HH PPS 2012: Sorting Out the Details

HH PPS 2012: Sorting Out the Details Presented by: Jean Ellis Director of OASIS and Distance Learning Fazzi Associates, Inc. December 8, 2011 243 King Street, Suite 246 Northampton, MA 01060 413-584-5300 fax: 413.584.0150 e-mail: info@fazzi.com www.fazzi.com

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HH PPS 2012: Sorting Out the Details December 8, 2011 Jean Ellis RN, Director OASIS & Distance Learning Fazzi Associates, Inc Process of Home Care OASIS Comprehensive Assessment Plan of Care Outcomes Process Patient Measures Reimbursement P4P Care Coordination + Care Management = Patient able to stay safely in home And out of the hospital Does provider behavior (visits and recerts), documentation, OASIS data collection, really matter? Yes it does! Provides credible information for changes in: o Policy o Payment o Quality 1

CY 2012 Final Rule Summary Payment decrease 2.31% ($430 M) o Market basket: 2.4% 1.4% (Affordable Care Act) 2% if quality data not submi ed (-0.6%) o Case mix creep coding adjustment 3.79% for 2012 1.32% in 2013 o Wage index update 2.31% payment reduction better than 3.35% proposed in July! Responding to Reimbursement Cuts Evaluate Operational Model Increase Revenue Improve Efficiencies Increase Accountability CY 2012 Final Rule Summary Hypertension codes 401.1 and 401.9 removed from case mix system Lower payments for high therapy episodes o 0-5 visits 3.75% (7.5% proposed) o 14 or 15 visits 2.5% (5% proposed) o 20 visits 5% (10% proposed) 2

CY 2012 Final Rule Summary Count Medicare covered visits when determining therapy visit close to and before the 13 and 19 therapy visit. OT is a dependent Medicare service and can be a qualifying Medicare service. CY 2012 Final Rule Summary Face to Face o Physicians in acute/post acute facility can inform certifying physicians of their encounters with the patient Improvements in quality measures o in pressure ulcers not publicly reported o ER visits from claims data Homebound clarified Real vs. Nominal Case Mix Weight Change REAL Change in patient characteristics Utilization of Part A& Part B benefits Type & severityof hospital stay Risk of Mortality during hospital stay Post acute care utilization Demographic status & living situation Last hospital stay prior to episode NOMINAL Change due to improvement in coding Coding practice changes Changes in treatment behaviors in response to PPS (i.e., therapy utilization) 3

Trends in Health Status Study of Medicare Patients (MEPS) Two measures of self-reported health status 1. Perceived health status of poor or fair as opposed to those indicating health status as good, very good, or excellent 2. If pain limited normal work (including work in the home) in the past 4 weeks extremely or quite a bit OR moderately, a little bit, or not at all Trends in Health Status 3. One measure derived from patient information screening for ADL A positive screen for needing assistance with ADL All three measures indicated a slight increase in the overall health status of the Medicare home health population. 2001-2008 Findings Patients on the average have shorter hospital stays. LOS in residen al post acute se ngs have slightly. Proportion of initial non-lupa home health episodes preceded by acute care within the previous 60 days has declined from 70.0 % to 62.7 %. Represents a smaller proportion of home health episodes in which the patient has been acutely ill in the very recent past. 4

Conclusions on Lower Acuity (drawn by CMS) More recertifications in home health care, more patients entering care from the community impact these results Acuity of patients has been mitigated by an increase in use of residential post-acute care along with an increase in those LOS 2008 The Origin of Case Mix Creep Based on CY 2005 HH claims data analysis o CMS observed a 12.78 % increase in the case-mix since 2000 o Identified 8.03 % of the total case-mix change as real o Decreased the 12.78 % of total case-mix change by 8.03 % o Reduced the national standardized 60-day episode payment rates and the NRS conversion factor over 4 years (2008-2010 2.75%; 2012 3.79%) Case Mix Creep Continues Continued Claims Data Analysis o 2005 to 2007 o 2007 to 2009 Updated claims analysis for this 2012 rulemaking compared change in case mix from 2000 to 2009 Result: Reduce national standardized 60-day episode rates by 5.06% to account for the entire residual amount of nominal case-mix change through 2009 5

