Payment Update and PDGM

This final rule delivers on a number of statutory imperatives from the Bipartisan Budget Act of 2018. They include:

1. Implementation of the Patient-Driven Groupings Model (PDGM) which is an alternate case-mix adjustment methodology with a 30-day unit of payment
2. An aggregate Medicare payment increase to home health agencies (HHAs) in CY 2020 of 1.3%, or $250 million, which reflects the effects of the 1.5% home health payment update ($290 million increase) and a 0.2% aggregate decrease (-$40 million) in payments to HHAs due to the changes in the rural add-on percentages
3. Rate updates also include an adjustment to the CY 2020 30-day payment amount to offset CMS’ assumptions of provider behavior changes upon implementation of the PDGM

Possibly the most important change from the proposed rule to the final rule is the reduction of the impact of the behavior assumption adjustments from -8.01% in the proposed rule down to -4.36% in the final rule with a 30-day payment amount of $1,864.03. This is a positive development and a reflection that CMS took into account the concerns of LeadingAge and our partners in the home health stakeholder community. The reason provided is that the effects observed with the transition to MS-DRGs in the hospital payment system in 2008 were about half of the assumed behavior change expected by CMS. That coupled with recognition of the magnitude of the changes happening concurrently in the home health provider community has resulted in this scaled-back adjustment.

However, we still believe that payment adjustments ought to be based on observed behavior as opposed to assumptions and continue to advocate for the bipartisan, bicameral Home Health Payment Innovation Act (S.433/ H.R.2573) legislation that would remove the behavior assumption adjustment entirely for CY 2020. We urge you to continue voicing your support for the legislation with your elected officials. The bills have been gaining cosponsors which is a positive sign but your voice is critical to have CY 2020 rates reflect the true PDGM design, not behavior assumptions.

Requests for Anticipated Payment (RAP)

Another area of concern from the comments that LeadingAge submitted in tandem with our colleagues representing ElevatingHome and the Visiting Nurse Associations of America (VNAA) was the plan to phase out and ultimately remove RAP payments. In the final rule, CMS will reduce the split-percentage payment amount, paid in response to a Request for Anticipated Payment (RAP), to 20% for existing HHAs beginning in CY 2020 with elimination of split-percentage payments for all HHAs in CY 2021. For CY 2021, there will be no up-front payment made in response to a RAP; however, RAPs will still be submitted by all HHAs every 30 days to alert the claims processing system that a beneficiary is under a home health period of care. Additionally, HHAs must submit the zero-pay RAP within 5 calendar days of each 30-day period or be subject to a late penalty. As a consolation in CY 2021, CMS plans on reducing administrative burden by streamlining the information required in order to submit the RAP.

Therapist Assistants Providing Maintenance Therapy

LeadingAge supported the proposal to allow therapist assistants to perform maintenance therapy services. We encourage CMS to continue to identify barriers to patient care created by artificial limits on the scope of practice of all home care professionals. In the final rule, CMS is modifying current regulations to allow therapist assistants to perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements. This is consistent with the skilled nursing facility setting which is helpful for LeadingAge members, many of whom operate in several service lines, to have consistent policies to the extent allowed in regulation.

Home Health Value-Based Purchasing (HHVBP) Model

As a general principle, we support transparency efforts across the spectrum of health care services. Transparency is key to the transfer and adaption of knowledge, the critical step in all quality improvement efforts. We encourage CMS to continue to develop and share quality data in partnership with organizations providing services and beneficiaries who rely on those services.

The proposal to publicly report the Total Performance Scores (TPS) and TPS Percentile Ranking from the Performance Year 5 (CY 2020) Annual TPS and Payment Adjustment Report (Annual Report) for each HHA in the nine Model states that qualified for a payment adjustment for CY 2020 is included in the final rule. CMS expects that these data would be made public after December 1, 2021, the date they intend to complete the CY 2020 Annual Report appeals process and issuance of the final Annual Report to each HHA.

Updates to the Home Health Quality Reporting Program (HH QRP)

From the vantage point of our submitted comments, there are both positives and negatives to take away from the changes included in the final rule. We supported the adoption of the two new measures “Transfer of Health Information to Providers of Post-Acute Care” and “Transfer of Health Information to Patient Post-Acute Care” that are designed to improve patient safety by ensuring that the patient’s medication list is provided to a provider and the patient as part of the discharge process. Both are included in the final rule.

We strongly opposed the removal of pain measures from the HH QRP and Home Health CAHPS survey. While we anticipated CMS would remove the measures from the QRP as they did earlier in the year with the skilled nursing final rule, we take encouragement that they heeded comments from LeadingAge and others in response to stakeholder feedback about the importance of monitoring pain in home health care settings and the concerns raised that the removal would impact the validity of the survey. CMS is not removing Question 10, “In the last 2 months of care, did you and a home health provider from this agency talk about pain,” from the Home Health CAHPS survey.