
estimated HH PPS payments to be paid as outliers. To do so, we first
returned the 2.5 percent held for the target CY 2010 outlier pool to
the national, standardized 60-day episode rates, the national per visit
rates, the LUPA add-on payment amount, and the NRS conversion factor
for CY 2010. We then reduced the rates by 5 percent as required by
section 1895(b)(3)(C) of the Act, as amended by section 3131(b)(1) of
the Affordable Care Act. For CY 2011 and subsequent calendar years we
target up to 2.5 percent of estimated total payments to be paid as
outlier payments, and apply a 10 percent agency-level outlier cap.
2. Proposed Changes to the Methodology Used To Estimate Episode Cost
As stated earlier, an episode's estimated cost is determined by
multiplying the national wage-adjusted per-visit payment amounts by
discipline by the number of visits by discipline reported on the home
health claim. An episode's estimated cost is then used to determine
whether an episode will receive an outlier payment and the amount of
the outlier payment. Analysis of CY 2015 home health claims data
indicates that there is significant variation in the visit length by
discipline for outlier episodes. Those agencies with 10 percent of
their total payments as outlier payments are providing shorter but more
frequent skilled nursing visits than agencies with less than 10 percent
of their total payments as outlier payments (see Table 22).
Table 22--Average Number and Length of Skilled Nursing Visits by the
Percentage of Outlier Payments to Total Payments at the Agency Level
(Current Outlier Methodology), CY 2015
------------------------------------------------------------------------
Avg.
Avg. # of minutes per
skilled skilled
nursing nursing
visits visit
------------------------------------------------------------------------
<1% Total Outlier Payments.................... 21.7 47.2
1% to <5% Total Outlier Payments.............. 26.7 44.0
5% to <10% Total Outlier Payments............. 26.7 44.3
10% Total Outlier Payments.................... 44.5 35.6
------------------------------------------------------------------------
Source: CY 2015 home health claims data from the standard analytic file
(as of December 31, 2015) for which we had a linked OASIS assessment.
Note(s): These results are based on simulations using CY 2015
utilization and the CY2017 payment parameters.
As shown in Table 23, the number of skilled nursing visits is
significantly higher than the number of visits for the five other
disciplines of care and therefore, outlier payments are predominately
driven by the provision of skilled nursing services.
Table 23--Average Number of Visits by Discipline for Outlier Episodes
------------------------------------------------------------------------
Average
Discipline number of
visits
------------------------------------------------------------------------
Home health aide........................................... 8.8
Medical social services.................................... 0.3
Occupational therapy....................................... 2.3
Physical therapy........................................... 5.1
Skilled nursing............................................ 34.0
Speech-language pathology.................................. 0.7
------------------------------------------------------------------------
Source: CY 2015 home health claims data from the standard analytic file
(as of December 31, 2015) for which we had a linked OASIS assessment.
Note(s): These results are based on simulations using CY 2015
utilization and the CY2017 payment parameters.
As a result of the analysis of CY 2015 home health claims data, we
are concerned the current methodology for calculating outlier payments
may create a financial disincentive for providers to treat medically
complex beneficiaries who require longer visits. The home health
environment differs from hospitals and other institutional
environments. In the home setting, the patient has a greater role in
determining how, when, and even if, certain interventions will be
implemented. Individual skill, cognitive and functional ability, and
financial resources affect the ability of home health patients to
safely manage their health care needs, interventions, and medication
regimens.\5\ Clinically complex patients generally use more health
services, have functional limitations, need more assistance to perform
activities of daily living (ADLs), require social support and community
resources, and require more complex medical interventions.\6\ For
example, patients using home total parenteral nutrition (TPN) must cope
with very high-tech needs at home and because of the complexity of TPN
therapy, a high level of knowledge and expertise is required in the
clinical management of these patients.\7\ In addition to the direct
patient care needs, patient education aims at instruction on the care
of the central venous access device, administration procedures and
monitoring for complications, overall well-being, parenteral nutrition
composition and frequency, test results, medications, practical and
psychosocial
[[Page 43739]]
issues.\8\ Visit frequency for home TPN patients varies and length of
nursing visits can range from 15 minutes for infusion site and catheter
assessment to 10 hours for direct patient care.\9\ For those patients
who require assistance with bathing, research has shown older persons
are more likely to have negative expectations regarding the
inevitability of further physical decline after they experience bathing
difficulties.\10\ As older home health patients decline, they may be
more likely to accept assistance with bathing and this may have the
unintended consequence of reliance on bathing assistance, which could
lead to further functional decline in the performance of other ADLs. To
mitigate further functional decline, home health nursing intensity and
visit time increases as home nursing interventions are targeted to work
with patients and caregivers on bathing sub-tasks, assistance in
modifying the home environment through the acquisition and use of
adaptive equipment and devising strategies to support patients in
dealing with pain and fatigue that could prevent independent
bathing.\11\
---------------------------------------------------------------------------
\5\ Ibid.
\6\ Rich, E., Lipson, D., Libersky, J., Parchman, M. (2012).
Coordinating Care for Adults with Complex Care Needs in the Patient-
Centered Medical Home: Challenges and Solutions. AHRQ Publication
No. 12-0010, https://pcmh.ahrq.gov/page/coordinating-care-adults-complex-care-needs-patient-centered-medical-home-challenges-and.
\7\ Huisman-deWaal, G. Achterberg, T., Jansen, J., Wanten, G.,
Schoonhoven, L. (2010). ``High-tech'' home care: Overview of
professional care in patients on home parenteral nutrition and
implications for nursing care. Journal of Clinical Nursing. (20),
2125-2134.
\8\ Ibid.
\9\ Piamjariyakul, U., Ross, V., Yadrich, D.M., Williams, A.,
Howard, L., Smith, C. (2010). Complex Home Care: Part I-Utilization
and Costs to Families for Health Care Services Each Year. Nursing
Economics. 28(4), 255-263
\10\ Friedman, B., Yanen, L., Liebel, D., Powers, B. (2014).
Effects of Home Visiting Nurse Intervention versus Care as Usual on
Individual Activities of Daily Living: A Secondary Analysis of a
Randomized Trial. BMC Geriatrics. 14(24), 1-13.
\11\ Ibid.
---------------------------------------------------------------------------
Higher nursing visit intensity and longer visits are a generally a
response to instability of the patient's condition, and/or inability to
effectively and safely manage their condition and self-care activities;
therefore, more clinically complex, frail, elderly patients will
require more intensive and frequent home health surveillance, increased
home health care utilization, and costs.12 13
---------------------------------------------------------------------------
\12\ Fried. L., Ferrucci, L., Darer, J., Williamson, J.,
Anderson, G. (2004). Untangling the Concepts of Disability, Frailty
and Comorbidity: Implications for Improved Targeting and Care.
Journal of Gerontology. 59(3), 255-263.
\13\ Riggs, J., Madigan, E., Fortinsky, R. (2011). Home Health
Care Nursing Visit Intensity and Heart Failure Patient Outcomes.
Home Health Care Managing Practice. 23(6), 412-420.
---------------------------------------------------------------------------
In addition to the clinical information described above,
Mathematica Policy Research published a report in 2010 titled ``Home
Health Independence Patients: High Use, but Not Financial Outliers.''
\14\ In this report, Mathematica described their analysis of the
relationships among the proxy demonstration target group for the Home
Health Independence Demonstration, patients who receive outlier
payments, and the agencies that serve them. As part of their research,
Mathematica examined the degree of overlap between the proxy
demonstration target group, who are ill, permanently disabled
beneficiaries, and those beneficiaries receiving outlier payments. The
study found that ``Only a small fraction of proxy demonstration
patients generate outlier payments and that differences between the
proxy demonstration and outlier patient groups examined in this study
suggest that outlier payments are not generally being used to serve the
types of severely, permanently disabled beneficiaries that were
addressed by the demonstration concept.''
---------------------------------------------------------------------------
\14\ Cheh, Valerie and Schurrer, John. Home Health Independence
Patients: High Use, but Not Financial Outliers, Report to Centers
for Medicare and Medicaid, Mathematical Policy Research. March 31,
2010.
---------------------------------------------------------------------------
Therefore, we are proposing to change the methodology used to
calculate outlier payments, using a cost-per-unit approach rather than
a cost-per-visit approach. Using this approach, we would convert the
national per-visit rates in section III.C.3. into per 15 minute unit
rates (see Table 24). The new per-unit rates by discipline would then
be used, along with the visit length data by discipline reported on the
home health claim in 15 minute increments (15 minutes = 1 unit), to
calculate the estimated cost of an episode to determine whether the
claim will receive an outlier payment and the amount of payment for an
episode of care. We note that this change in the methodology would be
budget neutral as we would still target to pay out 2.5 percent of total
payments as outlier payments in accordance with section 1895(b)(5)(A)
of the Act, which requires us to pay up to, but no more than, 2.5
percent of total HH PPS payments as outlier payments.
Table 24--Proposed Cost-per-Unit Payment Rates for the Calculation of Outlier Payments
----------------------------------------------------------------------------------------------------------------
Proposed CY
2017 national Average Cost-per-unit
Visit type per-visit minutes- per- (1 unit = 15
payment rates visit minutes)
----------------------------------------------------------------------------------------------------------------
Home health aide................................................ $64.09 62.2 $15.46
Medical social services......................................... 226.87 56.4 60.34
Occupational therapy............................................ 155.77 47.1 49.61
Physical therapy................................................ 154.72 46.6 49.80
Skilled nursing................................................. 141.54 44.7 47.50
Speech-language pathology....................................... 168.16 48.1 52.44
----------------------------------------------------------------------------------------------------------------
Source: CY 2015 home health claims data from the standard analytic file (as of December 31, 2015) for which we
had a linked OASIS assessment.
Note(s): Excludes LUPAs.
We believe that this proposed change to the outlier methodology
will result in more accurate outlier payments where the calculated cost
per episode accounts for not only the number of visits during an
episode of care, but also the length of the visits performed. This, in
turn, may address some of the findings from the home health study,
where margins were lower for patients with medically complex needs that
typically require longer visits, thus potentially creating an incentive
to treat less complex patients.
Table 25 shows the difference in the average number of visits and
the average minutes per visit for outlier episodes under the current
outlier methodology and the proposed outlier methodology by the
percentage of outlier payments to total payments at the agency level.
[[Page 43740]]
Table 25--Average Number of Visits and Minutes per Visit by the Percentage of Outlier Payments to Total Payments
at the Agency Level for Outlier Episodes for the Current and Proposed Outlier Methodologies, CY 2015
----------------------------------------------------------------------------------------------------------------
Current Outlier Proposed Outlier
Methodology (Cost per Methodology (Cost per
Visit) Unit)
---------------------------------------------------
Avg. Avg.
Avg. # of minutes per Avg. # of minutes per
visits visit visits visit
----------------------------------------------------------------------------------------------------------------
<1% Total Outlier Payments.................................. 39.7 48.9 38.5 52.6
1% to <5% Total Outlier Payments............................ 44.7 49.2 43.5 52.0
5% to <10% Total Outlier Payments........................... 44.7 49.6 54.8 55.2
10% Total Outlier Payments.................................. 60.7 44.0 56.4 65.6
----------------------------------------------------------------------------------------------------------------
Source: CY 2015 home health claims data from the standard analytic file (as of December 31, 2015) for which we
had a linked OASIS assessment.
Note(s): These results are based on simulations using CY 2015 utilization and the CY2017 payment parameters.
Analysis of the impact of the change from a cost-per-visit to a
cost-per-unit approach indicates that approximately two-thirds of
outlier episodes under the cost-per-unit approach would have still
received outlier payments under the current cost-per-visit approach,
while about one-third of outlier episodes under the current cost per
visit approach would not receive outlier payments under the cost-per-
unit approach. Table 26 shows the average number of visits and the
visit length for the episodes that would receive outlier payments under
the current cost-per-visit approach, but not under the proposed cost-
per-unit approach, as well as the average number of visits and the
visit length for the episodes that would receive outlier payments under
the proposed cost-per-unit approach, but not under the current cost-
per-visit approach. Those episodes that would only receive outlier
payments under the current cost-per-visit approach have less average
resource use (calculated by multiplying the number of visits with the
number of minutes) than those episodes that would only receive outlier
payments under the proposed cost-per-unit approach. These results
indicate that the change from the current cost-per-visit methodology to
the proposed cost-per-unit methodology would result in more accurate
outlier payments that better account for the intensity of the visits
performed rather than only visit volume.
Table 26--Average Number of Visits and Visit Length for Episodes That Receive Outlier Payments Only Under the
Current Outlier Methodology and for Episodes That Receive Outlier Payments Only Under the Proposed Outlier
Methodology, CY 2015
----------------------------------------------------------------------------------------------------------------
Episodes that only would Episodes that only would
receive outlier payments under receive outlier payments under
the current methodology the proposed methodology
---------------------------------------------------------------
Avg. # of Avg. minutes Avg. # of Avg. minutes
visits per visit visits per visit
----------------------------------------------------------------------------------------------------------------
<1% Total Outlier Payments...................... 36.8 39.9 29.8 63.4
1% to <5% Total Outlier Payments................ 37.6 38.5 30.6 65.6
5% to <10% Total Outlier Payments............... 43.8 36.4 30.2 85.9
10% Total Outlier Payments...................... 46.1 27.5 31.9 104.5
----------------------------------------------------------------------------------------------------------------
Source: CY 2015 home health claims data from the standard analytic file (as of December 31, 2015) for which we
had a linked OASIS assessment.
Note(s): These results are based on simulations using CY 2015 utilization and the CY2017 payment parameters.
In addition, we examined the impact of changing from the current
cost-per-visit methodology to the proposed cost-per-unit methodology on
a subset of the vulnerable patient populations identified in the home
health study. Our simulations indicate that certain subgroups
identified in the home health study may benefit from the change from
the current outlier methodology to the proposed outlier methodology.
Table 27 shows some of the vulnerable patient populations that may
benefit from the proposed changes to the outlier methodology. As shown
in Table 27, preliminary analysis indicates that a larger percentage of
episodes of care for patients with a fragile overall health status will
qualify for outlier payments under the proposed methodology than under
the current methodology (24.1 percent versus 20.1 percent). Similarly,
a larger percentage of episodes of care for patients who need
assistance with bathing will qualify for outlier payments under the
proposed methodology than under the current methodology (29.1 percent
versus 27.0 percent). In addition, a larger percentage of episodes of
care for patients who need caregiver assistance or who have surgical
wounds will qualify for outlier payments under the proposed methodology
versus under the current methodology (7.7 percent versus 6.7 percent
and 19.0 percent versus 18.1 percent, respectively). Furthermore, there
are small increases in the percentage of episodes of care that would
qualify for outlier payments for the patients who need parenteral
nutrition or have poorly controlled cardiac dysrhythmia or pulmonary
disorders. These results suggest that the proposed change to the
outlier methodology may address some of the findings from the home
health study and may alleviate potential financial
[[Page 43741]]
disincentives to treat patients with medically complex needs.
Table 27--Impact of the Proposed Outlier Methodology Change on Subgroups of Vulnerable Patient Populations
Identified in the Home Health Study
----------------------------------------------------------------------------------------------------------------
Overall percentage Percent of outliers Percent of outliers
Subgroups identified in the home health study for all non-LUPA based on cost-per- based on cost-per-
episodes (%) visit approach (%) unit approach (%)
----------------------------------------------------------------------------------------------------------------
Needs caregiver assistance.................... 6.8 6.7 7.7
Fragile-serious overall status................ 21.9 20.1 24.1
Needs assistance with bathing................. 20.1 27.0 29.1
Parenteral Nutrition.......................... 0.2 0.2 0.4
Poorly Controlled Cardiac Dysrhythmia......... 4.3 3.4 3.8
Poorly Controlled Pulmonary Disorder.......... 7.8 5.4 6.0
Surgical Wound................................ 17.6 18.1 19.0
----------------------------------------------------------------------------------------------------------------
Source: CY 2015 home health claims data from the standard analytic file (as of December 31, 2015) for which we
had a linked OASIS assessment.
Note(s): These results are based on simulations using CY 2015 utilization and the CY2017 payment parameters.
In concert with our proposal to change to a cost-per-unit approach
to estimate episode costs and determine whether an outlier episode
should receive outlier payments, we are proposing to implement a cap on
the amount of time per day that would be counted toward the estimation
of an episode's costs for outlier calculation purposes. Specifically,
we propose to limit the amount of time per day (summed across the six
disciplines of care) to 8 hours or 32 units per day when estimating the
cost of an episode for outlier calculation purposes. We note that this
proposal is consistent with the definition of ``part-time'' or
``intermittent'' set out in section 1861(m) of the Act, which limits
the amount of skilled nursing and home health aide minutes combined to
less than 8 hours each day and 28 or fewer hours each week (or, subject
to review on a case-by-case basis as to the need for care, less than 8
hours each day and 35 or fewer hours per week). We also note that we
are not limiting the amount of care that can be provided on any given
day. We are only limiting the time per day that can be credited towards
the estimated cost of an episode when determining if an episode should
receive outlier payments and calculating the amount of the outlier
payment. For instances when more than 8 hours of care is provided by
one discipline of care, the number of units for the line item will be
capped at 32 units for the day for outlier calculation purposes. For
rare instances when more than one discipline of care is provided and
there is more than 8 hours of care provided in one day, the episode
cost associated with the care provided during that day will be
calculated using a hierarchical method based on the cost per unit per
discipline shown in Table 24. The discipline of care with the lowest
associated cost per unit will be discounted in the calculation of
episode cost in order to cap the estimation of an episode's cost at 8
hours of care per day. For example, if an HHA provided 4.5 hours of
skilled nursing and 4.5 hours of home health aide services, all 4.5
hours of skilled nursing would be counted in the episode's estimated
cost and 3.5 hours of home health aide services would be counted in the
episode's estimated cost (8 hours - 4.5 hours = 3.5 hours) since home
health aide services has a lower cost-per-unit than skilled nursing
services.
We note that preliminary analysis suggests that this proposed cap
will have a limited impact on episodes overall. Out of approximately
5.4 million episodes in our preliminary analytic file for 2015, only
15,384 episodes or 0.28 percent of all home health episodes reported
instances where over 8 hours of care were provided in a single day
(which could have resulted from data entry errors as we currently do
not use visit length for payment). Of those 15,384 episodes, only 1,591
would be outlier episodes under the proposed outlier methodology.
Therefore, we estimate that only 1,600 episodes or so, out of 5.4
million episodes, would be impacted due to the proposed 8 hour cap.
3. Proposed Fixed Dollar Loss (FDL) Ratio
For a given level of outlier payments, there is a trade-off between
the values selected for the FDL ratio and the loss-sharing ratio. A
high FDL ratio reduces the number of episodes that can receive outlier
payments, but makes it possible to select a higher loss-sharing ratio,
and therefore, increase outlier payments for qualifying outlier
episodes. Alternatively, a lower FDL ratio means that more episodes can
qualify for outlier payments, but outlier payments per episode must
then be lower.
The FDL ratio and the loss-sharing ratio must be selected so that
the estimated total outlier payments do not exceed the 2.5 percent
aggregate level (as required by section 1895(b)(5)(A) of the Act).
Historically, we have used a value of 0.80 for the loss-sharing ratio
which, we believe, preserves incentives for agencies to attempt to
provide care efficiently for outlier cases. With a loss-sharing ratio
of 0.80, Medicare pays 80 percent of the additional estimated costs
above the outlier threshold amount.
In the CY 2011 HH PPS final rule (75 FR 70398), in targeting total
outlier payments as 2.5 percent of total HH PPS payments, we
implemented an FDL ratio of 0.67, and we maintained that ratio in CY
2012. Simulations based on CY 2010 claims data completed for the CY
2013 HH PPS final rule showed that outlier payments were estimated to
comprise approximately 2.18 percent of total HH PPS payments in CY
2013, and as such, we lowered the FDL ratio from 0.67 to 0.45. We
stated that lowering the FDL ratio to 0.45, while maintaining a loss-
sharing ratio of 0.80, struck an effective balance of compensating for
high-cost episodes while allowing more episodes to qualify as outlier
payments (77 FR 67080). The national, standardized 60-day episode
payment amount is multiplied by the FDL ratio. That amount is wage-
adjusted to derive the wage-adjusted FDL amount, which is added to the
case-mix and wage-adjusted 60-day episode payment amount to determine
the outlier threshold amount that costs have to exceed before Medicare
would pay 80 percent of the additional estimated costs.
[[Page 43742]]
For this proposed rule, simulating payments using preliminary CY
2015 claims data (as of December 31, 2015) and the CY 2016 payment
rates (80 FR 68649 through 68652), we estimate that outlier payments in
CY 2016 would comprise 2.23 percent of total payments. Based on
simulations using CY 2015 claims data and the CY 2017 payment rates in
section III.C.3 of this proposed rule, we estimate that outlier
payments would comprise approximately 2.58 percent of total HH PPS
payments in CY 2017 under the current outlier methodology, a percent
change of approximately 15.7 percent. This increase is attributable to
the increase in the national per-visit amounts through the rebasing
adjustments and the decrease in the national, standardized 60-day
episode payment amount as a result of the rebasing adjustment and the
nominal case-mix growth reduction.
Given the statutory requirement to target up to, but no more than,
2.5 percent of total payments as outlier payments, we are proposing a
change to the FDL ratio for CY 2017 as we believe that maintaining an
FDL ratio of 0.45 with a loss-sharing ratio of 0.80 is no longer
appropriate given the percentage of outlier payments projected for CY
2017. We note that we are not proposing a change to the loss-sharing
ratio (0.80) in order for the HH PPS to remain consistent with payment
for high-cost outliers in other Medicare payment systems (for example,
IRF PPS, IPPS, etc.) Under the current outlier methodology, the FDL
ratio would need to be changed from 0.45 to 0.48 to pay up to, but no
more than, 2.5 percent of total payments as outlier payments. Under the
proposed outlier methodology which would use a cost per unit rather
than a cost per visit when calculating episode costs, we estimate that
we will pay out 2.74 percent in outlier payments in CY 2017 using an
FDL ratio of 0.48 and that the FDL ratio will need to be changed to
0.56 to pay up to, but no more than, 2.5 percent of total payments as
outlier payments.
Therefore, in addition to the proposal to change the methodology
used to calculate outlier payments, we are proposing to change the FDL
ratio from 0.45 to 0.56 for CY 2017. We note that in the final rule, we
will update our estimate of outlier payments as a percent of total HH
PPS payments using the most current and complete year of HH PPS data
(CY 2015 claims data as of June 30, 2016) and therefore, we may adjust
the final FDL ratio accordingly. We invite public comments on the
proposed changes to the outlier payment calculation methodology and the
associated changes in the regulations text at Sec. 484.240 as well as
the proposed change to the FDL ratio.
E. Proposed Payment Policies for Negative Pressure Wound Therapy (NPWT)
Using a Disposable Device
1. Background
Negative pressure wound therapy (NPWT) is a medical procedure in
which a vacuum dressing is used to enhance and promote healing in
acute, chronic, and burn wounds. The therapy involves using a sealed
wound dressing attached to a pump to create a negative pressure
environment in the wound. Applying continued or intermittent vacuum
pressure helps to increase blood flow to the area and draw out excess
fluid from the wound. Moreover, the therapy promotes wound healing by
preparing the wound bed for closure, by reducing edema, by promoting
granulation tissue formation and perfusion, and by removing exudate and
infectious material. The wound type and/or the location of the wound
determine whether the vacuum can either be applied continuously or
intermittently. NPWT can be utilized for varying lengths of time, as
indicated by the severity of the wound, from a few days of use up to a
span of several months.
In addition to the conventional NPWT systems classified as durable
medical equipment (DME), NPWT can also be performed with a single-use
disposable system that consists of a non-manual vacuum pump, a
receptacle for collecting exudate, and dressings for the purposes of
wound therapy. These disposable systems consist of a small pump, which
eliminates the need for a bulky canister. Unlike conventional NPWT
systems classified as DME, disposable NPWT systems have a preset
continuous negative pressure, there is no intermittent setting, they
are pocket-sized and easily transportable, and they are generally
battery-operated with disposable batteries.\15\
---------------------------------------------------------------------------
\15\ Single use negative pressure wound therapy. CME Online.
2013 www.pfiedler.com.
---------------------------------------------------------------------------
Section 1895 of the Act requires that the HH PPS includes payment
for all covered home health services. Section 1861(m) of the Act
defines what items and services are considered to be ``home health
services'' when furnished to a Medicare beneficiary under a home health
plan of care when provided in the beneficiary's place of residence.
Those services include:
Part-time or intermittent nursing care
Physical or occupational therapy or speech-language
pathology services
Medical social services
Part-time or intermittent services of a home health aide
Medical supplies
A covered osteoporosis drug
Durable medical equipment (DME)
The unit of payment under the HH PPS is a national, standardized
60-day episode payment amount with applicable adjustments. The
national, standardized 60-day episode payment amount includes costs for
the home health services outlined above per section 1861(m) of the Act,
except for DME and the covered osteoporosis drug. Section 1814(k) of
the Act specifically excludes DME from the national, standardized 60-
day episode rate and consolidated billing requirements. DME continues
to be paid outside of the HH PPS. The cost of the covered osteoporosis
drug (injectable calcitonin), which is covered where a woman is
postmenopausal and has a bone fracture, is also not included in the
national, standardized 60-day episode payment amount, but must be
billed by the HHA while a patient is under a home health plan of care
since the law requires consolidated billing of osteoporosis drugs. The
osteoporosis drug itself continues to be paid on a reasonable cost
basis.
Medical supplies are included in the definition of ``home health
services'' and the cost of such supplies is included in the national,
standardized 60-day episode payment amount. Medical supplies are items
that, due to their therapeutic or diagnostic characteristics, are
essential in enabling HHA personnel to conduct home visits or to carry
out effectively the care the physician has ordered for the treatment or
diagnosis of the patient's illness or injury. Supplies are classified
into two categories, specifically:
Routine: Supplies used in small quantities for patients
during the usual course of most home visits; or
Non-routine: Supplies needed to treat a patient's specific
illness or injury in accordance with the physician's plan of care and
meet further conditions.
Both routine and non-routine medical supplies are included in the
national, standardized 60-day episode payment amount for every Medicare
home health patient regardless of whether or not the patient requires
medical supplies during the episode. The law requires that all medical
supplies (routine and non-routine) be provided by the HHA while the
patient is under a home health plan of care. A disposable NPWT system
would be considered a non-routine supply for home health.
As required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the
[[Page 43743]]
Act, for home health services to be covered, the patient must receive
such services under a plan of care established and periodically
reviewed by a physician. As described in Sec. 484.18 of the Medicare
Conditions of Participation (CoPs), the plan of care that is developed
in consultation with the agency staff, is to cover all pertinent
diagnoses, including the types of services and equipment required for
the treatment of those diagnoses as well as any other appropriate
items, including DME. Consolidated billing requirements ensure that
only the HHA can bill for home health services, with the exception of
DME and therapy services provided by physicians, when a patient is
under a home health plan of care. The types of service most affected by
the consolidated billing edits tend to be non-routine supplies and
outpatient therapies, since these services are routinely billed by
providers other than HHAs, or are delivered by HHAs to patients not
under home health plans of care.
As provided under section 1834(k)(5) of the Act, a therapy code
list was created based on a uniform coding system (that is, the HCPCS)
to identify and track these outpatient therapy services paid under the
Medicare Physician Fee Schedule (MPFS). The list of therapy codes,
along with their respective designation, can be found on the CMS Web
site, specifically at http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage. Two of the designations that
are used for therapy services are: ``Always therapy'' and ``sometimes
therapy.'' An ``always therapy'' service must be performed by a
qualified therapist under a certified therapy plan of care, and a
``sometimes therapy'' service may be performed by physician or a non-
physician practitioner outside of a certified therapy plan of care. CPT
codes 97607 and 97608 are categorized as a ``sometimes'' therapy, which
may be performed by either a physician or a non-physician practitioner
outside of a certified therapy plan of care, as described in section
200.9 of Chapter 4 of the Medicare Claims Processing Manual.\16\
---------------------------------------------------------------------------
\16\ https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf.
---------------------------------------------------------------------------
2. The Consolidated Appropriations Act of 2016
As mentioned in section III.A.1 above, for patients under a home
health plan of care, payment for part-time or intermittent skilled
nursing, physical therapy, speech-language pathology, occupational
therapy, medical social services, part-time or intermittent home health
aide visits, and routine and non-routine supplies are included in the
episode payment amount. A disposable NPWT system is currently
considered a non-routine supply and thus payment for the disposable
NPWT system is included in the episode payment amount. The Consolidated
Appropriations Act of 2016 (Pub. L 114-113) amends both section 1834 of
the Act (42 U.S.C. 1395m) and section 1861(m)(5) of the Act (42 U.S.C.
1395x(m)(5)), requiring a separate payment to a HHA for an applicable
disposable device when furnished on or after January 1, 2017, to an
individual who receives home health services for which payment is made
under the Medicare home health benefit. Section 1834(s)(2) of the Act
defines an applicable device as a disposable negative pressure wound
therapy device that is an integrated system comprised of a non-manual
vacuum pump, a receptacle for collecting exudate, and dressings for the
purposes of wound therapy used in lieu of a conventional NPWT DME
system.
As required by the Consolidated Appropriations Act of 2016 (Pub. L
114-113), the separate payment amount for NPWT using a disposable
system is to be set equal to the amount of the payment that would be
made under the Medicare Hospital Outpatient Prospective Payment System
(OPPS) using the Level I Healthcare Common Procedure Coding System
(HCPCS) code, otherwise referred to as Current Procedural Terminology
(CPT-4) codes, for which the description for a professional service
includes the furnishing of such a device.
Under the OPPS, CPT codes 97607 and 97608 (APC 5052--Level 2 Skin
Procedures), include furnishing the service as well as the disposable
NPWT device. The codes are defined as follows:
HCPCS 97607--Negative pressure wound therapy, (for
example, vacuum assisted drainage collection), utilizing disposable,
non-durable medical equipment including provision of exudate management
collection system, topical application(s), wound assessment, and
instructions for ongoing care, per session; total wound(s) surface area
less than or equal to 50 square centimeters.
HCPCS 97608--Negative pressure wound therapy, (for
example, vacuum assisted drainage collection), utilizing disposable,
non-durable medical equipment including provision of exudate management
collection system, topical application(s), wound assessment, and
instructions for ongoing care, per session; total wound(s) surface area
greater than 50 square centimeters.
3. Proposed Payment Policies for NPWT Using a Disposable Device
For the purposes of paying for NPWT using a disposable device for a
patient under a Medicare home health plan of care and for which payment
is otherwise made under section 1895(b) of the Act, CMS is proposing
that for instances where the sole purpose for an HHA visit is to
furnish NPWT using a disposable device, Medicare will not pay for the
visit under the HH PPS. Instead, we propose that since furnishing NPWT
using a disposable device for a patient under a home health plan of
care is to be paid separately, based on the OPPS amount, which includes
payment for both the device and furnishing the service, the HHA must
bill these visits separately under type of bill 34x (used for patients
not under a HH plan of care, Part B medical and other health services,
and osteoporosis injections) along with the appropriate HCPCS code
(97607 or 97608). Visits performed solely for the purposes of
furnishing NPWT using a disposable device are not to be reported on the
HH PPS claim (type of bill 32x).
If NPWT using a disposable device is performed during the course of
an otherwise covered HHA visit (for example, while also furnishing a
catheter change), we propose that the HHA must not include the time
spent furnishing NPWT in their visit charge or in the length of time
reported for the visit on the HH PPS claim (type of bill 32x).
Providing NPWT using a disposable device for a patient under a home
health plan of care will be separately paid based on the OPPS amount
relating to payment for covered OPD services. In this situation, the
HHA bills for NPWT performed using a disposable device under type of
bill 34x along with the appropriate HCPCS code (97607 or 97608).
Additionally, this same visit should also be reported on the HH PPS
claim (type of bill 32x), but only for the time spent furnishing the
services unrelated to the provision of NPWT.
As noted in section III.E.1, since these two CPT codes (97607 and
97608) are considered ``sometimes'' therapy codes, NPWT using a
disposable device for patients under a home health plan of care can be
performed, in accordance to State law, by a registered nurse, physical
therapist, or occupational therapist and the visits would be reported
on the type of bill 34x using revenue codes 0559, 042X, 043X. The
[[Page 43744]]
descriptions for CPT codes 97607 and 97608 include performing a wound
assessment, therefore we believe that it would only be appropriate for
these visits to be performed by a registered nurse, physical therapist,
or occupational therapist as defined in Sec. 484.4 of the Medicare
Conditions of Participation (CoPs).
The payment amount for both 97607and 97608 will be set equal to the
amount of the payment that would be made under the OPPS and subject to
the area wage adjustment policies in place under the OPPS, for CY 2017
and each subsequent year. Please see Medicare Hospital OPPS Web page
for Addenda A and B at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html. These addenda are a ``snapshot'' of HCPCS codes and their
status indicators, APC groups, and OPPS payment rates that are in
effect at the beginning of each quarter. Section 504(b)(1) of the
Consolidated Appropriations Act of 2016 (Pub. L 114-113) amends section
1833(a)(1) of the Act, which requires that furnishing the NPWT using a
disposable device be subject to beneficiary coinsurance in the amount
of 20 percent. The amount paid to the HHA by Medicare will be equal to
80 percent of the lesser of the actual charge or the payment amount as
determined by the OPPS for the year.
In order for a beneficiary to receive NPWT using a disposable
device under the home health benefit, the beneficiary must also qualify
for the home health benefit in accordance with the existing eligibility
requirements. To be eligible for Medicare home health services, as set
out in sections 1814(a) and 1835(a) of the Act, a physician must
certify that the Medicare beneficiary (patient) meets the following
criteria:
Is confined to the home
Needs skilled nursing care on an intermittent basis or
physical therapy or speech-language pathology; or have a continuing
need for occupational therapy
Is under the care of a physician
Receive services under a plan of care established and reviewed
by a physician; and
Has had a face-to-face encounter related to the primary reason
for home health care with a physician or allowed Non-Physician
Practitioner (NPP) within a required timeframe.
As set forth in Sec. Sec. 409.32 and 409.44, to be considered a
skilled service, the service must be so inherently complex that it can
be safely and effectively performed only by, or under the supervision
of, professional or technical personnel. Additionally, care is deemed
as ``reasonable and necessary'' based on information reflected in the
home health plan of care, the OASIS as required by Sec. 484.55, or a
medical record of the individual patient. Coverage for NPWT using a
disposable device will be determined based upon a doctor's order as
well as patient preference. Research has shown that patients prefer
wound dressing materials that afford the quickest wound healing, pain
reduction, maximum exudate absorption to minimize drainage and odor,
and they indicated some willingness to pay out of pocket costs.\17\
Treatment decisions as to whether to use a disposable NPWT system
versus a conventional NPWT DME system is determined by the
characteristics of the wound, as well as, patient goals and preferences
discussed with the ordering physician to best achieve wound healing and
reduction.
---------------------------------------------------------------------------
\17\ Corbett, L., Ennis, W. (2014). What Do Patients Want?
Patient Preferences in Wound Care. 3(8), 537-543.
---------------------------------------------------------------------------
We are soliciting public comment on all aspects of the proposed
payment policies for furnishing a disposable NPWT device as articulated
in this section as well as the corresponding proposed changes to the
regulations at Sec. 409.50 in section VII of this proposed rule.
