III.D. Proposed Rural Add-On Payments for CYs 2019 Through 2022

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1 August 31, 2018 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS 1689 P P.O. Box 8013 Baltimore, MD Submitted electronically LeadingAge appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) [CMS-1689-P] Medicare and Medicaid Programs; CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; Home Health Quality Reporting Requirements; Home Infusion Therapy Requirements; and Training Requirements for Surveyors of National Accrediting Organizations proposed rule posted in the July 12 th Federal Register. We offer these comments in the spirit of collaboration and look forward to working with the Centers for Medicare and Medicaid Services (CMS) to ensure a smooth and successful transition to the revised payment system. The mission of LeadingAge is to be the trusted voice for aging. The members of LeadingAge and partners touch the lives of millions of individuals, families, employees and volunteers every day. Our over 6,000 members and partners include nonprofit organizations representing the entire field of aging services, 38 state associations, hundreds of businesses, consumer groups, foundations and research centers. LeadingAge is also a part of the Global Ageing Network, whose membership spans 30 countries. LeadingAge is a 501(c)(3) tax-exempt charitable organization focused on education, advocacy and applied research. Our comments will focus on the following sections of the proposed rule: III.D. Proposed Rural Add-On Payments for CYs 2019 Through 2022 III. F. Proposed Implementation of the Patient-Driven Groupings Model (PDGM) for CY 2020 III. H. The Role of Remote Patient Monitoring Under the Medicare Home Health Benefit IV. Home Health Value-Based Purchasing (HHVBP) Model III.D. Proposed Rural Add-On Payments for CYs 2019 Through 2022 While LeadingAge and its rural members appreciates the extension of the rural add-on included in the proposed rule as a result of the Bipartisan Budget Act, the $20 million decrease in funding and planned phase out cause some concerns. We encourage CMS to monitor the effects of the

2 mandated approach to the rural add-on payments, particularly for the low density and all other categories, to see if there is an impact on access to home health services. LeadingAge members in rural communities cite the additional transportation costs for delivering home health services in rural and frontier areas as well as the workforce struggle of recruiting local talent to staff rural agencies. In light of the alternative to home health services often being institutional settings that are more expensive and potentially at great distances from a beneficiary s natural support system, we suggest that CMS pay special attention to the unique challenges of home health agencies serving rural communities. Particularly with the proposal to move to the cost per minute plus non-routine supplies (CPM+NRS), it will be important to ensure that payment for rural home health agencies accounts for the costs to provide care accurately. III. F. Proposed Implementation of the Patient-Driven Groupings Model (PDGM) for CY 2020 LeadingAge is supportive of reimbursement policy that has grounding in clinical characteristics of the beneficiaries utilizing home health services. We thank CMS for their attention to the comments that LeadingAge and others submitted regarding the Home Health Groupings Model (HHGM) proposal and acknowledge the improvements made in the PDGM proposal. However, there remain some questions and concerns with the PDGM as described in the final rule. Initially, we would like to recommend that CMS offer further communication around transition plan development, a transition timeline, implementation, and post-implementation technical assistance. LeadingAge and its members have concerns about the feasibility of a successful implementation by January 1, 2020 without significant efforts on the part of CMS and all stakeholders. Adequate time is necessary for home health agencies, their business partners, and vendors to update systems to implement the new payment models. Staff will need to be trained to be successful in the new assignment of beneficiaries into the accurate home health resource group. PDGM is complex and stakeholder input could aid CMS with its efforts as well as reduce unintended consequences for beneficiaries. We are grateful for the stakeholder engagement that has occurred earlier in the year and hope to continue our productive conversations with CMS on the transition to a new payment approach. Clinical group categories Of the clinical grouping categories, LeadingAge members expressed some concerns about the case-mix weights particularly for the behavioral health group. This group has significantly lower case-mix weights in Table 49 (we assume that the case-mix proposed weights are for CY 2020 with the implementation of PDGM and CY 2019 is a typo). Beneficiaries with behavioral health conditions can be challenging for home health agencies and relatively lower case-mix weights might not account for the services necessary to appropriately care for this subset of beneficiaries. Relative values by discipline Given the relative values in costs per hour by discipline (Table 32), concerns still exist that CMS might be overcorrecting with the significant reduction in therapy weights. As we previously commented on the HHGM, LeadingAge agrees with CMS that the use of a therapy threshold to

