Medicare Home Health Prospective Payment System

Transcription

1 Medicare Home Health Prospective Payment System Payment Rule Brief Proposed Rule Program Year: CY 2014 Overview, Resources, and Comment Submission On July 3, 2013, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2014 proposed payment rule for the Home Health (HH) Prospective Payment System (PPS). The proposed rule reflects the annual update to the Medicare fee-for-service (FFS) HH payment rates and policies based on regulatory changes put forward by CMS and legislative changes previously adopted by Congress. A copy of the proposed rule Federal Register (FR) and other resources related to the HH PPS are available on the CMS Web site at Payment/HomeHealthPPS/index.html. An online version of the proposed rule is available at Comments on the proposed rule are due to CMS by Monday, August 26 and can be submitted electronically at by using the Web site s search feature to search for file code 1450-P. A brief of the proposed rule is provided below along with FR page references for additional details. Program changes adopted by CMS would be effective for discharges on or after January 1, 2013 unless otherwise noted. HH Payment Rates for CY 2014 FR pages 40,295-40,299 CMS is proposing changes that significantly revise the HH payment rates for CY The Affordable Care Act (ACA) of 2010 requires CMS to rebase the HH payment rates over a four year period beginning in CY As proposed, the rebasing would reduce the 60-day episode rate and NRS conversion factor, but increase the pervisit and LUPA add-on amounts. CMS is also proposing to apply significant across-the-board reductions to the Home Health Resource Group (HHRG) case-mix weights. This change is required to be budget neutral and would necessitate a significant increase to the 60-day episode rate for CY Additional detail on the payment rebasing and HHRG case-mix weight changes is provided below. The tables below show the various HH payment rates for CY 2014 compared to the rates currently in effect: National Standardized 60-Day Episode Payment Rate The proposed 60-day episode rate includes a marketbasket increase of plus 2.4%, a rebasing reduction of minus 3.5%, a budget neutrality increase of plus 35.17% to account for the proposed HHRG case-mix weight reductions, and small adjustments to account for other proposed changes to the payment system. Final Proposed Percent 1 P age

2 CY 2013 CY 2014 Change 60-Day Episode Rate 2, $2, % National Per-Visit Amounts and LUPA Add-On Amount Payments for HH episodes with four visits or fewer are made outside of the 60-day episode rate. CMS uses national per-visit amounts by service discipline and a low utilization payment adjustment (LUPA) add-on to pay for these episodes. The national per-visit amounts are also used for outlier calculations. The per-visit amounts include a marketbasket increase of plus 2.4%, a rebasing increase of plus 3.5%, and a slight adjustment for budget neutrality. Per-Visit Amounts Final Proposed Percent CY 2013 CY 2014 Change Home Health Aide $51.79 $ % Medical Social Services $ $ % Occupational Therapy $ $ % Physical Therapy $ $ % Skilled Nursing $ $ % Speech Language Pathology Therapy $ $ % LUPA Add-On Amount $95.85 $ % In the proposed rule, CMS cites an analysis that shows there is additional cost associated with the first visit for three HH disciplines: physical therapy (PT), skilled nursing (SN), and speech language pathology therapy (SLP). For CY 2014, in lieu of the proposed single LUPA add-on payment amount of $102.91, CMS is proposing to increase the per-visit payment amounts for the first PT, SN, and SLP visit in LUPA episodes that occur as the only episode or an initial episode in a sequence of adjacent episodes by factors that CMS cites as the proportional increase in minutes for an initial visit over non-initial visits. For CY 2014, CMS would increase the PT per-visit amount by , SN per-visit amount by , and SLP per-visit amount by CMS provides the following example for the proposed policy: for LUPA episodes that occur as the only episode or an initial episode in a sequence of adjacent episodes, if the first skilled visit is SN, the payment for that visit would be $ $ ( multiplied by the proposed SN per-visit amount of $121.23). NRS Conversion Factor Prior to 2008, HH PPS payments for non-routine medical supplies (NRS) had been included in the national 60-day episode payment rate. The amount related to NRS was calculated using cost data from facilities audited cost reports. In CY 2008, CMS carved out the NRS component from the 60-day episode rate and established a separate national NRS conversion factor with six severity group weights to provide more adequate reimbursement for episodes with a high utilization of NRS. The NRS conversion factor includes a marketbasket increase of plus 2.4% and a rebasing decrease of minus 2.58%. Final Proposed Percent CY 2013 CY 2014 Change NRS Conversion Factor $53.97 $ % Points Relative Payment Severity Level (Scoring) Weight Amount $ to $ to $ P age