F. Update on Subsequent Research and Analysis Related to Section
3131(d) of the Affordable Care Act
Section 3131(d) of the Patient Protection and Affordable Care Act
(Pub. L. 111-148), as amended by the Health Care and Education
Reconciliation Act of 2010 (Pub. L. 111-152), (collectively referred to
as ``The Affordable Care Act''), directed the Secretary of Health and
Human Services (the Secretary) to conduct a study on HHA costs involved
with providing ongoing access to care to low-income Medicare
beneficiaries or beneficiaries in medically underserved areas and in
treating beneficiaries with high levels of severity of illness and to
submit a Report to Congress on the study's findings and
recommendations. As part of the study, the Affordable Care Act stated
that we may also analyze methods to potentially revise the home health
prospective payment system (HH PPS). In the CY 2016 HH PPS proposed
rule (80 FR 39840), we summarized the Report to Congress on the home
health study, required by section 3131(d) of the Affordable Care Act,
and provided information on the initial research and analysis conducted
to potentially revise the HH PPS case-mix methodology to address the
home health study findings outlined in the Report to Congress. In this
proposed rule, we are providing an update on additional research and
analysis conducted on the Home Health Groupings Model (HHGM), one of
the model options referenced in the CY 2016 HH PPS proposed rule (80 FR
39866).
The premise of the HHGM starts with a clinical foundation where
home health episodes are grouped by primary diagnosis based on what
home health interventions would be required during the episode of care.
In addition to the clinical groupings, the HHGM incorporates other
information from the OASIS and claims data to further group home health
episodes for payment. Each home health episode is categorized into
different sub-groups within each of the five categories below:
Timing (early or late; that is, episode is placed into 1 of 2
groups)
Referral source (community, acute, or post-acute admission
source; that is, episode is placed into 1 of 3 groups)
Clinical grouping (musculoskeletal rehab, neuro/stroke rehab,
wounds, MMTA, behavioral, or complex; that is, episode is placed into 1
of 6 groups)
Functional/cognitive level (low, medium, or high; that is,
episode is placed into 1 of 3 groups)
Comorbidity adjustment (first, second, or third, tier based on
secondary diagnoses; that is, episode is placed into 1 of 3 groups)
In total there would be 324 possible payment groupings an episode
can be grouped into under the HHGM. Unlike the current payment model,
the HHGM does not rely on the number of therapy visits performed to
influence payment.
Similar to the current payment system, episodes under the HHGM are
first classified as ``early'' or ``late'' depending on when they occur
within a sequence of adjacent episodes, as outlined in our regulations
at Sec. 484.230. Currently, the first two 60-day episodes of care are
considered ``early'' and third or later 60-day episodes of care are
considered ``late''. However, recent analysis shows that there is a
substantial difference in the number of visits that occur during the
first 30 days of a 60-day episode of care compared to the second 30
days in a 60-day episode of care (see Figure 4, below).
[[Page 43745]]
[GRAPHIC] [TIFF OMITTED] TP05JY16.006
Given the differences in the number of visits occurring in the
first 30 days versus the second 30 days in a 60-day episode of care,
and to better account for the relationship between episode
characteristics and episode cost, we modeled all episodes as 30-day
episodes of care, instead of 60-day episodes of care as in the current
payment system. Under the HHGM, the first 30-day episode in a sequence
of adjacent episodes was classified as an early episode. All subsequent
episodes in a sequence (second or later) of adjacent episodes were
classified as late episodes if separated by no more than a 60-day gap
in care.
After taking into account whether the 30-day episode of care was
``early'' versus ``late'', each episode was then classified into one of
three referral source categories depending on whether the beneficiary
was admitted from an acute or post-acute care facility within 14 days
prior to being admitted to home health (community, acute, or post-
acute). Patients admitted to home health from the community, an acute
setting of care, or a post-acute setting of care had different
observable patterns of resource use and thus, under the HHGM, episodes
of care for those patients would be paid differently.
We then grouped episodes into one of six clinical groups based on
the primary diagnosis listed on the OASIS for each episode. We created
these groups to describe the most common types of care that HHAs
provide. We have reviewed all possible ICD-9-CM codes that could be
recorded on the OASIS and assigned each code into one of the following
clinical groups: Musculoskeletal Rehabilitation; Neuro/Stroke
Rehabilitation; Wound Care; Medication Management, Teaching and
Assessment (MMTA); Behavioral Health Care; and Complex Medical Care.
The HHGM designates a functional/cognitive level for each episode
based on items identified on the OASIS that impact resource use. Using
home health episodes from 2013, we estimated a regression model that
determines the relationship between the responses for certain OASIS
items and resource use.\18\ The coefficients from the regression show
how much more or less, on average, an episode's resource use is
depending on responses to these items which is then used to predict
resource use for each individual episodes. Ranking the episodes by
predicted resource use and then identifying thresholds that divides
episodes into three groups of roughly the same size allows us to assign
each episode to into a low, medium or high functional/cognitive level.
---------------------------------------------------------------------------
\18\ ``Resource use'' is an estimate of the cost of an episode.
It is measured by multiplying the number of minutes of services that
occur during an episode by a wage rate for the disciplines providing
the care.
---------------------------------------------------------------------------
Finally, our exploratory analyses have determined that secondary
diagnoses (comorbidities) provide additional information that can
predict resource use even after controlling for episode timing,
referral source, the clinical grouping (based in the patient's primary
diagnosis) and functional/cognitive level. Therefore, we further
differentiated episodes into based on the presence of certain secondary
diagnoses. We explored two options. For the first option we determined
the commonly occurring comorbidities (incidence of over 0.1 percent)
reported on the OASIS that were also associated with above average
resource use. We then divided the comorbidities into a low or high
group based on average resource use associated with the comorbidity. We
then placed episodes into three tiers: Episodes for beneficiaries with
no comorbidities reported on the OASIS in the low or high group (Tier
1); episodes for beneficiaries with comorbidities in the low, but not
high group as reported on the OASIS (Tier 2); and episodes for
beneficiaries with comorbidities in the high group reported on the
OASIS (Tier 3). For the second option, we used the major complication
or comorbidity (MCC) and complication and comorbidity (CC) list from
the Inpatient Prospective Payment System (IPPS).
[[Page 43746]]
Using the CC and MMC list we placed episodes into three tiers: Episodes
where beneficiaries had no MCC or CC diagnoses reported on either the
OASIS or any inpatient or professional claim within 90 days of the
start of home care (Tier 1); episodes where beneficiaries had CC but no
MCC diagnoses reported on either the OASIS or any inpatient or
professional claim within 90 days of the start of home care (Tier 2);
and episodes where beneficiaries had at least one MCC diagnosis
reported on either the OASIS or any inpatient or professional claim
within 90 days of the start of home care (Tier 3).
We determined the case-mix weight for each of the 324 different
HHGM payment groups by estimating a regression between episode resource
use and binary variables controlling for the five dimensions described
above (episode timing, admission source, HHGM clinical group,
functional/cognitive level, and comorbidities). After estimating this
model on home health episodes from 2013 (excluding LUPA and outlier
episodes), we then used the results of the model to predict the
expected average resource use of each episode based on these six
characteristics. We divide the predicted resource use of each episode
by the overall average resource use (of all 2013 episodes) to calculate
the average case-mix of all episodes within a particular payment group
(that is, each combination of the sub-groups within the five main
groups). That case-mix weight is then used to adjust the base payment
rate to then determine each episode's payment.
In many ways, the structure of the HHGM is similar to the current
payment system. However, by either adding to or removing certain
components of the current payment system, the HHGM could help to
strengthen the HH PPS by addressing the margin differences noted in the
home health study and by removing unintended financial incentives (for
example, the current therapy thresholds). As noted in the 3131(d)
study, margin differences exist across beneficiary characteristics such
as parenteral nutrition, traumatic wounds, whether bathing assistance
was needed, and admission source. These margin differences would be
addressed by moving to a HHGM approach where those characteristics are
better accounted for in the model. Additionally, the HHGM aligns with
how clinicians generally identify the types of patients they see in
home health, which, in turn, better defines the home health benefit in
a more transparent manner so that the payer understands the primary
reason for home care. We feel that the HHGM will address the findings
highlighted in the 3131(d) report, specifically improving the payment
accuracy for purchased home health services, promote fair compensation
to HHAs, and increase the quality of care for beneficiaries. We plan to
release a more detailed Technical Report in the future on this
additional research and analysis conducted on the HHGM. When we release
the technical report, we are also planning to release a list of the
ICD-9-CM and ICD-10-CM codes assigned to each of the clinical groups
within the HHGM to further assist the industry in analyzing the HHGM
model. While we are not soliciting comments on the HHGM in this
proposed rule, once the Technical Report is released, we will post a
link on our Home Health Agency (HHA) Center Web site (https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html) to
receive comments and feedback on the model.
FF. Update on Future Plans To Group HH PPS Claims Centrally During
Claims Processing
In the CY 2011 HH PPS proposed rule (75 FR 43236) we solicited
comments on potential plans to group HH PPS claims centrally during
claims processing and received many comments in support of this
initiative. In grouping HH PPS Claims centrally during processing, we
are describing a process whereby all of the information necessary to
group the claim and assign a Health Insurance Prospective Payment
System (HIPPS) score which determines payment is available and
processed within the Fiscal Intermediary Shared System (FISS). In that
rule, we discussed the potential use of the treatment authorization
field to group HH PPS claims within the claims processing system. In
conducting further analysis, we determined that the use of the
treatment authorization field was not a viable option. In our analysis,
we determined that the information we planned to report in this field
was not permitted by the Health Insurance Portability Accountability
Act (HIPAA). In this section, we are soliciting comments on another
process identified whereby all of the information necessary to group HH
PPS claims occurs centrally during claims processing.
As we outlined in the previous rule, Medicare makes payment under
the HH PPS on the basis of a national, standardized 60-day episode
payment amount that is adjusted for case-mix and geographic wage
variations. The national, standardized 60-day episode payment amount
includes services from the six HH disciplines (skilled nursing, HH
aide, physical therapy, speech-language pathology, occupational
therapy, and medical social services) and non-routine medical supplies.
Durable medical equipment covered under HH is paid for outside the HH
PPS payment. To adjust for case-mix, the HH PPS uses a 153-category
case-mix classification to assign patients to a home health resource
group (HHRG). Clinical needs, functional status, and service
utilization are computed from responses to selected data elements in
the Outcome & Assessment Information Set (OASIS) instrument. On
Medicare claims, the HHRGs are represented as HIPPS codes.
At a patient's start of care and before the start of each
subsequent 60-day episode, the HHA is required to perform a
comprehensive clinical assessment of the patient and complete the OASIS
assessment instrument. The OASIS instrument collects data concerning 3
dimensions of the patient's condition: (1) Clinical severity
(orthopedic, neurological or diabetic conditions, etc.); (2) Functional
status (comprised of 6 activities of daily living (ADLs)); and (3)
Service utilization (therapy visits provided during episode). HHAs
enter data collected from their patients' OASIS assessments into a data
collection software tool. For Medicare patients, the data collection
software invokes HH PPS Grouper software to assign a HIPPS code to the
patient's OASIS assessment. The HHA includes the HIPPS code assigned by
HH PPS Grouper software on the Medicare HH PPS bill, ultimately
enabling our claims processing system to reimburse the HHA for services
provided to patients receiving Medicare home health services.
The HHA is separately required to electronically submit OASIS
assessments for their Medicare and Medicaid patients to us. On the HH
PPS Web site at https://www.qtso.com/havendownload.html, we provide a
free OASIS assessment data collection tool (JHAVEN) which includes the
HH PPS grouper software, a separate HH PPS grouper program which can be
incorporated into an HHA's own data collection software, and HH PPS
data specifications for use by HHAs or software vendors desiring to
build their own HH PPS grouper. Most HHAs do not use the JHAVEN
freeware, instead preferring to employ software vendors to create and
maintain a customized assessment data collection tool which can be
integrated into the HHA's billing software. Likewise, many vendors
employed by HHAs do not utilize the
[[Page 43747]]
HH PPS grouper freeware, instead preferring to build their own HH PPS
grouper from the data specifications which we provide.
Prior to the CY 2008, we made infrequent, minor changes to the HH
PPS Grouper software. Since CY 2008, the HH PPS Grouper became more
complex and more sensitive to annual diagnosis coding changes. As a
result, in recent years, HHAs have been required to update their
grouper software twice a year. Most HHAs employ software vendors to
effectuate these updates. HHAs have expressed concerns to us that the
bi-annual grouper updates coupled with the additional complexity of the
grouper has increased provider and vendor burden.
We continue to identify OASIS assessments submitted with erroneous
HIPPS codes through a process of comparing the submitted HIPPS code to
the HIPPS code returned by our assessment system. These errors may
occur when HHAs or their software vendors inaccurately replicate the HH
PPS Grouper algorithm into the HHA's customized software. HHAs have
expressed concerns that the HH PPS Grouper complexities increase their
vulnerability to submit an inaccurate HIPPS code on the Medicare bill.
We believe that embedding the HH PPS Grouper within the claims
processing system would mitigate the provider's vulnerability and
improve payment accuracy.
We recently implemented a process where we match the claim and the
OASIS assessment in order to validate the HIPPS code on the Medicare
bill. In addition, we have conducted an analysis and prototype testing
of a java-based grouper with our FISS maintenance contractor. We
believe that making additional enhancements to the claim and OASIS
matching process would enable us to collect all of the other necessary
information to assign a HIPPS code within the claims processing system.
Adopting such a process would improve payment accuracy by improving the
accuracy for HIPPS codes on bills, decrease costs, and burden to HHAs.
We are soliciting public comments on this potential enhancement as
described above. If we implemented grouping HH PPS claims centrally
within the claims processing system, the HHA would no longer have to
maintain a separate process outside of our claims processing system,
thus reducing the costs and burden to HHAs associated with the updates
of the grouper software as well as the ongoing agency costs associated
with embedding the HH PPS Grouper within JHAVEN. Finally, this
enhancement would also address current payment vulnerabilities
associated with the reporting of incorrect HIPPS codes on the claim.
IV. Proposed Provisions of the Home Health Value-Based Purchasing
(HHVBP) Model
A. Background
As authorized by section 1115A of the Act and finalized in the CY
2016 HH PPS final rule, we implemented the HHVBP Model to begin on
January 1, 2016. The HHVBP Model has an overall purpose of improving
the quality and delivery of home health care services to Medicare
beneficiaries. The specific goals of the Model are to: (1) Provide
incentives for better quality care with greater efficiency; (2) study
new potential quality and efficiency measures for appropriateness in
the home health setting; and, (3) enhance the current public reporting
process.
Using the randomized selection methodology finalized in the CY 2016
HH PPS final rule, nine states were selected for inclusion in the HHVBP
Model, representing each geographic area across the nation. All
Medicare-certified HHAs that provide services in Arizona, Florida,
Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and
Washington (competing HHAs), are required to compete in the Model.
Requiring all Medicare-certified HHAs in the selected states to
participate in the Model ensures that: (1) There is no selection bias;
(2) participating HHAs are representative of HHAs nationally; and, (3)
there is sufficient participation to generate meaningful results.
As finalized in the CY 2016 HH PPS final rule, the HHVBP Model will
utilize the waiver authority under section 1115A(d)(1) of the Act to
adjust Medicare payment rates under section 1895(b) of the Act
beginning in calendar year (CY) 2018 based on performance on applicable
measures. Payment adjustments will be increased incrementally over the
course of the HHVBP Model in the following manner: (1) A maximum
payment adjustment of 3 percent (upward or downward) in CY 2018; (2) a
maximum payment adjustment of 5 percent (upward or downward) in CY
2019; (3) a maximum payment adjustment of 6 percent (upward or
downward) in CY 2020; (4) a maximum payment adjustment of 7 percent
(upward or downward) in CY 2021; and, (5) a maximum payment adjustment
of 8 percent (upward or downward) in CY 2022. Payment adjustments will
be based on each HHA's Total Performance Score (TPS) in a given
performance year (PY) on (1) a set of measures already reported via
OASIS and HHCAHPS for all patients serviced by the HHA, or determined
by claims data and, (2) three New Measures where points are achieved
for reporting data.
B. Smaller- and Larger-Volume Cohorts Proposals
The HHVBP Model compares a competing HHA's performance on quality
measures against the performance of other competing HHAs within the
same state and size cohort. Within each of the nine selected states,
each competing HHA is grouped to either the smaller-volume cohort or
the larger-volume cohort, as defined in Sec. 484.305. The larger-
volume cohort is defined as the group of competing HHAs within the
boundaries of selected states that are participating in HHCAHPS in
accordance with Sec. 484.250 and the smaller-volume cohort is defined
as the group of competing HHAs within the boundaries of selected states
that are exempt from participation in HHCAHPS in accordance with Sec.
484.250 (80 FR 68664). An HHA can be exempt from the HHCAHPS reporting
requirements for a calendar year period if it has less than 60 eligible
unique HHCAHPS patients annually as specified in Sec. 484.250. In the
CY 2016 HH PPS final rule, we finalized that when there are too few
HHAs in the smaller-volume cohort in each state (such as when there are
only one or two HHAs competing within a smaller-volume cohort in a
given state) to compete in a fair manner, the HHAs would be included in
the larger-volume cohort for purposes of calculating the TPS and
payment adjustment percentage without being measured on HHCAHPS (80 FR
68664).
1. Proposal to Eliminate Smaller- and Larger-Volume Cohorts Solely for
Purposes of Setting Performance Benchmarks and Thresholds
In the CY 2016 HH PPS final rule (80 FR 68681-68682), we finalized
a scoring methodology for determining achievement points for each
measure under which HHAs will receive points along an achievement
range, which is a scale between the achievement threshold and a
benchmark. The achievement thresholds are calculated as the median of
all HHAs' performance on the specified quality measure during the
baseline period and the benchmark is calculated as the mean of the top
decile of all HHAs' performance on the specified quality measure during
the baseline period.
[[Page 43748]]
We previously finalized that under the HHVBP Model, we would
calculate both the achievement threshold and the benchmark separately
for each selected state and for HHA cohort size. Under this
methodology, benchmarks and achievement thresholds would be calculated
for both the larger-volume cohort and for the smaller-volume cohort of
HHAs in each state (which we defined in each state based on a baseline
period from January 1, 2015 through December 31, 2015). We also
finalized that, in determining improvement points for each measure,
HHAs would receive points along an improvement range, which we defined
as a scale indicating the change between an HHA's performance during
the performance period and the HHA's performance in the baseline period
divided by the difference between the benchmark and the HHAs
performance in the baseline period. We finalized that both the
benchmarks and the achievement thresholds would be calculated
separately for each state and for HHA cohort size.
We finalized the above policies based on extensive analyses of the
2013-2014 OASIS, claims, and HHCAHPS archived data. We believed that
these data were sufficient to predict the effect of using cohorts for
benchmarking and threshold purposes because they have been used for
several years in other CMS quality initiatives such as the Home Health
Quality Reporting Program.
Since the publication of the CY 2016 HH PPS final rule, we have
continued to evaluate the calculation of the benchmarks and achievement
thresholds using the most recent CY 2015 data that is now available. We
have calculated benchmarks and achievement thresholds for the OASIS
measures for the smaller- and larger-volume cohorts and state-wide for
each of the nine states using these data. Our review of the benchmarks
and achievement thresholds for each of the cohorts and states indicates
that the benchmark values for the smaller-volume cohorts varied
considerably more from state-to-state than the benchmark values for the
larger-volume cohorts. Some inter-state variation in the benchmarks and
achievement thresholds for each of the measures was expected due to
different state regulatory environments. However, the overall variation
in these values was more than we expected, given the previous analyses
we did. For example, with respect to the Improvement in Bed
Transferring measure, we discovered that variation in the benchmark
values between the smaller-volume cohorts was nearly three times
greater than the variation in the benchmark values for the larger-
volume cohorts or the statewide benchmarks. We also discovered that
this large variation affected most of the measures. We are concerned
that this high variation is not the result of expected differences like
state regulatory policy, but is instead the result of (1) the cohort is
so small that there are not enough HHAs in the cohort to calculate the
values using the finalized methodology (mean of the top decile); or (2)
the cohort is large enough to calculate the values using the finalized
methodology, but there are not enough HHAs in the cohort to generate
reliable values.
We have included three tables in this proposed rule to help
illustrate this issue. Each of the three tables include the 10
benchmarks for the OASIS measures that were calculated for the Model
using the 2015 QIES roll-up file data for each state. We did not
include the claims measures and the HHCAHPS measures in this example
because we do not have all of the 2015 data available. These three
tables demonstrate the relationship between the size of the cohort and
degree of variation of the different benchmark values among the states.
Table 28, Table 29 and Table 30 represent the benchmarks for the OASIS
measures for the smaller-volume cohorts, larger-volume cohorts and
state-wide (which includes HHAs from both smaller- and larger-volume
cohorts) respectively. For example, the difference in benchmark values
for Iowa and Nebraska (two of the four states that have smaller-volume
cohorts) for the Improvement in Bed Transfers measure is 13.1 (72.7 for
Iowa and 85.8 for Nebraska) for the smaller-volume cohort (Table 28),
4.1 (78.1 for Iowa to 82.2 for Nebraska) for the larger-volume cohort
(Table 29) and 5.5 (77.6 for Iowa to 83.1 for Nebraska) for the state
level cohort (Table 30). We believe that the higher range for the
smaller-volume cohorts is a result of there being a fewer number of
HHAs in these cohorts.
Table 28--Smaller-Volume Cohort Benchmarks
--------------------------------------------------------------------------------------------------------------------------------------------------------
State
-----------------------------------------------------------------------------------------
AZ FL IA MA MD NC NE TN WA
--------------------------------------------------------------------------------------------------------------------------------------------------------
Oasis-Based Measures:
Discharged to Community................................... 77.0 88.8 73.6 82.0 ........ 75.1 81.1 79.4
Drug Education on All Medications Provided to Patient/ 100.0 100.0 100.0 100.0 ........ 98.5 100.0 100.0
Caregiver during all Episodes of Care....................
Improvement in Ambulation- Locomotion..................... 90.6 90.5 72.7 75.6 ........ 60.1 84.0 85.2
Improvement in Bathing.................................... 82.0 91.2 79.5 71.8 ........ 72.1 77.4 81.5
Improvement in Bed Transferring........................... 68.8 80.4 72.7 74.1 ........ 55.1 85.8 79.0
Improvement in Dyspnea.................................... 84.2 90.4 81.3 62.6 ........ 62.5 80.3 93.7
Improvement in Management of Oral Medications............. 63.0 74.0 58.4 62.0 ........ 62.8 65.8 58.9
Improvement in Pain Interfering with Activity............. 83.2 97.3 82.6 82.3 ........ 58.5 78.2 69.0
Influenza Immunization Received for Current Flu Season.... 73.4 89.8 90.8 83.8 ........ 89.2 83.6 88.9
Pneumococcal Polysaccharide Vaccine Ever Received......... 95.8 91.5 95.8 95.3 ........ 83.6 97.0 100.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 43749]]
Table 29--Larger-Volume Cohort Benchmarks
--------------------------------------------------------------------------------------------------------------------------------------------------------
State
-----------------------------------------------------------------------------------------
AZ FL IA MA MD NC NE TN WA
--------------------------------------------------------------------------------------------------------------------------------------------------------
Oasis-Based Measures:
Discharged to Community................................... 82.1 85.6 78.3 81.2 81.1 78.2 80.3 81.0 83.1
Drug Education on All Medications Provided to Patient/ 99.8 100.0 99.9 100.0 99.9 99.7 99.9 99.8 99.7
Caregiver during all Episodes of Care....................
Improvement in Ambulation- Locomotion..................... 76.4 92.4 76.7 76.1 76.5 75.2 80.8 77.2 70.8
Improvement in Bathing.................................... 84.2 94.2 81.9 81.0 81.0 78.9 86.6 83.5 77.7
Improvement in Bed Transferring........................... 76.4 85.4 78.1 80.2 77.5 74.5 82.2 76.8 73.5
Improvement in Dyspnea.................................... 85.9 90.5 81.3 82.2 85.1 85.5 80.7 84.2 80.7
Improvement in Management of Oral Medications............. 69.4 80.5 68.1 73.2 71.7 63.9 68.1 72.2 64.0
Improvement in Pain Interfering with Activity............. 88.6 96.7 81.0 89.5 84.4 81.5 86.0 81.7 75.5
Influenza Immunization Received for Current Flu Season.... 88.0 93.3 88.1 90.1 87.9 88.0 95.2 88.2 87.0
Pneumococcal Polysaccharide Vaccine Ever Received......... 92.5 93.6 94.4 93.8 92.1 93.4 97.0 92.7 92.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 30--State Level Cohort Benchmarks
--------------------------------------------------------------------------------------------------------------------------------------------------------
State
-----------------------------------------------------------------------------------------
AZ FL IA MA MD NC NE TN WA
--------------------------------------------------------------------------------------------------------------------------------------------------------
Oasis-Based Measures:
Discharged to Community................................... 81.8 86.3 77.7 81.9 81.1 78.2 80.5 80.9 83.1
Drug Education on All Medications Provided to Patient/ 99.8 100.0 100.0 100.0 99.9 99.7 99.9 99.8 99.7
Caregiver during all Episodes of Care....................
Improvement in Ambulation- Locomotion..................... 77.5 92.1 76.2 76.3 76.5 75.2 82.9 77.9 70.8
Improvement in Bathing.................................... 84.1 93.8 81.8 80.3 81.0 78.9 84.6 83.5 77.7
Improvement in Bed Transferring........................... 75.9 84.8 77.6 80.1 77.5 74.5 83.1 77.3 73.5
Improvement in Dyspnea.................................... 85.8 90.5 81.9 81.7 85.1 85.5 81.3 85.8 80.7
Improvement in Management of Oral Medications............. 69.1 79.6 67.3 72.0 71.7 64.1 68.3 72.2 64.0
Improvement in Pain Interfering with Activity............. 88.1 96.8 81.5 88.4 84.4 81.5 84.3 81.7 75.5
Influenza Immunization Received for Current Flu Season.... 87.6 92.9 88.9 90.1 87.9 88.3 94.4 88.2 87.0
Pneumococcal Polysaccharide Vaccine Ever Received......... 92.9 93.3 94.8 94.2 92.1 93.4 97.0 93.3 92.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
The three tables are based on the analysis using the most current
data available. The results highlight that there is a greater degree of
interstate variation in the benchmark values for the cohorts that have
fewer HHAs as compared to the variation in benchmark values for the
cohorts that have a greater number of HHAs.
We also performed a similar analysis with the achievement
thresholds and comparing how the individual benchmarks and achievement
thresholds would fluctuate from one year to the next for the smaller-
volume cohorts, larger-volume cohorts, and the state level cohorts. The
results of those analyses were similar.
Based on the analyses that we have described, we are concerned that
if we separate HHAs into smaller- and larger-volume cohorts by state
for purposes of calculating the benchmarks and achievement thresholds,
HHAs in the smaller-volume cohorts could be required to meet
performance standards that are greater than the level of performance
that HHAs in the larger-volume cohorts would be required to achieve.
For this reason, we are proposing to calculate the benchmarks and
achievement thresholds at the state level rather than at the smaller-
and larger-volume cohort level for all model years, beginning with CY
2016. This change will eliminate the increased variation caused by
having few HHAs in the cohort but still takes into account that there
will be some inter-state variation in the values due to state
regulatory differences.
We seek public comments on this proposal.
2. The Payment Adjustment Methodology
We finalized in the CY 2016 HH PPS final rule that we would use a
linear exchange function (LEF) to translate a competing HHA's TPS into
a value-based payment adjustment percentage under the HHVBP Model (80
FR 68686). We also finalized that we would calculate the LEF separately
for each smaller-volume cohort and larger-volume cohort. In addition,
we finalized that if an HHA does not have a minimum of 20 episodes of
care during a performance year to generate a performance score on at
least five measures, we would not include the HHA in the LEF and we
would not calculate a payment adjustment percentage for that HHA.
Since the publication of the CY 2016 HH PPS final rule, we have
continued
[[Page 43750]]
to evaluate the payment adjustment methodology using the most recent
data available. We updated our analysis of the 10 OASIS quality
measures and two claims-based measures using the newly available 2014
QIES Roll Up File data, which was not available prior to the issuance
of that final rule.\19\ We also determined the size of the cohorts
using the 2014 Quality Episode File based on OASIS assessments rather
than archived quality data sources that were used in the CY 2016 rule,
whereby the HHAs reported at least five measures with over 20 episodes
of care. Based on this data, we determined that with respect to
performance year 2016, there were only three states (AZ, FL, NE) that
have more than 10 HHAs in the smaller-volume cohort; one state (IA)
that has 8-10 HHAs in the smaller-volume cohort, three states (NC, MA,
TN) that have 1-3 HHAs in the smaller-volume cohort; and two states
(MD, WA) that have no HHAs in the smaller-volume cohort. In the CY 2016
HH PPS final rule (80 FR 68664), we finalized that when there are too
few HHAs in the smaller-volume cohort in each state to compete in a
fair manner, the HHAs in that cohort would be included in the larger-
volume cohort for purposes of calculating their payment adjustment
percentage. The CY 2016 rule further defines too few as when there is
only one or two HHAs competing within a smaller-volume cohort in a
given state.
---------------------------------------------------------------------------
\19\ We did not update our analysis of the HHCAHPS measures
because more recent data was not available.
---------------------------------------------------------------------------
We also used the more current data source mentioned above to
analyze the effects of outliers on the LEF. As indicated by the payment
distributions set forth in Table 23 of this rule, the LEF is designed
so that the majority of the payment adjustment values fall closer to
the median and only a small percentage of HHAs receive adjustments at
the higher and lower ends of the distribution. However, when we looked
at the more recent data, we discovered that if there are only three or
four HHAs in the cohort, one HHA outlier could skew the payment
adjustments and deviate the payment distribution from the intended
design of the LEF payment methodology where HHAs should fall close to
the median of the payment distribution. For example, if there are only
three HHAs in the cohort, we concluded that there is a high likelihood
that those HHAs would have payment adjustments of -2.5 percent, -2.0
percent and +4.5 percent when the maximum payment adjustment is 5
percent, none falling close to the mean, with the result that those
HHAs would receive payment adjustments at the higher or lower ends of
the distribution. As the size of the cohort increases, we determined
that this became less of an issue, and that the majority of the HHAs
would have payment adjustments that are close to the median. This is
illustrated in the payment distribution in Table 23 of this rule. Under
the payment distribution for the larger-volume cohorts, 80 percent of
the HHAs in AZ, IA, FL and NE would receive a payment adjustment
ranging from -2.2 percent to +2.2 percent when the maximum payment
adjustment is 5 percent (See state level cohort in Table 23). Arizona
is a state that has a smaller-volume cohort with only nine HHAs but its
payment distribution is comparable, ranging from -1 percent to +1
percent even with one outlier that is at 5 percent.
In order to determine the minimum number of HHAs that would have to
be in a smaller-volume cohort in order to insulate that cohort from the
effect of outliers, we analyzed performance results related to the
OASIS and claims-based measures, as well as HHCAHPS, using 2013 and
2014 data. We specifically simulated the impact that outliers would
have on cohort sizes ranging from four HHAs to twelve HHAs. We found
that the LEF was less susceptible to large variation from outlier
impacts once the cohort size reached a minimum of eight HHAs. We also
found that a minimum of eight HHAs would allow for four states with
smaller-volume cohorts to have 80 percent of their payment adjustments
fall between -2.3 percent and + 2.4 percent. As a result of this
analysis, we are proposing that a smaller-volume cohort have a minimum
eight HHAs in order for the HHAs in that cohort to be compared only
against each other, and not against the HHAs in the larger-volume
cohort. We believe this proposal would better mitigate the impact of
outliers as compared to our current policy, while also enabling us to
evaluate the impact of the Model on competition between smaller-volume
HHAs.
We are also proposing that if a smaller-volume cohort in a state
has fewer than eight HHAs, those HHAs would be included in the larger-
volume cohort for that state for purposes of calculating the LEF and
payment adjustment percentages. If finalized, this change would apply
to the CY 2018 payment adjustments and thereafter. We will continue to
analyze and review the most current cohort size data as it becomes
available. We seek public comments on this proposal.
C. Quality Measure Proposals
In the CY 2016 HH PPS final rule, we finalized a set of quality
measures in Figure 4a: Final PY1 Measures and Figure 4b: Final PY1 New
Measures (80 FR 68671-68673) for the HHVBP Model to be used in the
first performance year (PY1), referred to as the ``starter set''.
The measures were selected for the Model using the following
guiding principles: (1) Use a broad measure set that captures the
complexity of the services HHAs provide; (2) Incorporate the
flexibility for future inclusion of the Improving Medicare Post-Acute
Care Transformation (IMPACT) Act of 2014 measures that cut across post-
acute care settings; (3) Develop `second generation' (of the HHVBP
Model) measures of patient outcomes, health and functional status,
shared decision making, and patient activation; (4) Include a balance
of process, outcome and patient experience measures; (5) Advance the
ability to measure cost and value; (6) Add measures for appropriateness
or overuse; and (7) Promote infrastructure investments. This set of
quality measures encompasses the multiple National Quality Strategy
(NQS) domains \20\ (80 FR 68668). The NQS domains include six priority
areas identified in the CY 2016 HH PPS final rule (80 FR 68668) as the
CMS Framework for Quality Measurement Mapping. These areas are: (1)
Clinical quality of care, (2) Care coordination, (3) Population &
community health, (4) Person- and Caregiver-centered experience and
outcomes, (5) Safety, and (6) Efficiency and cost reduction. Figures 5
and 6 of the CY 2016 HH PPS final rule identified 15 outcome measures
(five from the HHCAHPS, eight from OASIS, and two from the Chronic Care
Warehouse (claims)), and nine process measures (six from OASIS, and
three New Measures, which were not previously reported in the home
health setting).
---------------------------------------------------------------------------
\20\ 2015 Annual Report to Congress, http://www.ahrq.gov/workingforquality/reports/annual-reports/nqs2015annlrpt.htm.
---------------------------------------------------------------------------
During implementation of the Model, we determined that four of the
measures finalized for PY1 require further consideration before
inclusion in the HHVBP Model measure set as described below.
Specifically, we are proposing to remove the following measures, as
described in Figure 4a of the CY 2016 HH PPS final rule, from the set
of applicable measures: (1) Care Management: Types and Sources of
Assistance; (2) Prior Functioning ADL/IADL; (3) Influenza Vaccine Data
Collection Period: Does this episode of care include any dates on or
between
[[Page 43751]]
October 1 and March 31?; and (4) Reason Pneumococcal Vaccine Not
Received. We are proposing to remove these four measures, for the
reasons discussed below, beginning with the CY 2016 Performance Year
(PY1) calculations, and believe this will not cause substantial change
in the first annual payment adjustment that will occur in CY 2018, as
each measure is equally weighted and will not be represented in the
calculations. The proposed revisions to the measure set, as set forth
in Table 31 would be applicable to each performance year subject to any
changes made through future rulemaking.
We are proposing to remove the ``Care Management: Types and Sources
of Assistance'' measure because (1) a numerator and denominator for the
measure were not made available in the CY2016 HH PPS final rule; and
(2) the potential OASIS items that could be utilized in the development
of the measure were not fully specified in the CY 2016 HH PPS final
rule. We want to further consider the appropriate numerator and
denominator for the OASIS data source before proposing the inclusion of
this measure in the HHVBP Model.
We are proposing to remove the ``Prior Functioning ADL/IADL''
measure because (1) the NQF endorsed measure (NQF0430) included in the
2016 HH PPS final rule does not apply to home health agencies; and (2)
the NQF endorsed measure (NQF0430) refers to a measure that utilizes
the AM-PAC (Activity Measure for Post-Acute Care) tool that is not
currently (and has never been) collected by home health agencies.
We are proposing to remove the ``Influenza Vaccine Data Collection
Period: Does this episode of care include any dates on or between
October 1 and March 31?'' measure because this datum element (OASIS
item M1041) is used to calculate another HHVBP measure ``Influenza
Immunization Received for Current Flu Season'' and was not designed as
an additional and separate measure of performance.
