Patient-Driven Groupings Model Proposed for Home Health

Regulation | July 03, 2018 | by Aaron Tripp

The Centers for Medicare and Medicaid Services (CMS) released for public inspection the calendar year (CY) 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case-Mix Adjustment Methodology Refinements proposed rule on July 2, 2018.

In their press release, CMS Administrator Seema Verma says “The redesign of the home health payment system encourages value over volume and removes incentives to provide unnecessary care.” Some of the proposals including an increase of 2.1%, or $400 million, in Medicare payments to home health agencies in CY 2019, revising the unit of payment to 30-day periods of care, and a budget neutral case-mix methodology refinement were included from the Bipartisan Budget Act of 2018.

The Patient-Driven Groupings Model (PDGM) is proposed to begin on or after January 1, 2020. LeadingAge participated in the technical expert panel earlier in the year on payment revisions and shared concerns about case-mix weight reductions for therapy episodes and about the cost reports as accurate to assess resource use, especially administrative costs. The justification of the move towards basing payment on clinical characteristics of beneficiaries rather than service utilization is analogous to the recently proposed Patient-Driven Payment Model for Medicare skilled nursing facility payment.

To assist stakeholders in commenting on this proposed payment change CMS has shared several resources. A provider-level impact file estimated for CY 2019 can be downloaded. Also a grouper tool that can be used to understand how the proposed payment grouping parameters would be used to determine case-mix assignments that are part of the payment calculation is available for download.

In an ongoing effort to make improvements to the health care delivery system and to reduce unnecessary burden, CMS is proposing to eliminate the requirement that the certifying physician estimate how much longer skilled services are required when recertifying the need for continued home health care. They suggest this could reduce claims denials that solely result from an estimation missing from the recertification statement. Additionally, stemming from the Bipartisan Budget Act, a proposal to amend regulations to allow medical record documentation from home health agencies to be used to support the basis for certification of home health eligibility is included in the rule.

Other aspects of the proposal include:

  • Allowing the cost of remote patient monitoring to be reported by home health agencies on the Medicare cost report form,
  • Discussing the implementation of temporary transitional payments for home infusion therapy services to begin on January 1, 2019, and  
  • An update on the progress towards developing public reporting of performance under the Health Value-Based Purchasing (HHVBP) Model and refinements to the model.

LeadingAge will begin to review the proposed rule and share further analyses and summaries as soon as materials are completed. Public comments are accepted through August 31, 2018. We encourage members to review the rule and associated CMS resources and share your comments, questions, and concerns with Aaron Tripp, Director, Long-Term Care Policy and Analytics by email or phone at 202-508-9433.