2017 HOME HEALTH PPS AND VALUE BASED PURCHASING UPDATE

Transcription

1 2017 HOME HEALTH PPS AND VALUE BASED PURCHASING UPDATE Presented By: Melinda A. Gaboury, CEO Healthcare Provider Solutions, Inc. healthcareprovidersolutions.com FINAL 2017 PAYMENT RATES HOME HEALTH Outlier calculation extensive changes 3% rural add on continues through % payment sequestration continues CY 2017 FINAL Base Episode Rate: $2, CY 2016 Base Episode Rate: $2, Market basket Index (inflation factor): 2.5% Budget neutrality factor: 0.5 1

2 CASE MIX WEIGHT CHANGES 2017 Weight Weight FINAL FINAL FINAL FINAL / AFKS AFLS AFMS BHLS BHMS CFKS CFKS CGKS CHKS LUPA RATES Final HHA $ $ $ $64.23 MSS $ $ $ $ OT $ $ $ $ PT $ $ $ $ SN $ $ $ $ SLP $ $ $ $

3 LUPA ADD-ON RATES In the CY 2014 HH PPS Final Rule - changed the methodology for calculating the LUPA add-on amount by finalizing the use of three LUPA add-on factors: for SN for PT for SLP 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. Non-Routine Medical Supplies Severity Level Points 2016 FINAL Urban 2017 Final Urban 1 0 $14.22 $ $51.35 $ $ $ $ $ $ $ $ $

4 Limit of 8 hours per day used in calculation of cost in the Outlier Calculation Fixed Dollar Loss Ratio = 0.55 ( ) Loss Sharing Ratio = 80% 4

5 OUTLIER CALCULATIONS Example: HHRG = C2F2S4 (1 st Episode & NRS Level 3) = HIPPS = 1BGNU RALEIGH, NC CBSA (WAKE COUNTY) = Wage Adjusted Episode Amount = $3, plus NRS add-on of $ = $3, Calculation FINAL 2017 Calculation Fixed $ Loss Ratio 0.45 Fixed $ Loss Ratio 0.55 Loss Sharing Ratio 0.80 Loss Sharing Ratio 0.80 OUTLIER CALCULATIONS Wage Adjusted Fixed Dollar Loss Amount Base PPS Amount x 0.45 $2, x 0.45 = $1, $1, x x = $ $1, x = $ $ = $1, Wage Adjusted Outlier Threshold $1, $3, = $4, FINAL 2017 Wage Adjusted Fixed Dollar Loss Amount Base PPS Amount x 0.55 $2, x 0.55 = $1, $1, x x = $1, $1, x = $ $1, = $1, Wage Adjusted Outlier Threshold $1, $3, = $4,

6 2016 Wage Adjusted Imputed Cost of the Episode 120 Skilled Nursing Visits 120 x $ = $16, $16, $4, = $11, x 0.80 = $9, Proposed 2017 Wage Adjusted Imputed Cost of the Episode 120 Skilled Nursing Visits = 15, 30 OR 45 minute visits 120 x 1 =120 units OR 120 x 2 = 240 units OR 120 x 3 = 360 units 120 X = $5, OR 240 x = $11, OR 360 x = $17, $5, $4, = $ OR $11, $4, = $6, x 0.80 = $5, OR $17, $4, = $12, x 0.80 = $9, FINAL OASIS QUALITY MONITORING A new numerical standard for the submission of OASIS to avoid payment rate reductions Compliance with this performance requirement can be measured through the use of an uncomplicated mathematical formula. This pay for reporting performance requirement metric has been titled as the Quality Assessments Only (QAO) formula because only those OASIS assessments that contribute, or could contribute, to creating a quality episode of care are included in the computation. The formula based on this definition is as follows: 6

7 2016/2017 FINAL OASIS QUALITY MONITORING Final Decision: After consideration of the public comments received, we are adopting as final, our proposal to establish a pay-for- reporting performance requirement, with the modifications stated below: For episodes beginning on or after July 1st, 2015 and before June 30th, 2016, HHAs must score at least 70 percent on the QAO metric of pay-for-reporting performance requirement or be subject to a 2 percentage point reduction to their market basket update for CY Minimum OASIS reporting requirement for the 2 nd and subsequent years of the OASIS pay-for-reporting performance requirement program. However, we will consider increasing the requirement in subsequent years. We anticipate rates of at least 80 percent or higher, not exceed 90 percent, in 2018 & NO OASIS NO PAYMENT MLN Matters Number: MM9585 Related Change Request (CR) #: CR 9585 Related CR Release Date: October 27, 2016 Effective Date: April 1, 2017 Related CR Transmittal #: R3629CP Implementation Date: April 3, 2017 Submission of an OASIS assessment is a condition of payment for HH episodes of care. OASIS reporting regulations require the OASIS to be transmitted within 30 days of completing the assessment of the beneficiary. In most cases, this 30-day period will have elapsed by the time a 60-day episode of HH services is completed and the HHA submits the final claim for that episode to Medicare. If the OASIS assessment is not found in the QIES upon receipt of a final claim for an HH episode and the receipt date of the claim is more than 30 days after the assessment completion date, Medicare systems will deny the HH claim. (While the regulation requires the assessment to be submitted within 30 days, the initial implementation of this edit will allow 40 days.) In denying the claim, Medicare will supply the following remittance messages: Group Code of CO Claim Adjustment Reason Code 272 7