We are proposing to remove the ``Reason Pneumococcal Vaccine Not
Received'' measure because (1) these data are reported as an element of
the record for clinical decision making and inform agency policy (that
is, so that the agency knows what proportion of its patients did not
receive the vaccine because it was contraindicated (harmful) for the
patient or that the patient chose to not receive the vaccine); and (2)
this measure itemizes the reason for the removal of individuals for
whom the vaccine is not appropriate, which is already included in the
numerator of the ``Pneumococcal Polysaccharide Vaccine Ever Received''
measure also included in the HHVBP Model.
Because the starter set is defined as the quality measures selected
for the first year of the Model only, we propose to revise Sec.
484.315 to refer to ``a set of quality measures'' rather than ``a
starter set of quality measures'' and to revise Sec. 484.320 (a), (b),
(c), and (d) to remove the phrase ``in the starter set''. We are also
proposing to delete the definition of ``Starter set'' in Sec. 484.305
because that definition would no longer be used in the HHVBP Model
regulations following the proposed revisions to Sec. Sec. 484.315 and
484.320.
The proposed revised set of applicable measures is presented in
Table 31, which excludes the four measures we propose to be removed. We
propose that this measure set will be applicable to PY1 and each
subsequent performance year until such time that another set of
applicable measures, or changes to this measure set, are proposed and
finalized in future rulemaking. Moving forward, we plan to utilize an
implementation contractor who will invite a group of measure experts to
provide advice on the adjustment of the current measure set.
---------------------------------------------------------------------------
\21\ For more detailed information on the proposed measures
utilizing OASIS refer to the OASIS-C1/ICD-9, Changed Items & Data
Collection Resources dated September 3, 2014 available at
www.oasisanswers.com/LiteratureRetrieve.aspx?ID=215074.
For NQF endorsed measures see The NQF Quality Positioning System
available at http://www.qualityforum.org/QPS. For non-NQF measures
using OASIS see links for data tables related to OASIS measures at
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html. For
information on HHCAHPS measures see https://homehealthcahps.org/SurveyandProtocols/SurveyMaterials.aspx.
Table 31--Proposed Measure Set for the HHVBP Model \21\
--------------------------------------------------------------------------------------------------------------------------------------------------------
NQS domains Measure title Measure type Identifier Data source Numerator Denominator
--------------------------------------------------------------------------------------------------------------------------------------------------------
Clinical Quality of Care........ Improvement in Outcome........... NQF0167........... OASIS (M1860)..... Number of home Number of home
Ambulation- health episodes health episodes
Locomotion. of care where the of care ending
value recorded on with a discharge
the discharge during the
assessment reporting period,
indicates less other than those
impairment in covered by
ambulation/ generic or
locomotion at measure-specific
discharge than at exclusions.
the start (or
resumption) of
care.
Clinical Quality of Care........ Improvement in Bed Outcome........... NQF0175........... OASIS (M1850)..... Number of home Number of home
Transferring. health episodes health episodes
of care where the of care ending
value recorded on with a discharge
the discharge during the
assessment reporting period,
indicates less other than those
impairment in bed covered by
transferring at generic or
discharge than at measure-specific
the start (or exclusions.
resumption) of
care.
Clinical Quality of Care........ Improvement in Outcome........... NQF0174........... OASIS (M1830)..... Number of home Number of home
Bathing. health episodes health episodes
of care where the of care ending
value recorded on with a discharge
the discharge during the
assessment reporting period,
indicates less other than those
impairment in covered by
bathing at generic or
discharge than at measure-specific
the start (or exclusions.
resumption) of
care.
Clinical Quality of Care........ Improvement in Outcome........... NA................ OASIS (M1400)..... Number of home Number of home
Dyspnea. health episodes health episodes
of care where the of care ending
discharge with a discharge
assessment during the
indicates less reporting period,
dyspnea at other than those
discharge than at covered by
start (or generic or
resumption) of measure-specific
care. exclusions.
[[Page 43752]]
Communication & Care Discharged to Outcome........... NA................ OASIS (M2420)..... Number of home Number of home
Coordination. Community. health episodes health episodes
where the of care ending
assessment with discharge or
completed at the transfer to
discharge inpatient
indicates the facility during
patient remained the reporting
in the community period, other
after discharge. than those
covered by
generic or
measure-specific
exclusions.
Efficiency & Cost Reduction..... Acute Care Outcome........... NQF0171........... CCW (Claims)...... Number of home Number of home
Hospitalization: health stays for health stays that
Unplanned patients who have begin during the
Hospitalization a Medicare claim 12-month
during first 60 for an unplanned observation
days of Home admission to an period. A home
Health. acute care health stay is a
hospital in the sequence of home
60 days following health payment
the start of the episodes
home health stay. separated from
other home health
payment episodes
by at least 60
days.
Efficiency & Cost Reduction..... Emergency Outcome........... NQF0173........... CCW (Claims)...... Number of home Number of home
Department Use health stays for health stays that
without patients who have begin during the
Hospitalization. a Medicare claim 12-month
for outpatient observation
emergency period. A home
department use health stay is a
and no claims for sequence of home
acute care health payment
hospitalization episodes
in the 60 days separated from
following the other home health
start of the home payment episodes
health stay. by at least 60
days.
Patient Safety.................. Improvement in Outcome........... NQF0177........... OASIS (M1242)..... Number of home Number of home
Pain Interfering health episodes health episodes
with Activity. of care where the of care ending
value recorded on with a discharge
the discharge during the
assessment reporting period,
indicates less other than those
frequent pain at covered by
discharge than at generic or
the start (or measure-specific
resumption) of exclusions.
care.
Patient Safety.................. Improvement in Outcome........... NQF0176........... OASIS (M2020)..... Number of home Number of home
Management of health episodes health episodes
Oral Medications. of care where the of care ending
value recorded on with a discharge
the discharge during the
assessment reporting period,
indicates less other than those
impairment in covered by
taking oral generic or
medications measure-specific
correctly at exclusions.
discharge than at
start (or
resumption) of
care.
Population/Community Health..... Influenza Process........... NQF0522........... OASIS (M1046)..... Number of home Number of home
Immunization health episodes health episodes
Received for during which of care ending
Current Flu patients (a) with discharge,
Season. received or transfer to
vaccination from inpatient
the HHA or (b) facility during
had received the reporting
vaccination from period, other
HHA during than those
earlier episode covered by
of care, or (c) generic or
was determined to measure-specific
have received exclusions.
vaccination from
another provider.
Population/Community Health..... Pneumococcal Process........... NQF0525........... OASIS (M1051)..... Number of home Number of home
Polysaccharide health episodes health episodes
Vaccine Ever during which of care ending
Received. patients were with discharge or
determined to transfer to
have ever inpatient
received facility during
Pneumococcal the reporting
Polysaccharide period, other
Vaccine (PPV). than those
covered by
generic or
measure-specific
exclusions.
Clinical Quality of Care........ Drug Education on Process........... NA................ OASIS (M2015)..... Number of home Number of home
All Medications health episodes health episodes
Provided to of care during of care ending
Patient/Caregiver which patient/ with a discharge
during all caregiver was or transfer to
Episodes of Care. instructed on how inpatient
to monitor the facility during
effectiveness of the reporting
drug therapy, how period, other
to recognize than those
potential adverse covered by
effects, and how generic or
and when to measure-specific
report problems exclusions.
(since the
previous OASIS
assessment).
Patient & Caregiver-Centered Care of Patients.. Outcome........... CAHPS............. NA................ NA.
Experience.
Patient & Caregiver-Centered Communications Outcome........... CAHPS............. NA................ NA.
Experience. between Providers
and Patients.
Patient & Caregiver-Centered Specific Care Outcome........... CAHPS............. NA................ NA.
Experience. Issues.
Patient & Caregiver-Centered Overall rating of Outcome........... CAHPS............. NA................ NA.
Experience. home health care.
Patient & Caregiver-Centered Willingness to Outcome........... CAHPS............. NA................ NA.
Experience. recommend the
agency.
[[Page 43753]]
Population/Community Health..... Influenza Process........... NQF0431 (Used in Reported by HHAs Healthcare Number of
Vaccination other care through Web personnel in the healthcare
Coverage for Home settings, not Portal. denominator personnel who are
Health Care Home Health). population who working in the
Personnel. during the time healthcare
from October 1 facility for at
(or when the least 1 working
vaccine became day between
available) October 1 and
through March 31 March 31 of the
of the following following year,
year: (a) regardless of
received an clinical
influenza responsibility or
vaccination patient contact.
administered at
the healthcare
facility, or
reported in
writing or
provided
documentation
that influenza
vaccination was
received
elsewhere: or (b)
were determined
to have a medical
contraindication/
condition of
severe allergic
reaction to eggs
or to other
components of the
vaccine or
history of
Guillain-Barre
Syndrome within 6
weeks after a
previous
influenza
vaccination; or
(c) declined
influenza
vaccination; or
(d) persons with
unknown
vaccination
status or who do
not otherwise
meet any of the
definitions of
the above-
mentioned
numerator
categories.
Population/Community Health..... Herpes zoster Process........... NA................ Reported by HHAs Total number of Total number of
(Shingles) through Web Medicare Medicare
vaccination: Has Portal. beneficiaries beneficiaries
the patient ever aged 60 years and aged 60 years and
received the over who report over receiving
shingles having ever services from the
vaccination?. received zoster HHA.
vaccine (shingles
vaccine).
Communication & Care Advance Care Plan. Process........... NQF0326........... Reported by HHAs Patients who have All patients aged
Coordination. through Web an advance care 65 years and
Portal. plan or surrogate older.
decision maker
documented in the
medical record or
documentation in
the medical
record that an
advanced care
plan was
discussed but the
patient did not
wish or was not
able to name a
surrogate
decision maker or
provide an
advance care plan.
--------------------------------------------------------------------------------------------------------------------------------------------------------
In the CY 2016 HH PPS final rule, we finalized that HHAs will be
required to begin reporting data on each of the three New Measures no
later than October 7, 2016 for the period July 2016 through September
2016 and quarterly thereafter. We now propose to require annual, rather
than quarterly reporting for one of the three New Measures, ``Influenza
Vaccination Coverage for Home Health Personnel,'' with the first annual
submission in April 2017 for PY2. Specifically, we are proposing to
require an annual submission in April for the prior 6-month reporting
period of October 1-March 31 to coincide with the flu season. Under
this proposal, for PY1, the HHA would report on this measure in October
2016 and January 2017. HHAs would report on this measure in April 2017
for PY2 and annually in April thereafter. We believe that changing the
reporting and submission periods for this measure from quarterly to
annually would avoid the need for HHAs to have to report zeroes in
multiple data fields for the two quarters (July through September, and
April through June) that fall outside of the parameters of the
denominator (October through March).
We are not proposing to change the quarterly reporting and
submission requirements as set forth in the CY 2016 HH PPS final rule
(80 FR 68674-68678) for the other two New Measures, ``Advanced Care
Planning'', and ``Herpes zoster (Shingles) vaccination: Has the patient
ever received the shingles vaccination?''
We are also proposing to increase the timeframe for submitting New
Measures data from seven calendar days (80 FR 68675-68678) to fifteen
calendar days following the end of each reporting period to account for
weekends and holidays.
We invite public comment on our proposals.
D. Appeals Process Proposal
In the CY 2016 HH PPS final rule (80 FR 68689), we stated that we
intended to propose an appeals mechanism in future rulemaking prior to
the application of the first payment adjustments scheduled for CY 2018.
We are proposing an appeals process for the HHVBP Model which includes
the period to review and request recalculation of both the Interim
Performance Reports and the Annual TPS and Payment Adjustment Reports,
as finalized in the CY 2016 HH PPS final rule (80 FR 68688-68689) and
subject to the modifications we are proposing here, and reconsideration
request process for the Annual TPS and Payment Adjustment Report only,
as described later in this section, which may only occur after an HHA
has first submitted a recalculation request for the Annual TPS and
Payment Adjustment Report.
As finalized in the CY 2016 HH PPS final rule, HHAs have the
opportunity to review their Interim Performance Report following each
quarterly posting. The Interim Performance Reports are posted on the
HHVBP Secure Portal quarterly, setting forth the HHA's measure scores
based on available data to date. The first Interim Performance Report
will be provided to all competing HHAs in July 2016 and will include
performance scores for the OASIS-based measures for the first quarter
of CY 2016. See Table 32 for data provided in each report. The
quarterly Interim Performance Reports
[[Page 43754]]
will provide competing HHAs with the opportunity to identify and
correct calculation errors and resolve discrepancies, thereby
minimizing challenges to the annual performance scores linked to
payment adjustment.
Competing HHAs also have the opportunity to review their Annual TPS
and Payment Adjustment Report. We will inform each competing HHA of its
TPS and payment adjustment percentage in an Annual TPS and Payment
Adjustment Report provided prior to the calendar year for which the
payment adjustment will be applied. The annual TPS will be calculated
based on the calculation of performance measures contained in the
Interim Performance Reports that have already been received by the HHAs
for the performance year.
We are proposing specific timeframes for the submission of
recalculation and reconsideration requests to ensure that the final
payment adjustment percentage for each competing Medicare-certified HHA
can be submitted to the Fiscal Intermediary Shared Systems in time to
allow for application of the payment adjustments beginning in January
of the following calendar year. We believe HHVBP payment adjustments
should be timely and that the appeals process should be designed so
that determinations on recalculations and reconsiderations can be made
in advance of the applicable payment year to reduce burden and
uncertainty for competing HHAs.
In this proposed rule, we are proposing to add new Sec. 484.335,
titled ``Appeals Process for the Home Health Value-Based Purchasing
Model,'' which would codify the recalculation request process finalized
in the CY 2016 HH PPS final rule and also a proposed reconsideration
request process for the Annual TPS and Payment Adjustment Report. The
first level of this appeals process would be the recalculation request
process, as finalized in the CY 2016 HH PPS final rule and subject to
the proposed modifications described later in this section. We are
proposing that the reconsideration request process for the Annual TPS
and Payment Adjustment Report would complete the appeals process, and
would be available only when an HHA has first submitted a recalculation
request for the Annual TPS and Payment Adjustment Report under the
process finalized in the CY 2016 HH PPS final rule, subject to the
modifications we are proposing here. We believe that this proposed
appeals process will allow the HHAs to seek timely corrections for
errors that may be introduced during the Interim Performance Reports
that could affect an HHA's payments.
To inform our proposal for an appeals process under the HHVBP Model
we reviewed the appeals policies for two CMS programs that are similar
in their program goals to the HHVBP Model, the Medicare Shared Savings
Program \22\ and Hospital Value-Based Purchasing Program,\23\ as well
as the appeals policy for the Comprehensive Care for Joint Replacement
Model \24\ that is being tested by the Center for Medicare and Medicaid
Innovation (CMMI).
---------------------------------------------------------------------------
\22\ Title 42--Public Health, Chapter IV--Centers for Medicare &
Medicaid Services, Department of Health and Human Services,
Subchapter B, Part 425--Medicare Shared Savings Program, Subpart I--
Reconsideration Review Process. (http://www.ecfr.gov/cgi-bin/text-idx?SID=880f6bd181904fc648f0e9a885103dba&mc=true&node=sp42.3.425.i&rgn=div6)
\23\ Title 42--Public Health, Chapter IV--Centers for Medicare &
Medicaid Services, Department of Health and Human Services,
Subchapter B, Part 412--Prospective Payment System for Inpatient
Hospital Services, Subpart I--Adjustments to the Base Operating DRG
Payment Amounts Under the Prospective Payment Systems for Inpatient
Operating Costs (http://www.ecfr.gov/cgi-bin/text-idx?SID=dd15db0a13792035b9b42b342270fad6&mc=true&node=sg42.2.412_1155_6412_1159.sg4&rgn=div7)
\24\ Title 42--Public Health, Chapter IV--Centers for Medicare &
Medicaid Services, Department of Health and Human Services,
Subchapter H--Health Care Infrastructure and Model Programs, Part
510-- Comprehensive Care for Joint Replacement Model. (http://www.ecfr.gov/cgi-bin/text-idx?SID=a18d6f5665d1fbf2e1ae955e1bf1b97c&mc=true&node=pt42.5.510&rgn=div5)
---------------------------------------------------------------------------
Under section 1115A(d) of the Act, there is no administrative or
judicial review under sections 1869 or 1878 of the Act or otherwise for
the following:
The selection of models for testing or expansion under
section 1115A of the Act.
The selection of organizations, sites or participants to
test those models selected.
The elements, parameters, scope, and duration of such
models for testing or dissemination.
Determinations regarding budget neutrality under section
1115A(b)(3) of the Act.
The termination or modification of the design and
implementation of a model under section 1115A(b)(3)(B) of the Act.
Decisions about expansion of the duration and scope of a
model under section 1115A(c) of the Act, including the determination
that a model is not expected to meet criteria described in section
1115A(c)(1) or (2) of the Act.
Table 32--HHVBP Model Performance Report Data Schedule
----------------------------------------------------------------------------------------------------------------
OASIS-Based measures Claims- and HHCAHPS-
Report type Publication date and new measures based measures
----------------------------------------------------------------------------------------------------------------
Interim Performance Scores.......... January................. 3 quarters of previous 2 quarters of previous
PY (9 months); [Jan- PY (6 months); [Jan-
Sept]. Jun].
Interim Performance Scores.......... April................... 12 months of previous 3 quarters of previous
PY [Jan-Dec]. PY (9 months); [Jan-
Sept].
Interim Performance Scores.......... July.................... 1st quarter of next PY 12 months of previous
(3 months); [Jan-Mar]. PY; [Jan-Dec].
Interim Performance Scores.......... October................. 2 quarters of next PY 1st quarter of next PY
(6 months); [Jan-Jun]. (3 months); [Jan-Mar].
-------------------------------------------------
Annual TPS and Payment Adjustment August.................. Entire 12 months of previous PY; [Jan-Dec].
Percentage.
-------------------------------------------------
Annual TPS and Payment Adjustment November................ Entire 12 months of previous PY [Jan-Dec] after
Percentage; (Final). all recalculations and reconsideration requests
processed.
----------------------------------------------------------------------------------------------------------------
[[Page 43755]]
1. Recalculation
HHAs may submit recalculation requests for both the Interim
Performance Reports and the Annual TPS and Payment Adjustment Report
via a form located on the HHVBP Secure Portal that is only accessible
to the competing HHAs. The request form would be entered by a person
who has legal authority to sign on behalf of the HHA and, as finalized
in the CY 2016 HH PPS final rule, must be submitted within 30 calendar
days of the posting of each performance report on the model-specific
Web site. For the reasons discussed later in this section, we are
proposing to change this policy to require that recalculation requests
for both the Interim Performance Report and the Annual TPS and Payment
Adjustment Report be submitted within 15 calendar days of the posting
of the Interim Performance Report and the Annual TPS and Payment
Adjustment Report on the HHVBP Secure Portal instead of 30 calendar
days.
For both the Interim Performance Reports and the Annual TPS and
Payment Adjustment Report, requests for recalculation must contain
specific information, as set forth in the CY 2016 HH PPS final rule (80
FR 68688). We are proposing that requests for reconsideration of the
Annual TPS and Payment Adjustment Report must also contain this same
information.
The provider's name, address associated with the services
delivered, and CMS Certification Number (CCN);
The basis for requesting recalculation to include the
specific quality measure data that the HHA believes is inaccurate or
the calculation the HHA believes is incorrect;
Contact information for a person at the HHA with whom CMS
or its agent can communicate about this request, including name, email
address, telephone number, and mailing address (must include physical
address, not just a post office box); and,
A copy of any supporting documentation the HHA wishes to
submit in electronic form via the model-specific Web page.
Following receipt of a request for recalculation of an Interim
Performance Report or the Annual TPS and Payment Adjustment Report, CMS
or its agent will:
Provide an email acknowledgement, using the contact
information provided in the recalculation request, to the HHA contact
notifying the HHA that the request has been received;
Review the request to determine validity, and determine
whether the recalculation request results in a score change, altering
performance measure scores or the HHA's TPS;
Conduct a review of quality data if recalculation results
in a performance score or TPS change, and recalculate the TPS using the
corrected performance data if an error is found; and,
Provide a formal response to the HHA contact, using the
contact information provided in the recalculation request, notifying
the HHA of the outcome of the review and recalculation process.
We anticipate providing this response as soon as administratively
feasible following the submission of the request.
We will not be responsible for providing HHAs with the underlying
source data utilized to generate performance measure scores because
HHAs have access to this data via the QIES system.
We are proposing that recalculation requests for the Interim
Performance Reports must be submitted within 15 calendar days of these
reports being posted on the HHVBP Secure Portal, rather than 30
calendar days as finalized in the CY 2016 HH PPS final rule. We believe
this would allow recalculations of the Interim Performance Reports
posted in July to be completed prior to the posting of the Annual TPS
and Payment Adjustment Report in August. We are proposing that
recalculation requests for the TPS or payment adjustment percentage
must be submitted within 15 calendar days of the Annual TPS and Payment
Adjustment Report being posted on the HHVBP Secure Portal, rather than
30 days as finalized in the CY 2016 HH PPS final rule. We are proposing
to shorten this timeframe to allow for a second level of appeals, the
proposed reconsideration request process, to be completed prior to the
generation of the final data files containing the payment adjustment
percentage for each competing Medicare-certified HHA and the submission
of those data files to the Fiscal Intermediary Share Systems. We
contemplated longer timeframes for the submission of both recalculation
and reconsideration requests for the Annual TPS and Payment Adjustment
Reports, but believe that this would result in appeals not being
resolved in advance of the payment adjustments being applied beginning
in January of the following calendar year. We invite comments on this
proposed timeframe for recalculation requests, as well as any
alternatives.
2. Reconsideration
We are proposing that if we determine that the calculation was
correct and deny the HHA request for recalculation of the Annual TPS
and Payment Adjustment Report, or if the HHA disagrees with the results
of a CMS recalculation of such report, the HHA may submit a
reconsideration request for the Annual TPS and Payment Adjustment
Report. The reconsideration request and supporting documentation would
be required to be submitted via the form on the HHVBP Secure Portal
within 15 calendar days of CMS' notification to the HHA contact of the
outcome of the recalculation request for the Annual TPS and Payment
Adjustment Report.
We propose that an HHA may request reconsideration of the outcome
of a recalculation request for its Annual TPS and Payment Adjustment
Report only. We believe that the ability to review the Interim
Performance Reports and submit recalculation requests on a quarterly
basis provides competing HHAs with a mechanism to address potential
errors in advance of receiving their annual TPS and payment adjustment
percentage. Therefore, we expect that in many cases, the
reconsideration request process proposed in this rule would result in a
mechanical review of the application of the formulas for the TPS and
the LEF, which could result in the determination that a formula was not
accurately applied. Reconsiderations would be conducted by a CMS
official who was not involved with the original recalculation request.
We are proposing that an HHA must submit the reconsideration
request and supporting documentation via the HHVBP Secure Portal within
15 calendar days of CMS' notification to the HHA contact of the outcome
of the recalculation process so that a decision on the reconsideration
can be made prior to the generation of the final data files containing
the payment adjustment percentage for each competing Medicare-certified
HHA and the submission of those data files to the Fiscal Intermediary
Share Systems. We believe that this would allow for finalization of the
interim performance scores, TPS, and annual payment adjustment
percentages in advance of the application of the payment adjustments
for the applicable performance year. As noted above, we contemplated
longer timeframes for the submission of both recalculation and
reconsideration requests, but believe this would result in appeals not
being resolved in advance of the payment adjustments being applied
beginning in January of the following calendar year. CMS invites
comments on its proposed timeframe for reconsideration requests, as
well as any alternatives.
[[Page 43756]]
We finalized in the CY 2016 HH PPS final rule (80 FR 68688) that
the final TPS and payment adjustment percentage would be provided to
competing HHAs in a final report no later than 60 calendar days in
advance of the payment adjustment taking effect. We are now proposing
that the final TPS and payment adjustment percentage be provided to
competing HHAs in a final report no later than 30 calendar days in
advance of the payment adjustment taking effect to account for
unforeseen delays that could occur between the time the Annual TPS and
Payment Adjustment Reports are posted and the appeals process is
completed.
We solicit comments on our proposals related to the appeals process
for the HHVBP Model described in this section and the associated
proposed regulation text at Sec. 484.335.
E. Public Display of Total Performance Scores for the HHVBP Model
In the CY 2016 HH PPS final rule (80 FR 68658), we stated that one
of the three goals of the HHVBP Model is to ``Enhance current public
reporting processes''. Annual publicly-available performance reports
would be a means of developing greater transparency of Medicare data on
quality and aligning the competitive forces within the market to
deliver care based on value over volume. The publicly-reported reports
will inform home health industry stakeholders (consumers, physicians,
hospitals) as well as all competing HHAs delivering care to Medicare
beneficiaries within selected state boundaries on their level of
quality relative to both their peers and their own past performance.
These public reports would provide home health industry stakeholders,
including providers and suppliers that refer their patients to HHAs, an
opportunity to confirm that the beneficiaries they are referring for
home health services are being provided the best possible quality of
care available.
We received support via public comments to publicly report the
HHVBP Model performance data because they would inform industry
stakeholders of quality improvements. These comments noted several
areas of value in performance data. Specifically, commenters suggested
that public reports would permit providers to direct patients to a
source of information about higher-performing HHAs based on quality
reports. Commenters offered that to the extent possible, accurate
comparable data will encourage HHAs to improve care delivery and
patient outcomes, while better predicting and managing quality
performance and payment updates. Although competing HHAs have direct
technical support and other tools to encourage best practices, we
believe public reporting of their Total Performance Score will
encourage providers and patients to utilize this information when
selecting a HHA to provide quality care.
We have employed a variety of means to ensure that we maintain
transparency while developing and implementing the HHVBP Model. This
same care is being taken as we plan public reporting in collaboration
with other CMS components that use many of the same quality measures.
We continue to engage and inform stakeholders about various aspects of
the HHVBP Model through CMS Open Door Forums and updates to the HHVBP
Model Innovation Center Web page (https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model). We have held
several webinars since December 2015 to educate competing HHAs. Topics
of the webinars ranged from an overview of the HHVBP Model to specific
content areas addressed in the CY 2016 HH PPS final rule. The primary
purpose of the focused attention provided to the competing HHAs through
the HHVBP learning systems and webinars is to facilitate direct
communication, sharing of information, and collaboration.
Section 1895(b)(3)(B)(v) of the Act requires HHAs to submit
patient-level quality of care data using the Outcome and Information
Assessment Set (OASIS) and the Home Health Consumer Assessment of
Health Care Providers and Systems (HHCAHPS). Section
1895(b)(3)(B)(v)(III) of the Act states that this quality data is to be
made available to the public. Thus, home health agencies have been
required to collect OASIS data since 1999 and report HHCAHPS data since
2012. Use of OASIS measures for the HHVBP Model logically follows, as
the validation through experience creates greater efficiency than
constructing an entirely new set of measures.
We are considering various public reporting platforms for the HHVBP
Model including Home Health Compare (HHC) and the Center for Medicare
and Medicaid Innovation (CMMI) Web page as a vehicle for maintaining
information in a centralized location and making information available
over the Internet. We believe the public reporting of competing HHAs'
performance scores under the HHVBP Model supports our continuing
efforts to empower consumers by providing more information to help them
make health care decisions, while also encouraging providers to strive
for higher levels of quality. As the public reporting mechanism for the
HHVBP Model is being developed, we are considering which data elements
reported will be meaningful to stakeholders and may inform the
selection of HHAs for care.
We are considering public reporting for the HHVBP Model, beginning
no earlier than CY 2019, to allow analysis of at least eight quarters
of performance data for the Model and the opportunity to compare how
those results align with other publicly reported quality data. We are
encouraged by the previous stakeholder comments and support for public
reporting that could assist patients, physicians, discharge planners,
and other referral sources to choose higher-performing HHAs.
V. Proposed Updates to the Home Health Care Quality Reporting Program
(HH QRP)
A. Background and Statutory Authority
Section 1895(b)(3)(B)(v)(II) of the Act requires that for 2007 and
subsequent years, each HHA submit to the Secretary in a form and
manner, and at a time, specified by the Secretary, such data that the
Secretary determines are appropriate for the measurement of health care
quality. To the extent that an HHA does not submit data in accordance
with this clause, the Secretary is directed to reduce the home health
market basket percentage increase applicable to the HHA for such year
by 2 percentage points. As provided at section 1895(b)(3)(B)(vi) of the
Act, depending on the market basket percentage for a particular year,
the 2 percentage point reduction under section 1895(b)(3)(B)(v)(I) of
the Act may result in this percentage increase, after application of
the productivity adjustment under section 1895(b)(3)(B)(vi)(I) of the
Act, being less than 0.0 percent for a year, and may result in payment
rates under the Home Health PPS for a year being less than payment
rates for the preceding year.
The Improving Medicare Post-Acute Care Transformation Act of 2014
(the IMPACT Act) imposed new data reporting requirements for certain
post-acute care (PAC) providers, including HHAs. For more information
on the statutory background of the IMPACT Act, please refer to the CY
2016 HH PPS final rule (80 FR 68690 through 68692).
In that final rule, we established our approach for identifying
cross-setting measures and processes for the adoption of measures,
including the application and purpose of the Measures Application
Partnership (MAP) and the notice and comment rulemaking process. More
information on the
[[Page 43757]]
IMPACT Act is also available at https://www.govtrack.us/congress/bills/113/hr4994.
In the CY 2016 HH PPS final rule (80 FR 68692), we also discussed
the reporting of OASIS data as it relates to the implementation of ICD-
10 on October 1, 2015. We submitted a new request for approval to OMB
for the OASIS-C1/ICD-10 version under the Paperwork Reduction Act (PRA)
process, including a new OMB control number (see 80 FR 15796). The new
information collection request for OASIS-C1/ICD-10 version was approved
under OMB control number 0938-1279 with a current expiration date of
May 31, 2018. To satisfy requirements in the IMPACT Act that HHAs
submit standardized patient assessment data in accordance with section
1899B(b) and to create consistency in the lookback period across
selected OASIS items, we have created a modified version of the OASIS,
OASIS-C2. We have submitted request for approval to OMB for the OASIS-
C2 version under the PRA process (81 FR 18855); also see https://www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing.html. The OASIS-C2 version will
replace the OASIS-C1/ICD-10 and will be effective for data collected
with an assessment completion date (M0090) on and after January 1,
2017. Information regarding the OASIS-C1/ICD-10 and C2 can be located
on the OASIS Data Sets Web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/OASIS-Data-Sets.html.
B. General Considerations Used for the Selection of Quality Measures
for the HH QRP
We refer readers to the CY 2016 HH PPS final rule (80 FR 68695
through 68698) for a detailed discussion of the considerations we apply
in measure selection for the Home Health Quality Reporting Program (HH
QRP), such as alignment with the CMS Quality Strategy,\25\ which
incorporates the three broad aims of the National Quality Strategy.\26\
Overall, we strive to promote high quality and efficiency in the
delivery of health care to the beneficiaries we serve. Performance
improvement leading to the highest quality health care requires
continuous evaluation to identify and address performance gaps and
reduce the unintended consequences that may arise in treating a large,
vulnerable, and aging population. Quality reporting programs (QRPs),
coupled with public reporting of quality information are critical to
the advancement of health care quality improvement efforts. Valid,
reliable, and relevant quality measures are fundamental to the
effectiveness of our QRPs. Therefore, selection of quality measures is
a priority for us in all of our QRPs.
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\25\ http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html.
\26\ http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm.
---------------------------------------------------------------------------
In this proposed rule, we propose to adopt for the HH QRP one
measure that we are specifying under section 1899B(c)(1)(C) of the Act
to meet the Medication Reconciliation domain: (1) Drug Regimen Review
Conducted with Follow-Up for Identified Issues-Post-Acute Care Home
Health Quality Reporting Program (Drug Regimen Review Conducted with
Follow-Up for Identified Issues-PAC HH QRP). Further, we are proposing
to adopt for the HH QRP three measures to meet the ``Resource Use and
other Measures'' domains required by section 1899B(d)(1) of the Act:
(1) Total Estimated Medicare Spending per Beneficiary--Post Acute Care
Home Health Quality Reporting Program (MSPB-PAC HH QRP); (2) Discharge
to Community--Post Acute Care Home Health Quality Reporting Program
(Discharge to Community-PAC HH QRP); and (3) Potentially Preventable
30-Day Post-Discharge Readmission Measure for Post-Acute Care Home
Health Quality Reporting Program (Potentially Preventable 30-Day Post-
Discharge Readmission Measure for HH QRP).
In our selection and specification of measures, we employ a
transparent process in which we seek input from stakeholders and
national experts and engage in a process that allows for pre-rulemaking
input on each measure, as required by section 1890A of the Act. To meet
this requirement, we provided the following opportunities for
stakeholder input: Our measure development contractor convened
technical expert panels (TEPs) that included stakeholder experts and
patient representatives on July 29, 2015 for the Drug Regimen Review
Conducted with Follow-Up for Identified Issues-PAC HH QRP; on August
25, 2015, September 25, 2015, and October 5, 2015, for the Discharge to
Community-PAC HH QRP; on August 12-13, 2015, and October 14, 2015, for
the Potentially Preventable 30-Day Post-Discharge Readmission Measure
for HH QRP; and on October 29-30, 2015, for the MSPB-PAC HH QRP
measures. In addition, we released draft quality measure specifications
for public comment on the Drug Regimen Review Conducted with Follow-Up
for Identified Issues-PAC HH QRP from September 18, 2015 to October 6,
2015, for the Discharge to Community-PAC HH QRP from November 9, 2015
to December 8, 2015, for the Potentially Preventable 30-Day Post-
Discharge Readmission Measure for HH QRP from November 2, 2015 to
December 1, 2015, and for the MSPB-PAC HH QRP measures from January 13,
2016 to February 5, 2016. Further, we opened a public mailbox,
[email protected], for the submission of public
comments. This PAC mailbox is accessible on our post-acute care quality
initiatives Web site, on the IMPACT Act of 2014 Data Standardization &
Cross Setting Measures Web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-MeasuresMeasures.html.
Additionally, we sought public input from the MAP Post-Acute Care,
Long-Term Care Workgroup during the annual public meeting held December
14-15, 2015. The MAP is composed of multi-stakeholder groups convened
by the NQF, our current contractor under section 1890(a) of the Act,
tasked to provide input on the selection of quality and efficiency
measures described in section 1890(b)(7)(B) of the Act. The MAP
reviewed each measure proposed in this rule for use in the HH QRP. For
more information on the MAP, we refer readers to the CY 2016 HH PPS
final rule (80 FR 68692 through 68694). Further, for more information
on the MAP's recommendations, we refer readers to the MAP 2015-2016
Considerations for Implementing Measures in Federal Programs public
report at http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx.
For measures that do not have NQF endorsement, or which are not
fully supported by the MAP for use in the HH QRP, we are proposing
measures for the HH QRP for the purposes of satisfying the measure
domains required under the IMPACT Act measures that most closely align
with the national priorities identified in the National Quality
Strategy (http://www.ahrq.gov/workingforquality/) and with respect to
which the MAP supports the measure concept. Further, we discuss below
the importance and high-priority status of
[[Page 43758]]
these proposed measures in the HH setting.
C. Process for Retaining, Removing, and Replacing Previously Adopted
Home Health Quality Reporting Program Measures for Subsequent Payment
Determinations
Consistent with the policies of other provider QRPs, including the
Hospital Inpatient Quality Reporting Program (Hospital IQR) (77 FR
53512 through 53513), the Hospital Outpatient Quality Reporting Program
(Hospital OQR) (77 FR 68471), the LTCH QRP (77 FR 53614 through 53615),
and the IRF QRP (77 FR 68500 through 68507), we are proposing that when
we initially adopt a measure for the HH QRP for a payment
determination, this measure will be automatically retained for all
subsequent payment determinations unless we propose to remove or
replace the measure, or unless the exception discussed below applies.