Rationale Our (CMS) goal is to pay increased costs associated with real changes in patient severity, and nominal coding change does not demonstrate that underlying changes in patient severity occurred, we believe it is necessary to exclude nominal case-mix effects that cannot be shown to be related to changes in patient severity. We believe that measurable changes in patient severity and patient need are appropriate bases for changes in payment. CY2012 60 day episode rate* CY2011 National Standardized 60 day episode payment rate Multiply by the CY2012 HH PPS payment update % of 1.4% Reduce by 3.79% for nominal change in case mix CY2012 National Standardized 60 day episode payment rate $2,192.07 X 1.014 X 0.9621 $2,138.52 *before case mix adjustment and wage adjustment based on the site of service for the beneficiary HH Discipline CY2011 per visit amounts LUPA Rates For HHAs that DO submit the required quality data Multiply by CY2012 payment update %of 1.4% CY2012 per visit payment For HHAs that DO NOT submit the required quality data Multiply by CY2012 payment update %of 1.4% minus 2 % points (-0.6%) CY2012 per visit payment HH Aide $50.42 X 1.014 $51.13 X 0.994 $50.12 MSS $178.46 X 1.014 $180.96 X 0.994 $177.39 OT $122.54 X 1.014 $124.26 X 0.994 $121.80 PT $121.73 X 1.014 $123.43 X 0.994 $121.00 SN $111.32 X 1.014 $112.88 X 0.994 $110.65 SLP $132.27 X 1.014 $134.12 X 0.994 $131.48 6

Therapy Case Mix Changes We (CMS) believe that the goal of the Medicare program is to ensure that beneficiaries receive the right care at the right time. The evolution of patterns of therapy utilization since the PPS began leaves doubt that appropriate care has been provided. Therapy Visit Observations The CY 2008 proposed regulation described a shift in the distribution of therapy visits per episode under the HH PPS that caused two peaks: o One below the therapy threshold of 10 therapy visits; o The other in the 10 to 13 visit range. Before the HH PPS, the distribution had one peak, at 5 to 7 therapy visits, well below the 10-visit therapy threshold in use prior to the 2008 refinements. Therapy Visit Observations The distribution of episodes changed again with the implementation of the 153-group case-mix system and its revised set of thresholds and therapy steps. o At the new 7-visit step (7 to 9 visits)---a sudden 50 % in the propor on of episodes. o At the new 14-visit therapy threshold---a 25 % in the proportion of episodes. 7

2010 and 2011 Med PAC Reports to Congress HH PPS contains incentives which likely result in agencies providing more therapy than is needed. Therapy episodes appear to be overpaid relative to others and that the amount of therapy changed significantly in response to the 2008 revisions to the payment system. HH PPS may overvalue therapy services and undervalue non-therapy services. Observations HHA margins average 17.7 percent in 2009, with 20 percent of agencies achieving an aggregate margin of 37 percent. HHAs with high margins had high case-mix values which were attributable to the agencies providing more therapy episodes. Evidence of Payment Incentive for High Therapy Visits 1-year change in the distribution of therapy services in 2008. o A significant portion of case-mix growth in 2008 and 2009 was due to the increased provision of therapy services. Analysis on the costs of high therapy services showed that the payment exceeds costs by 30 percent or more. Some agencies may be providing more therapy services to maximize reimbursement. 8

Episode Costs vs. Payments Average amount of payment exceeding costs 1-5 Therapy Visits ~ $300.00 14-19 Therapy Visits ~ $1,100.00 20+ Therapy Visits ~ $1,500.00 100% sample of 2009 claims based on 2009 dollars. Sample of 4,309 providers Normal Episodes- Non-LUPA, Non- PEP, Non- Outlier Episodes 2012 Payment Weight Changes 0 to 5 therapy visits were increased 14-15 therapy visits were decreased 20+ therapy visits were further decreased o Provide a disincentive for agencies to pad episodes just to 20 visits or slightly more, to be able to realize a large margin from that threshold Address concerns that non-therapy services are undervalued Adjustments budget neutral, average case mix weight = 1 Impact on Care? Therapy utilization is based on providing the right amount of care at the right time. Provider (HHA) behavior should not change. A shift in behavior from being a high therapy utilizing agency to a low therapy one is likely to raise red flags rightly so. 9