8 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 are finalizing 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). 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 device would be considered a non-routine supply for home health. NPWT USING A DISPOSABLE DEVICE 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. 8

9 NPWT USING A DISPOSABLE DEVICE 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 Typically outpatient therapy provided by a home health agency in the home does not require the patient to be homebound, etc. This service does require that ALL home health eligibility criteria are met, including homebound, medical necessity and F2F. NPWT USING A DISPOSABLE DEVICE Example # 4: On Monday, the nurse applies a new disposable NPWT device, and provides instructions for ongoing wound care. During this same visit, per the HH plan of care, the nurse changes the indwelling catheter and provides troubleshooting information and teaching regarding its maintenance. In this scenario, the billing procedures are as follows: The visit included applying a new disposable NPWT device as well as services unrelated to that NPWT service, which means the HHA will submit both a TOB 34x and a TOB 32x. For furnishing NPWT using a disposable device, that is, the application of the new disposable NPWT device and the time spent instructing the beneficiary about ongoing wound care, the HHA would bill using a TOB 34x with CPT code or For services not associated with furnishing NPWT using a disposable device, that is, for the replacement of the indwelling catheter and instructions about troubleshooting and maintenance, the HHA would bill under TOB 32x. 9

10 HOME HEALTH PRESSURE ULCER UPDATE 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. 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. HOME HEALTH QRP UPDATE The 6 process measures FINALIZED to be removed from the HH QRP: 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; Heart Failure Symptoms Addressed during All Episodes of Care. The technical analysis that supported our proposal to remove the six process measures can be found at Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html 10

11 HOME HEALTH QRP UPDATE CMS finalized the adding of four new measures that were developed to meet the requirements of the IMPACT Act. These 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 CMS did agree to address the potential for including socio-demographic status and socio-economic status (SES) as a risk factor for select measures once the national Quality Forum ( NQF) completes their trial for inclusion of SDS as a risk adjustment factor. VALUE BASED PURCHASING (VBP) PILOT FINAL UPDATE 2017 First Performance Year First Payment Year Baseline Year 11

12 VALUE BASED PURCHASING (VBP) PILOT FINAL UPDATE 2017 SMALL & LARGE COHORTS CMS is finalizing that the calculation of the benchmarks and achievement thresholds at the state level rather than at the smaller- and larger-volume cohort level for all model years, will begin with CY This change will eliminate the increased variation caused by having few HHAs in the cohort but still take into account that there will be some inter-state variation in the values due to state regulatory differences. We are also finalizing 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. VALUE BASED PURCHASING (VBP) PILOT FINAL UPDATE 2017 Measures: 14 Outcome Measures, 3 Process Measures, & 3 New Measures source OASIS (10), Claims (2), HHCAHPS (5) Outcome Measures 1. Improvement in Ambulation Locomotion (OASIS M1860) 2. Improvement in Bed Transferring (OASIS M1850) 3. Improvement in Bathing (OASIS M1830) 4. Improvement in Dyspnea (OASIS M1400) 5. Discharged to community (OASIS M2420) 6. Acute care hospitalization (unplanned within 60 days) (Claims) 7. Emergency Department use w/o hospitalization (Claims) 8. Improvement in pain interfering with activity (OASIS M1242) 9. Improvement in oral medication management (OASIS M2020) 10. *Prior functioning ADL/IADL (OASIS M1900) 11. Care of Patients (CAHPS) 12. Communication between providers and patients (CAHPS) 13. Specific care issues (CAHPS) 14. Overall rating of home health care (CAHPS) 15. Willingness to recommend the agency (CAHPS) *Items Removed from VBP Pilot 12