We are proposing to define the term ``remove'' to mean that the
measure is no longer a part of the HH QRP measure set, data on the
measure will no longer be collected for purposes of the HH QRP, and the
performance data for the measure will no longer be displayed on HH
Compare. We are also proposing to use the following criteria when
considering a quality measure for removal: (1) Measure performance
among HHAs is so high and unvarying that meaningful distinctions in
improvements in performance can no longer be made; (2) performance or
improvement on a measure does not result in better patient outcomes;
(3) a measure does not align with current clinical guidelines or
practice; (4) a more broadly applicable measure (across settings,
populations, or conditions) for the particular topic is available; (5)
a measure that is more proximal in time to desired patient outcomes for
the particular topic is available; and (6) a measure that is more
strongly associated with desired patient outcomes for the particular
topic is available. These items may still appear on OASIS for
previously established purposes that are non-related to our HH QRP.
HHAs will be able to access these reports using the Certification and
Survey Provider Enhanced Reports (CASPER) system and can use the
information for their own monitoring and quality improvement efforts.
Further, we are proposing to define ``replace'' to mean that we
would adopt a different quality measure in place of a currently used
quality measure, for one or more of the reasons described above.
Additionally, we are proposing that any such ``removal'' or
``replacement'' will take place through notice-and-comment rulemaking,
unless we determine that a measure is causing concern for patient
safety. Specifically, in the case of a HH QRP measure for which there
is a reason to believe that the continued collection raises possible
safety concerns or would cause other unintended consequences, we
propose to promptly remove the measure and publish the justification
for the removal in the Federal Register during the next rulemaking
cycle. In addition, we will immediately notify HHAs and the public
through the usual communication channels, including listening session,
memos, email notification, and Web postings. If we removed a measure
under these circumstances, we would also not continue to collect data
on that measure under our alternative authorities for purposes other
than the HH QRP.
We invite public comment on our proposed policy for retaining,
removing and replacing previously adopted quality measures, including
the criteria we propose to use when considering whether to remove a
quality measure from the HH QRP.
D. Quality Measures That Will Be Removed From the Home Health Quality
Initiative, and Quality Measures That Are Proposed for Removal From the
HH QRP Beginning With the CY 2018 Payment Determination
In 2015, we undertook a comprehensive reevaluation of all 81 HH
quality measures, some of which are used only in the Home Health
Quality Initiative (HHQI), and others which are also used in the HH
QRP. This review of all the measures was performed in accordance with
the guidelines from the CMS Measure Management System (MMS) (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MMS-Blueprint.html). The goal of this reevaluation was
to streamline the measure set, consistent with MMS guidance and in
response to stakeholder feedback. This reevaluation included a review
of the current scientific basis for each measure, clinical relevance,
usability for quality improvement, and evaluation of measure
properties, including reportability, and variability. Our measure
development and maintenance contractor convened a Technical Expert
Panel (TEP) on August 21, 2015, to review and advise on the
reevaluation results. The TEP provided feedback on which measures are
most useful for patients, caregivers, clinicians, and stakeholders, and
on analytics and an environmental scan conducted to inform measure set
revisions. Further information about the TEP feedback is available at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Health-Quality-Reporting-Program-HHQRP-TEP-.zip.
As a result of the comprehensive reevaluation described above, we
identified 28 HHQI measures that were either ``topped out'' and/or
determined to be of limited clinical and quality improvement value by
TEP members. Therefore, these measures will no longer be included in
the HHQI. A list of these measures, along with our reasons for no
longer including them in the HHQI, can be found at the following link
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
In addition, based on the results of the comprehensive reevaluation
and the TEP input, we are proposing to remove 6 process measures from
the HH QRP, beginning with the CY 2018 payment determination, because
they are ``topped out'' and therefore no longer have sufficient
variability to distinguish between providers in public reporting. These
6 measures are different than the 28 measures that will no longer be
included within the HHQI. If this proposal is finalized, items used to
calculate one or more of these six measures may still appear on the
OASIS for previously established purposes that are not related to the
HH QRP.
The 6 process measures we are proposing to remove from the HH QRP
are:
Pain Assessment Conducted;
Pain Interventions Implemented During All Episodes of
Care;
Pressure Ulcer Risk Assessment Conducted;
Pressure Ulcer Prevention in Plan of Care;
Pressure Ulcer Prevention Implemented During All Episodes
of Care; and
Heart Failure Symptoms Addressed During All Episodes of
Care.
The technical analysis that supports our proposal to remove the six
process measures can be found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
We invite public comment on our above proposal to remove 6 process
measures from the HH QRP.
E. Proposed Process for Adoption of Updates to HH QRP Measures
We believe that it is important to have in place a sub-regulatory
process to
[[Page 43759]]
incorporate non-substantive updates into the measure specifications so
that these measures remain up-to-date. We also recognize that some
changes are substantive in nature and might not be appropriate for
adoption using a sub-regulatory process.
Therefore, in the FY 2013 IPPS/LTCH PPS final rule (77 FR 53504
through 53505), we finalized a policy for the Hospital IQR Program
under which we use a subregulatory process to make nonsubstantive
updates to measures used for that program. For what constitutes
substantive versus nonsubstantive changes, we make this determination
on a case-by-case basis. Examples of nonsubstantive changes to measures
might include: Updated diagnosis or procedure codes, medication updates
for categories of medications, broadening of age ranges, and exclusions
for a measure. Nonsubstantive changes may also include updates to NQF-
endorsed measures based upon changes to guidelines upon which the
measures are based. Examples of changes that we might consider to be
substantive would be those in which: The changes are so significant
that the measure is no longer the same measure, or when a standard of
performance assessed by a measure becomes more stringent (for example,
changes in acceptable timing of medication, procedure/process, or test
administration). Another example of a substantive change might be where
the NQF has extended its endorsement of a previously endorsed measure
to a new setting, such as extending a measure from the inpatient
setting to hospice.
We are proposing to implement the same process for adopting updates
to measures in the HH QRP, and would apply this process, including our
policy for determining on a case-by-case basis whether an update is
substantive or nonsubstantive. We believe this process adequately
balances our need to incorporate updates to the HH QRP measures in the
most expeditious manner possible while preserving the public's ability
to comment on updates that do not fundamentally change a measure that
it is no longer the same measure that we originally adopted.
We invite public comment on this proposal.
F. Modifications to Guidance Regarding Assessment Data Reporting in the
OASIS
We are proposing modifications to our coding guidance modifications
related to certain pressure ulcer items on the OASIS. In the CY 2016 HH
PPS final rule (80 FR 68700), we adopted the NQF #0678 Percent of
Residents or Patients with Pressure Ulcers that are New or Worsened
(Short Stay) measure for use in the HH QRP for the CY 2018 HH QRP
payment determination and subsequent years. Concurrent with the
effective date for OASIS-C2 of January 1, 2017, we would use modified
guidance for the reporting of current pressure ulcers. The purpose of
this modification is to align with reporting guidance used in other
post-acute care settings and with the policies of relevant clinical
associations. Chapter 3 of the OASIS-C1/ICD-10 Guidance Manual
currently states ``Stage III and IV (full thickness) pressure ulcers
heal through a process of contraction, granulation, and
epithelialization. They can never be considered `fully healed' but they
can be considered closed when they are fully granulated and the wound
surface is covered with new epithelial tissue.'' We utilize
professional organizations, such as the National Pressure Ulcer
Advisory Panel (NPUAP) to provide clinical insight and expertise
related to the use and completion of relevant OASIS items. Based on the
currently published position statements and best practices available
from the NPUAP,\27\ effective January 1, 2017, full-thickness (Stage 3
or 4) pressure ulcers should not be reported on OASIS as unhealed
pressure ulcers once complete re-epithelialization has occurred. This
represents a change in past guidance, and will allow OASIS data
collection to conform to professional clinical guidelines, and align
with pressure ulcer reporting practices in other post-acute care
settings. In addition to revising guidance related to closed Stage 3
and 4 pressure ulcers, we are changing the reporting instructions when
a graft is applied to a pressure ulcer. Current guidance states that
when a graft is placed on a pressure ulcer, the wound remains a
pressure ulcer and is not concurrently reported as a surgical wound on
the OASIS. In order to align with reporting guidance in other post-
acute care settings, effective January 1, 2017, once a graft is applied
to a pressure ulcer, the wound will be reported on OASIS as a surgical
wound, and no longer be reported as a pressure ulcer.
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\27\ http://www.npuap.org/wp-content/uploads/2012/01/Reverse-Staging-Position-Statement.pdf.
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G. Proposed HH QRP Quality, Resource Use, and Other Measures for the CY
2018 Payment Determination and Subsequent Years
For the CY 2018 payment determination and subsequent years, in
addition to the quality measures we would retain if our proposed policy
on retaining measures is finalized, we are proposing to adopt four new
measures. These four measures were developed to meet the requirements
of the IMPACT Act. These proposed measures are:
MSPB-PAC HH QRP;
Discharge to Community-PAC HH QRP;
Potentially Preventable 30-Day Post-Discharge Readmission
Measure for HH QRP; and
Drug Regimen Review Conducted With Follow-Up for
Identified Issues-PAC HH QRP
For the risk-adjustment of the resource use and other measures, we
understand the important role that sociodemographic status plays in the
care of patients. However, we continue to have concerns about holding
agencies to different standards for the outcomes of their patients of
diverse sociodemographic status because we do not want to mask
potential disparities or minimize incentives to improve the outcomes of
disadvantaged populations. We routinely monitor the impact of
sociodemographic status on agencies' results on our measures.
The NQF is currently undertaking a 2-year trial period in which new
measures and measures undergoing maintenance review will be assessed to
determine if risk-adjusting for sociodemographic factors is
appropriate. For 2 years, NQF will conduct a trial of temporarily
allowing inclusion of sociodemographic factors in the risk-adjustment
approach for some performance measures. At the conclusion of the trial,
NQF will issue recommendations on future permanent inclusion of
sociodemographic factors. During the trial, measure developers are
expected to submit information such as analyses and interpretations as
well as performance scores with and without sociodemographic factors in
the risk adjustment model.
Furthermore, the Office of the Assistant Secretary for Planning and
Evaluation (ASPE) is conducting research to examine the impact of
sociodemographic status on quality measures, resource use, and other
measures under the Medicare program as directed by the IMPACT Act. We
will closely examine the findings of the ASPE reports and related
Secretarial recommendations and consider how they apply to our quality
programs at such time as they are available.
We are inviting public comment on how socioeconomic and demographic
factors should be used in risk adjustment for the resource use
measures.
[[Page 43760]]
1. Proposal To Address the IMPACT Act Domain of Resource Use and Other
Measures: MSPB-PAC HH QRP
Section 1899B(d)(1)(A) of the Act requires that no later than the
specified application date (which under section 1899B(a)(1)(E)(ii) is
October 1, 2016 for SNFs, IRFs and LTCHs and January 1, 2017 for HHAs),
the Secretary specify a measure to address the domain of resource use
measures, including total estimated Medicare spending per beneficiary.
We are proposing to adopt the measure, MSPB-PAC HH QRP, for which we
would begin to collect data on January 1, 2017 for the CY 2018 payment
determination and subsequent years as a Medicare fee-for-service (FFS)
claims-based measure to meet this requirement.
Rising Medicare expenditures for post-acute care as well as wide
variation in spending for these services underlines the importance of
measuring resource use for providers rendering these services. Between
2001 and 2013, Medicare PAC spending grew at an average annual rate of
6.1 percent and doubled to $59.4 billion, while payments to inpatient
hospitals grew at an annual rate of 1.7 percent over this same
period.\28\ A study commissioned by the Institute of Medicine found
that variation in PAC spending explains 73 percent of variation in
total Medicare spending across the United States.\29\
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\28\ MedPAC, ``A Data Book: Health Care Spending and the
Medicare Program,'' (2015). 114.
\29\ Institute of Medicine, ``Variation in Health Care Spending:
Target Decision Making, Not Geography,'' (Washington, DC: National
Academies 2013). 2.
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We reviewed the NQF's consensus-endorsed measures and were unable
to identify any NQF-endorsed resource use measures for PAC settings.
Therefore, we are proposing to adopt this MSPB-PAC HH QRP measure under
section 1899B(e)(2)(B) of the Act, which allows us to specify a measure
under section 1899B that is not NQF-endorsed if the measure deals with
a specified area or medical topic the Secretary has determined to be
appropriate for which there is no feasible or practical NQF-endorsed
measure. We recognize that there are other measures that address
Medicare spending per beneficiary, but we are not aware of any such
measures that have been endorsed or adopted specifically for the home
health setting. Given the current lack of resource use measures for PAC
settings, our proposed MSPB-PAC HH QRP measure has the potential to
provide valuable information to HHAs on their relative Medicare
spending in delivering services to approximately 3.5 million Medicare
beneficiaries.\30\
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\30\ Figures for 2013. MedPAC, ``Medicare Payment Policy,''
Report to the Congress (2015). xvii-xviii.
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The proposed MSPB-PAC HH QRP episode-based measure would provide
actionable and transparent information to support HHAs' efforts to
promote care coordination and deliver high quality care at a lower cost
to Medicare. The MSPB-PAC HH QRP measure holds HHAs accountable for the
Medicare payments within an ``episode of care'' (episode), which
includes the period during which a patient is directly under the HHA's
care, as well as a defined period after the end of the HHA treatment,
which may be reflective of and influenced by the services furnished by
the HHA. MSPB-PAC HH QRP episodes, constructed according to the
methodology described below, have high levels of Medicare spending with
substantial variation. In FY 2014, Medicare FFS beneficiaries
experienced 5,379,410 MSPB-PAC HH QRP episodes triggered by admission
to a HHA. The mean payment-standardized, risk-adjusted episode spending
for these episodes was $10,348 during that fiscal year. There was
substantial variation in the Medicare payments for these MSPB-PAC HH
QRP episodes--ranging from approximately $2,480 at the 5th percentile
to approximately $31,964 at the 95th percentile. This variation was
partially driven by variation in payments occurring following HH
treatment.
Evaluating Medicare payments during an episode creates a continuum
of accountability between providers and has the potential to improve
post-treatment care planning and coordination. While some stakeholders
throughout the measure development process supported the MSPB-PAC
measures and believe that measuring Medicare spending is critical for
improving efficiency, others believe that resource use measures do not
reflect quality of care in that they do not take into account patient
outcomes or experience beyond those observable in claims data. However,
we believe that HHAs involved in the provision of high quality PAC care
as well as appropriate discharge planning and post-discharge care
coordination will perform well on this measure because beneficiaries
will experience fewer costly adverse events (for example, avoidable
hospitalizations, infections, and emergency room usage). Further, it is
important that the cost of care be explicitly measured so that, in
conjunction with other quality measures, we can recognize HHAs that are
involved in the provision of high quality care at lower cost.
We have undertaken development of MSPB-PAC measures for each of the
four PAC settings. In addition to this measure proposal, we proposed a
LTCH-specific MSPB-PAC measure in the FY 2017 IPPS/LTCH proposed rule
(81 FR 25216 through 25220), an IRF-specific MSPB-PAC measure in the FY
2017 IRF PPS proposed rule (81 FR 24197 through 24201), and a SNF-
specific MSPB-PAC measure in the FY 2017 SNF PPS proposed rule (81 FR
24258 through 24262). These four setting-specific MSPB-PAC measures are
closely aligned in terms of episode construction and measure
calculation. Each of the MSPB-PAC measures assess Medicare Part A and
Part B spending during an episode, and the numerator and denominator
are defined similarly for each of the MSPB-PAC measures. However,
developing setting-specific measures allows us to account for
differences between settings in payment policy, the types of data
available, and the underlying health characteristics of beneficiaries.
For example, the MSPB-PAC HH QRP measure compares episodes triggered by
Partial Episode Payment (PEP) and Low-Utilization Payment Adjustment
(LUPA) claims only with episodes of the same type, as detailed below.
The MSPB-PAC measures mirror the general construction of the
inpatient prospective payment system (IPPS) hospital MSPB measure,
which was adopted for the Hospital IQR Program beginning with the FY
2014 program, and was implemented in the Hospital VBP Program beginning
with the FY 2015 program. The measure was endorsed by the NQF on
December 6, 2013 (NQF #2158).\31\ The hospital MSPB measure evaluates
hospitals' Medicare spending relative to the Medicare spending for the
national median hospital during a hospital MSPB episode. It assesses
Medicare Part A and Part B payments for services performed by hospitals
and other healthcare providers during a hospital MSPB episode, which
comprises the periods immediately prior to, during, and following a
patient's hospital inpatient stay.32 33 Similarly, the MSPB-
PAC
[[Page 43761]]
measures assess all Medicare Part A and Part B payments for FFS claims
with a start date that begins at the episode trigger and continues for
the length of the episode window (which, as discussed in this section,
is the time period during which Medicare FFS Part A and Part B services
are counted towards the MSPB-PAC HH QRP episode). However, there are
differences between the MSPB-PAC measures, as proposed, and the
hospital MSPB measure that reflect differences in payment policies and
the nature of care provided in each PAC setting. For example, the MSPB-
PAC measures exclude a limited set of services (for example, for
clinically unrelated services) provided to a beneficiary during the
episode window while the hospital MSPB measure does not exclude any
services.\34\
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\31\ QualityNet, ``Measure Methodology Reports: Medicare
Spending Per Beneficiary (MSPB) Measure,'' (2015). http://www.qualitynet.org/dcs/ContentServer?pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228772053996.
\32\ QualityNet, ``Measure Methodology Reports: Medicare
Spending Per Beneficiary (MSPB) Measure,'' (2015). http://www.qualitynet.org/dcs/ContentServer?pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228772053996.
\33\ FY 2012 IPPS/LTCH PPS final rule (76 FR 51619).
\34\ FY 2012 IPPS/LTCH PPS final rule (76 FR 51620).
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MSPB-PAC episodes may begin within 30 days of discharge from an
inpatient hospital as part of a patient's trajectory from an acute to a
PAC setting. A home health episode beginning within 30 days of
discharge from an inpatient hospital will therefore be included: Once
in the hospital's MSPB measure, and once in the HHA's MSPB-PAC measure.
Aligning the hospital MSPB and MSPB-PAC measures in this way creates
continuous accountability and aligns incentives to improve care
planning and coordination across inpatient and PAC settings.
We have sought and considered the input of stakeholders throughout
the measure development process for the MSPB-PAC measures. We convened
a TEP consisting of 12 panelists with combined expertise in all of the
PAC settings on October 29 and 30, 2015, in Baltimore, Maryland. A
follow-up email survey was sent to TEP members on November 18, 2015, to
which 7 responses were received by December 8, 2015. The MSPB-PAC TEP
Summary Report is available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/Technical-Expert-Panel-on-Medicare-Spending-Per-Beneficiary.pdf. The measures were also presented to the MAP Post-Acute
Care/Long-Term Care (PAC/LTC) Workgroup on December 15, 2015. As the
MSPB-PAC measures were under development, there were three voting
options for members: Encourage continued development, do not encourage
further consideration, and insufficient information.\35\ The MAP PAC/
LTC Workgroup voted to ``encourage continued development'' for each of
the MSPB-PAC measures.\36\ The MAP PAC/LTC Workgroup's vote of
``encourage continued development'' was affirmed by the MAP
Coordinating Committee on January 26, 2016.\37\ The MAP's concerns
about the MSPB-PAC measures, as outlined in its final report, ``MAP
2016 Considerations for Implementing Measures in Federal Programs:
Post-Acute Care and Long-Term Care,'' and Spreadsheet of Final
Recommendations were taken into consideration during our measure
development process and are discussed as part of our responses to
public comments we received during the measure development process,
described below.38 39
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\35\ National Quality Forum, Measure Applications Partnership,
``Process and Approach for MAP Pre-Rulemaking Deliberations, 2015-
2016'' (February 2016) http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81693.
\36\ National Quality Forum, Measure Applications Partnership
Post-Acute Care/Long-Term Care Workgroup, ``Meeting Transcript--Day
2 of 2'' (December 15, 2015) 104-106 http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81470.
\37\ National Quality Forum, Measure Applications Partnership,
``Meeting Transcript--Day 1 of 2'' (January 26, 2016) 231-232 http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81637.
\38\ National Quality Forum, Measure Applications Partnership,
``MAP 2016 Considerations for Implementing Measures in Federal
Programs: Post-Acute Care and Long-Term Care'' Final Report,
(February 2016) http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx.
\39\ National Quality Forum, Measure Applications Partnership,
``Spreadsheet of MAP 2016 Final Recommendations'' (February 1, 2016)
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81593.
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Since the MAP's review and recommendation of continued development,
we have continued to refine the risk adjustment model and conduct
measure testing for the proposed MSPB-PAC measures. The proposed MSPB-
PAC measures are both consistent with the information submitted to the
MAP and support the scientific acceptability of these measures for use
in quality reporting programs.
In addition, a public comment period, accompanied by draft measures
specifications, was originally open from January 13 to 27, 2016 and
twice extended to January 29 and February 5. A total of 45 comments on
the MSPB-PAC measures were received during this 3.5 week period. The
comments received also covered each of the MAP's concerns as outlined
in their Final Recommendations.\40\ The MSPB-PAC Public Comment Summary
Report is available https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/2016_03_24_mspb_pac_public_comment_summary_report.pdf and
contains the public comments. If finalized, the proposed MSPB-PAC HH
QRP measure, along with the other MSPB-PAC measures, as applicable,
will be submitted for NQF consideration of endorsement.
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\40\ National Quality Forum, Measure Applications Partnership,
``Spreadsheet of MAP 2016 Final Recommendations'' (February 1, 2016)
http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=81593.
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To calculate the MSPB-PAC HH QRP measure for each HHA, we first
define the construction of the MSPB-PAC HH QRP episode, including the
length of the episode window as well as the services included in the
episode. Next, we apply the methodology for the measure calculation.
The specifications are discussed further in this section. More detailed
specifications for the proposed MSPB-PAC measures, including the MSPB-
PAC HH QRP measure in this proposed rule, are available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/2016_04_06_mspb_pac_measure_specifications_for_rulemaking.pdf.
a. Episode Construction
An MSPB-PAC HH QRP episode begins at the episode trigger, which is
defined as the patient's admission to a HHA. This admitting HHA is the
provider for whom the MSPB-PAC HH QRP measure is calculated (that is,
the attributed provider). The episode window is the time period during
which Medicare FFS Part A and Part B services are counted towards the
MSPB-PAC HH QRP episode. Because Medicare FFS claims are already
reported to the Medicare program for payment purposes, HHAs will not be
required to report any additional data to CMS for calculation of this
measure. Thus, there will be no additional data collection burden from
the implementation of this measure.
Our proposed MSPB-PAC HH QRP episode construction methodology
differentiates between episodes triggered by standard HH claims (for
which there is no PEP or LUPA adjustment) and claims for which PEP and
LUPA adjustments apply, reflecting the HHA PPS payment policy.
Standard, PEP, and LUPA episodes would be compared only with standard,
PEP and LUPA episodes, respectively. Differences in episode
construction
[[Page 43762]]
between these three episode types are noted below; they otherwise share
the same definition.
The episode window is comprised of a treatment period and an
associated services period. For MSPB-PAC HH Standard and LUPA QRP
episodes, the treatment period begins at the trigger (that is, on the
first day of the home health claim) and ends after 60 days. For MSPB-
PAC PEP QRP episodes, the treatment period begins at the trigger (that
is, on the first day of the home health claim) and ends at discharge.
The treatment period includes those services that are provided directly
or reasonably managed by the HHA that are directly related to the
beneficiary's care plan. The associated services period is the time
during which Medicare Part A and Part B services (with certain
exclusions) are counted towards the episode. The associated services
period begins at the episode trigger and ends 30 days after the end of
the treatment period. The distinction between the treatment period and
the associated services period is important because clinical exclusions
of services may differ for each period. Certain services are excluded
from the MSPB-PAC HH QRP episodes because they are clinically unrelated
to HHA care, and/or because HHAs may have limited influence over
certain Medicare services delivered by other providers during the
episode window. These limited service-level exclusions are not counted
towards a given HHA's Medicare spending to ensure that beneficiaries
with certain conditions and complex care needs receive the necessary
care. Certain services that have been determined by clinicians to be
outside of the control of a HHA include: planned hospital admissions,
management of certain preexisting chronic conditions (for example,
dialysis for end-stage renal disease (ESRD), and enzyme treatments for
genetic conditions), treatment for preexisting cancers, organ
transplants, and preventive screenings (for example, colonoscopy and
mammograms). Exclusion of such services from the MSPB-PAC HH QRP
episode ensures that facilities do not have disincentives to treat
patients with certain conditions or complex care needs.
An MSPB-PAC episode may begin during the associated services period
of an MSPB-PAC HH QRP episode in the 30 days post-treatment. One
possible scenario occurs where a HHA discharges a beneficiary who is
then admitted to a SNF within 30 days. The SNF claim would be included
once as an associated service for the attributed provider of the first
MSPB-PAC HH QRP episode and once as a treatment service for the
attributed provider of the second MSPB-PAC SNF episode. As in the case
of overlap between hospital and PAC episodes discussed earlier, this
overlap is necessary to ensure continuous accountability between
providers throughout a beneficiary's trajectory of care, as both
providers share incentives to deliver high quality care at a lower cost
to Medicare. Even within the HH setting, one MSPB-PAC HH QRP episode
may begin in the associated services period of another MSPB-PAC HH QRP
episode in the 30 days post-treatment. The second HH claim would be
included once as an associated service for the attributed HHA of the
first MSPB-PAC HH QRP episode and once as a treatment service for the
attributed HHA of the second MSPB-PAC HH QRP episode. Again, this
ensures that HHAs have the same incentives throughout both MSPB-PAC HH
QRP episodes to deliver quality care and engage in patient-focused care
planning and coordination. If the second MSPB-PAC HH QRP episode were
excluded from the second HHA's MSPB-PAC HH QRP measure, that HHA would
not share the same incentives as the first HHA of the first MSPB-PAC HH
QRP episode. The MSPB-PAC HH QRP measure is designed to benchmark the
resource use of each attributed provider against what their spending is
expected to be as predicted through risk adjustment. As discussed
further below, the measure takes the ratio of observed spending to
expected spending for each episode and then takes the average of those
ratios across all of the attributed provider's episodes. The measure is
not a simple sum of all costs across a provider's episodes, thus
mitigating concerns about double counting.
b. Measure Calculation
Medicare payments for Part A and Part B claims for services
included in MSPB-PAC HH QRP episodes, defined according to the
methodology previously discussed, are used to calculate the MSPB-PAC HH
QRP measure. Measure calculation involves determination of the episode
exclusions, the approach for standardizing payments for geographic
payment differences, the methodology for risk adjustment of episode
spending to account for differences in patient case mix, and the
specifications for the measure numerator and denominator. The measure
calculation is performed separately for MSPB-PAC HH QRP standard, PEP,
and LUPA episodes to ensure that they are compared only to other
standard, PEP, and LUPA episodes, respectively. The final MSPB-PAC HH
QRP measure would combine the three ratios above to construct one HHA
score as described below.
(1) Exclusion Criteria
In addition to service-level exclusions that remove some payments
from individual episodes, we exclude certain episodes in their entirety
from the MSPB-PAC HH QRP measure to ensure that the MSPB-PAC HH QRP
measure accurately reflects resource use and facilitates fair and
meaningful comparisons between HHAs. The proposed episode-level
exclusions are as follows:
Any episode that is triggered by a HH claim outside the 50
states, DC, Puerto Rico, and U.S. territories.
Any episode where the claim(s) constituting the attributed
HHA provider's treatment have a standard allowed amount of zero or
where the standard allowed amount cannot be calculated.
Any episode in which a beneficiary is not enrolled in
Medicare FFS for the entirety of a 90-day lookback period (that is, a
90-day period prior to the episode trigger) plus episode window
(including where a beneficiary dies), or is enrolled in Part C for any
part of the lookback period plus episode window.
Any episode in which a beneficiary has a primary payer
other than Medicare for any part of the 90-day lookback period plus
episode window.
Any episode where the claim(s) constituting the attributed
HHA provider's treatment include at least one related condition code
indicating that it is not a prospective payment system bill.
(2) Standardization and Risk Adjustment
Section 1899B(d)(2)(C) of the Act requires that the MSPB-PAC
measures are adjusted for the factors described under section
1886(o)(2)(B)(ii) of the Act, which include adjustment for factors such
as age, sex, race, severity of illness, and other factors that the
Secretary determines appropriate. Medicare payments included in the
MSPB-PAC HH QRP measure are payment-standardized and risk-adjusted.
Payment standardization removes sources of payment variation not
directly related to clinical decisions and facilitates comparisons of
resource use across geographic areas. We propose to use the same
payment standardization methodology as that used in the NQF-endorsed
hospital MSPB measure. This methodology removes geographic payment
differences, such as wage index and geographic practice cost index
(GPCI), incentive payment adjustments, and
[[Page 43763]]
other add-on payments that support broader Medicare program goals
including indirect graduate medical education (IME) and hospitals
serving a disproportionate share of uninsured patients (DSH).\41\
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\41\ QualityNet, ``CMS Price (Payment) Standardization--Detailed
Methods'' (Revised May 2015) https://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1228772057350.
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Risk adjustment uses patient claims history to account for case-mix
variation and other factors that affect resource use but are beyond the
influence of the attributed HHA. To assist with risk adjustment for
MSPB-PAC HH QRP episodes, we create mutually exclusive and exhaustive
clinical case mix categories using the most recent institutional claim
in the 60 days prior to the start of the MSPB-PAC HH QRP episode. The
beneficiaries in these clinical case mix categories have a greater
degree of clinical similarity than the overall HHA patient population,
and allow us to more accurately estimate Medicare spending. Our
proposed MSPB-PAC HH QRP model, adapted for the HH setting from the
NQF-endorsed hospital MSPB measure, uses a regression framework with a
90-day hierarchical condition category (HCC) lookback period and
covariates including the clinical case mix categories, HCC indicators,
age brackets, indicators for originally disabled, ESRD enrollment, and
long-term care status, and selected interactions of these covariates
where sample size and predictive ability make them appropriate. During
the public comment period that ran from January 13 to February 5, 2016
discussed above, we sought and considered public comment regarding the
treatment of hospice services occurring within the MSPB-PAC HH QRP
episode window. Given the comments received, we propose to include the
Medicare spending for hospice services but risk adjust for them, such
that MSPB-PAC HH QRP episodes with hospice are compared to a benchmark
reflecting other MSPB-PAC HH QRP episodes with hospice. We believe that
this provides a balance between the measure's intent of evaluating
Medicare spending and ensuring that providers do not have incentives
against the appropriate use of hospice services in a patient-centered
continuum of care.
As noted previously, we understand the important role that
sociodemographic status, beyond age, plays in the care of patients.
However, we continue to have concerns about holding providers to
different standards for the outcomes of their patients of diverse
sociodemographic status because we do not want to mask potential
disparities or minimize incentives to improve the outcomes of
disadvantaged populations. We routinely monitor the impact of
sociodemographic status on providers' results on our measures.
The NQF is currently undertaking a 2-year trial period in which new
measures and measures undergoing maintenance review will be assessed to
determine if risk-adjusting for sociodemographic factors is
appropriate. For 2 years, NQF will conduct a trial of temporarily
allowing inclusion of sociodemographic factors in the risk-adjustment
approach for some performance measures. At the conclusion of the trial,
NQF will issue recommendations on future permanent inclusion of
sociodemographic factors. During the trial, measure developers are
expected to submit information such as analyses and interpretations as
well as performance scores with and without sociodemographic factors in
the risk adjustment model.
Furthermore, ASPE is conducting research to examine the impact of
sociodemographic status on quality measures, resource use, and other
measures under the Medicare program as required under the IMPACT Act.
We will closely examine the findings of the ASPE reports and related
Secretarial recommendations and consider how they apply to our quality
programs at such time as they are available.
While we conducted analyses on the impact of age by sex on the
performance of the MSPB-PAC HH QRP risk-adjustment model, we are not
proposing to adjust the MSPB-PAC HH measure for socioeconomic and
demographic factors at this time. As this MSPB-PAC HH QRP measure will
be submitted to the NQF for consideration of endorsement, we prefer to
await the results of this trial and study before deciding whether to
risk adjust for socioeconomic and demographic factors. We will monitor
the results of the trial, studies, and recommendations. We are inviting
public comment on how socioeconomic and demographic factors should be
used in risk adjustment for the MSPB-PAC HH QRP measure.
(3) Measure Numerator and Denominator
The MPSB-PAC HH QRP measure is a payment-standardized, risk-
adjusted ratio that compares a given HHA's Medicare spending against
the Medicare spending of other HHAs within a performance period.
Similar to the hospital MSPB measure, the ratio allows for ease of
comparison over time as it obviates the need to adjust for inflation or
policy changes.
The MSPB-PAC HH QRP measure is calculated as the ratio of the MSPB-
PAC Amount for each HHA divided by the episode-weighted median MSPB-PAC
Amount across all HHAs. To calculate the MSPB-PAC Amount for each HHA,
one calculates the average of the ratio of the standardized spending
for HHA standard episodes over the expected spending (as predicted in
risk adjustment) for HHA standard episodes, the average of the ratio of
the standardized spending for HHA PEP episodes over the expected
spending (as predicted in risk adjustment) for HHA PEP episodes, and
the average of the ratio of the standardized spending for HHA LUPA
episodes over the expected spending (as predicted in risk adjustment)
for HHA LUPA episodes. This quantity is then multiplied by the average
episode spending level across all HHAs nationally for standard, PEP,
and LUPA episodes. The denominator for a HHA's MSPB-PAC HH QRP measure
is the episode-weighted national median of the MSPB-PAC Amounts across
all HHAs. An MSPB-PAC HH QRP measure of less than 1 indicates that a
given HHA's Medicare spending is less than that of the national median
HHA during a performance period. Mathematically, this is represented in
equation (A) below:
[[Page 43764]]
[GRAPHIC] [TIFF OMITTED] TP05JY16.007
Where:
Yij = attributed standardized spending for episode i and
provider j
Yij = expected standardized spending for episode i and
provider j, as predicted from risk adjustment
nj = number of episodes for provider j
n = total number of episodes nationally
i[isin]{Ij{time} = all episodes i in the set of episodes
attributed to provider j.
a. Data Sources
The MSPB-PAC HH QRP resource use measure is an administrative
claims-based measure. It uses Medicare Part A and Part B claims from
FFS beneficiaries and Medicare eligibility files.
b. Cohort
The measure cohort includes Medicare FFS beneficiaries with a HHA
treatment period ending during the data collection period.
c. Reporting
If this proposed measure is finalized, we intend to provide initial
confidential feedback to providers, prior to public reporting of this
measure, based on Medicare FFS claims data from discharges in CY 2016.
We intend to publicly report this measure using claims data from
discharges in CY 2017. We are proposing a minimum of 20 episodes for
reporting and inclusion in the HH QRP. For the reliability calculation,
as described in the measure specifications provided above, we used data
from FY 2014. The reliability results support the 20 episode case
minimum, and 94.27 percent of HHAs had moderate or high reliability
(above 0.4).
We invite public comment on our proposal to adopt the MSPB-PAC HH
QRP measure for the HH QRP.
2. Proposal To Address the IMPACT Act Domain of Resource Use and Other
Measures: Discharge to Community-Post Acute Care Home Health Quality
Reporting Program
Section 1899B(d)(1)(B) of the Act requires that no later than the
specified application date (which under section 1899B(a)(1)(E)(ii) is
October 1, 2016 for SNFs, IRFs and LTCHs and January 1, 2017 for HHAs),
the Secretary specify a measure to address the domain of discharge to
community. We are proposing to adopt the measure, Discharge to
Community--PAC HH QRP for the HH QRP, beginning with the CY 2018
payment determination and subsequent years as a Medicare fee-for-
service (FFS) claims-based measure to meet this requirement.