Hypertension Codes Trends in reporting of hypertension codes from 2000 to 2008 showed a large in the reporting of codes 401.1 and 401.9 in 2008. 2008 claims data indicated the average number of visits for claims with code 401.9 was slightly lower than the average for claims not reporting these hypertension codes. Hypertension Codes 2008-2009 claims data o Continued prevalence of 1.5-2 x in use of 401.9 over 2005-2009 data Currently these diagnoses are not predictors of higher home health patient resource costs and indicate a lower cost associated with home health patients when these codes are reported. Increasing Accuracy of HH PPS Case Mix readjustments designed to be budget neutral Intention: o Redirect resources to groups in accordance with updated information on resource use o To avoid having therapy resources dominate the results of the resource modeling procedure o To reduce incentives to provide higher numbers of therapy visits than would be clinically indicated 10

Outlier Payments No changes. Some of the episodes in the 20+ therapy group may be eligible for outlier payments. 2010 claims data indicate outlier payments to be approximately 1.9 % of total HH PPS Payments which is still under the goal of 2.5%. Market Basket and Quality Reporting The home health market basket, a price not cost index, is a factor in reimbursement. HHAs that do not meet the quality reporting requirements are subject to a 2 percent reduction to the home health market basket increase. 2 Quality Reporting Conditions for Payment Submit OASIS assessments for episodes beginning on or after July 1, 2010 and before July 1, 2011. o Exception: HHAs certified on or after May 1, 2011 are excluded. Participate in HHCAHPS survey via approved vendor. 11

Home Health Compare Outcome Measures Health Status Outcomes Clinical status improvement 1. Improvement in dyspnea 2. Improvement with pain interfering with activity 3. Improvement in status of surgical wounds Functional status improvement 4. Improvement in ambulation 5. Improvement in bathing 6. Improvement in bed transferring 7. Improvement in management of oral medications Home Health Compare Outcome Measures Utilization Outcomes 8. Acute care hospitalization 9. Emergency department use w/o hospitalization From claims data Jan. 2012 Potentially Avoidable Event 10. Increase in the number of pressure ulcers will not be publicly reported Home Health Compare Process of Care Measures 1. Timely initiation of care 2. Influenza immunization received for current flu season 3. Pneumococcal polysaccharide vaccine ever received 4. Heart failure symptoms addressed during short-term episodes of care 5. Diabetic foot care and patient education implemented during short-term episodes of care 6. Pain assessment conducted 7. Pain interventions implemented during short-term episodes of care 12

Home Health Compare Process of Care Measures 8. Depression assessment conducted 9. Drug education on all medications provided to patient/caregiver during short-term episodes 10. Multifactor falls risk assessment for patients > 65 11. Pressure ulcer prevention plans implemented 12. Pressure ulcer risk assessment conducted 13. Pressure ulcer prevention included in the plan of care ED Use Without Hospitalization Only 25 % of ER visits correctly reported on item M2300, compared to analysis of ER claims. o The measure from M2300 is unreliable, not directly observed. o 90% ED claims submitted within 2 months of occurrence. Public reporting of the claims-based measure will begin as early as January 2012, contingent on the measure s readiness for public reporting; o Details of the measure specifications will be provided when finalized. Increase in Number of Pressure Ulcers Rates for this measure do not distinguish between poor performance and good performance. The risk adjustment model for this measure is insufficient. The measure will not be publicly reported effective as early as October 2011. Agency will continue to get reports via CASPER. 13