3 determine payment is problematic and leads to fraudulent behavior by some providers. The concern we had with the HHGM and still have with PDGM is that it can diminish the importance of appropriate therapy in improving care outcomes for older adults and persons with disabilities. The use of therapy is an important treatment to reduce hospital readmissions due to falls. Older adults are being discharged from hospitals earlier and they are choosing home health over nursing home services. The reduction in therapy payments will have a major impact on the access to home health services because of the increase costs of recruiting and retaining qualified physical and occupational therapists throughout the country, especially in rural/frontier areas. Physical and occupational therapies improve functional levels, which ultimately enables the older adult to remain independent in their own home. The reduction in payment for therapy also is contrary to the Jimmo Settlement Agreement that states skilled maintenance services are Medicare covered services nursing or therapy services to maintain the patient s condition or to prevent or slow further deterioration. Even though no improvement is expected, there may be specific instances where the skills of a qualified therapist, registered nurse, or (when provided by regulation) a licensed practical nurse are required to perform nursing/therapy maintenance services that would otherwise be considered unskilled because of the patient s special medical complications or where the needed services are of such complexity that the skills of such a practitioner are required to perform it safely and effectively. Request for anticipated payment (RAP) LeadingAge has heard from members that they are not in favor of phasing out the RAP payments even with the move to 30-day units of service. Within nonprofit providers, particularly smaller organizations, cash flow can still be an issue if RAP payments were to go away. While we are supportive of measures to ensure program integrity broadly, not all organizations that request RAP payments are fraudulent. We recommend continuing the practice of RAP payments for existing home health agencies as well as considering the cash flow requirements of new home health agencies who also have capitalization needs. Behavioral assumptions LeadingAge and its members feel that the degree to which CMS is assuming the three behavioral changes by providers due to the PDGM proposal takes an unnecessarily cynical view of home health agencies. The members of LeadingAge are mission-driven, nonprofit organizations who seek to provide quality care to the older adults who rely on their services. According to the proposed rule, if no behavioral assumptions were made the 30-day payment amount to achieve budget neutrality would be $1, With all three assumptions, upcoding, increased comorbidity diagnoses, and low utilization payment adjustment (LUPA) avoidance, that amount drops over 6% to $1, We believe that the degree of downward shift through these assumptions goes too far and has the potential to have negative consequences for providers who are already following appropriate clinical practices. We would recommend that CMS reevaluate these assumptions before implementing PDGM in 2020.