This proposed measure assesses successful discharge to the
community from a HH setting, with successful discharge to the community
including no unplanned hospitalizations and no deaths in the 31 days
following discharge from the HH agency setting. Specifically, this
proposed measure reports a HHA's risk-standardized rate of Medicare FFS
patients who are discharged to the community following a HH episode, do
not have an unplanned admission to an acute care hospital or LTCH in
the 31 days following discharge to community, and remain alive during
the 31 days following discharge to community. The term ''community,''
for this measure, is defined as home/self-care, without home health
services, based on Patient Discharge Status Codes 01 and 81 on the
Medicare FFS claim.42 43 This measure is specified uniformly
across the PAC settings, in terms of the definition of the discharge to
community outcome, the approach to risk adjustment, and the measure
calculation.
---------------------------------------------------------------------------
\42\ Further description of patient discharge status codes can
be found, for example, at the following Web page: https://med.noridianmedicare.com/web/jea/topics/claim-submission/patient-status-codes.
\43\ This definition is not intended to suggest that board and
care homes, assisted living facilities, or other settings included
in the definition of ``community'' for the purpose of this measure
are the most integrated setting for any particular individual or
group of individuals under the Americans with Disabilities Act (ADA)
and Section 504.
---------------------------------------------------------------------------
Discharge to a community setting is an important health care
outcome for many patients for whom the overall goals of post-acute care
include optimizing functional improvement, returning to a previous
level of independence, and avoiding institutionalization. Returning to
the community is also an important outcome for many patients who are
not expected to make functional improvement during their HH episode and
for patients who may be expected to decline functionally due to their
medical condition. The discharge to community outcome offers a multi-
dimensional view of preparation for community life, including the
cognitive, physical, and psychosocial elements involved in a discharge
to the community.44 45
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\44\ El-Solh AA, Saltzman SK, Ramadan FH, Naughton BJ. Validity
of an artificial neural network in predicting discharge destination
from a post-acute geriatric rehabilitation unit. Archives of
physical medicine and rehabilitation. 2000;81(10):1388-1393.
\45\ Tanwir S, Montgomery K, Chari V, Nesathurai S. Stroke
rehabilitation: Availability of a family member as caregiver and
discharge destination. European journal of physical and
rehabilitation medicine. 2014;50(3):355-362.
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In addition to being an important outcome from a patient and family
perspective, patients discharged to community settings, on average,
incur lower costs over the recovery episode, compared with patients
discharged to institutional settings.46 47 Given the high
costs of care in institutional settings, encouraging post-acute
providers to prepare patients for discharge to community, when
clinically appropriate, may have cost-saving implications for the
Medicare program.\48\ Also, providers have discovered that successful
discharge to the community was a major driver of their ability to
achieve savings, where capitated payments for post-acute care were in
place.\49\ For patients who
[[Page 43765]]
require long-term care due to persistent disability, discharge to
community could result in lower long-term care costs for Medicaid and
for patients' out-of-pocket expenditures.\50\
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\46\ Dobrez D, Heinemann AW, Deutsch A, Manheim L, Mallinson T.
Impact of Medicare's prospective payment system for inpatient
rehabilitation facilities on stroke patient outcomes. American
journal of physical medicine & rehabilitation/Association of
Academic Physiatrists. 2010;89(3):198-204.
\47\ Gage B, Morley M, Spain P, Ingber M. Examining Post Acute
Care Relationships in an Integrated Hospital System Final Report.
RTI International;2009.
\48\ Newcomer RJ, Ko M, Kang T, Harrington C, Hulett D, Bindman
AB. Health Care Expenditures After Initiating Long-term Services and
Supports in the Community Versus in a Nursing Facility. Med Care.
2016 Mar;54(3):221-228.
\49\ Doran JP, Zabinski SJ. Bundled payment initiatives for
Medicare and non-Medicare total joint arthroplasty patients at a
community hospital: bundles in the real world. The Journal of
arthroplasty. 2015;30(3):353-355.
\50\ Newcomer RJ, Ko M, Kang T, Harrington C, Hulett D, Bindman
AB. Health Care Expenditures After Initiating Long-term Services and
Supports in the Community Versus in a Nursing Facility. Med Care.
2016 Jan 12. Epub ahead of print.
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Analyses conducted for ASPE on PAC episodes, using a 5 percent
sample of 2006 Medicare claims, revealed that relatively high average,
unadjusted Medicare payments associated with discharge from IRFs, SNFs,
LTCHs, or HHAs to institutional settings, as compared with payments
associated with discharge from these PAC providers to community
settings.\51\ Average, unadjusted Medicare payments associated with
discharge to community settings ranged from $0 to $4,017 for IRF
discharges; $0 to $3,544 for SNF discharges, $0 to $4,706 for LTCH
discharges, and $0 to $992 for HHA discharges. In contrast, payments
associated with discharge to non-community settings were considerably
higher, ranging from $11,847 to $25,364 for IRF discharges, $9,305 to
$29,118 for SNF discharges, $12,465 to $18,205 for LTCH discharges, and
$7,981 to $35,192 for HHA discharges.\52\
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\51\ Gage B, Morley M, Spain P, Ingber M. Examining Post Acute
Care Relationships in an Integrated Hospital System. Final Report.
RTI International;2009.
\52\ Ibid.
---------------------------------------------------------------------------
Measuring and comparing agency-level discharge to community rates
is expected to help differentiate among agencies with varying
performance in this important domain, and to help avoid disparities in
care across patient groups. Variation in discharge to community rates
has been reported within and across post-acute settings, across a
variety of facility-level characteristics such as geographic location
(for example, regional location, urban or rural location), ownership
(for example, for-profit or nonprofit), freestanding or hospital-based
units, and across patient-level characteristics such as race and
gender.53 54 55 56 57 58 In the HH Medicare FFS population,
using CY 2013 national claims data, we found that approximately 82
percent of episodes ended with a discharge to the community. A multi-
center study of 23 LTCHs demonstrated that 28.8 percent of 1,061
patients who were ventilator-dependent on admission were discharged to
home.\59\ A single-center study revealed that 31 percent of LTCH
hemodialysis patients were discharged to home.\60\ One study noted that
64 percent of beneficiaries who were discharged from the home health
episode did not use any other acute or post-acute services paid by
Medicare in the 30 days after discharge \61\ and a second study noted
that between 58 percent and 63 percent of beneficiates were discharged
to home with rates varying by admission site.\62\ However, significant
numbers of patients were admitted to hospitals (29 percent) and lesser
numbers to SNFs (7.6 percent), IRFs (1.5 percent), home health (7.2
percent) or hospice (3.3 percent).\63\
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\53\ Reistetter TA, Karmarkar AM, Graham JE, et al. Regional
variation in stroke rehabilitation outcomes. Archives of physical
medicine and rehabilitation. 2014;95(1):29-38.
\54\ El-Solh AA, Saltzman SK, Ramadan FH, Naughton BJ. Validity
of an artificial neural network in predicting discharge destination
from a post-acute geriatric rehabilitation unit. Archives of
physical medicine and rehabilitation. 2000;81(10):1388-1393.
\55\ March 2015 Report to the Congress: Medicare Payment Policy.
Medicare Payment Advisory Commission;2015.
\56\ Bhandari VK, Kushel M, Price L, Schillinger D. Racial
disparities in outcomes of inpatient stroke rehabilitation. Archives
of physical medicine and rehabilitation. 2005;86(11):2081-2086.
\57\ Chang PF, Ostir GV, Kuo YF, Granger CV, Ottenbacher KJ.
Ethnic differences in discharge destination among older patients
with traumatic brain injury. Archives of physical medicine and
rehabilitation. 2008;89(2):231-236.
\58\ Berges IM, Kuo YF, Ostir GV, Granger CV, Graham JE,
Ottenbacher KJ. Gender and ethnic differences in rehabilitation
outcomes after hip-replacement surgery. American journal of physical
medicine & rehabilitation/Association of Academic Physiatrists.
2008;87(7):567-572.
\59\ Scheinhorn DJ, Hassenpflug MS, Votto JJ, et al. Post-ICU
mechanical ventilation at 23 long-term care hospitals: a multicenter
outcomes study. Chest. 2007;131(1):85-93.
\60\ Thakar CV, Quate-Operacz M, Leonard AC, Eckman MH. Outcomes
of hemodialysis patients in a long-term care hospital setting: a
single-center study. American journal of kidney diseases: the
official journal of the National Kidney Foundation. 2010;55(2):300-
306.
\61\ Wolff JL, Meadow A, Weiss CO, Boyd CM, Leff B. Medicare
home health patients' transitions through acute and post-acute care
settings. Medical care. 2008;46(11):1188-1193.
\62\ Riggs JS, Madigan EA. Describing Variation in Home Health
Care Episodes for Patients with Heart Failure. Home Health Care
Management & Practice 2012; 24(3) 146-152.
\63\ Ibid.
---------------------------------------------------------------------------
Discharge to community is an actionable health care outcome, as
targeted interventions have been shown to successfully increase
discharge to community rates in a variety of post-acute
settings.64 65 66 67 68 Many of these interventions involve
discharge planning or specific rehabilitation strategies, such as
addressing discharge barriers and improving medical and functional
status.69 70 71 72 73 The effectiveness of these
interventions suggests that improvement in discharge to community rates
among post-acute care patients is possible through modifying provider-
led processes and interventions.
---------------------------------------------------------------------------
\64\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating Siebens
Domain Management Model for Inpatient Rehabilitation to Increase
Functional Independence and Discharge Rate to Home in Geriatric
Patients. Archives of physical medicine and rehabilitation.
2015;96(7):1310-1318.
\65\ Wodchis WP, Teare GF, Naglie G, et al. Skilled nursing
facility rehabilitation and discharge to home after stroke. Archives
of physical medicine and rehabilitation. 2005;86(3):442-448.
\66\ Berkowitz RE, Jones RN, Rieder R, et al. Improving
disposition outcomes for patients in a geriatric skilled nursing
facility. Journal of the American Geriatrics Society.
2011;59(6):1130-1136.
\67\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating use of
the Siebens Domain Management Model during inpatient rehabilitation
to increase functional independence and discharge rate to home in
stroke patients. PM & R: the journal of injury, function, and
rehabilitation. 2015;7(4):354-364.
\68\ Parker, E., Zimmerman, S., Rodriguez, S., & Lee, T.
Exploring best practices in home health care: a review of available
evidence on select innovations. Home Health Care Management and
Practice, 2014; 26(1): 17-33.
\69\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating Siebens
Domain Management Model for Inpatient Rehabilitation to Increase
Functional Independence and Discharge Rate to Home in Geriatric
Patients. Archives of physical medicine and rehabilitation.
2015;96(7):1310-1318.
\70\ Wodchis WP, Teare GF, Naglie G, et al. Skilled nursing
facility rehabilitation and discharge to home after stroke. Archives
of physical medicine and rehabilitation. 2005;86(3):442-448.
\71\ Berkowitz RE, Jones RN, Rieder R, et al. Improving
disposition outcomes for patients in a geriatric skilled nursing
facility. Journal of the American Geriatrics Society.
2011;59(6):1130-1136.
\72\ Kushner DS, Peters KM, Johnson-Greene D. Evaluating use of
the Siebens Domain Management Model during inpatient rehabilitation
to increase functional independence and discharge rate to home in
stroke patients. PM & R: the journal of injury, function, and
rehabilitation. 2015;7(4):354-364.
\73\ Parker, E., Zimmerman, S., Rodriguez, S., & Lee, T.
Exploring best practices in home health care: a review of available
evidence on select innovations. Home Health Care Management and
Practice, 2014; 26(1): 17-33.
---------------------------------------------------------------------------
A TEP convened by our measure development contractor was strongly
supportive of the importance of measuring discharge to community
outcomes, and implementing the proposed measure, Discharge to
Community-PAC HH QRP into the HH QRP. The panel provided input on the
technical specifications of this proposed measure, including the
feasibility of implementing the measure, as well as the overall measure
reliability and validity. A summary of the TEP proceedings is available
on the PAC Quality Initiatives Downloads and Videos Web page at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
[[Page 43766]]
We also solicited stakeholder feedback on the development of this
measure through a public comment period held from November 9, 2015
through December 8, 2015. Several stakeholders and organizations,
including the MedPAC, among others, supported this measure for
implementation. The public comment summary report for the proposed
measure is available on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
The NQF-convened MAP met on December 14 and 15, 2015, and provided
input on the use of this proposed Discharge to Community-PAC HH QRP
measure in the HH QRP. The MAP encouraged continued development of the
proposed measure to meet the mandate of the IMPACT Act. The MAP
supported the alignment of this proposed measure across PAC settings,
using standardized claims data. More information about the MAP's
recommendations for this measure is available at http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx.
Since the MAP review the measure and recommended continued
development, we have continued to refine the risk adjustment model and
conduct measure testing for this measure. This proposed measure is
consistent with the information submitted to the MAP and is
scientifically acceptable for current specification in the HH QRP.
We reviewed the NQF's consensus-endorsed measures and were unable
to identify any NQF-endorsed resource use or other measures for post-
acute care focused on discharge to the community. In addition, we are
unaware of any other post-acute care measures for discharge to
community that have been endorsed or adopted by other consensus
organizations. Therefore, we are proposing the measure, Discharge to
Community-PAC HH QRP, under the Secretary's authority to specify non-
NQF-endorsed measures under section 1899B(e)(2)(B) of the Act.
We are proposing to use data from the Medicare FFS claims and
Medicare eligibility files to calculate this proposed measure. We are
proposing to use data from the ``Patient Discharge Status Code'' on
Medicare FFS claims to determine whether a patient was discharged to a
community setting for calculation of this proposed measure. In all PAC
settings, we tested the accuracy of determining discharge to a
community setting using the ``Patient Discharge Status Code'' on the
PAC claim by examining whether discharge to community coding based on
PAC claim data agreed with discharge to community coding based on PAC
assessment data. We found excellent agreement between the two data
sources in all PAC settings, ranging from 94.6 percent to 98.8 percent.
Specifically, in the HH setting, using 2013 data, we found 97 percent
agreement in discharge to community codes when comparing ``Patient
Discharge Status Code'' from claims and Discharge Disposition (M2420)
and Inpatient Facility (M2410) on the OASIS C discharge assessment,
when the claims and OASIS assessment had the same discharge date. We
further examined the accuracy of ``Patient Discharge Status Code'' on
the PAC claim by assessing how frequently discharges to an acute care
hospital were confirmed by follow-up acute care claims. We found that
50 percent of HH claims with acute care discharge status codes were
followed by an acute care claim in the 31 days after HH discharge. We
believe these data support the use of the ``Patient Discharge Status
Code'' for determining discharge to a community setting for this
measure. In addition, the proposed measure has high feasibility because
all data used for measure calculation are derived from Medicare FFS
claims and eligibility files, which are already available to us.
Based on the evidence discussed above, we are proposing to adopt
the measure entitled, ``Discharge to Community-PAC HH QRP'', for the HH
QRP for the CY 2018 payment determination and subsequent years. This
proposed measure is calculated utilizing 2 years of data as defined
below. We are proposing a minimum of 20 eligible episodes in a given
HHA for public reporting of the proposed measure for that HHA. Since
Medicare FFS claims data are already reported to the Medicare program
for payment purposes, and Medicare eligibility files are also
available, HHAs will not be required to report any additional data to
CMS for calculation of this measure. The proposed measure denominator
is the risk-adjusted expected number of discharges to community. The
proposed measure numerator is the risk-adjusted estimate of the number
of home health patients who are discharged to the community, do not
have an unplanned readmission to an acute care hospital or LTCH in the
31-day post-discharge observation window, and who remain alive during
the post-discharge observation window. The measure is risk-adjusted for
variables such as age and sex, principal diagnosis, comorbidities, and
ESRD status among other variables. For technical information about this
proposed measure, including information about the measure calculation,
risk adjustment, and denominator exclusions, we refer readers the
document titled Proposed Measure Specifications for Measures Proposed
in the CY 2017 HH QRP proposed rule, available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
If this proposed measure is finalized, we intend to provide initial
confidential feedback to home health agencies, prior to the public
reporting of this measure, based on Medicare FFS claims data from
discharges in CYs 2015 and 2016. We intend to publicly report this
measure using claims data from discharges in CYs 2016 and 2017. We plan
to submit this proposed measure to the NQF for consideration for
endorsement.
We invite public comment on our proposal to adopt the measure,
Discharge to Community--PAC HH QRP for the HH QRP.
3. Proposal To Address the IMPACT Act Domain of Resource Use and Other
Measures: Potentially Preventable 30-Day Post-Discharge Readmission
Measure for Post-Acute Care Home Health Quality Reporting Program
Section 1899B(d)(1)(C) of the Act requires that no later than the
specified application date (which under section 1899B(a)(1)(E)(ii) is
October 1, 2016 for SNFs, IRFs and LTCHs and January 1, 2017 for HHAs),
the Secretary specify measures to address the domain of all-condition
risk-adjusted potentially preventable hospital readmission rates. We
are proposing the measure Potentially Preventable 30-Day Post-Discharge
Readmission Measure for HH QRP as a Medicare FFS claims-based measure
to meet this requirement beginning with the CY 2018 payment
determination.
The proposed measure assesses the facility-level risk-standardized
rate of unplanned, potentially preventable hospital readmissions for
Medicare FFS beneficiaries that take place within 30 days of a HH
discharge. The HH admission must have occurred within up to 30 days of
discharge from a prior proximal hospital stay, which is defined as an
inpatient admission to an acute care hospital (including IPPS, CAH, or
a psychiatric hospital). Hospital
[[Page 43767]]
readmissions include readmissions to a short-stay acute-care hospital
or a LTCH, with a diagnosis considered to be unplanned and potentially
preventable. This proposed measure is claims-based, requiring no
additional data collection or submission burden for HHAs. Because the
measure denominator is based on HH admissions, each Medicare
beneficiary may be included in the measure multiple times within the
measurement period. Readmissions counted in this measure are identified
by examining Medicare FFS claims data for readmissions to either acute
care hospitals (IPPS or CAH) or LTCHs that occur during a 30-day window
beginning two days after HH discharge. This measure is conceptualized
uniformly across the PAC settings, in terms of the measure definition,
the approach to risk adjustment, and the measure calculation. Our
approach for defining potentially preventable hospital readmissions is
described in more detail below.
Hospital readmissions among the Medicare population, including
beneficiaries that utilize PAC, are common, costly, and often
preventable.74 75 The MedPAC estimated that 17 to 20 percent
of Medicare beneficiaries discharged from the hospital were readmitted
within 30 days. MedPAC found that more than 75 percent of 30-day and
15-day readmissions and 84 percent of 7-day readmissions were
considered ``potentially preventable.'' \76\ In addition, MedPAC
calculated that annual Medicare spending on potentially preventable
readmissions would be $12 billion for 30-day, $8 billion for 15-day,
and $5 billion for 7-day readmissions.\77\ For hospital readmissions
from one post-acute care setting, SNFs, MedPAC deemed 76 percent of
these readmissions as ``potentially avoidable''--associated with $12
billion in Medicare expenditures.\78\ Mor et al. analyzed 2006 Medicare
claims and SNF assessment data (Minimum Data Set), and reported a 23.5
percent readmission rate from SNFs, associated with $4.3 billion in
expenditures.\79\ An analysis of data from a nationally representative
sample of Medicare FFS beneficiaries receiving home health services in
2004 show that home health patients receive significant amounts of
acute and post-acute services after discharge from home health care.
Within 30 days of discharge from home health, 29 percent of patients
were admitted to a hospital.\80\ Focusing on readmissions, Madigan and
colleagues studied 74,580 Medicare home health patients with a
rehospitalization within 30 days of the index hospital discharge. The
30-day rehospitalization rate was 26 percent with the largest
proportion related to a cardiac-related diagnosis (42 percent).\81\
Fewer studies have investigated potentially preventable readmission
rates from other post-acute care settings.
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\74\ Friedman, B., and Basu, J.: The rate and cost of hospital
readmissions for preventable conditions. Med. Care Res. Rev.
61(2):225-240, 2004. doi:10.1177/1077558704263799.
\75\ Jencks, S.F., Williams, M.V., and Coleman, E.A.:
Rehospitalizations among patients in the Medicare Fee-for-Service
Program. N. Engl. J. Med. 360(14):1418-1428, 2009. doi:10.1016/
j.jvs.2009.05.045
\76\ MedPAC: Payment policy for inpatient readmissions, in
Report to the Congress: Promoting Greater Efficiency in Medicare.
Washington, DC, pp. 103-120, 2007. Available from http://www.medpac.gov/documents/reports/Jun07_EntireReport.pdf.
\77\ ibid.
\78\ ibid.
\79\ Mor, V., Intrator, O., Feng, Z., et al. The revolving door
of rehospitalization from skilled nursing facilities. Health Aff.
29(1):57-64, 2010. doi:10.1377/hlthaff.2009.0629.
\80\ Wolff, J. L., Meadow, A., Weiss, C.O., Boyd, C.M., Leff, B.
Medicare Home Health Patients' Transitions Through Acute And Post-
Acute Care Settings.'' Medicare Care 11(46) 2008; 1188-1193.
\81\ Madigan, E. A., N. H. Gordon, et al. ``Rehospitalization in
a national population of home health care patients with heart
failure.'' Health Serv Res 47(6): 2013; 2316-2338.
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We have addressed the high rates of hospital readmissions in the
acute care setting as well as in PAC. For example, we developed the
following measure: Rehospitalization During the First 30 Days of Home
Health (NQF #2380), as well as similar measures for other PAC providers
(NQF #2502 for IRFs, NQF #2510 for SNFs NQF #2512 for LTCHs).\82\ These
measures are endorsed by the NQF, and the NQF-endorsed measure (NQF
#2380) was adopted into the HH QRP in the CY 2014 HH PPS final rule (80
FR 68691 through 68692). Note that these NQF-endorsed measures assess
all-cause unplanned readmissions.
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\82\ National Quality Forum: All-Cause Admissions and
Readmissions Measures. pp. 1-319, April 2015. Available from http://www.qualityforum.org/Publications/2015/04/All-Cause_Admissions_and_Readmissions_Measures_-_Final_Report.aspx.
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Several general methods and algorithms have been developed to
assess potentially avoidable or preventable hospitalizations and
readmissions for the Medicare population. These include the Agency for
Healthcare Research and Quality's (AHRQ's) Prevention Quality
Indicators, approaches developed by MedPAC, and proprietary approaches,
such as the 3M\TM\ algorithm for Potentially Preventable
Readmissions.83 84 85 Recent work led by Kramer et al. for
MedPAC identified 13 conditions for which readmissions were deemed as
potentially preventable among SNF and IRF populations.86 87
Although much of the existing literature addresses hospital
readmissions more broadly and potentially avoidable hospitalizations
for specific settings like long-term care, these findings are relevant
to the development of potentially preventable readmission measures for
PAC.88 89 90
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\83\ Goldfield, N.I., McCullough, E.C., Hughes, J.S., et al.
Identifying potentially preventable readmissions. Health Care Finan.
Rev. 30(1):75-91, 2008. Available from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195042/.
\84\ National Quality Forum: Prevention Quality Indicators
Overview. 2008.
\85\ MedPAC: Online Appendix C: Medicare Ambulatory Care
Indicators for the Elderly. pp. 1-12, prepared for Chapter 4, 2011.
Available from http://www.medpac.gov/documents/reports/Mar11_Ch04_APPENDIX.pdf?sfvrsn=0.
\86\ Kramer, A., Lin, M., Fish, R., et al. Development of
Inpatient Rehabilitation Facility Quality Measures: Potentially
Avoidable Readmissions, Community Discharge, and Functional
Improvement. pp. 1-42, 2015. Available from http://www.medpac.gov/documents/contractor-reports/development-of-inpatient-rehabilitation-facility-quality-measures-potentially-avoidable-readmissions-community-discharge-and-functional-improvement.pdf?sfvrsn=0.
\87\ Kramer, A., Lin, M., Fish, R., et al. Development of
Potentially Avoidable Readmission and Functional Outcome SNF Quality
Measures. pp. 1-75, 2014. Available from http://www.medpac.gov/documents/contractor-reports/mar14_snfqualitymeasures_contractor.pdf?sfvrsn=0.
\88\ Allaudeen, N., Vidyarthi, A., Maselli, J., et al.
Redefining readmission risk factors for general medicine patients.
J. Hosp. Med. 6(2):54-60, 2011. doi:10.1002/jhm.805.
\89\ Gao, J., Moran, E., Li, Y.-F., et al. Predicting
potentially avoidable hospitalizations. Med. Care 52(2):164-171,
2014. doi:10.1097/MLR.0000000000000041.
\90\ Walsh, E.G., Wiener, J.M., Haber, S., et al. Potentially
avoidable hospitalizations of dually eligible Medicare and Medicaid
beneficiaries from nursing facility and home[hyphen]and
community[hyphen]based services waiver programs. J. Am. Geriatr.
Soc. 60(5):821-829, 2012. doi:10.1111/j.1532-5415.2012.03920.
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Potentially Preventable Readmission Measure Definition: We
conducted a comprehensive environmental scan, analyzed claims data, and
obtained input from a TEP to develop a definition and list of
conditions for which hospital readmissions are potentially preventable.
The Ambulatory Care Sensitive Conditions and Prevention Quality
Indicators, developed by AHRQ, served as the starting point in this
work. For patients in the 30-day post-PAC discharge period, a
potentially preventable readmission refers to a readmission for which
the probability of occurrence could be minimized with adequately
planned, explained, and implemented post discharge instructions,
including the establishment of appropriate follow-up ambulatory care.
Our list of PPR
[[Page 43768]]
conditions is categorized by 3 clinical rationale groupings:
Inadequate management of chronic conditions;
Inadequate management of infections; and
Inadequate management of other unplanned events
Additional details regarding the definition for potentially
preventable readmissions are available in the document titled Proposed
Measure Specifications for Measures Proposed in the CY 2017 HH QRP
proposed rule available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
This proposed measure focuses on readmissions that are potentially
preventable and also unplanned. Similar to the Rehospitalization During
the First 30 Days of Home Health measure (NQF #2380), this proposed
measure uses the current version of the CMS Planned Readmission
Algorithm as the main component for identifying planned readmissions. A
complete description of the CMS Planned Readmission Algorithm, which
includes lists of planned diagnoses and procedures, can be found on the
CMS Web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html. In addition to the CMS Planned Readmission Algorithm,
this proposed measure incorporates procedures that are considered
planned in post-acute care settings, as identified in consultation with
TEPs. Full details on the planned readmissions criteria used, including
the CMS Planned Readmission Algorithm and additional procedures
considered planned for post-acute care, can be found in the document
titled Proposed Measure Specifications for Measures Proposed in the CY
2017 HH QRP proposed rule available at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
The proposed measure, Potentially Preventable 30-Day Post-Discharge
Readmission Measure for HH QRP, assesses potentially preventable
readmission rates while accounting for patient demographics, principal
diagnosis in the prior hospital stay, comorbidities, and other patient
factors. While estimating the predictive power of patient
characteristics, the model also estimates an agency-specific effect,
common to patients treated in each agency. This proposed measure is
calculated for each HHA based on the ratio of the predicted number of
risk-adjusted, unplanned, potentially preventable hospital readmissions
that occur within 30 days after an HH discharge, including the
estimated agency effect, to the estimated predicted number of risk-
adjusted, unplanned hospital readmissions for the same patients treated
at the average HHA. A ratio above 1.0 indicates a higher than expected
readmission rate (worse), while a ratio below 1.0 indicates a lower
than expected readmission rate (better). This ratio is referred to as
the standardized risk ratio (SRR). The SRR is then multiplied by the
overall national raw rate of potentially preventable readmissions for
all HH episodes. The resulting rate is the risk-standardized
readmission rate (RSRR) of potentially preventable readmissions.
An eligible HH episode is followed until: (1) The 30-day post-
discharge period ends; or (2) the patient is readmitted to an acute
care hospital (IPPS or CAH) or LTCH. If the readmission is unplanned
and potentially preventable, it is counted as a readmission in the
measure calculation. If the readmission is planned, the readmission is
not counted in the measure rate.
This measure is risk adjusted. The risk adjustment modeling
estimates the effects of patient characteristics, comorbidities, and
select health care variables on the probability of readmission. More
specifically, the risk-adjustment model for HHAs accounts for
demographic characteristics (age, sex, original reason for Medicare
entitlement), principal diagnosis during the prior proximal hospital
stay, body system specific surgical indicators, comorbidities, length
of stay during the patient's prior proximal hospital stay, intensive
care and coronary care unit (ICU and CCU) utilization, ESRD status, and
number of acute care hospitalizations in the preceding 365 days.
The proposed measure is calculated using 3 consecutive calendar
years of FFS data, in order to ensure the statistical reliability of
this measure for smaller agencies. In addition, we are proposing a
minimum of 20 eligible episodes for public reporting of the proposed
measure. For technical information about this proposed measure
including information about the measure calculation, risk adjustment,
and exclusions, we refer readers to our Proposed Measure Specifications
for Measures Proposed in the CY 2017 HH QRP proposed rule at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
A TEP convened by our measure contractor provided recommendations
on the technical specifications of this proposed measure, including the
development of an approach to define potentially preventable hospital
readmission for PAC. Details from the TEP meetings, including TEP
members' ratings of conditions proposed as being potentially
preventable, are available in the TEP summary report available on the
CMS Web site at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html. We also
solicited stakeholder feedback on the development of this measure
through a public comment period held from November 2 through December
1, 2015. Comments on the measure varied, with some commenters
supportive of the proposed measure, while others either were not in
favor of the measure, or suggested potential modifications to the
measure specifications, such as including standardized function data. A
summary of the public comments is also available on the CMS Web site at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
The NQF-convened MAP encouraged continued development of the
proposed measure. Specifically, the MAP stressed the need to promote
shared accountability and ensure effective care transitions. More
information about the MAP's recommendations for this measure is
available at http://www.qualityforum.org/Publications/2016/02/MAP_2016_Considerations_for_Implementing_Measures_in_Federal_Programs_-_PAC-LTC.aspx.
At the time of the MAP, the risk-adjustment model was still under
development. Following completion of that development work, we were
able to test for measure validity and reliability as identified in the
measure specifications document provided above. Testing results are
within range for similar outcome measures finalized in public reporting
and value-based purchasing programs, including the Rehospitalization
During the First 30 Days of Home Health Measure (NQF #2380) adopted
into the HH QRP.
We reviewed the NQF's consensus endorsed measures and were unable
to identify any NQF-endorsed measures focused on potentially
preventable
[[Page 43769]]
hospital readmissions. We are unaware of any other measures for this
IMPACT Act domain that have been endorsed or adopted by other consensus
organizations. Therefore, we are proposing the Potentially Preventable
30-Day Post-Discharge Readmission Measure for HH QRP under the
Secretary's authority to specify non-NQF-endorsed measures under
section 1899B(e)(2)(B) of the Act, for the HH QRP for the CY 2018
payment determination and subsequent years given the evidence
previously discussed above.
We plan to submit the proposed measure to the NQF for consideration
of endorsement. If this proposed measure is finalized, we intend to
provide initial confidential feedback to providers, prior to public
reporting of this proposed measure, based on 3 calendar years of claims
data from discharges in CYs 2014, 2015 and 2016. We intend to publicly
report this proposed measure using claims data from CYs 2015, 2016 and
2017.
We are inviting public comment on our proposal to adopt the
measure, Potentially Preventable 30-Day Post-Discharge Readmission
Measure for HH QRP.
4. Proposal To Address the IMPACT Act Domain of Medication
Reconciliation: Drug Regimen Review Conducted With Follow-Up for
Identified Issues--Post-Acute Care Home Health Quality Reporting
Program
Section 1899B(c)(1)(C) of the Act requires that no later than the
specified application date (which under section 1899B(a)(1)(E)(i) is
October 1, 2018 for SNFs, IRFs and LTCHs and January 1, 2017 for HHAs),
the Secretary specify quality measures to address the domain of
medication reconciliation. We are proposing to adopt the quality
measure, Drug Regimen Review Conducted with Follow-Up for Identified
Issues--PAC HH QRP for the HH QRP as a patient-assessment based, cross-
setting quality measure to meet this requirement with data collection
beginning January 1, 2017, beginning with the CY 2018 payment
determination.
This proposed measure assesses whether PAC providers were
responsive to potential or actual clinically significant medication
issue(s) when such issues were identified. Specifically, the proposed
quality measure reports the percentage of patient episodes in which a
drug regimen review was conducted at the start of care or resumption of
care and timely follow-up with a physician occurred each time potential
clinically significant medication issues were identified throughout
that episode. For this proposed quality measure, a drug regimen review
is defined as the review of all medications or drugs the patient is
taking in order to identify potential clinically significant medication
issues. This proposed quality measure utilizes both the processes of
medication reconciliation and a drug regimen review in the event an
actual or potential medication issue occurred. The proposed measure
informs whether the PAC agency identified and addressed each clinically
significant medication issue and if the agency responded or addressed
the medication issue in a timely manner. Of note, drug regimen review
in PAC settings is generally considered to include medication
reconciliation and review of the patient's drug regimen to identify
potential clinically significant medication issues.\91\ This measure is
applied uniformly across the PAC settings.
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\91\ Institute of Medicine. Preventing Medication Errors.
Washington, DC: National Academies Press; 2006.
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Medication reconciliation is a process of reviewing an individual's
complete and current medication list. Medication reconciliation is a
recognized process for reducing the occurrence of medication
discrepancies that may lead to Adverse Drug Events (ADEs). Medication
discrepancies occur when there is conflicting information documented in
the medical records.
The World Health Organization regards medication reconciliation as
a standard operating protocol necessary to reduce the potential for
ADEs that cause harm to patients. Medication reconciliation is an
important patient safety process that addresses medication accuracy
during transitions in patient care and in identifying preventable
ADEs.\92\ The Joint Commission added medication reconciliation to its
list of National Patient Safety Goals (2005), suggesting that
medication reconciliation is an integral component of medication
safety.\93\ The Society of Hospital Medicine published a statement in
agreement of the Joint Commission's emphasis and value of medication
reconciliation as a patient safety goal.\94\ There is universal
agreement that medication reconciliation directly addresses patient
safety issues that can result from medication miscommunication and
unavailable or incorrect information.95 96 97 98
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\92\ Leotsakos A., et al. Standardization in patient safety: The
WHO High 5s project. Int J Qual Health Care. 2014:26(2):109-116.
\93\ The Joint Commission. 2016 Long Term Care: National Patient
Safety Goals Medicare/Medicaid Certification-based Option.
(NPSG.03.06.01).
\94\ Greenwald, J.L., Halasyamani, L., Greene, J., LaCivita, C.,
et al. (2010). Making inpatient medication reconciliation patient
centered, clinically relevant and implementable: A consensus
statement on key principles and necessary first steps. Journal of
Hospital Medicine, 5(8), 477-485.
\95\ IHI. Medication Reconciliation to Prevent Adverse Drug
Events [Internet]. Cambridge, MA: Institute for Healthcare
Improvement; [cited 2016 Jan 11]. Available from: http://www.ihi.org/topics/adesmedicationreconciliation/Pages/default.aspx.
Leotsakos A., et al. Standardization in patient safety: The WHO High
5s project. Int J Qual Health Care. 2014:26(2):109-116.
\96\ The Joint Commission. 2016 Long Term Care: National Patient
Safety Goals Medicare/Medicaid Certification-based Option.
(NPSG.03.06.01).
\97\ Greenwald, J.L., Halasyamani, L., Greene, J., LaCivita, C.,
et al. (2010). Making inpatient medication reconciliation patient
centered, clinically relevant and implementable: A consensus
statement on key principles and necessary first steps. Journal of
Hospital Medicine, 5(8), 477-485.
\98\ The Joint Commission. 2016 Long Term Care: National Patient
Safety Goals Medicare/Medicaid Certification-based Option.
(NPSG.03.06.01).