HHCAHPS Survey that asks patients to report on and rate their experiences with health care. o Available in six languages. Medicare-certified agencies are/were required to: o Contract with an approved HHCAHPS survey vendor. o Submit data collected for the 1 st quarter 2011 to the Home Health CAHPS Data Center on July 21, 2011 with no late submissions. HHCAHPS Monitor their HHCAHPS survey vendors to ensure that their HHCAHPS data are submitted on time to the Home Health Care CAHPS Data Center. Submit timely exemption if applicable: Participation Exemption Request. o Medicare-certified HHAs with fewer than 60 HHCAHPS eligible, unduplicated or unique patients April 1, 2010 to March 31, 2011. o Became Medicare certified after April 1, 2011. HHCAHPS Public reporting of five measures o Three composite measures Patient care (Q9, Q16, Q19, and Q24); Communications between providers and patients (Q2, Q15, Q17, Q18, Q22, and Q23); Specific care issues on medications, home safety, and pain (Q3, Q4, Q5, Q10, Q12, Q13, and Q14); o Two global ratings of care Overall rating of care given by the HHA s care providers, The patient s willingness to recommend the HHA to family and friends. 14

HHCAHPS CY2013 HHCAHPS data collection and reporting are required for four continuous quarters. o Second quarter 2011 through first quarter 2012. HHCAHPS survey vendors are required to submit data files quarterly: o October 21, 2011 o January 23, 2012 o April 19, 2012 o July 19, 2012. Face-to-Face Medicare Benefit Policy Manual Physician certification requirement for MCR payment o Home health services needed o Patient confined to the home o Needs skilled nursing on an intermittent basis, PT, SLP ORcontinuing OT o POC established o Services furnished while under the care of a physician Face-to-Face Physician needs to see the patient o Quality of Care Issue Reduce acute care hospitalizations Effective Treatment Plan o Effort to curb Medicare fraud o Care Coordination 15

Face-to-Face Clarified Physician who cared for the patient in an acute or post-acute setting but does not follow patient in the community may: o Certify the need for HH based on his/her contact with the patient (F2F) o Initiate the POC and o Transfer/hand off the patient s care to a designated community based physician who assumes care for the patient, reviews and signs off on the POC OR Face-to-Face Clarified Patient s own physician may certify the patient conducting his/her own encounter OR When an acute/post acute stay precedes home care, may use documentation communicated from the acute/post acute physician performing a F2F assuming it includes the requirements of the F2F. o E.g., Discharge summary, Discharge plan and orders for services, a face-to-face encounter with the patient. o Phone call or email between providers can fill in the gaps. Face-to-Face Clarified Other physicians (e.g. Urgent care physician or physician s partner) may not conduct the F2F encounter for the certifying physician. Acute/post acute physician or NPP are subject to same financial restrictions as the certifying physician (Stark, anti-kickback, etc.). o May not be paid to conduct F2F encounters. 16

Face-to-Face Clarified Certifying physician documents (does not attest )indicating he/she, allowed Non Physician Practitioner (NPP) or physician caring for patient in acute/post acute stay had F2F encounter o NP or CNS working with certifying physician o Certified nurse-midwife as authorized by State law o PA under supervision of certifying physician Documentation includes: o Patient s name o Date of encounter Face-to-Face 90 days before or 30 days after SOC o How the clinical condition, as seen during the encounter, supports homebound status and the need for skilled services o The physician s signature (original signature, a faxed copy, copy of original document with signature or electronic signature but not stamped signature) o Date of the physician s signature Face-to-Face Clarified Certifying physician may: o Generate documentation from the (E)MR where entries contain clinical info about the patient s condition during the encounter o Use info extracted from the physician s (E)MR (notes, discharge summary, discharge plan) by the physician s support staff o Clearly incorporate allowed practitioner communication in certification 17

Face-to-Face Clarified Must reflect the patient s condition at the time of the certifying or acute/post acute physician encounter o Requires another encounter if the reason for admission is different than condition at F2F when standards of practice indicate examination of patient by physician or NPP necessary to establish effective treatment plan F2F required only for initial certification HHA may: Face-to-Face Clarified o Facilitate communication between the acute/post-acute physician and the community physician HHA may NOT: o Draft document for the physician to sign o Allow physician to use clinical info from HHA SOC assessment to document the encounter requirements o Accept verbal communication of the encounter from the physician and document the encounter as part of the certification for the physician to sign Face-to-Face Clarified Where a F2F did not occur within the allowed time period, a provider may complete another OASIS with a SOC date equal to the date when all Medicare eligibility is met. Medicare will not pay for services provided before the date of eligibility. 18