13 VALUE BASED PURCHASING (VBP) PILOT FINAL UPDATE 2017 Process Measures 1. *Influenza vaccine data collection period (OASIS M1041) 2. Influenza immunization received (OASIS M1046) 3. Pneumococcal vaccine ever received (OASIS M1051) 4. *Reason Pneumococcal vaccine not received (OASIS M1056) 5. Drug education for all medications (OASIS M2015) 6. *Care management: Types and sources of assistance (OASIS M2102) *Items REMOVED from VBP Pilot VALUE BASED PURCHASING (VBP) PILOT FINAL UPDATE 2017 New Measures HH Agency would enter into a separate web portal reporting begins no later than October 7, 2016 for July September 2016 therefore the 1 st Quarter report will not include this data. 1. Influenza vaccination of HH staff 2. Herpes zoster - shingles vaccines for HHA patients 3. Advanced (Directives) Care planning This rule finalized the 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 finalizing 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 change, for PY1, the HHA would report on this measure in October 2016 and January HHAs would report on this measure in April 2017 for PY2 and annually in April thereafter. Quarterly reporting will still be required for Herpes zoster & Advance Care planning. Also, finalized to allow 15 days vs. 7 for submitting the data following the end of the reporting period. 13

14 VALUE BASED PURCHASING (VBP) PILOT FINAL UPDATE 2017 REPORTING PROPOSED UPDATE 2017 Review Quarterly Quality Reports July 2016 FIRST report (for 1 st Quarter 2016) days to request recalculation of scores CMS will not be required to provide backup for the calculation agencies will need to monitor their own data Opportunity to review Total Performance Score (TPS) and payment adjustment calculations August 1, 2017 FIRST notification days to request recalculation Final report no later than November 1, 2017 to reflect payment adjustments for

15 VALUE BASED PURCHASING (VBP) PILOT FINAL UPDATE 2017 Finalized that if it is determined 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. Finalized that a HHA may request reconsideration of the outcome of a recalculation request for its Annual TPS and Payment Adjustment Report only. 15

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18 SPEAKER INFORMATION Melinda A. Gaboury, COS-C Chief Executive Officer Healthcare Provider Solutions, Inc. 810 Royal Parkway, Suite 200 Nashville, TN healthcareprovidersolutions.com 18

19 CMS-1648-F 23 an episode s clinical score. The points for the functional variables are added together to determine an episode s functional score. TABLE 3: Case-Mix Adjustment Variables and Scores Case-Mix Adjustment Variables and Scores Episode number within sequence of adjacent episodes 1 or 2 1 or Therapy visits EQUATION: CLINICAL DIMENSION 1 Primary or Other Diagnosis = Blindness/Low Vision Primary or Other Diagnosis = Blood disorders Primary or Other Diagnosis = Cancer, selected benign neoplasms Primary Diagnosis = Diabetes Other Diagnosis = Diabetes Primary or Other Diagnosis = Dysphagia AND Primary or Other Diagnosis = Neuro 3 Stroke 7 Primary or Other Diagnosis = Dysphagia AND M1030 (Therapy at home) = 3 (Enteral) 8 Primary or Other Diagnosis = Gastrointestinal disorders Primary or Other Diagnosis = Gastrointestinal disorders AND. 7.. M1630 (ostomy)= 1 or 2 10 Primary or Other Diagnosis = Gastrointestinal disorders AND Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis,.... OR Neuro 2 - Peripheral neurological disorders, OR Neuro 3 - Stroke, OR Neuro 4 - Multiple Sclerosis 11 Primary or Other Diagnosis = Heart Disease OR Hypertension Primary Diagnosis = Neuro 1 - Brain disorders and paralysis Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis AND M1840 (Toilet transfer) = 2 or more 14 Primary or Other Diagnosis = Neuro 1 - Brain disorders and paralysis OR Neuro 2 - Peripheral neurological disorders AND M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3 15 Primary or Other Diagnosis = Neuro 3 - Stroke Primary or Other Diagnosis = Neuro 3 - Stroke AND.... M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3 17 Primary or Other Diagnosis = Neuro 3 - Stroke AND.... M1860 (Ambulation) = 4 or more 18 Primary or Other Diagnosis = Neuro 4 - Multiple Sclerosis AND AT LEAST ONE OF THE FOLLOWING: M1830 (Bathing) = 2 or more OR M1840 (Toilet transfer) = 2 or more OR