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The performance of timely medication reconciliation is valuable to
the process of drug regimen review. Preventing and responding to ADEs
is of critical importance as ADEs account for significant increases in
health services utilization and costs,99 100 including
subsequent emergency room visits and re-hospitalizations. ADEs are
associated with an estimated $3.5 billion in annual health care costs
and 7,000 deaths annually.\101\
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\99\ Jha A.K., Kuperman G.J., Rittenberg E., et al. Identifying
hospital admissions due to adverse drug events using a computer-
based monitor. Pharmacoepidemiol Drug Saf. 2001;10(2):113-119.
\100\ Hohl C.M., Nosyk B., Kuramoto L., et al. Outcomes of
emergency department patients presenting with adverse drug events.
Ann Emerg Med. 2011;58:270-279.
\101\ Kohn L.T., Corrigan J.M., Donaldson M.S., ``To Err Is
Human: Building a Safer Health System,'' National Academies Press,
Washington, DC 1999
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Medication errors include the duplication of medications, delivery
of an incorrect drug, inappropriate drug omissions, or errors in the
dosage, route, frequency, and duration of medications. Medication
errors are one of the most common types of medical error and can occur
at any point in the process of ordering and delivering a medication.
Medication errors have the potential to result in an
ADE.102 103 104 105 106 107
[[Page 43770]]
Inappropriately prescribed medications are also considered a major
healthcare concern in the United States for the elderly population,
with costs of roughly $7.2 billion annually.108 109
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\102\ Institute of Medicine. To err is human: Building a safer
health system. Washington, DC: National Academies Press; 2000.
\103\ Lesar T.S., Briceland L., Stein D.S. Factors related to
errors in medication prescribing. JAMA. 1997:277(4): 312-317.
\104\ Bond C.A., Raehl C.L., & Franke T. Clinical pharmacy
services, hospital pharmacy staffing, and medication errors in
United States hospitals. Pharmacotherapy. 2002:22(2): 134-147.
\105\ Bates D.W., Cullen D.J., Laird N., Petersen L.A., Small
S.D., et al. Incidence of adverse drug events and potential adverse
drug events. Implications for prevention. JAMA. 1995:274(1): 29-34.
\106\ Barker K.N., Flynn E.A., Pepper G.A., Bates D.W., & Mikeal
R.L. Medication errors observed in 36 health care facilities. JAMA.
2002: 162(16):1897-1903.
\107\ Bates D.W., Boyle D.L., Vander Vliet M.B., Schneider J, &
Leape L. Relationship between medication errors and adverse drug
events. J Gen Intern Med. 1995:10(4): 199-205.
\108\ Institute of Medicine. To err is human: Building a safer
health system. Washington, DC: National Academies Press; 2000
\109\ Greenwald, J.L., Halasyamani, L., Greene, J., LaCivita,
C., et al. (2010). Making inpatient medication reconciliation
patient centered, clinically relevant and implementable: A consensus
statement on key principles and necessary first steps. Journal of
Hospital Medicine, 5(8), 477-485.
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There is strong evidence that medication discrepancies can occur
during transfers from acute care facilities to post-acute care
facilities. Discrepancies can occur when there is conflicting
information documented in the medical records. Almost one-third of
medication discrepancies have the potential to cause patient harm.\110\
Potential medication problems upon admission to HHAs have been reported
as occurring at a rate of 39 percent of reviewed charts \111\ and mean
medication discrepancies between 2.0 2.3 and 2.1 2.4.\112\ Similarly, medication discrepancies were noted as
patients transitioned from the hospital to home health settings.\113\
An estimated fifty percent of patients experienced a clinically
important medication error after hospital discharge in an analysis of
two tertiary care academic hospitals.\114\
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\110\ Wong, J.D.., et al. ``Medication reconciliation at
hospital discharge: Evaluating discrepancies.'' Annals of
Pharmacotherapy 42.10 (2008): 1373-1379.
\111\ Vink J., Morton D., Ferreri S. Medication-Related Problems
in the Home Care Setting. The Consultant Pharmacist. Vol 26 No 7
2011 478-484
\112\ Setter S.M., Corbett C.F., Neumiller J.J., Gates B.J., et
al. Effectiveness of a pharmacist-nurse intervention on resolving
medication discrepancies for patients transitioning from hospital to
home health care, Am J Health-Syst Pharm, vol. 66, pp. 2027-2031,
2009
\113\ Zillich A.J., Snyder M.E., Frail C.K., Lewis J.L., et al.
A Randomized, Controlled Pragmatic Trial of Telephonic Medication
Therapy Management to Reduce Hospitalization in Home Health Patient,
Health Services Research, vol. 49, no. 5, pp. 1537-1554, 2014.
\114\ Kripalani, Sunil, et al. ``Effect of a pharmacist
intervention on clinically important medication errors after
hospital discharge: A randomized trial. ``Annals of internal
medicine 157.1 (2012): 1-10.
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Medication reconciliation has been identified as an area for
improvement during transfer from the acute care facility to the
receiving post-acute care facility. PAC facilities report gaps in
medication information between the acute care hospital and the
receiving post-acute care setting when performing medication
reconciliation.115 116 Hospital discharge has been
identified as a particularly high risk time point, with evidence that
medication reconciliation identifies high levels of
discrepancy.117 118 119 120 121 122 Also, there is evidence
that medication reconciliation discrepancies occur throughout the
patient stay.123 124 With respect to older patients who may
have multiple comorbid conditions and thus multiple medications,
transitions between acute and post-acute care settings can be further
complicated,\125\ and medication reconciliation and patient knowledge
(medication literacy) can be inadequate post-discharge.\126\ The
proposed quality measure, Drug Regimen Review Conducted with Follow-Up
for Identified Issues-PAC HH QRP, provides an important component of
care coordination for PAC settings and would affect a large proportion
of the Medicare population who transfer from hospitals into PAC
settings each year. For example, in 2013, 3.2 million Medicare FFS
beneficiaries had a home health episode.
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\115\ Gandara, Esteban, et al. ``Communication and information
deficits in patients discharged to rehabilitation facilities: An
evaluation of five acute care hospitals.'' Journal of Hospital
Medicine 4.8 (2009): E28-E33.
\116\ Gandara, Esteban, et al. ``Deficits in discharge
documentation in patients transferred to rehabilitation facilities
on anticoagulation: Results of a system wide evaluation.'' Joint
Commission Journal on Quality and Patient Safety 34.8 (2008): 460-
463.
\117\ Coleman E.A., Smith J.D., Raha D., Min S.J. Post hospital
medication discrepancies: Prevalence and contributing factors. Arch
Intern Med. 2005 165(16):1842-1847.
\118\ Wong J.D., Bajcar J.M., Wong G.G., et al. Medication
reconciliation at hospital discharge: Evaluating discrepancies. Ann
Pharmacother. 2008 42(10):1373-1379.
\119\ Hawes E.M., Maxwell W.D., White S.F., Mangun J., Lin F.C.
Impact of an outpatient pharmacist intervention on medication
discrepancies and health care resource utilization in post
hospitalization care transitions. Journal of Primary Care &
Community Health. 2014; 5(1):14-18.
\120\ Foust J.B., Naylor M.D., Bixby M.B., Ratcliffe S.J.
Medication problems occurring at hospital discharge among older
adults with heart failure. Research in Gerontological Nursing. 2012,
5(1): 25-33.
\121\ Pherson E.C., Shermock K.M., Efird L.E., et al.
Development and implementation of a post discharge home-based
medication management service. Am J Health Syst Pharm. 2014; 71(18):
1576-1583.
\122\ Pronovosta P., Weasta B., Scwarza M., et al. Medication
reconciliation: A practical tool to reduce the risk of medication
errors. J Crit Care. 2003; 18(4): 201-205.
\123\ Bates D.W., Cullen D.J., Laird N., Petersen L.A., Small
S.D., et al. Incidence of adverse drug events and potential adverse
drug events. Implications for prevention. JAMA. 1995:274(1): 29-34.
\124\ Himmel, W., M. Tabache, and M.M. Kochen. ``What happens to
long-term medication when general practice patients are referred to
hospital?. ``European journal of clinical pharmacology 50.4 (1996):
253-257.
\125\ Chhabra, P.T., et al. (2012). ``Medication reconciliation
during the transition to and from long-term care settings: A
systematic review.'' Res Social Adm Pharm 8(1): 60-75.
\126\ Hume K., Tomsik E. Enhancing Patient Education and
Medication Reconciliation Strategies to Reduce Readmission Rates.
Hosp Pharm; 2014; 49(2):112-114.
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A TEP convened by our measure development contractor provided input
on the technical specifications of this proposed quality measure, Drug
Regimen Review Conducted with Follow-Up for Identified Issues-PAC HH
QRP, including components of reliability, validity and the feasibility
of implementing the measure across PAC settings. The TEP supported the
measure's implementation across PAC settings and was supportive of our
plans to standardize this measure for cross-setting development. A
summary of the TEP proceedings is available on the PAC Quality
Initiatives Downloads and Video Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
We solicited stakeholder feedback on the development of this
measure by means of a public comment period held from September 18
through October 6, 2015. Through public comments submitted by several
stakeholders and organizations, we received support for implementation
of this proposed measure. The public comment summary report for the
proposed measure is available on the CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html.
The NQF-convened MAP met on December 14 and 15, 2015, and provided
input on the use of this proposed quality measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues-PAC HH QRP. The MAP
encouraged continued development of the proposed quality measure for
the HH QRP to meet the mandate of the IMPACT Act. The MAP agreed with
the measure gaps identified by CMS including medication reconciliation,
and stressed that medication reconciliation be present as an ongoing
process. More information about the MAPs recommendations for this
measure is available at http://www.qualityforum.org/Setting_Priorities/Partnership/MAP_Final_Reports.aspx.
Since the MAP's review, we have continued to refine this proposed
[[Page 43771]]
measure in compliance with the MAP's recommendations. The proposed
measure is both consistent with the information submitted to the MAP
and supports its scientific acceptability for use in the HH QRP.
Therefore, we are proposing this measure for implementation in the HH
QRP as required by the IMPACT Act.
We reviewed the NQF's endorsed measures and identified one NQF-
endorsed cross-setting and quality measure related to medication
reconciliation, which applies to the SNF, LTCH, IRF, and HH settings of
care: Care for Older Adults (COA) (NQF #0553). The quality measure,
Care for Older Adults (COA) (NQF #0553) assesses the percentage of
adults 66 years and older who had a medication review. The Care for
Older Adults (COA) (NQF #0553) measure requires at least one medication
review conducted by a prescribing practitioner or clinical pharmacist
during the measurement year and the presence of a medication list in
the medical record. This is in contrast to the proposed quality
measure, Drug Regimen Review Conducted with Follow-Up for Identified
Issues-PAC HH QRP, which reports the percentage of patient episodes in
which a drug regimen review was conducted at the time of admission and
that timely follow-up with a physician or physician-designee occurred
each time one or more potential clinically significant medication
issues were identified throughout that episode.
After careful review of both quality measures, we have decided to
propose the quality measure, Drug Regimen Review Conducted with Follow-
Up for Identified Issues-PAC HH QRP for the following reasons:
The IMPACT Act requires the implementation of quality
measures, using patient assessment data that are standardized and
interoperable across PAC settings. The proposed quality measure, Drug
Regimen Review Conducted with Follow-Up for Identified Issues-PAC HH
QRP, employs three standardized patient-assessment data elements for
each of the four PAC settings so that data are standardized,
interoperable, and comparable; whereas, the Care for Older Adults (COA)
(NQF #0553) quality measure does not contain data elements that are
standardized across all four PAC settings;
The proposed quality measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues-PAC HH QRP, requires the
identification of clinically potential medication issues at the
beginning, during and at the end of the patient's episode to capture
data on each patient's complete HH episode; whereas, the Care for Older
Adults (COA) (NQF #0553) quality measure only requires annual
documentation in the form of a medication list in the medical record of
the target population;
The proposed quality measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues-PAC HH QRP, includes
identification of the potential clinically significant medication
issues and communication with the physician (or physician designee) as
well as resolution of the issue(s) within a rapid time frame (by
midnight of the next calendar day); whereas, the Care for Older Adults
(COA) (NQF #0553) quality measure does not include any follow-up or
time frame in which the follow-up would need to occur;
The proposed quality measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues-PAC HH QRP, does not
have age exclusions; whereas, the Care for Older Adults (COA) (NQF
#0553) quality measure limits the measure's population to patients aged
66 and older; and
The proposed quality measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues-PAC HH QRP, would be
reported to HHAs quarterly to facilitate internal quality monitoring
and quality improvement in areas such as patient safety, care
coordination and patient satisfaction; whereas, the Care for Older
Adults (COA) (NQF #0553) quality measure would not enable quarterly
quality updates, and thus data comparisons within and across PAC
providers would be difficult due to the limited data and scope of the
data collected.
Therefore, based on the evidence discussed above, we are proposing
to adopt the quality measure entitled, Drug Regimen Review Conducted
with Follow-Up for Identified Issues-PAC HH QRP, for the HH QRP for CY
2018 payment determination and subsequent years. We plan to submit the
quality measure to the NQF for consideration of endorsement.
The calculation of the proposed quality measure would be based on
the data collection of three standardized items that would be added to
the OASIS. The collection of data by means of the standardized items
would be obtained at start or resumption of care and end of care. For
more information about the data submission required for this proposed
measure, we refer readers to Section I. Form, Manner, and Timing of
OASIS Data Submission and OASIS Data for Annual Payment Update.
The standardized items used to calculate this proposed quality
measure will replace existing items currently used for data collection
within the OASIS. The proposed measure denominator is the number of
patient episodes with an end of care assessment during the reporting
period. The proposed measure numerator is the number of episodes in the
denominator where the medical record contains documentation of a drug
regimen review conducted at: (1) Start or resumption of care; and (2)
end of care with a look back through the home health patient episode
with all potential clinically significant medication issues identified
during the course of care and followed-up with a physician or physician
designee by midnight of the next calendar day. This measure is not risk
adjusted. For technical information about this proposed measure,
including information about the measure calculation and discussion
pertaining to the standardized items used to calculate this measure, we
refer readers to the document titled Proposed Measure Specifications
for Measures Proposed in the CY 2017 HH QRP proposed rule available at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
Data for the proposed quality measure, Drug Regimen Review
Conducted with Follow-Up for Identified Issues--PAC HH QRP, would be
collected using the OASIS with submission through the QIES ASAP system.
We invite public comment on our proposal to adopt the quality
measure, Drug Regimen Review Conducted with Follow-Up for Identified
Issues--PAC HH QRP for CY 2018 APU determination and subsequent years.
H. HH QRP Quality Measures and Measure Concepts Under Consideration for
Future Years
We invite public comment on the importance, relevance,
appropriateness, and applicability of each of the quality measures
listed in Table 33 for use in future years in the HH QRP.
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We are developing a measure related to the IMPACT Act domain,
``Accurately communicating the existence of and providing for the
transfer of health information and care preferences of an individual to
the individual, family caregiver of the individual, and providers of
services furnishing items and services to the individual, when the
individual transitions.'' We are also considering application of two
IMPACT Act measures to the HH QRP, to assess the incidence of falls
with major injury and functional assessment and goals setting. We are
additionally considering application of four standardized functional
measures to the HH QRP; two that would assess change in function across
the HH episode and two that would assess actual function at discharge
relative to expected function. Finally, we are considering a measure
related to health and well-being, Percent of Residents or Patients Who
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
(Short Stay).
Based on input from stakeholders, we have identified additional
concept areas for potential future measure development for the HH QRP.
These include ``efficacy'' measures that pair processes, such as
assessment and care planning, with outcomes, such as emergency
treatment for injuries or increase in pain. The prevalence of mental
health and behavioral problems was identified as an option to address
outcomes for special populations. In addition, CMS is considering
development of measures that assess if functional abilities were
maintained during a care episode and composite measures that combine
multiple evidence-based processes. CMS invites feedback on the
importance, relevance, appropriateness, and applicability of these
measure constructs.
I. Form Manner and Timing of OASIS Data Submission and OASIS Data for
Annual Payment Update
1. Regulatory Authority
The HH conditions of participation (CoPs) at Sec. 484.55(d)
require that the
[[Page 43773]]
comprehensive assessment be updated and revised (including the
administration of the OASIS) no less frequently than: (1) The last 5
days of every 60 days beginning with the start of care date, unless
there is a beneficiary-elected transfer, significant change in
condition, or discharge and return to the same HHA during the 60-day
episode; (2) within 48 hours of the patient's return to the home from a
hospital admission of 24-hours or more for any reason other than
diagnostic tests; and (3) at discharge.
It is important to note that to calculate quality measures from
OASIS data, there must be a complete quality episode, which requires
both a Start of Care (initial assessment) or Resumption of Care OASIS
assessment and a Transfer or Discharge OASIS assessment. Failure to
submit sufficient OASIS assessments to allow calculation of quality
measures, including transfer and discharge assessments, is a failure to
comply with the CoPs.
HHAs are not required to submit OASIS data for patients who are
excluded from the OASIS submission requirements as described in the
December 23, 2005, final rule ``Medicare and Medicaid Programs:
Reporting Outcome and Assessment Information Set Data as Part of the
Conditions of Participation for Home Health Agencies'' (70 FR 76202).
As set forth in the CY 2008 HH PPS final rule (72 FR 49863), HHAs
that become Medicare certified on or after May 31 of the preceding year
are not subject to the OASIS quality reporting requirement nor any
payment penalty for quality reporting purposes for the following year.
For example, HHAs certified on or after May 31, 2014, are not subject
to the 2 percentage point reduction to their market basket update for
CY 2015. These exclusions only affect quality reporting requirements
and payment reductions, and do not affect the HHA's reporting
responsibilities as announced in the December 23, 2005 OASIS final
rules (70 FR 76202).
2. Home Health Quality Reporting Program Requirements for CY 2017
Payment and Subsequent Years
In the CY 2014 HH PPS final rule (78 FR 72297), we finalized a
proposal to consider OASIS assessments submitted by HHAs to CMS in
compliance with HH CoPs and Conditions for Payment for episodes
beginning on or after July 1, 2012, and before July 1, 2013, as
fulfilling one portion of the quality reporting requirement for CY
2014.
In addition, we finalized a proposal to continue this pattern for
each subsequent year beyond CY 2014. OASIS assessments submitted for
episodes beginning on July 1 of the calendar year 2 years prior to the
calendar year of the Annual Payment Update (APU) effective date and
ending June 30 of the calendar year one year prior to the calendar year
of the APU effective date; fulfill the OASIS portion of the HH QRP
requirement.
3. Previously Established Pay-for-Reporting Performance Requirement for
Submission of OASIS Quality Data
Section 1895(b)(3)(B)(v)(I) of the Act states that for 2007 and
each subsequent year, the home health market basket percentage increase
applicable under such clause for such year shall be reduced by 2
percentage points if a home health agency does not submit quality data
to the Secretary in accordance with subclause (II) for such a year.
This pay-for-reporting requirement was implemented on January 1, 2007.
In the CY 2016 HH PPS final rule (80 FR 68703 through 68705), we
finalized a proposal to define the quantity of OASIS assessments each
HHA must submit to meet the pay-for-reporting requirement. We designed
a pay-for-reporting performance system model that could accurately
measure the level of an HHA's submission of OASIS data. The performance
system is based on the principle that each HHA is expected to submit a
minimum set of two matching assessments for each patient admitted to
their agency. These matching assessments together create what is
considered a quality episode of care, consisting ideally of a Start of
Care (SOC) or Resumption of Care (ROC) assessment and a matching End of
Care (EOC) assessment.
Section 80 of Chapter 10 of the Medicare Claims Processing Manual
states, ``If a Medicare beneficiary is covered under an MA Organization
during a period of home care, and subsequently decides to change to
Medicare FFS coverage, a new start of care OASIS assessment must be
completed that reflects the date of the beneficiary's change to this
pay source.'' We wish to clarify that the SOC OASIS assessment
submitted when this change in coverage occurs will not be used in our
determination of a quality assessment for the purpose of determining
compliance with data submission requirements. In such a circumstance,
the original SOC or ROC assessment submitted while the Medicare
beneficiary is covered under an MA Organization would be considered a
quality assessment within the pay-for-reporting, APU, Quality
Assessments Only methodology. For further information on successful
submission of OASIS assessments, types of assessments submitted by an
HHA that fit the definition of a quality assessment, defining the
``Quality Assessments Only'' (QAO) formula, and implementing a pay-for-
reporting performance requirement over a 3-year period, please see the
CY 2016 HH PPS final rule (80 FR 68704 to 68705). HHAs must score at
least 70 percent on the QAO metric of pay-for-reporting performance
requirement for CY 2017 (reporting period July 1, 2015 to June 30,
2016), 80 percent for CY 2018 (reporting period July 1, 2016 to June
30, 2017) and 90 percent for CY 2019 (reporting period July 1, 2017 to
June 30, 2018) or be subject to a 2 percentage point reduction to their
market basket update for that reporting period.
In this proposed rule we are not proposing any additional policies
related to the pay-for-reporting performance requirement.
4. Proposed Timeline and Data Submission Mechanisms for Measures
Proposed for the CY 2018 Payment Determination and Subsequent Years
a. Claims Based Measures
The MSPB-PAC HH QRP, Discharge to Community--PAC HH QRP, and
Potentially Preventable 30-Day Post-Discharge Readmission Measure for
HH QRP, which we have proposed in this proposed rule, are Medicare FFS
claims-based measures. Because claims-based measures can be calculated
based on data that are already reported to the Medicare program for
payment purposes, no additional information collection will be required
from HHAs. As previously discussed in V.G., for the Discharge to
Community--PAC HH QRP measure we propose to use 2 years of claims data,
beginning with CYs 2015 and 2016 claims data to inform confidential
feedback and CYs 2016 and 2017 claims data for public reporting. For
the Potentially Preventable 30-Day Post-Discharge Readmission Measure
for HH QRP we propose to use 3 years of claims data, beginning with CY
2014, 2015 and 2016 claims data to inform confidential feedback reports
for HHAs, and CY 2015, 2016 and 2017 claims data for public reporting.
For the MSPB-PAC HH QRP measure, we propose to use one year of claims
data beginning with CY 2016 claims data to inform confidential feedback
reports for HHAs, and CY 2017 claims data for public reporting for the
HH QRP.
[[Page 43774]]
b. Assessment-Based Measures Using OASIS Data Collection
As discussed in section V.G of this proposed rule, for the proposed
measure, Drug Regimen Review Conducted with Follow-Up for Identified
Issues--PAC HH QRP, affecting CY 2018 payment determination and
subsequent years, we are proposing that HHAs would submit data by
completing data elements on the OASIS and then submitting the OASIS to
CMS through the QIES ASAP system beginning January 1, 2017. For more
information on HH QRP reporting through the QIES ASAP system, refer to
CMS Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html.
We propose to use standardized data elements in OASIS C2 to
calculate the proposed measure: Drug Regimen Review Conducted with
Follow-Up for Identified Issues--PAC HH QRP. The data elements
necessary to calculate this measure using the OASIS are available on
our Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.
We invite public comments on the proposed HH QRP data collection
requirements for the proposed measure affecting CY 2018 payment
determination and subsequent years.
5. Proposed Timeline and Data Submission Mechanisms for the CY 2018
Payment Determination and Subsequent Years for New HH QRP Assessment-
Based Quality Measure
In the CY 2016 HH PPS final rule (80 FR 68695 through 68698) for
the FY 2018 payment determination, we finalized that HHAs must submit
data on the quality measure NQF #0678 Percent of Residents or Patients
with Pressure Ulcers that are New or Worsened (Short Stay) using CY
2017 data, for example, patients who are admitted to the HHA on and
after January 1, 2017, and discharged from the HHA up to and including
December 31, 2017. However, for CY 2018 APU purposes this timeframe
would be impossible to achieve, given the processes we have established
associated with APU determinations, such as the opportunity for
providers to seek reconsideration for determinations of non-compliance.
Therefore, for both the measure NQF #0678 Percent of Residents or
Patients with Pressure Ulcers that are New or Worsened (Short Stay)
that we finalized in the CY 2016 HH PPS rule, and the CY 2017 HH PPS
proposed measure, Drug Regimen Review Conducted with Follow-Up for
Identified Issues--PAC HH QRP, we propose that we would collect two
quarters of data for CY 2018 APU determination to remain consistent
with the January release schedule for the OASIS and to give HHAs
sufficient time to update their systems so that they can comply with
the new data reporting requirements, and to give us a sufficient amount
of time to determine compliance for the CY 2018 program. The proposed
use of two quarters of data for the initial year of quality reporting
is consistent with the approach we have used to implement new measures
in a number of other QRPs, including the LTCH, IRF, and Hospice QRPs in
which only one quarter of data was used.
We invite public comments on our proposal to adopt a calendar year
data collection time frame, using an initial 6-month reporting period
from January 1, 2017, to June 30, 2017 for CY 2018 payment
determinations, for the application of measure NQF #0678 Percent of
Residents or Patients with Pressure Ulcers that are New or Worsened
(Short Stay) that we finalized in the CY 2016 HH PPS rule, and the CY
2017 HH PPS proposed measure, Drug Regimen Review Conducted with
Follow-Up for Identified Issues--PAC HH QRP.
6. Data Collection Timelines and Requirements for the CY 2019 Payment
Determinations and Subsequent Years
In CY 2014 HH PPS final rule (78 FR 72297), we finalized our use of
a July 1-June 30 time frame for APU determinations. In alignment with
the previously established timeframe data collection for a given
calendar year APU determination time period, beginning with the CY 2019
payment determination, we propose for both the finalized measure, NQF
#0678 Percent of Residents or Patients with Pressure Ulcers that are
New or Worsened (Short Stay), and the proposed measure, Drug Regimen
Review Conducted with Follow-Up for Identified Issues--PAC HH QRP, to
use 12 months of data collection, specifically assessments submitted
July 1, 2017 through June 30, 2018, for the CY 2019 payment
determination. We further propose to continue to use the same 12-month
timeframe of July 1-June 30 for these measures for subsequent years for
APU determinations.
We invite comment on these proposals for the data collection
timelines and requirements.
7. Proposed Data Review and Correction Timeframes for Data Submitted
Using the OASIS Instrument
In addition, to remain consistent with the SNF, LTCH and IRF QRPs,
as well as to comply with the requirements of section of section
1899B(g) of the Act, we are also proposing to implement calendar year
provider review and correction periods for the OASIS assessment-based
quality measures implemented into the HH QRP in satisfaction of the
IMPACT Act, that is, finalized NQF #0678 Percent of Residents or
Patients with Pressure Ulcers that are New or Worsened (Short Stay) and
the proposed Drug Regimen Review Conducted with Follow-Up for
Identified Issues--PAC HH QRP. More specifically, we are proposing that
HHAs would have approximately 4.5 months after the reporting quarter to
correct any errors of their assessment-based data (that appear on the
CASPER generated Quality Measure reports) to calculate the measures.
During the time of data submission for a given quarterly reporting
period and up until the quarterly submission deadline, HHAs could
review and perform corrections to errors in the assessment data used to
calculate the measures and could request correction of measure
calculations. However, once the quarterly submission deadline occurs,
the data is ``frozen'' and calculated for public reporting and
providers can no longer submit any corrections. As laid out in Table
34, the first calendar year reporting quarter is January 1, 2017
through March 31, 2017. The final deadline for submitting corrected
data would be August 15, 2017 for CY Quarter 1, and subsequently and
sequentially, November 15, 2017 for CY 2017 Quarter 2, February 15,
2018 for CY 2017 Quarter 3 and May 15, 2018 for CY 2017 Quarter 4. We
note that this proposal to review and correct data does not replace
other requirements associated with timely data submission. We would
encourage HHAs to submit timely assessment data during a given
quarterly reporting period and review their data and information early
during the review and correction period so that they can identify
errors and resubmit data before the data submission deadline.
[[Page 43775]]
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We invite public comments on our proposal to adopt a calendar year
data collection time frame, with a 4.5 month period of time for review
and correction beginning with CY 2017 for the measure NQF #0678 Percent
of Residents or Patients with Pressure Ulcers that are New or Worsened
(Short Stay) that we finalized in the CY 2016 HH PPS rule, and the CY
2017 HH PPS proposed measure, Drug Regimen Review Conducted with
Follow-Up for Identified Issues-PAC HH QRP for the HH QRP.
Further, we propose that the OASIS assessment-based measures
already finalized for adoption into the HH QRP follow a similar CY
schedule of data reporting using quarterly data collection/submission
reporting periods followed by 4.5 months during which providers will
have an opportunity to review and correct their data up until the
quarterly data submission deadlines as provided in Table 35 for all
reporting years unless otherwise specified. This policy would apply to
all proposed and finalized assessment-based measures in the HH QRP.
Table 35--Proposed CY Data Collection Submission Quarterly Reporting Periods, Quarterly Review and Correction
Periods and Data Submission Deadlines for Measures Specified in Satisfaction of the IMPACT Act in Subsequent
Years
----------------------------------------------------------------------------------------------------------------
Proposed quarterly
Proposed data review and correction
Proposed CY data collection quarter collection/submission periods and data Proposed correction
quarterly reporting submission quarterly deadlines *
period deadlines *
----------------------------------------------------------------------------------------------------------------
Quarter 1........................... January 1-March 31..... April 1-August 15..... August 15.
Quarter 2........................... April 1-June 30........ July 1-November 15.... November 15.
Quarter 3........................... July 1-September 30.... October 1-February 15. February 15.
Quarter 4........................... October 1-December 31.. January 1-May 15...... May 15.
----------------------------------------------------------------------------------------------------------------
*We note that the submission deadlines provided pertain to the correction of data and that the submission of
OASIS data must continue to adhere to all submission deadline requirements as imposed under the Conditions of
Participation.
We invite public comment on our use of CY quarterly data
collection/submission reporting periods with quarterly data submission
deadlines that follow a period of approximately 4.5 months of time to
enable the review and correction of such data for OASIS assessment-
based measures.
J. Public Display of Quality Measure Data for the HH QRP and Procedures
for the Opportunity To Review and Correct Data and Information
Medicare home health regulations, as codified at Sec. 484.250(a),
require HHAs to submit OASIS assessments and Home Health Care Consumer
Assessment of Healthcare Providers and Systems Survey[supreg] (HHCAHPS)
data to meet the quality reporting requirements of section
1895(b)(3)(B)(v) of the Act. Section 1899B(g) of the Act requires that
data and information of provider performance on quality measures and
resource use and other measures be made publicly available beginning
not later than 2 years after the applicable specified application date.
In future rulemaking, we intend to propose a policy to publicly display
performance information for individual HHAs on IMPACT Act measures, as
required under the Act. In addition, sections 1895(b)(3)(B)(v)(III) and
1899B(g) of the Act require the Secretary to establish procedures for
making data submitted under subclause (II) available to the
[[Page 43776]]
public. Under section 1899B(g)(2), such procedures must ensure,
including through a process consistent with the process applied under
section 1886(b)(3)(B)(viii)(VII) of the Act, which refers to public
display and review requirements in the Hospital IQR Program, that a
home health agency has the opportunity to review and submit corrections
to its data and information that are to be made public for the agency
prior to such data being made public through a process consistent with
the Hospital Inpatient Quality Reporting Program (Hospital IQR). We
recognize that public reporting of quality data is a vital component of
a robust quality reporting program and are fully committed to ensuring
that the data made available to the public are meaningful. Further, we
agree that measures for comparing performance across home health
agencies requires should be constructed from data collected in a
standardized and uniform manner. In this proposed rule, we are
proposing procedures that would allow individual HHAs to review and
correct their data and information on IMPACT Act measures that are to
be made public before those measure data are made public.
1. Proposals for the Review and Correction of Data Used To Calculate
the Assessment-Based Measures Prior to Public Display
As provided in section V.I.7., and in Table 34, for assessment-
based measures, we are proposing to provide confidential feedback
reports to HHAs that contain performance information that the HHAs can
review, during the review and correction period, and correct the data
used to calculate the measures for the HH QRP that the HHA submitted
via the QIES ASAP system. In addition, during the review period, the
HHA would be able to request correction of any errors in the
assessment-based measure rate calculations.
We propose that these confidential feedback reports would be
available to each HHA using the Certification and Survey Provider
Enhanced Reporting (CASPER) System. We refer to these reports as the HH
Quality Measure (QM) Reports. We intend to provide monthly updates to
the data contained in these reports that pertain to assessment-based
data, as data become available. The reports will contain both agency-
and patient-level data used to calculate the assessment-based quality
measures. The CASPER facility level QM reporting would include the
numerator, denominator, agency rate, and national rate. The CASPER
patient-level QM Reports would also contain individual patient
information that HHAs can use to identify patients that were included
in the quality measures so as to identify any potential errors. In
addition, we would make other reports available to HHAs through the
CASPER System, including OASIS data submission reports and provider
validation reports, which would contain information on each HHA's data
submission status, including details on all items the HHA submitted in
relation to individual assessments and the status of the HHA's
assessment (OASIS) records that they submitted. When available,
additional information regarding the content and availability of these
confidential feedback reports would be provided on the HH QRP Web site
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/index.html.
As previously proposed in section V.I.7., for those measures that
use assessment-based data, HHAs would have 4.5 months after the
conclusion of each reporting quarter to review and update their
reported measure data for the quarter, including correcting any errors
that they find on the CASPER-generated Review and Correct, QM reports
pertaining to their assessment-based data used to calculate the
assessment-based measures. However, at the conclusion of this 4.5 month
review and correction period, the data reported for that quarter would
be ``frozen'' and used to calculate measure rates for public reporting.
We would encourage HHAs to submit timely assessment data during each
quarterly reporting period and to review their data and information
early during the 4.5 month review and correction period so they can
identify errors and resubmit data before the data submission deadline.
We believe that the proposed data submission period along with a
review and correction period, consisting of the reporting quarter plus
approximately 4.5 months, is sufficient time for HHAs to submit, review
and, where necessary, correct their data and information. We also
propose that, in addition to the data submission/correction and review
period, HHAs will have a 30-day preview period prior to public display
during which they can preview the performance information on their
measures that will be made public. We also propose to provide this
preview report using the Certification and Survey Provider Enhanced
Reporting (CASPER) System because HHAs are familiar with this system.
The CASPER preview reports for the reporting quarter would be available
after the 4.5 month review and correction period ends, and would be
refreshed quarterly or annually for each measure, depending on the
length of the reporting period for that measure. We propose to give
HHAs 30 days to review this information, beginning from the date on
which they can access the preview report. Corrections to the underlying
data would not be permitted during this time; however, HHAs would be
able to ask for a correction to their measure calculations during the
30-day preview period. If we determine that the measure, as it is
displayed in the preview report, contains a calculation error, we would
suppress the data on the public reporting Web site, recalculate the
measure and publish the corrected rate at the time of the next
scheduled public display date. This process is consistent with informal
processes used in the Hospital IQR program. If finalized, we intend to
utilize a subregulatory mechanism, such as our HH QRP Web site, to
explain the technical details for how and when providers may contest
their measure calculations. We further propose to increase the current
preview period of 15 days to 30 days beginning with the public display
of the measures finalized for the CY 2018 payment determination. This
preview period would include all measures that are to be publicly
displayed under the current quarterly refresh schedule used for posting
quality measure data on the Medicare.gov Home Health Compare site.
We invite public comment on these proposals.
2. Proposals for Review and Correction of Data Used To Calculate
Claims-Based Measures Prior To Public Display
In addition to assessment-based measures, we have also proposed
claims-based measures for the HH QRP. As noted previously, section
1899B(g)(2) of the Act requires prepublication provider review and
correction procedures that are consistent with those followed in the
Hospital IQR program. Under the Hospital IQR Program's procedures, for
claims-based measures, we give hospitals 30 days to preview their
claims-based measures and data in a preview report containing aggregate
hospital-level data. We propose to adopt a similar process for the HH
QRP.