4 Comorbidity adjustment LeadingAge members have concerns that the comorbidity adjustment is relatively complex for a small number of cases and question the amounts of the adjustment. We agree with comments noted in the proposal that the presence of multiple comorbidities has more of an effect on home health resource use than a single comorbidity and that any case-mix adjustment should account for multiple comorbidities. However the 11 comorbidity subgroups and 27 subgroup interactions represent a small proportion of home health claims based on the analysis provided. An estimate using recent data of nearly 63% of claims periods with no comorbidity adjustment under the PDGM formula might not accurately reflect the cost or serving a beneficiary pool with multiple diagnoses, which are common among older adults. Comparing the differential between no, low, and high comorbidity adjustments an average of $35 for a low adjustment and $350 for a high adjustment seems potentially out of sync with the costs of serving these more complex beneficiaries. III. H. The Role of Remote Patient Monitoring Under the Medicare Home Health Benefit LeadingAge believes that the proposal for remote patient monitoring is a positive development because it can focus, shorten, and make the home visit far more effective with biometric data, medication adherence data, trends, and indications of change of condition prior to the visit. That said we have some concerns with the proposal. First, CMS is still only paying for the actual visit. We know that remote patient monitoring can potentially eliminate the need for a visit for beneficiaries that are stable, which can reduce unnecessary costs. Use of this model of care should not cause providers to still feel a need to send the direct care staff to receive reimbursement. Second, counting remote patient monitoring as an administrative cost seems to indicate that it would cut into provider s margins and does not seem to provide sufficient incentive for providers to broadly adopt the practice and incorporate it into their operations, especially given the competitive markets and rising labor costs. LeadingAge encourage CMS to think more broadly about telehealth and telemedicine to include virtual visits as a potential strategy to address workforce challenges. Additionally, we submit a recommendation with made to the Center for Medicare and Medicaid Innovation Center (CMMI) last year: Chronic Care Management in the Community using Telehealth and Remote Monitoring This demonstration would involve the guiding principles of patient-centered care, small scale testing, benefit design and price transparency. The demonstration would be led by home health agencies (HHA), home care providers (HCPs), life plan communities (LPCs; also referred to as continuing care retirement communities or CCRCs), and housing with services providers (HSPs), and would explicitly encourage the use of telehealth and remote monitoring technologies. Such a demonstration should test and evaluate the cost-effectiveness of a payment system similar to the payment methodology used in the Independence at Home Demonstration. Under this demonstration, home health agencies, life plan communities, assisted living (AL) providers, and

5 housing with services providers would receive annual incentive payments. Payment amounts would be based on a percentage of the Medicare savings (Parts A, B and D) achieved as a result of efficacy-proven telehealth services used to help older adults manage chronic conditions, improve health outcomes, and reduce hospitalizations, hospital readmissions, and transitions to higher levels or care (independent living to AL, or AL to skilled nursing). The demonstration would be aimed at populations 60 years or older with 2 or more of 5 chronic conditions (diabetes, heart failure, hypertension, chronic obstructive pulmonary disease, and asthma), and living in the community including their own homes, independent living, senior housing, affordable housing, and assisted living communities as well independent living and AL levels of LPCs. The payment model should allow home health care providers to bill for services such as monitoring, educating, triaging, and managing participants health, as well as coordinating with primary care or specialty providers when needed for additional interventions, like medication titration, change of medications, ordering laboratory tests, or modifying any other part of the care plan. The eligibility for payment should not be limited to rural areas. IV. Home Health Value-Based Purchasing (HHVBP) Model In concept, LeadingAge supports the shift towards composite measures for the HHVBP model. We note that normalized composite measures might be more meaningful towards a holistic picture of a beneficiary s status. As far as public facing data, it might also be more relevant consumers and families as opposed to narrow clinical process measures such as the ones proposed for removal. Questions arose about CMS intention to expand the number of states that are included in the HHVBP model. LeadingAge members are interested to know if CMS has a timeline for model expansion. However, members in states that have HHVBP have concerns about the proposal. Providers are at risk for as much as a 7% payment adjustment as a result of performance in They need adequate time to understand the impact of the proposed change to composite measures on reimbursement and ensure performance meets the aims that CMS is striving to incentivize. Implementation that begins January 1, 2019 will not provide agencies with sufficient time to conduct the necessary analysis and adopt the required operational changes. Finally on HHVBP, we heard from members about concerns with public reporting, particularly for providers who are not participating in the HHVBP but that are in markets that service beneficiaries within HHVBP states. LeadingAge wants to ensure that the variation of participation by geography does not give advantages or disadvantages to providers based purely on state lines. Members in non-participating states will not have the same quality information publicly available as the participating providers, which could be confusing to consumers and referral sources when selecting an agency. CMS should ensure all agencies servicing selected areas are represented and clearly define the differences in the quality information reported.

6 Again, LeadingAge appreciates the opportunity to submit comments on the proposed rule. We look forward to continuing our positive working relationship with CMS as home health payment system revisions evolve. Please do not hesitate to contact us if you wish to discuss any of these comments further. Sincerely, Aaron Tripp Director, Long-Term Care Policy & Analytics

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