Therapy Correction Change before to no later than. Where more than one discipline of therapy is being provided, the qualified therapist from each discipline must provide the therapy service and functionally reassess the patient during the visit which would occur close to but no later than the 19 th visit per the plan of care. Count Covered Medicare Visits For Medicare payment purposes: o Count only Medicare-covered visits to determine when the required therapy assessment visits which are to occur close to both the 14th and 20th Medicare-covered therapy visits but no later than the 13th and 19th Medicare-covered therapy visits should occur. Remember to place both covered and non-covered visits on the bill! Services and Outcomes Studies concluded that, although delegation of care to therapy support-personnel such as assistants may extend the productivity of the qualified physical therapist, it appears to result in less efficient and effective services. Are you happy with your outcomes? 19

30 Day Therapy Reassessments Where the therapy goals in the plan of care have not been met, but the doctor has instead ordered a temporary interruption in therapy: o We (CMS) would usually expect that the unique clinical condition of the patient would enable the HHA to anticipate that an interruption in therapy may be needed. o The HHA should ensure that the requirements are met earlier than the end of the 30-day period to ensure the HHA meets the 30-day requirement. 30 Day Therapy Reassessment Where unexpected sudden changes in the patient s condition result in a need to stop therapy: o Document evidence in the medical record that would support an unexpected change in the patient s condition and precludes delivery of the therapy service. o Delay the 30-day qualified therapist visit, assessment, and measurement requirement until the patient s physician orders therapy to resume. OT as a Qualifying Service Clarification A patient is eligible/qualifies for Medicare home care when the needfor intermittent skilled nursing care, or PT or SLP or continuing OT is determined. OT is a dependent service, not a qualifying service. For Medicare to cover (pay for) a dependent service (OT, HHA, MSW) the dependent service must be followed by a qualifying skilled visit (SN, PT, SLP) except when certain unexpected circumstances occur, such as an unexpected inpatient admission or the death of the beneficiary. 20

OT as a Qualifying Services Clarification OT becomes a qualifyingservice after the 1 st OT visit is followed by a qualifying skilled visit of a SN, PT, SLP. o Continuing need for OT Subsequent OT services do not require another qualifying service to follow them both in the current and in subsequent certification periods (subsequent adjacent episodes). Once occupational therapy has become a qualifying service, it remains a qualifying service from that point on as long as the services continue to meet the criteria for covered care. Confined to the Home Clarification The patient first must meet one of the following two requirements. o Need physical assistance leaving the home or o Leaving the home is medically contraindicated. If the patient meets one of those requirements, the patient must then also meetthe two additional requirements as follows: o There must also be a normal inability to leave home and o Leaving the home must require a considerable and taxing effort. Case Management Comprehensive Assessments ooasis data Plan of Care Care Coordination and Communication Episode Goals that are continually evaluated and modified until met 21

Recertify or Discharge Clear Goals o Accomplished or modified o Visit notes clearly address goals o Teach back clearly identifies changes in learning and patient behavior Clinical Summary o Contrast beginning and end of episode o Clearly identifies measureable changes in health status Process of Home Care OASIS Comprehensive Assessment Plan of Care Outcomes Process Patient Measures Reimbursement P4P Care Coordination + Care Management = Patient able to stay safely in home And out of the hospital Resources 2012 Final Rule; CMS-1353-F http://www.ofr.gov/ofrupload/ofrdata/2011-28416_pi.pdf http://www.gpo.gov/fdsys/pkg/fr-2011-11- 04/pdf/2011-28416.pdf HHCAHPS Protocols and Guidelines Manual https://homehealthcahps.org 22

Questions? jellis@fazzi.com Fazzi Associates 243 King Street, Suite #246 Northampton, MA 01060 413-584-5300 www.fazzi.com 23