Prior to the public display of our claims-based measures, in
alignment with the Hospital IQR, HAC and Hospital VBP programs, we
propose to make available through the CASPER system a confidential
preview report that will contain information pertaining
[[Page 43777]]
to their claims-based measure rate calculations, including agency and
national rates. This information would be accompanied by additional
confidential information based on the most recent administrative data
available at the time we extract the claims data for purposes of
calculating the rates.
We propose to create data extracts using claims data for these
claims based measures, at least 90 days after the last discharge date
in the applicable period (12 calendar months preceding), which we will
use for the calculations. For example, if the last discharge date in
the applicable period for a measure is December 31, 2017, for data
collection January 1, 2017, through December 31, 2017, we would create
the data extract on approximately March 31, 2018, at the earliest, and
use that data to calculate the claims-based measures for the 2017
reporting period. We propose that beginning with data for measures that
will be publicly displayed by January 1, 2019, and for which will need
to coincide with the quarterly refresh schedule on Home Health Compare,
the claims-based measures will be calculated at least 90 days after the
last discharge date using claims data from the applicable reporting
period. This timeframe allows us to balance the need to provide timely
program information to HHAs with the need to calculate the claims-based
measures using as complete a data set as possible. Since HHAs would not
be able to submit corrections to the underlying claims snapshot or add
claims (for those measures that use HH claims) to this data set, at the
conclusion of the 90-day period following the last date of discharge
used in the applicable period, we would consider the HH claims data to
be complete for purposes of calculating the claims-based measures. We
wish to convey the importance that HHAs ensure the completeness and
correctness of their claims prior to the claims ``snapshot''. We seek
to have as complete a data set as possible. We recognize that the
proposed approximately 90 day ``run-out'' period is less than the
Medicare program's current timely claims filing policy under which
providers have up to 1 year from the date of discharge to submit
claims. We considered a number of factors in determining that the
proposed approximately 90 day run-out period is appropriate to
calculate the claims-based measures. After the data extract is created,
it takes several months to incorporate other data needed for the
calculations (particularly in the case of risk-adjusted, and/or
episode-based measures). We then need to generate and check the
calculations. Because several months lead time is necessary after
acquiring the data to generate the claims-based calculations, if we
were to delay our data extraction point to 12 months after the last
date of the last discharge in the applicable period, we would not be
able to deliver the calculations to HHAs sooner than 18 to 24 months
after the last discharge. We believe this would create an unacceptably
long delay, both for HHAs and for us to deliver timely calculations to
HHAs for quality improvement.
As noted, under this proposed procedure, during the 30-day preview
period, HHAs would not be able to submit corrections to the underlying
claims data or add new claims to the data extract. This is for two
reasons. First, for certain measures, some of the claims data used to
calculate the measure are derived not from the HHA's claims, but from
the claims of another provider. For example, the proposed measure
Potentially Preventable 30-Day Post-Discharge Readmission Measure for
HH QRP uses claims data submitted by the hospital to which the patient
was readmitted. HHAs are not able to make corrections to these hospital
claims, although the agency could request that the hospital reconfirm
that its submissions are correct. Second, even where HHA claims are
used to calculate the measures, it would not be not possible to correct
the data after it is extracted for the measures calculation. This is
because it is necessary to take a static ``snapshot'' of the claims in
order to perform the necessary measure calculations.
As noted previously, we propose to provide HHAs a 30-day preview
period to review their confidential preview reports. HHAs would have 30
days from the date the preview report is made available to review this
information. The 30-day preview period would be the only time when HHAs
would be able to see their claims-based measure rates before they are
publicly displayed. HHAs could request that we correct our measure
calculation during the 30-day preview period if the HHA believes the
measure rate is incorrect. If we agree that the measure rate, as it is
displayed in the preview report, contains a calculation error, we would
suppress the data on the public reporting Web site, recalculate the
measure, and publish the corrected measure rate at the time of the next
scheduled public display date. If finalized, we intend to utilize a
subregulatory mechanism, such as our HH QRP Web site, to explain the
technical details regarding how and when providers may contest their
measure calculations. We refer readers to the discussion inV.I.2 for
additional information on these preview reports.
In addition, because the claims-based measures used for the HH QRP
are re-calculated on an annual basis, these confidential CASPER QM
preview reports for claims-based measures would be refreshed annually.
An annual refresh is being utilized to ensure consistency in our
display of claims based measures, and it will include both claims-based
measures that satisfy the IMPACT Act, as well as all other HH QRP
claims-based measures.
We invite public comment on these proposals for the public display
of quality measure data.
K. Mechanism for Providing Feedback Reports to HHAs
Section 1899B(f) of the Act requires the Secretary to provide
confidential feedback measure reports to post-acute care providers on
their performance on the measures specified under paragraphs (c)(1) and
(d)(1), beginning 1 year after the specified application date that
applies to such measures and PAC providers. We propose to build upon
the current confidential quality measure reports we already generate
for HHAs so as to also provide data and information on the measures
implemented in satisfaction of the IMPACT Act. As a result, HHAs could
review their performance on these measures, as well as those already
adopted in the HH QRP. We propose that these additional confidential
feedback reports would be made available to each HHA through the CASPER
System. Data contained within these CASPER reports would be updated, as
previously described, on a monthly basis as the data become available
except for claims-based measures, which will only be updated on an
annual basis.
We intend to provide detailed procedures to HHAs on how to obtain
their new confidential feedback reports in CASPER on the HH QRP Web
site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Requirements.html. We also propose to use the QIES ASAP
system to provide these new confidential quality measure reports in a
manner consistent with how HHAs have obtained such reports to date. The
QIES ASAP system is a confidential and secure system with access
granted to providers, or their designees.
We invite public comment on this proposal to satisfy the
requirement to provide confidential feedback reports to
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HHAs specific to the requirements of the Act.
L. Home Health Care CAHPS[supreg] Survey (HHCAHPS)
In the CY 2016 HH PPS final rule (80 FR 68623), we stated that the
home health quality measures reporting requirements for Medicare-
certified agencies includes the Home Health Care CAHPS[supreg]
(HHCAHPS) Survey for the CY 2017 and 2018 Annual Payment Update (APU)
periods. We are continuing to maintain the stated HHCAHPS data
requirements for CY 2017 and CY 2018 that were stated in CY 2016 and in
previous HH PPS rules, for the continuous monthly data collection and
quarterly data submission of HHCAHPS data.
1. Background and Description of HHCAHPS
As part of the HHS Transparency Initiative, we implemented a
process to measure and publicly report patient experiences with home
health care, using a survey developed by the Agency for Healthcare
Research and Quality's (AHRQ's) Consumer Assessment of Healthcare
Providers and Systems (CAHPS[supreg]) program and endorsed by the
National Quality Forum (NQF) in March 2009 (NQF Number 0517) and NQF
re-endorsed in 2015. The HHCAHPS Survey is approved under OMB Control
Number 0938-1066. The HHCAHPS survey is part of a family of
CAHPS[supreg] surveys that asks patients to report on and rate their
experiences with health care. The Home Health Care CAHPS[supreg]
(HHCAHPS) survey presents home health patients with a set of
standardized questions about their home health care providers and about
the quality of their home health care.
Prior to this survey, there was no national standard for collecting
information about patient experiences that enabled valid comparisons
across all HHAs. The history and development process for HHCAHPS has
been described in previous rules and is also available on the official
HHCAHPS Web site at https://homehealthcahps.org and in the annually-
updated HHCAHPS Protocols and Guidelines Manual, which is downloadable
from https://homehealthcahps.org.
Since April 2012, for public reporting purposes, we report five
measures from the HHCAHPS Survey--three composite measures and two
global ratings of care that are derived from the questions on the
HHCAHPS survey. The publicly reported data are adjusted for differences
in patient mix across HHAs. We update the HHCAHPS data on Home Health
Compare on www.medicare.gov quarterly. Each HHCAHPS composite measure
consists of four or more individual survey items regarding one of the
following related topics:
Patient care (Q9, Q16, Q19, and Q24);
Communications between providers and patients (Q2, Q15,
Q17, Q18, Q22, and Q23); and
Specific care issues on medications, home safety, and pain
(Q3, Q4, Q5, Q10, Q12, Q13, and Q14).
The two global ratings are the overall rating of care given by the
HHA's care providers (Q20), and the patient's willingness to recommend
the HHA to family and friends (Q25).
The HHCAHPS survey is currently available in English, Spanish,
Chinese, Russian, and Vietnamese. The OMB number on these surveys is
the same (0938-1066). All of these surveys are on the Home Health Care
CAHPS[supreg] Web site, https://homehealthcahps.org. We continue to
consider additional language translations of the HHCAHPS in response to
the needs of the home health patient population.
All of the requirements about home health patient eligibility for
the HHCAHPS survey and conversely, which home health patients are
ineligible for the HHCAHPS survey are delineated and detailed in the
HHCAHPS Protocols and Guidelines Manual, which is downloadable at
https://homehealthcahps.org. Home health patients are eligible for
HHCAHPS if they received at least two skilled home health visits in the
past 2 months, which are paid for by Medicare or Medicaid.
Home health patients are ineligible for inclusion in HHCAHPS
surveys if one of these conditions pertains to them:
Are under the age of 18;
Are deceased prior to the date the sample is pulled;
Receive hospice care;
Receive routine maternity care only;
Are not considered survey eligible because the state in
which the patient lives restricts release of patient information for a
specific condition or illness that the patient has; or
Are ``No Publicity'' patients, defined as patients who on
their own initiative at their first encounter with the HHAs make it
very clear that no one outside of the agencies can be advised of their
patient status, and no one outside of the HHAs can contact them for any
reason.
We stated in previous rules that Medicare-certified HHAs are
required to contract with an approved HHCAHPS survey vendor. This
requirement continues, and Medicare-certified agencies also must
provide on a monthly basis a list of their patients served to their
respective HHCAHPS survey vendors. Agencies are not allowed to
influence at all how their patients respond to the HHCAHPS survey.
As previously required, HHCAHPS survey vendors are required to
attend introductory and all update trainings conducted by CMS and the
HHCAHPS Survey Coordination Team, as well as to pass a post-training
certification test. We have approximately 30 approved HHCAHPS survey
vendors. The list of approved HHCAHPS survey vendors is available at
https://homehealthcahps.org.
2. HHCAHPS Oversight Activities
We stated in prior final rules that all approved HHCAHPS survey
vendors are required to participate in HHCAHPS oversight activities to
ensure compliance with HHCAHPS protocols, guidelines, and survey
requirements. The purpose of the oversight activities is to ensure that
approved HHCAHPS survey vendors follow the HHCAHPS Protocols and
Guidelines Manual.
In the CY 2013 HH PPS final rule (77 FR 67094, 67164), we codified
the current guideline that all approved HHCAHPS survey vendors fully
comply with all HHCAHPS oversight activities. We included this survey
requirement at Sec. 484.250(c)(3).
3. HHCAHPS Requirements for the CY 2017 APU
For the CY 2017 APU, we require continuous monthly HHCAHPS data
collection and reporting for four quarters. The data collection period
for the CY 2017, APU includes the second quarter 2015 through the first
quarter 2016 (the months of April 2015 through March 2016). HHAs are
required to submit their HHCAHPS data files to the HHCAHPS Data Center
for the second quarter 2015 by 11:59 p.m., EST on October 15, 2015; for
the third quarter 2015 by 11:59 p.m., EST on January 21, 2016; for the
fourth quarter 2015 by 11:59 p.m., EST on April 21, 2016; and for the
first quarter 2016 by 11:59 p.m., EST on July 21, 2016. These deadlines
are firm; no exceptions are permitted.
For the CY 2017 APU, we require that all HHAs with fewer than 60
HHCAHPS-eligible unduplicated or unique patients in the period of April
1, 2014, through March 31, 2015, are exempt from the HHCAHPS data
collection and submission requirements for the CY 2017 APU, upon
completion of the CY 2017 HHCAHPS Participation Exemption Request form,
and upon CMS verification of the HHA patient counts. Agencies with
fewer than 60
[[Page 43779]]
HHCAHPS-eligible, unduplicated or unique patients in the period of
April 1, 2014, through March 31, 2015, are required to submit their
patient counts on the CY 2017 HHCAHPS Participation Exemption Request
form posted on https://homehealthcahps.org from April 1, 2015, to 11:59
p.m., EST to March 31, 2016. This deadline is firm, as are all of the
quarterly data submission deadlines for the HHAs that participate in
HHCAHPS.
We automatically exempt HHAs receiving Medicare certification after
the period in which HHAs do their patient count. HHAs receiving
Medicare-certification on or after April 1, 2015, are exempt from the
HHCAHPS reporting requirement for the CY 2017 APU. These newly-
certified HHAs do not need to complete the HHCAHPS Participation
Exemption Request Form for the CY 2017 APU.
4. HHCAHPS Requirements for the CY 2018 APU
For the CY 2018 APU, we require continuous monthly HHCAHPS data
collection and reporting for four quarters. The data collection period
for the CY 2018, APU includes the second quarter 2016 through the first
quarter 2017 (the months of April 2016 through March 2017). HHAs will
be required to submit their HHCAHPS data files to the HHCAHPS Data
Center for the second quarter 2016 by 11:59 p.m., EST on October 20,
2016; for the third quarter 2016 by 11:59 p.m., EST on January 19,
2017; for the fourth quarter 2016 by 11:59 p.m., EST on April 20, 2017;
and for the first quarter 2017 by 11:59 p.m., EST on July 20, 2017.
These deadlines are firm; no exceptions will be permitted.
For the CY 2018 APU, we require that all HHAs with fewer than 60
HHCAHPS-eligible unduplicated or unique patients in the period of April
1, 2015 through March 31, 2016, are exempt from the HHCAHPS data
collection and submission requirements for the CY 2018 APU, upon
completion of the CY 2018 HHCAHPS Participation Exemption Request form,
and upon CMS verification of the HHA patient counts. Agencies with
fewer than 60 HHCAHPS-eligible, unduplicated or unique patients in the
period of April 1, 2015, through March 31, 2016, are required to submit
their patient counts on the CY 2018 HHCAHPS Participation Exemption
Request form posted on https://homehealthcahps.org from April 1, 2016,
to 11:59 p.m., EST to March 31, 2017. This deadline is firm, as are all
of the quarterly data submission deadlines for the HHAs that
participate in HHCAHPS.
We automatically exempt HHAs receiving Medicare certification after
the period in which HHAs do their patient count. HHAs receiving
Medicare-certification on or after April 1, 2016, are exempt from the
HHCAHPS reporting requirement for the CY 2018 APU. These newly-
certified HHAs do not need to complete the HHCAHPS Participation
Exemption Request Form for the CY 2018 APU.
5. HHCAHPS Requirements for the CY 2019 APU
For the CY 2019 APU, we require continuous monthly HHCAHPS data
collection and reporting for four quarters. The data collection period
for the CY 2018, APU includes the second quarter 2017 through the first
quarter 2018 (the months of April 2017 through March 2018). HHAs will
be required to submit their HHCAHPS data files to the HHCAHPS Data
Center for the second quarter 2017 by 11:59 p.m., EST on October 19,
2017; for the third quarter 2017 by 11:59 p.m., EST on January 18,
2018; for the fourth quarter 2017 by 11:59 p.m., EST on April 19, 2018;
and for the first quarter 2018 by 11:59 p.m., EST on July 19, 2018.
These deadlines are firm; no exceptions will be permitted.
For the CY 2019 APU, we require that all HHAs with fewer than 60
HHCAHPS-eligible unduplicated or unique patients in the period of April
1, 2016 through March 31, 2017, are exempt from the HHCAHPS data
collection and submission requirements for the CY 2019 APU, upon
completion of the CY 2019 HHCAHPS Participation Exemption Request form,
and upon CMS verification of the HHA patient counts. Agencies with
fewer than 60 HHCAHPS-eligible, unduplicated or unique patients in the
period of April 1, 2016, through March 31, 2017, are required to submit
their patient counts on the CY 2019 HHCAHPS Participation Exemption
Request form posted on https://homehealthcahps.org from April 1, 2017,
to 11:59 p.m., EST to March 31, 2018. This deadline is firm, as are all
of the quarterly data submission deadlines for the HHAs that
participate in HHCAHPS.
We automatically exempt HHAs receiving Medicare certification after
the period in which HHAs do their patient count. HHAs receiving
Medicare-certification on or after April 1, 2017, are exempt from the
HHCAHPS reporting requirement for the CY 2019 APU. These newly-
certified HHAs do not need to complete the HHCAHPS Participation
Exemption Request Form for the CY 2019 APU.
6. HHCAHPS Requirements for the CY 2020 APU
For the CY 2020 APU, we require continued monthly HHCAHPS data
collection and reporting for four quarters. The data collection period
for the CY 2020, APU includes the second quarter 2018 through the first
quarter 2019 (the months of April 2018 through March 2019). HHAs will
be required to submit their HHCAHPS data files to the HHCAHPS Data
Center for the second quarter 2018 by 11:59 p.m., EST on October 18,
2018; for the third quarter 2018 by 11:59 p.m., EST on January 17,
2019; for the fourth quarter 2018 by 11:59 p.m., EST on April 18, 2019;
and for the first quarter 2019 by 11:59 p.m., EST on July 19, 2019.
These deadlines are firm; no exceptions will be permitted.
For the CY 2020 APU, we require that all HHAs with fewer than 60
HHCAHPS-eligible unduplicated or unique patients in the period of April
1, 2017, through March 31, 2018, are exempt from the HHCAHPS data
collection and submission requirements for the CY 2020 APU, upon
completion of the CY 2020 HHCAHPS Participation Exemption Request form,
and upon CMS verification of the HHA patient counts. Agencies with
fewer than 60 HHCAHPS-eligible, unduplicated or unique patients in the
period of April 1, 2017, through March 31, 2018, are required to submit
their patient counts on the CY 2020 HHCAHPS Participation Exemption
Request form posted on https://homehealthcahps.org from April 1, 2018,
to 11:59 p.m., EST to March 31, 2019. This deadline is firm, as are all
of the quarterly data submission deadlines for the HHAs that
participate in HHCAHPS.
We automatically exempt HHAs receiving Medicare certification after
the period in which HHAs do their patient count. HHAs receiving
Medicare-certification on or after April 1, 2018 are exempt from the
HHCAHPS reporting requirement for the CY 2020 APU. These newly-
certified HHAs do not need to complete the HHCAHPS Participation
Exemption Request Form for the CY 2020 APU.
7. HHCAHPS Reconsiderations and Appeals Process
HHAs should monitor their respective HHCAHPS survey vendors to
ensure that vendors submit their HHCAHPS data on time, by accessing
their HHCAHPS Data Submission Reports on https://homehealthcahps.org.
This helps HHAs ensure that their data are submitted in the proper
format for data
[[Page 43780]]
processing to the HHCAHPS Data Center.
We continue the OASIS and HHCAHPS reconsiderations and appeals
process that we have finalized and that we have used for prior all
periods cited in the previous rules, and utilized in the CY 2012 to CY
2016 APU determinations. We have described the HHCAHPS reconsiderations
and appeals process requirements in the APU Notification Letter that we
send to the affected HHAs annually in September. HHAs have 30 days from
their receipt of the letter informing them that they did not meet the
HHCAHPS requirements to reply to us with documentation that supports
their requests for reconsideration of the annual payment update to us.
It is important that the affected HHAs send in comprehensive
information in their reconsideration letter/package because we will not
contact the affected HHAs to request additional information or to
clarify incomplete or inconclusive information. If clear evidence to
support a finding of compliance is not present, then the 2 percent
reduction in the annual payment update will be upheld. If clear
evidence of compliance is present, then the 2 percent reduction for the
APU will be reversed. We notify affected HHAs by December 31 of the
decisions that affects payments in the annual year beginning on January
1. If we determine to uphold the 2 percent reduction for the annual
payment update, the affected HHA may further appeal the 2 percent
reduction via the Provider Reimbursement Review Board (PRRB) appeals
process, which is described in the December letter.
8. Summary
We did not propose any changes to the participation requirements,
or to the requirements pertaining to the implementation of the Home
Health CAHPS[supreg] Survey (HHCAHPS). We only updated the information
to reflect the dates for future APU years. We again strongly encourage
HHAs to keep up-to-date about the HHCAHPS by regularly viewing the
official Web site for the HHCAHPS at https://homehealthcahps.org. HHAs
can also send an email to the HHCAHPS Survey Coordination Team at
[email protected] or to CMS at [email protected], or telephone
toll-free (1-866-354-0985) for more information about the HHCAHPS
Survey.
VI. Collection of Information Requirements
While this proposed rule contains information collection
requirements, this rule does not add new, nor revise any of the
existing information collection requirements, or burden estimate. The
information collection requirements discussed in this rule for the
OASIS-C1 data item set had been previously approved by the Office of
Management and Budget (OMB) on February 6, 2014 and scheduled for
implementation on October 1, 2014. The extension of OASIS-C1/ICD-9
version was reapproved under OMB control number 0938-0760 with a
current expiration date of March 31, 2018. This version of the OASIS
will be discontinued once the OASIS-C1/ICD-10 version is approved and
implemented. In addition, to facilitate the reporting of OASIS data as
it relates to the implementation of ICD-10 on October 1, 2015, CMS
submitted a new request for approval to OMB for the OASIS-C1/ICD-10
version under the Paperwork Reduction Act (PRA) process. CMS is
requesting a new OMB control number for the proposed revised OASIS item
as announced in the 30-day Federal Register notice (80 FR 15797). The
new information collection request is currently pending OMB approval.
VII. Response to Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
VIII. Regulatory Impact Analysis
A. Statement of Need
Section 1895(b)(1) of the Act requires the Secretary to establish a
HH PPS for all costs of HH services paid under Medicare. In addition,
section 1895(b)(3)(A) of the Act requires (1) the computation of a
standard prospective payment amount include all costs for HH services
covered and paid for on a reasonable cost basis and that such amounts
be initially based on the most recent audited cost report data
available to the Secretary, and (2) the standardized prospective
payment amount be adjusted to account for the effects of case-mix and
wage levels among HHAs. Section 1895(b)(3)(B) of the Act addresses the
annual update to the standard prospective payment amounts by the HH
applicable percentage increase. Section 1895(b)(4) of the Act governs
the payment computation. Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of
the Act require the standard prospective payment amount to be adjusted
for case-mix and geographic differences in wage levels. Section
1895(b)(4)(B) of the Act requires the establishment of appropriate
case-mix adjustment factors for significant variation in costs among
different units of services. Lastly, section 1895(b)(4)(C) of the Act
requires the establishment of wage adjustment factors that reflect the
relative level of wages, and wage-related costs applicable to HH
services furnished in a geographic area compared to the applicable
national average level.
Section 1895(b)(3)(B)(iv) of the Act provides the Secretary with
the authority to implement adjustments to the standard prospective
payment amount (or amounts) for subsequent years to eliminate the
effect of changes in aggregate payments during a previous year or years
that was the result of changes in the coding or classification of
different units of services that do not reflect real changes in case-
mix. Section 1895(b)(5) of the Act provides the Secretary with the
option to make changes to the payment amount otherwise paid in the case
of outliers because of unusual variations in the type or amount of
medically necessary care. Section 1895(b)(3)(B)(v) of the Act requires
HHAs to submit data for purposes of measuring health care quality, and
links the quality data submission to the annual applicable percentage
increase.
Section 421(a) of the MMA requires that HH services furnished in a
rural area, for episodes and visits ending on or after April 1, 2010,
and before January 1, 2016, receive an increase of 3 percent of the
payment amount otherwise made under section 1895 of the Act. Section
210 of the MACRA amended section 421(a) of the MMA to extend the 3
percent increase to the payment amounts for serviced furnished in rural
areas for episodes and visits ending before January 1, 2018.
Section 3131(a) of the Affordable Care Act mandates that starting
in CY 2014, the Secretary must apply an adjustment to the national,
standardized 60-day episode payment rate and other amounts applicable
under section 1895(b)(3)(A)(i)(III) of the Act to reflect factors such
as changes in the number of visits in an episode, the mix of services
in an episode, the level of intensity of services in an episode, the
average cost of providing care per episode, and other relevant factors.
In addition, section 3131(a) of the Affordable Care Act mandates that
rebasing must be phased-in over a 4-year period in equal increments,
not to exceed 3.5 percent of the amount (or
[[Page 43781]]
amounts) as of the date of enactment (2010) under section
1895(b)(3)(A)(i)(III) of the Act, and be fully implemented in CY 2017.
The HHVBP Model will apply a payment adjustment based on an HHA's
performance on quality measures to test the effects on quality and
costs of care. The HHVBP Model was implemented in January 2016 as
described in the CY 2016 HH PPS final rule.
B. Overall Impact
We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Act, section 202 of the
Unfunded Mandates Reform Act of 1995 (UMRA, March 22, 1995; Pub. L.
104-4), Executive Order 13132 on Federalism (August 4, 1999), and the
Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity).
Section 3(f) of Executive Order 12866 defines a ``significant
regulatory action'' as an action that is likely to result in a rule:
(1) Having an annual effect on the economy of $100 million or more in
any 1 year, or adversely and materially affecting a sector of the
economy, productivity, competition, jobs, the environment, public
health or safety, or state, local or tribal governments or communities
(also referred to as ``economically significant''); (2) creating a
serious inconsistency or otherwise interfering with an action taken or
planned by another agency; (3) materially altering the budgetary
impacts of entitlement grants, user fees, or loan programs or the
rights and obligations of recipients thereof; or (4) raising novel
legal or policy issues arising out of legal mandates, the President's
priorities, or the principles set forth in the Executive Order.
A regulatory impact analysis (RIA) must be prepared for major rules
with economically significant effects ($100 million or more in any 1
year).The net transfer impacts related to the changes in payments under
the HH PPS for CY 2017 are estimated to be -$180 million. The savings
impacts related to the HHVBP model are estimated at a total projected
5-year gross savings of $378 million assuming a very conservative
savings estimate of a 6 percent annual reduction in hospitalizations
and a 1.0 percent annual reduction in SNF admissions. Therefore, we
estimate that this rulemaking is ``economically significant'' as
measured by the $100 million threshold, and hence also a major rule
under the Congressional Review Act. Accordingly, we have prepared a
Regulatory Impact Analysis that to the best of our ability presents the
costs and benefits of the rulemaking. In accordance with the provisions
of Executive Order 12866, this regulation was reviewed by the Office of
Management and Budget.
In addition, section 1102(b) of the Act requires us to prepare a
RIA if a rule may have a significant impact on the operations of a
substantial number of small rural hospitals. This analysis must conform
to the provisions of section 603 of RFA. For purposes of section
1102(b) of the Act, we define a small rural hospital as a hospital that
is located outside of a metropolitan statistical area and has fewer
than 100 beds. This proposed rule is applicable exclusively to HHAs.
Therefore, the Secretary has determined this rule would not have a
significant economic impact on the operations of small rural hospitals.
Executive Order 13563 emphasizes the importance of quantifying both
costs and benefits, of reducing costs, of harmonizing rules, and of
promoting flexibility. The net transfer impacts related to the changes
in payments under the HH PPS for CY 2017 are estimated to be -$180
million. The savings impacts related to the HHVBP Model are estimated
at a total projected 6-year gross savings of $378 million assuming a
very conservative savings estimate of a 6 percent annual reduction in
hospitalizations and a 1.0 percent annual reduction in SNF admissions.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2016, that
threshold is approximately $146 million. This proposed rule is not
anticipated to have an effect on State, local, or tribal governments,
in the aggregate, or on the private sector of $146 million or more.
1. HH PPS
The update set forth in this rule applies to Medicare payments
under HH PPS in CY 2017. Accordingly, the following analysis describes
the impact in CY 2017 only. We estimate that the net impact of the
policies in this rule is approximately $180 million in decreased
payments to HHAs in CY 2017. We applied a wage index budget neutrality
factor and a case-mix weights budget neutrality factor to the rates as
discussed in section III.C.3 of this proposed rule. Therefore, the
estimated impact of the 2017 wage index and the recalibration of the
case-mix weights for 2017 is zero. The -$180 million impact reflects
the distributional effects of the 2.3 percent HH payment update
percentage ($420 million increase), the effects of the fourth year of
the four-year phase-in of the rebasing adjustments to the national,
standardized 60-day episode payment amount, the national per-visit
payment rates, and the NRS conversion factor for an impact of -2.3
percent ($420 million decrease), the effects of the -0.97 percent
adjustment to the national, standardized 60-day episode payment rate to
account for nominal case-mix growth for an impact of -0.9 percent ($160
million decrease), and the effects of the proposed change to the FDL
ratio of 0.45 to 0.56 for an impact of -0.1 percent ($20 million
decrease). The $180 million in decreased payments is reflected in the
last column of the first row in Table 36 as a 1.0 percent decrease in
expenditures when comparing CY 2016 payments to estimated CY 2017
payments.
The RFA requires agencies to analyze options for regulatory relief
of small entities, if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, small entities
include small businesses, nonprofit organizations, and small
governmental jurisdictions. Most hospitals and most other providers and
suppliers are small entities, either by nonprofit status or by having
revenues of less than $7.5 million to $38.5 million in any one year.
For the purposes of the RFA, we estimate that almost all HHAs are small
entities as that term is used in the RFA. Individuals and states are
not included in the definition of a small entity. The economic impact
assessment is based on estimated Medicare payments (revenues) and HHS's
practice in interpreting the RFA is to consider effects economically
``significant'' only if greater than 5 percent of providers reach a
threshold of 3 to 5 percent or more of total revenue or total costs.
The majority of HHAs' visits are Medicare-paid visits and therefore the
majority of HHAs' revenue consists of Medicare payments. Based on our
analysis, we
[[Page 43782]]
conclude that the policies proposed in this rule would result in an
estimated total impact of 3 to 5 percent or more on Medicare revenue
for greater than 5 percent of HHAs. Therefore, the Secretary has
determined that this HH PPS proposed rule would have a significant
economic impact on a substantial number of small entities. Further
detail is presented in Table 39, by HHA type and location.
With regards to options for regulatory relief, we note that in the
CY 2014 HH PPS final rule we finalized rebasing adjustments to the
national, standardized 60-day episode rate, non-routine supplies (NRS)
conversion factor, and the national per-visit payment rates for each
year, 2014 through 2017 as described in section II.C and III.C.3 of
this proposed rule. Since the rebasing adjustments are mandated by
section 3131(a) of the Affordable Care Act, we cannot offer HHAs relief
from the rebasing adjustments for CY 2017. For the 0.97 percent
reduction to the national, standardized 60-day episode payment amount
for CY 2017 described in section III.C.3 of this proposed rule, we
believe it is appropriate to reduce the national, standardized 60-day
episode payment amount to account for the estimated increase in nominal
case-mix in order to move towards more accurate payment for the
delivery of home health services where payments better align with the
costs of providing such services. In the alternatives considered
section for the CY 2016 HH PPS proposed rule (80 FR 39839), we note
that we considered reducing the 60-day episode rate in CY 2016 only to
account for nominal case-mix growth between CY 2012 and CY 2014.
However, we instead finalized a reduction to the 60-day episode rate
over a three-year period (CY 2016, CY 2017, and CY 2018) to account for
estimated nominal case-mix growth between CY 2012 and CY 2014 in order
to lessen the impact on HHAs in a given year (80 FR 68646).
Executive Order 13563 specifies, to the extent practicable,
agencies should assess the costs of cumulative regulations. However,
given potential utilization pattern changes, wage index changes,
changes to the market basket forecasts, and unknowns regarding future
policy changes, we believe it is neither practicable nor appropriate to
forecast the cumulative impact of the rebasing adjustments on Medicare
payments to HHAs for future years at this time. Changes to the Medicare
program may continue to be made as a result of the Affordable Care Act,
or new statutory provisions. Although these changes may not be specific
to the HH PPS, the nature of the Medicare program is such that the
changes may interact, and the complexity of the interaction of these
changes would make it difficult to predict accurately the full scope of
the impact upon HHAs for future years beyond CY 2017. We note that the
rebasing adjustments to the national, standardized 60-day episode
payment rate and the national per-visit rates are capped at the
statutory limit of 3.5 percent of the CY 2010 amounts (as described in
the preamble in section II.C. of this proposed rule) for each year,
2014 through 2017. The NRS rebasing adjustment will be -2.82 percent in
each year, 2014 through 2017.
2. HHVBP Model
Under the HHVBP Model, the first payment adjustment will apply in
CY 2018 based on PY1 (CY 2016) data and the final payment adjustment
will apply in CY 2022 based on PY5 (CY 2020) data. In the CY 2016 HH
PPS final rule, the overall impact of HHVBP Model from CY 2018-CY 2022
was approximately a reduction of $380 million. That estimate was based
on the five performance years of the Model and only two payment
adjustment years. We now estimate that this will be approximately a
decrease of $378 million. This estimate represents the five performance
years (CY 2016-CY 2020) and applying the payment adjustments from CY
2018 through CY 2021. We assume that the behavior changes and savings
will continue into 2021 because HHAs will continue to receive quality
reports until July 2021. Although behavior changes and savings could
persist into CY 2022, HHAs would not be receiving quality reports so we
did not include it in our savings assumptions.
C. Detailed Economic Analysis
1. HH PPS
This rule proposes updates for CY 2017 to the HH PPS rates
contained in the CY 2016 HH PPS final rule (80 FR 68624 through 68719).
The impact analysis of this proposed rule presents the estimated
expenditure effects of policy changes proposed in this rule. We use the
latest data and best analysis available, but we do not make adjustments
for future changes in such variables as number of visits or case-mix.
This analysis incorporates the latest estimates of growth in
service use and payments under the Medicare HH benefit, based primarily
on Medicare claims data from 2015. We note that certain events may
combine to limit the scope or accuracy of our impact analysis, because
such an analysis is future-oriented and, thus, susceptible to errors
resulting from other changes in the impact time period assessed. Some
examples of such possible events are newly-legislated general Medicare
program funding changes made by the Congress, or changes specifically
related to HHAs. In addition, changes to the Medicare program may
continue to be made as a result of the Affordable Care Act, or new
statutory provisions. Although these changes may not be specific to the
HH PPS, the nature of the Medicare program is such that the changes may
interact, and the complexity of the interaction of these changes could
make it difficult to predict accurately the full scope of the impact
upon HHAs.
Table 36 represents how HHA revenues are likely to be affected by
the policy changes proposed in this rule. For this analysis, we used an
analytic file with linked CY 2015 OASIS assessments and HH claims data
for dates of service that ended on or before December 31, 2015 (as of
March 31, 2016). The first column of Table 36 classifies HHAs according
to a number of characteristics including provider type, geographic
region, and urban and rural locations. The second column shows the
number of facilities in the impact analysis. The third column shows the
payment effects of the CY 2017 wage index. The fourth column shows the
payment effects of the CY 2016 case-mix weights. The fifth column shows
the effects the 0.97 percent reduction to the national, standardized
60-day episode payment amount to account for nominal case-mix growth.
The sixth column shows the effects of the rebasing adjustments to the
national, standardized 60-day episode payment rate, the national per-
visit payment rates, and NRS conversion factor. For CY 2017, the
average impact for all HHAs due to the effects of rebasing is an
estimated 2.3 percent decrease in payments. The seventh column shows
the effects of revising the FDL ratio used to compute outlier payments
from 0.45 to 0.56. The eighth column shows the effects of the change to
the outlier methodology. The ninth column shows the effects of the CY
2017 home health payment update percentage.
The last column shows the combined effects of all the policies
proposed in this rule. Overall, it is projected that aggregate payments
in CY 2017 would decrease by 1.0 percent. As illustrated in Table 36,
the combined effects of all of the changes vary by specific types of
providers and by location. We note that some individual HHAs within the
same
[[Page 43783]]
group may experience different impacts on payments than others due to
the distributional impact of the CY 2017 wage index, the extent to
which HHAs had episodes in case-mix groups where the case-mix weight
decreased for CY 2017 relative to CY 2016, the percentage of total HH
PPS payments that were subject to the low-utilization payment
adjustment (LUPA) or paid as outlier payments, and the degree of
Medicare utilization.