20 CMS-1648-F 24 Case-Mix Adjustment Variables and Scores M1850 (Transferring) = 2 or more OR M1860 (Ambulation) = 4 or more Primary or Other Diagnosis = Ortho 1 - Leg Disorders or Gait 19 Disorders AND M1324 (most problematic pressure ulcer stage)= 1, 2, 3 or 4 20 Primary or Other Diagnosis = Ortho 1 - Leg OR Ortho 2 - Other orthopedic disorders AND M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) 21 Primary or Other Diagnosis = Psych 1 Affective and other psychoses, depression Primary or Other Diagnosis = Psych 2 - Degenerative and other organic psychiatric disorders Primary or Other Diagnosis = Pulmonary disorders Primary or Other Diagnosis = Pulmonary disorders AND M1860 (Ambulation) = 1 or more Primary Diagnosis = Skin 1 -Traumatic wounds, burns, and postoperative complications Other Diagnosis = Skin 1 - Traumatic wounds, burns, post-operative complications Primary or Other Diagnosis = Skin 1 -Traumatic wounds, burns, and post-operative complications OR Skin 2 Ulcers and other skin conditions 3... AND M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) 28 Primary or Other Diagnosis = Skin 2 - Ulcers and other skin conditions Primary or Other Diagnosis = Tracheostomy Primary or Other Diagnosis = Urostomy/Cystostomy M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral) M1030 (Therapy at home) = 3 (Enteral) M1200 (Vision) = 1 or more M1242 (Pain)= 3 or M1311 = Two or more pressure ulcers at stage 3 or M1324 (Most problematic pressure ulcer stage)= 1 or M1324 (Most problematic pressure ulcer stage)= 3 or M1334 (Stasis ulcer status)= M1334 (Stasis ulcer status)= M1342 (Surgical wound status)= M1342 (Surgical wound status)= M1400 (Dyspnea) = 2, 3, or M1620 (Bowel Incontinence) = 2 to M1630 (Ostomy)= 1 or M2030 (Injectable Drug Use) = 0, 1, 2, or FUNCTIONAL DIMENSION 46 M1810 or M1820 (Dressing upper or lower body)= 1, 2, or M1830 (Bathing) = 2 or more M1840 (Toilet transferring) = 2 or more M1308 Current Number of Unhealed Pressure Ulcers at Each Stage or Unstageable will be changed to M1311 Current Number of Unhealed Pressure Ulcers at Each Stage under the new OASIS C2 format, effective January 1, 2017.

21 CMS-1648-F 25 Case-Mix Adjustment Variables and Scores 49 M1850 (Transferring) = 2 or more M1860 (Ambulation) = 1, 2 or M1860 (Ambulation) = 4 or more Source: CY 2015 Medicare claims data for episodes ending on or before December 31, 2015 (as of June 30, 2016) for which we had a linked OASIS assessment. LUPA episodes, outlier episodes, and episodes with SCIC or PEP adjustments were excluded. Note(s): Points are additive; however, points may not be given for the same line item in the table more than once. In updating the four-equation model for CY 2017, using complete 2015 data as of June 30, 2016 (the last update to the four-equation model for CY 2016 used 2014 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 2014 and The CY 2017 four-equation model resulted in 119 point-giving variables being used in the model (as compared to the 124 point-giving variables for the 2016 recalibration). Of those 119 variables, the CY 2017 four-equation model had 113 variables that were also present in the CY 2016 four-equation model. Of those 113 variables, the points for 33 variables increased in the CY 2017 four-equation model compared to CY 2016 and the points for 33 variables decreased in the CY equation model compared to CY There were 47 variables with the same point values between CY 2016 and CY There were 6 variables that were added to the model in CY 2017 that weren t in the model in CY Also, 11 variables were in the model in CY 2016 but dropped in CY 2017 due to the absence of additional resources associated with these variables. In other words, these variables are not associated with additional resources beyond what is captured by the other case-mix adjustment variables in the regression model. Step 2: Re-define 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.

22 CMS-1648-F 26 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, therapy visits. Step 2.2: Third episodes and beyond, 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 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 to guide where we placed our thresholds. We tried to group 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 4. TABLE 4: 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: Equation(s) used to calculate points: (see Table 3) (2&4) 2 For Step 1, 49.2 percent of episodes were in the medium functional level (All with score 14). For Step 2.1, 70.7 percent of episodes were in the low functional level (Most with score 5 and 6). For Step 2.2, 78.7 percent of episodes were in the medium functional level (Most with score 2). For Step 3, 51.0 percent of episodes were in the medium functional level (Most with score 10). For Step 4, 51.2 percent of episodes were in the medium functional level (Most with score 5 and 6).

23 CMS-1648-F 27 Severity Dimension Level Clinical C1 0 to 1 0 to 1 0 to 1 0 to 1 0 to 3 C2 2 to 3 2 to to 9 4 to 16 C Functional F1 0 to 13 0 to 6 0 to 6 0 to 1 0 to 2 F to 13 7 to 10 2 to 9 3 to 6 F 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 5 shows the regression coefficients for the variables in the payment regression model updated with CY 2015 data. The R-squared value for the payment regression model is (an increase from for the CY 2016 recalibration).

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