Table 36-- Estimated Home Health Agency Impacts by Facility Type and Area of the Country, CY 2017
--------------------------------------------------------------------------------------------------------------------------------------------------------
60-day
episode HH
CY 2017 CY 2017 rate Revised Revised payment
Number of wage index case-mix nominal Rebas-ing outlier outlier update Total %
Agencies \1\ % weights case-mix \4\ % FDL % method- percentage
\2\ % reduct-ion ology % \5\ %
\3\ %
--------------------------------------------------------------------------------------------------------------------------------------------------------
All Agencies................................ 11,167 0.0 0.0 -0.9 -2.3 -0.1 0.0 2.3 -1.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Facility Type and Control
--------------------------------------------------------------------------------------------------------------------------------------------------------
Free-Standing/Other Vol/NP.................. 1,087 -0.2 -0.1 -0.9 -2.2 -0.1 0.9 2.3 -0.3
Free-Standing/Other Proprietary............. 8,715 0.1 0.0 -0.9 -2.3 -0.1 -0.3 2.3 -1.2
Free-Standing/Other Government.............. 362 0.1 0.1 -0.9 -2.2 -0.1 0.3 2.3 -0.4
Facility-Based Vol/NP....................... 690 -0.1 -0.1 -0.9 -2.2 -0.1 0.8 2.3 -0.3
Facility-Based Proprietary.................. 109 0.0 0.0 -0.9 -2.2 -0.1 0.4 2.3 -0.5
Facility-Based Government................... 204 -0.3 0.0 -0.9 -2.3 -0.1 0.8 2.3 -0.5
Subtotal: Freestanding.................. 10,164 0.0 0.0 -0.9 -2.3 -0.1 -0.1 2.3 -1.1
Subtotal: Facility-based................ 1,003 -0.1 0.0 -0.9 -2.2 -0.1 0.8 2.3 -0.2
Subtotal: Vol/NP........................ 1,777 -0.2 -0.1 -0.9 -2.2 -0.1 0.9 2.3 -0.3
Subtotal: Proprietary................... 8,824 0.1 0.0 -0.9 -2.3 -0.1 -0.3 2.3 -1.2
Subtotal: Government.................... 566 -0.1 0.1 -0.9 -2.3 -0.1 0.5 2.3 -0.5
--------------------------------------------------------------------------------------------------------------------------------------------------------
Facility Type and Control: Rural
--------------------------------------------------------------------------------------------------------------------------------------------------------
Free-Standing/Other Vol/NP.................. 279 0.1 0.1 -0.9 -2.2 -0.1 0.8 2.3 0.1
Free-Standing/Other Proprietary............. 873 0.0 -0.1 -0.9 -2.3 -0.1 0.2 2.3 -0.9
Free-Standing/Other Government.............. 261 0.2 0.0 -0.9 -2.4 -0.1 -0.2 2.3 -1.1
Facility-Based Vol/NP....................... 333 0.3 0.1 -0.9 -2.2 -0.1 0.5 2.3 0.0
Facility-Based Proprietary.................. 54 -0.1 0.1 -0.9 -2.3 -0.1 0.5 2.3 -0.5
Facility-Based Government................... 152 0.1 0.2 -0.9 -2.2 -0.1 0.4 2.3 -0.2
--------------------------------------------------------------------------------------------------------------------------------------------------------
Facility Type and Control: Urban
--------------------------------------------------------------------------------------------------------------------------------------------------------
Free-Standing/Other Vol/NP.................. 807 -0.3 -0.2 -0.9 -2.2 -0.1 0.9 2.3 -0.5
Free-Standing/Other Proprietary............. 7,837 0.1 0.0 -0.9 -2.3 -0.1 -0.4 2.3 -1.3
Free-Standing/Other Government.............. 101 0.0 0.0 -0.9 -2.3 -0.1 0.2 2.3 -0.8
Facility-Based Vol/NP....................... 357 -0.2 -0.1 -0.9 -2.2 -0.1 0.9 2.3 -0.3
Facility-Based Proprietary.................. 55 0.1 -0.1 -0.9 -2.2 -0.1 0.3 2.3 -0.6
Facility-Based Government................... 52 -0.6 -0.1 -0.9 -2.3 -0.1 1.1 2.3 -0.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
Facility Location: Urban or Rural
--------------------------------------------------------------------------------------------------------------------------------------------------------
Rural....................................... 1,952 0.2 0.0 -0.9 -2.3 -0.1 0.0 2.3 -0.8
Urban....................................... 9,209 0.0 0.0 -0.9 -2.3 -0.1 0.0 2.3 -1.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Facility Location: Region of the Country
--------------------------------------------------------------------------------------------------------------------------------------------------------
Northeast................................... 848 -0.4 0.0 -0.9 -2.1 -0.1 0.8 2.3 -0.4
Midwest..................................... 2,992 0.0 0.0 -0.9 -2.4 -0.1 0.4 2.3 -0.7
South....................................... 5,310 -0.1 0.0 -0.9 -2.3 -0.1 -0.6 2.3 -1.7
West........................................ 1,968 0.6 0.0 -0.9 -2.3 -0.1 0.3 2.3 -0.1
Other....................................... 49 -0.3 0.1 -0.9 -2.2 -0.1 0.9 2.3 -0.2
Puerto Rico................................. 41 -0.5 0.1 -0.8 -2.2 -0.1 0.5 2.3 -0.7
--------------------------------------------------------------------------------------------------------------------------------------------------------
Facility Location: Region of the Country (Census Region)
--------------------------------------------------------------------------------------------------------------------------------------------------------
New England................................. 347 -0.7 0.1 -0.9 -2.1 -0.1 0.3 2.3 -1.1
Mid Atlantic................................ 501 -0.3 -0.1 -0.9 -2.1 -0.1 1.1 2.3 -0.1
East North Central.......................... 2,271 0.0 0.1 -0.9 -2.4 -0.1 0.4 2.3 -0.6
West North Central.......................... 721 0.0 -0.1 -0.9 -2.3 -0.1 0.6 2.3 -0.5
South Atlantic.............................. 1,791 -0.3 -0.1 -0.9 -2.3 -0.1 -0.6 2.3 -2.0
East South Central.......................... 426 -0.1 0.0 -0.9 -2.4 -0.1 0.0 2.3 -1.1
West South Central.......................... 3,093 0.3 0.0 -0.9 -2.3 -0.1 -0.8 2.3 -1.5
Mountain.................................... 672 0.2 0.1 -0.9 -2.3 -0.1 -0.2 2.3 -0.9
Pacific..................................... 1,296 0.7 0.0 -0.9 -2.3 -0.1 0.6 2.3 0.3
--------------------------------------------------------------------------------------------------------------------------------------------------------
Facility Size (Number of 1st Episodes)
--------------------------------------------------------------------------------------------------------------------------------------------------------
<100 episodes............................... 3,177 0.0 0.3 -0.9 -2.3 -0.1 0.4 2.3 -0.3
100 to 249.................................. 2,733 0.1 0.2 -0.9 -2.4 -0.1 0.1 2.3 -0.7
250 to 499.................................. 2,342 0.1 0.0 -0.9 -2.3 -0.1 0.0 2.3 -0.9
500 to 999.................................. 1,597 0.0 0.0 -0.9 -2.3 -0.1 -0.1 2.3 -1.1
1,000 or More............................... 1,318 0.0 -0.1 -0.9 -2.3 -0.1 0.0 2.3 -1.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: CY 2015 Medicare claims data for episodes ending on or before December 31, 2015 (as of December 31, 2015) for which we had a linked OASIS
assessment.
\1\ The impact of the CY 2017 home health wage index is offset by the wage index budget neutrality factor described in section III.C.3 of this proposed
rule.
\2\ The impact of the CY 2017 home health case-mix weights reflects the recalibration of the case-mix weights as outlined in section III.B of this
proposed rule offset by the case-mix weights budget neutrality factor described in section III.C.3 of this proposed rule.
[[Page 43784]]
\3\ The 0.97 percent reduction to the national, standardized 60-day episode payment amount in CY 2017 is estimated to have a 0.9 percent impact on
overall HH PPS expenditures.
\4\ The impact of rebasing includes the rebasing adjustments to the national, standardized 60-day episode payment rate (-2.74 percent after the CY 2017
payment rate was adjusted for the wage index and case-mix weight budget neutrality factors and the nominal case-mix reduction), the national per-visit
rates (+2.9 percent), and the NRS conversion factor (-2.82 percent). The estimated impact of the NRS conversion factor rebasing adjustment is an
overall -0.01 percent decrease in estimated payments to HHAs
\4\ The CY 2017 home health payment update percentage reflects the home health market basket update of 2.8 percent, reduced by a 0.5 percentage point
multifactor productivity (MFP) adjustment as required under section 1895(b)(3)(B)(vi)(I) of the Act, as described in section III.C.1 of this proposed
rule.
Region Key:
New England = Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont;
Middle Atlantic = Pennsylvania, New Jersey, New York;
South Atlantic = Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia;
East North Central = Illinois, Indiana, Michigan, Ohio, Wisconsin;
East South Central = Alabama, Kentucky, Mississippi, Tennessee;
West North Central = Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota;
West South Central = Arkansas, Louisiana, Oklahoma, Texas;
Mountain = Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming;
Pacific = Alaska, California, Hawaii, Oregon, Washington;
Other = Guam, Puerto Rico, Virgin Islands
2. HHVBP Model
Table 37 displays our analysis of the distribution of possible
payment adjustments at the 3-percent, 5-percent, 6-percent, 7-percent,
and 8-percent rates that are being used in the Model using the 2013 and
2014 OASIS measures, hospitalization measure and Emergency Department
(ED) measure from QIES, and Home Health CAHPS data. The impacts below
also account for the proposals to change the smaller-volume cohort size
determination, calculate achievement threshold and benchmark proposals
at the state level, and revise the applicable measures. We determined
the distribution of possible payment adjustments based on ten (10)
OASIS quality measures, two (2) claims-based measures in QIES, the
three (3)New Measures (with the assumption that all HHAs reported on
all New Measures and received full points), and QIES Roll Up File data
in the same manner as they would be in the Model. The five (5) HHCAHPS
measures are based on archived data. The size of the cohorts were
determined using the 2014 Quality Episode File based on OASIS
assessments (the Model will use the year before each performance year),
whereby the HHAs reported at least five measures with over 20
observations. The basis of the payment adjustment was derived from
complete 2014 claims data. We note that this impact analysis is based
on the aggregate value of all nine (9) selected states.
Table 38 displays our analysis of the distribution of possible
payment adjustments based on the same 2013-2014 data used to calculate
Table 37, providing information on the estimated impact of this
proposed rule. We note that this impact analysis is based on the
aggregate value of all nine (9) selected states. All Medicare-certified
HHAs that provide services in Massachusetts, Maryland, North Carolina,
Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee are
required to compete in this Model. Value-based incentive payment
adjustments for the estimated 1,900 plus HHAs in the selected states
that compete in the HHVBP Model are stratified by size as described in
this proposed rule. Under the proposal described, there must be a
minimum of eight (8) HHAs in any cohort.
Those HHAs that are in states that do not have at least eight small
HHAs would not have a smaller-volume cohort and thus there would only
be one cohort that would include all the HHAS in that state. As
indicated in Table 38, under this proposal, Massachusetts, Maryland,
North Carolina, Tennessee and Washington would only have one cohort and
Florida, Arizona, Iowa, Nebraska would have a smaller-volume cohort and
a larger-volume cohort. For example, Iowa has 29 HHAs eligible to be
exempt from being required to have their beneficiaries complete HHCAHPS
surveys because they provided HHA services to less than 60
beneficiaries in 2013. Therefore, those 29 HHAs would be competing in
Iowa's smaller-volume cohort if the performance year was 2014.
Using 2013-2014 data and the payment adjustment of 5-percent (as
applied in CY 2019), based on the ten (10) OASIS quality measures, two
(2) claims-based measures in QIES, the five (5) HHCAHPS measures (based
on the archived data), and the three (3) New Measures (with the
assumption that all HHAs submitted data), Table 38 illustrates that
smaller-volume HHAs in Iowa would have a mean payment adjustment of
positive 0.62 percent and the payment adjustment ranges from -2.3
percent at the 10th percentile to +3.8 percent at the 90th percentile.
As a result of using the OASIS quality and claims-based measures, the
same source data (from QIES rather than archived data) that the Model
will use for implementation, and adding the assumption that all HHAs
will submit data for each of the New Measures when calculating the
payment adjustments, the range of payment adjustments for all cohorts
in this proposed rule is lower than that was included in HH PPS 2016
rule. This difference is largely due to the lowered variation in TPS
caused by the assumption that all HHAs will submit data for each of the
New Measures.
Table 39 provides the payment adjustment distribution based on
proportion of dually-eligible beneficiaries, average case mix (using
HCC scores), proportion that reside in rural areas, as well as HHA
organizational status. Besides the observation that higher proportion
of dually-eligible beneficiaries serviced is related to better
performance, the payment adjustment distribution is consistent with
respect to these four categories.
The payment adjustment percentages were calculated at the state and
size level so that each HHA's payment adjustment was calculated as it
would be in the Model. Hence, the values of each separate analysis in
the tables are representative of what they would be if the baseline
year was 2013 and the performance year was 2014. There were 1,839 HHAs
in the nine selected states out of 1,991 HHAs that were found in the
HHA data sources that yielded a sufficient number of measures to
receive a payment adjustment in the Model. It is expected that a
certain number of HHAs will not be subject to the payment adjustment
because they may be servicing too small of a population to report on an
adequate number of measures to calculate a TPS.
[[Page 43785]]
Table 37--HHVBP Model: Adjustment Distribution by Percentile Level of Quality Total Performance Score at Different Model Payment Adjustment Rates
[Percentage]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Payment adjustment distribution Range 10% 20% 30% 40% Median 60% 70% 80% 90%
--------------------------------------------------------------------------------------------------------------------------------------------------------
3% Payment Adjustment For Performance year 1 of the Model..... 3.08 -1.23 -0.87 -0.56 -0.30 -0.02 0.27 0.61 1.11 1.85
5% Payment Adjustment For Performance year 2 of the Model..... 5.12 -2.04 -1.45 -0.94 -0.50 -0.03 0.46 1.01 1.85 3.08
6% Payment Adjustment For Performance year 3 of the Model..... 6.15 -2.45 -1.74 -1.13 -0.61 -0.04 0.55 1.21 2.22 3.70
7% Payment Adjustment For Performance year 4 of the Model..... 7.18 -2.86 -2.03 -1.32 -0.71 -0.04 0.64 1.42 2.59 4.32
8% Payment Adjustment For Performance year 5 of the Model..... 8.25 -3.27 -2.32 -1.50 -0.81 -0.05 0.73 1.62 2.96 4.93
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 38--HHVBP Model: HHA Cohort Payment Adjustment Distributions by State/Cohort
[Based on a 5-percent payment adjustment]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Average
COHORT # of payment 10% 20% 30% 40% Median 60% 70% 80% 90%
HHA adj. (%)
--------------------------------------------------------------------------------------------------------------------------------------------------------
HHA Cohort in States with no small cohorts (percent)
--------------------------------------------------------------------------------------------------------------------------------------------------------
MA................................................. 127 0.00 -2.20 -1.50 -1.10 -0.70 -0.30 0.00 0.80 1.40 2.70
MD................................................. 53 0.56 -1.50 -1.10 -0.80 -0.10 0.20 0.50 1.40 2.00 3.60
NC................................................. 172 0.16 -1.90 -1.50 -1.00 -0.50 0.10 0.50 0.90 1.70 2.40
TN................................................. 135 0.36 -2.00 -1.30 -0.80 -0.40 -0.10 0.30 0.90 2.00 3.10
WA................................................. 59 0.71 -1.70 -0.70 -0.30 0.20 0.50 0.80 1.70 2.30 2.90
--------------------------------------------------------------------------------------------------------------------------------------------------------
Smaller-volume HHA Cohort in states with small cohort (percent)
--------------------------------------------------------------------------------------------------------------------------------------------------------
AZ small........................................... 9 0.53 -1.20 -0.70 -0.70 -0.50 -0.30 -0.10 0.60 0.90 5.00
FL small........................................... 130 -0.14 -2.20 -1.70 -1.20 -0.60 -0.20 0.10 0.40 1.20 1.80
IA small........................................... 29 0.62 -2.30 -1.10 -0.80 0.00 0.30 0.90 1.70 2.30 3.80
NE small........................................... 16 0.48 -1.70 -1.60 -1.20 -0.60 -0.40 1.30 2.20 2.40 4.00
--------------------------------------------------------------------------------------------------------------------------------------------------------
Larger-volume HHA Cohort in states with small cohorts (percent)
--------------------------------------------------------------------------------------------------------------------------------------------------------
AZ large........................................... 112 -0.06 -2.20 -1.50 -1.10 -0.70 -0.30 0.10 0.50 1.30 2.30
FL large........................................... 889 0.37 -2.10 -1.50 -0.90 -0.40 0.00 0.60 1.30 2.20 3.30
IA large........................................... 107 -0.21 -2.30 -1.60 -1.30 -0.70 -0.20 0.10 0.50 1.00 1.80
NE large........................................... 49 0.31 -1.80 -1.20 -0.90 -0.60 -0.10 0.30 0.70 1.80 3.70
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 39--PAYMENT ADJUSTMENT DISTRIBUTIONS BY CHARACTERISTICS
[Based on a 5-percent payment adjustment]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Average
COHORT # of payment 10% 20% 30% 40% Median 60% 70% 80% 90%
HHA adj. (%)
--------------------------------------------------------------------------------------------------------------------------------------------------------
Low % Dually-eligible.............................. 621 0.18 -1.80 -1.30 -0.90 -0.50 0.00 0.40 0.90 1.50 2.50
Medium % Dually-eligible........................... 841 -0.15 -2.20 -1.70 -1.20 -0.80 -0.40 0.00 0.50 1.20 2.20
High % Dually-eligible............................. 416 1.21 -1.80 -0.80 -0.20 0.50 1.10 1.80 2.60 3.30 4.20
Low acuity......................................... 459 0.97 -1.70 -1.00 -0.40 0.10 0.70 1.30 2.10 2.90 4.00
Mid acuity......................................... 1089 0.83 -2.10 -1.50 -1.00 -0.60 -0.10 0.30 0.80 1.50 2.60
High acuity........................................ 338 -0.16 -2.10 -1.60 -1.30 -0.90 -0.50 -0.10 0.50 1.30 2.40
All non-rural...................................... 989 0.57 -2.10 -1.50 -0.90 -0.40 0.10 1.00 1.80 2.70 3.80
Up to 35% rural.................................... 141 0.01 -2.10 -1.50 -1.10 -0.60 -0.20 0.20 0.70 1.40 2.30
Over 35% rural..................................... 172 0.54 -1.80 -1.30 -0.90 -0.50 0.00 0.50 1.10 1.70 2.90
Church............................................. 62 0.80 -1.70 -0.90 -0.80 0.10 0.40 1.10 1.70 2.60 3.70
Private NP......................................... 168 0.22 -1.90 -1.30 -0.90 -0.30 0.10 0.50 0.90 1.70 2.50
Other.............................................. 84 0.40 -1.60 -1.10 -0.70 -0.40 0.20 0.60 1.00 1.80 2.60
Private FP......................................... 1315 0.20 -2.10 -1.50 -1.00 -0.60 -0.10 0.30 1.00 1.90 3.10
Federal............................................ 72 0.37 -2.20 -1.60 -1.10 -0.40 0.20 0.60 1.40 2.10 2.80
State.............................................. 5 -0.39 -2.50 -1.90 -1.40 -0.50 0.30 0.50 0.60 0.80 1.00
Local.............................................. 57 0.50 -1.50 -1.10 -0.70 0.00 0.30 0.60 0.90 1.40 2.40
--------------------------------------------------------------------------------------------------------------------------------------------------------
D. Alternatives Considered
As described in the CY 2016 HH PPS proposed rule (80 FR 39911), we
considered proposing to reduce the national, standardized 60-day
episode payment rate by 3.41 percent in CY 2016 to account for nominal
case-mix growth between CY 2012 and CY 2014. If we were to reduce the
national, standardized 60-day episode payment rate by 3.41 percent, we
estimated that the aggregate impact would have been a decrease of $600
million in payments to HHAs. However, instead of implementing a one-
time reduction in the national, standardized 60-day episode payment
rate of 3.41 percent in CY 2016 to account for nominal case-mix growth
from CY 2012 through CY 2014, we finalized a reduction to the national,
standardized 60-day episode payment rate of 0.97 percent in CY 2016, CY
2017, and CY 2018 to account for nominal case-mix growth from CY 2012
through CY 2014 (80 FR 68646). Since the 0.97 percent reduction to the
national, standardized 60-day episode payment rate to account for
nominal case-mix growth from 2012 to 2014 was finalized in the CY 2016
HH PPS final
[[Page 43786]]
rule, we did not consider alternatives to implementing this reduction
for CY 2017.
Section 3131(a) of the Affordable Care Act mandates that starting
in CY 2014, the Secretary must apply an adjustment to the national,
standardized 60-day episode payment rate and other amounts applicable
under section 1895(b)(3)(A)(i)(III) of the Act to reflect factors such
as changes in the number of visits in an episode, the mix of services
in an episode, the level of intensity of services in an episode, the
average cost of providing care per episode, and other relevant factors.
In addition, section 3131(a) of the Affordable Care Act mandates that
rebasing must be phased-in over a 4-year period in equal increments,
not to exceed 3.5 percent of the amount (or amounts) as of the date of
enactment (2010) under section 1895(b)(3)(A)(i)(III) of the Act, and be
fully implemented in CY 2017. Therefore, in the CY 2014 HH PPS final
rule (78 FR 77256), we finalized rebasing adjustments to the national,
standardized 60-day episode payment amount, the national per-visit
rates and the NRS conversion factor. As we noted in the CY 2014 HH PPS
final rule, because section 3131(a) of the Affordable Care Act requires
a four year phase-in of rebasing, in equal increments, to start in CY
2014 and be fully implemented in CY 2017, we do not have the discretion
to delay, change, or eliminate the rebasing adjustments once we have
determined that rebasing is necessary (78 FR 72283).
Section 1895(b)(3)(B) of the Act requires that the standard
prospective payment amounts for CY 2016 be increased by a factor equal
to the applicable HH market basket update for those HHAs that submit
quality data as required by the Secretary. For CY 2016, section 3401(e)
of the Affordable Care Act, requires that, in CY 2015 (and in
subsequent calendar years), the market basket update under the HHA
prospective payment system, as described in section 1895(b)(3)(B) of
the Act, be annually adjusted by changes in economy-wide productivity.
Beginning in CY 2015, section 1895(b)(3)(B)(vi)(I) of the Act, as
amended by section 3401(e) of the Affordable Care Act, requires the
application of the productivity adjustment described in section
1886(b)(3)(B)(xi)(II) of the Act to the HHA PPS for CY 2015 and each
subsequent CY. The -0.5 percentage point productivity adjustment to the
proposed CY 2017 home health market basket update (2.8 percent), is
discussed in the preamble of this rule and is not discretionary as it
is a requirement in section 1895(b)(3)(B)(vi)(I) of the Act (as amended
by the Affordable Care Act).
With regards to payments made under the HH PPS for high-cost
``outlier'' episodes of care (that is, episodes of care with unusual
variations in the type or amount of medically necessary care), we did
not consider maintaining the fixed-dollar loss (FDL) ratio at 0.45 in
section III.D.3 of this proposed rule because simulations using CY 2015
utilization data (that is, home health claims data) the proposed CY
2017 HH PPS payment rates resulted in an estimated 2.58 percent of
total HH PPS payments being paid as outlier payments using the existing
methodology (cost-per-visit) for calculating the cost of an episode of
care. Likewise, simulations using CY 2015 utilization data (that is,
home health claims data) the proposed CY 2017 HH PPS payment rates
resulted in an estimated 3.10 percent of total HH PPS payments being
paid as outlier payments using the proposed methodology (cost-per-unit)
for calculating the cost of an episode of care. The FDL ratio and the
loss-sharing ratio must be selected so that the estimated outlier
payments do not exceed the 2.5 percent of total HH PPS payments (as
required by section 1895(b)(5)(A) of the Act). We did not consider
proposing a change to the loss-sharing ratio (0.80) in order for the HH
PPS to remain consistent with payment for high-cost outliers in other
Medicare payment systems (for example, IRF PPS, IPPS, etc.)
With regards to the methodology used to calculate the cost of an
episode of care in order to determine the payment amount under the HH
PPS for high-cost ``outliers'' (that is, episodes of care with unusual
variations in the type or amount of medically necessary care), in
section III.D.2, we considered maintaining the current methodology used
to calculate the cost of an episode of care (cost-per-visit). However,
due to the findings from the home health study required as a result of
section 3131(d) of the Affordable Care Act (as discussed in section
III.D.2 of this proposed rule and in the CY 2016 HH PPS proposed rule
(80 FR 39864), we believe that the proposed methodology change (cost-
per-unit) helps to alleviate financial disincentives for providers to
treat medically complex beneficiaries who require longer visits. Since
the projection of the percentage of outlier dollars is the same as
before the change, the impact of this proposal is budget neutral.
As described in Section III.E of this proposed rule, the
Consolidated Appropriations Act of 2016 (Pub. L 114-113) amends both
Section 1834 of the Act (42 U.S.C. 1395m) and Section 1861(m)(5) of the
Act (42 U.S.C. 1395x(m)(5)), requiring a separate payment to a HHA for
an applicable disposable device when furnished on or after January 1,
2017, to an individual who receives home health services for which
payment is made under the Medicare home health benefit. Therefore, we
do not have the discretion to delay or eliminate the implementation of
a separate payment amount for NPWT performed using a disposable device
and thus we did not consider any alternatives regarding this proposal.
We invite comments on the alternatives discussed in this analysis.
E. Accounting Statement and Table
As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars_a004_a-4), in Table 40, we have
prepared an accounting statement showing the classification of the
transfers and costs associated with the HH PPS provisions of this
proposed rule. Table 40 provides our best estimate of the decrease in
Medicare payments under the HH PPS as a result of the changes presented
in this proposed rule for the HH PPS provisions.
Table 40--Accounting Statement: HH PPS Classification of Estimated
Transfers and Costs, From the CYs 2016 to 2017 *
------------------------------------------------------------------------
Category Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............ -$180 million.
From Whom to Whom? Federal Government to HHAs.
------------------------------------------------------------------------
Table 41 provides our best estimate of the decrease in Medicare
payments under the HHVBP Model as a result of the proposed changes
presented in this proposed rule for the HHVBP Model.
Table 41--Accounting Statement: HHVBP Model Classification of Estimated
Cost Savings for CY 2016-2021
------------------------------------------------------------------------
Category Savings
------------------------------------------------------------------------
6-Year Gross Savings...................... -$378 million.
Medicare Payments......................... Hospitals and SNFs.
------------------------------------------------------------------------
F. Conclusion
1. HH PPS
In conclusion, we estimate that the net impact of the HH PPS
policies in this rule is a decrease of 1.0 percent, or $180 million, in
Medicare payments to
[[Page 43787]]
HHAs for CY 2017. The -$180 million impact reflects the effects of the
2.3 percent CY 2017 HH payment update percentage ($420 million
increase), a 0.9 percent decrease in payments due to the 0.97 percent
reduction to the national, standardized 60-day episode payment rate in
CY 2016 to account for nominal case-mix growth from 2012 through 2014
($160 million decrease), the 0.1 percent decrease in payments due to
the change to the FDL ratio ($20 million decrease), and a 2.3 percent
decrease in in payments due to the third year of the 4-year phase-in of
the rebasing adjustments required by section 3131(a) of the Affordable
Care Act ($420 million decrease).
This analysis, together with the remainder of this preamble,
provides an initial Regulatory Flexibility Analysis.
2. HHVBP Model
In conclusion, we estimate there would be no net impact (to include
either a net increase or reduction in payments) in this proposed rule
in Medicare payments to HHAs competing in the HHVBP Model for CY 2017.
However, the overall economic impact of the HHVBP Model provision is an
estimated $378 million in total savings from a reduction in unnecessary
hospitalizations and SNF usage as a result of greater quality
improvements in the home health industry over the life of the HHVBP
Model. The financial estimates were based on the analysis of hospital,
home health and skilled nursing facility claims data from nine states
using the most recent 2014 Medicare claims data. A study published in
2002 by the Journal of the American Geriatric Society (JAGS),
``Improving patient outcomes of home health care: findings from two
demonstration trials of outcome-based quality improvement,'' formed the
basis for CMMI's projections.\127\ That study observed a
hospitalization relative rate of decline of 22-percent to 26-percent
over the 3-year and 4-year demonstration periods (the 1st year of each
being the base year) for the national and New York trials. CMMI assumed
a conservative savings estimate of up to a 6-percent ultimate annual
reduction in hospitalizations and up to a 1.0-percent ultimate annual
reduction in SNF admissions and took into account costs incurred from
the beneficiary remaining in the HHA if the hospitalization did not
occur; resulting in total projected six performance year gross savings
of $378 million. Based on the JAGS study, which observed
hospitalization reductions of over 20-percent, the 6-percent ultimate
annual hospitalization reduction assumptions are considered reasonable.
---------------------------------------------------------------------------
\127\ Shaughnessy, et al. ``Improving patient outcomes of home
health care: findings from two demonstration trials of outcome-based
quality improvement,'' available at http://www.ncbi.nlm.nih.gov/pubmed/12164991.
---------------------------------------------------------------------------
IX. Federalism Analysis
Executive Order 13132 on Federalism (August 4, 1999) establishes
certain requirements that an agency must meet when it promulgates a
final rule that imposes substantial direct requirement costs on state
and local governments, preempts state law, or otherwise has Federalism
implications. We have reviewed this proposed rule under the threshold
criteria of Executive Order 13132, Federalism, and have determined that
it will not have substantial direct effects on the rights, roles, and
responsibilities of states, local or tribal governments.
List of Subjects
42 CFR part 409
Health facilities, Medicare
42 CFR Part 484
Health facilities, Health professions, Medicare, and Reporting and
recordkeeping requirements.
For the reasons set forth in the preamble, the Centers for Medicare
& Medicaid Services amends 42 CFR chapter IV as set forth below:
PART 409--HOSPITAL INSURANCE BENEFITS
0
1. The authority citation for part 409 continues to read as follows:
Authority: Secs. 1102 and 1871 of the Act (42 U.S.C. 1302 and
1395hh).
0
2. Section 409.50 is revised to read as follows:
Sec. 409.50 Coinsurance for durable medical equipment (DME) and
applicable disposable devices furnished as a home health service.
The coinsurance liability of the beneficiary or other person for
DME or applicable disposable devices (as defined in section 1834(s)(2))
furnished as a home health service is 20 percent of the customary
(insofar as reasonable) charge for the services.
PART 484--HOME HEALTH SERVICES
0
3. The authority citation for part 484 continues to read as follows:
Authority: Secs 1102 and 1871 of the Act (42 U.S.C. 1302 and
1395(hh)) unless otherwise indicated.
0
4. Section 484.240 is amended by revising paragraph (d) to read as
follows:
Sec. 484.240 Methodology used for the calculation of the outlier
payment.
* * * * *
(d) CMS imputes the cost for each episode by multiplying the
national per-15 minute unit amount of each discipline by the number of
15 minute units in the discipline and computing the total imputed cost
for all disciplines.
* * * * *
0
5. Section 484.305 is amended by revising the definition of
``Benchmark'' and removing the definition of ``Starter Set'' and to
read as follows:
Sec. 484.305 Definitions.
* * * * *
Benchmark refers to the mean of the top decile of Medicare-
certified HHA performance on the specified quality measure during the
baseline period, calculated for each state.
* * * * *
0
6. Section 484.315 is amended by revising paragraph (a) to read as
follows:
Sec. 484.315 Data reporting for measures and evaluation under the
Home Health Value-Based Purchasing (HHVBP) Model.
(a) Competing home health agencies will be evaluated using a set of
quality measures.
* * * * *
Sec. 484.320 [Amended]
0
7. Section 484.320 is amended by:
0
a. Amending paragraphs (a), (b), and (c) by removing the phrase ``in
the starter set,''.
0
b. Amending paragraph (d) by removing the phrase ``in the starter
set''.
0
8. Section 484.335 is added to read as follows:
Sec. 484.335 Appeals Process for the Home Health Value-Based
Purchasing (HHVBP) Model.
(a) Requests for recalculation--(1) Matters for recalculation.
Subject to the limitations on review under section 1115A of the Act, a
HHA may submit a request for recalculation under this section if it
wishes to dispute the calculation of the following:
(i) Interim performance scores.
(ii) Annual total performance scores.
(iii) Application of the formula to calculate annual payment
adjustment percentages.
(2) Time for filing a request for recalculation. A recalculation
request must be submitted in writing within 15 calendar days after CMS
posts the HHA-specific information on the HHVBP Secure Portal, in a
time and manner specified by CMS.
(3) Content of request. (i) The provider's name, address associated
with the services delivered, and CMS Certification Number (CCN).
[[Page 43788]]
(ii) The basis for requesting recalculation to include the specific
quality measure data that the HHA believes is inaccurate or the
calculation the HHA believes is incorrect.
(iii) Contact information for a person at the HHA with whom CMS or
its agent can communicate about this request, including name, email
address, telephone number, and mailing address (must include physical
address, not just a post office box).
(iv) The HHA may include in the request for reconsideration
additional documentary evidence that CMS should consider. Such
documents may not include data that was to have been filed by the
applicable data submission deadline, but may include evidence of timely
submission.
(4) Scope of review for recalculation. In conducting the
recalculation, CMS will review the applicable measures and performance
scores, the evidence and findings upon which the determination was
based, and any additional documentary evidence submitted by the home
health agency. CMS may also review any other evidence it believes to be
relevant to the recalculation.
(5) Recalculation decision. CMS will issue a written notification
of findings. A recalculation decision is subject to the request for
reconsideration process in accordance with paragraph (b) of this
section.
(b) Requests for reconsideration--(1) Matters for reconsideration.
A home health agency may request reconsideration of the recalculation
of the annual total performance score and payment adjustment percentage
following a recalculation request submitted under Sec. 484.335(a) or
the decision to deny a HHA's recalculation request submitted under
paragraph (a) of this section.
(2) Time for filing a request for reconsideration. The request for
reconsideration must be submitted via the HHVBP Secure Portal within 15
calendar days from CMS' notification to the HHA contact of the outcome
of the recalculation process.
(3) Content of request. (i) The name of the HHA, address associated
with the services delivered, and CMS Certification Number (CCN).
(ii) The basis for requesting reconsideration to include the
specific quality measure data that the HHA believes is inaccurate or
the calculation the HHA believes is incorrect.
(iii) Contact information for a person at the HHA with whom CMS or
its agent can communicate about this request, including name, email
address, telephone number, and mailing address (must include physical
address, not just a post office box).
(iv) The HHA may include in the request for reconsideration
additional documentary evidence that CMS should consider. Such
documents may not include data that was to have been filed by the
applicable data submission deadline, but may include evidence of timely
submission.
(4) Scope of review for reconsideration. In conducting the
reconsideration review, CMS will review the applicable measures and
performance scores, the evidence and findings upon which the
determination was based, and any additional documentary evidence
submitted by the HHA. CMS may also review any other evidence it
believes to be relevant to the reconsideration. The HHA must prove its
case by a preponderance of the evidence with respect to issues of fact
(5) Reconsideration decision. CMS reconsideration officials will
issue a written determination.
Dated: June 2, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
Dated: June 23, 2016.
Sylvia M. Burwell,
Secretary, Department of Health and Human Services.
[FR Doc. 2016-15448 Filed 6-27-16; 4:15 pm]
BILLING CODE 4120-01-P