3 4 28 to $ to $ $ Rebasing of HH Payment Rates for CYs FR pages 40,284-40,290 The ACA requires CMS to rebase the HH payment rates over a four year period beginning in CY The law requires CMS to implement the rate changes in equal increments, not to exceed an adjustment of more than plus/minus 3.5% in a given year. To calculate the various rebasing adjustment factors, CMS analyzed the HH payment rates, cost report, and claims data to compare average cost and payment per episode. CMS used the 2012 HH payment rates to estimate the average payment per episode in CY 2013 and 2011 cost report and 2011/2012 claims data to estimate the average cost per episode (per visit cost estimates for the per-visit amounts) in CY National Standardized 60-Day Episode Payment Rate CMS has estimated that per episode payments exceed costs by 13.63%. To meet the ACA rebasing mandate, CMS is proposing to reduce the 60-day episode rate by the maximum allowable amount of minus 3.5% for CYs 2014 through National Per-Visit Amounts CMS has estimated that per visit costs exceed payments by between 19.5% and 33.1%. To meet the ACA rebasing mandate, CMS is proposing to increase the per-visit amounts by the maximum allowable amount of plus 3.5% for CYs 2014 through NRS Conversion Factor CMS has estimated that NRS payments per episode exceed costs by 9.92%. To meet the ACA rebasing mandate, CMS is proposing to reduce the NRS conversion factor by minus 2.58% for CYs 2014 through On average, CMS estimates that the proposed rebasing adjustments will reduce payments to HH providers by minus 3.4%. Complete detail on the source data and analytic methods used by CMS to develop the rebasing adjustments is provided in the FR pages referenced above. Rural Add-On for CY 2014 FR page 40,300 The ACA implemented a 3.0% increase to the payment amount for HH services provided in a rural area for episodes and visits ending on or after April 1, 2010 and before January 1, This 3.0% add-on is not subject to budget neutrality and is applied to the 60-day episode rate, the national per-visit amounts, LUPA add-on payments, and the NRS conversion factor. Effect of Sequestration for CY 2014 FR page reference not available While the proposed rule does not specifically address the 2.0% sequester reductions to all lines of Medicare payments authorized by the Budget Control Act (BCA) of 2011 and currently in effect through FFY 2021, sequester will continue unless Congress intervenes. Sequester is not applied to the payment rate; instead, it is applied to Medicare claims after determining co-insurance, any applicable deductibles, and any applicable Medicare secondary payment adjustments. Wage Index and Labor-Related Share or CY 2014 FR page 40,295 3 P age

4 The labor-related portion of the HH payment rates are adjusted for differences in area wage levels using a wage index. CMS is not proposing any major changes to the calculation of Medicare HH wage indexes. As has been the case in prior years, CMS would use the most recent inpatient hospital wage index, the FFY 2014 prerural floor and pre-reclassified hospital wage index, to adjust payment rates under the HH PPS for CY A complete list of the proposed wage indexes for payment in CY 2014 is available on the CMS Web site at Prospective-Payment-System-Regulations-and-Notices-Items/CMS P.html?DLPage=1&DLSort=2&DLSortDir=descending. These values will be updated for the final rule. CMS is proposing to maintain the labor-related share at % for CY HHRG Updates for CY 2014 FR pages 40,276-40,284 Background: Under the HH PPS, a 153-category case-mix classification system is used to assign patients to a HHRG. The clinical severity level, functional severity level, and service utilization are computed from responses to selected data elements in the Outcome and Assessment Information Set (OASIS) assessment instrument and are used to place the patient into a particular HHRG. Each HHRG has an associated case-mix weight which is used in calculating the payment for an episode. According to CMS, the HH PPS was designed to maintain an average case-mix weight of about 1.0. CMS currently estimates that the average case-mix weight under the HH PPS is Piggy-backing on the ACA mandate to rebase the HH payment rates, CMS is using its administrative authority to propose an acrossthe-board reduction to the HHRG weights in an attempt to reset the average weight to 1.0. To achieve this, CMS is proposing to apply a reduction of about minus 26% to each of the HHRG payment weights (1.0 / = -26%). This change is required to be budget neutral and would necessitate an increase to the 60-day episode rate of plus 35.17% for CY The current and newly proposed weights by HHRG are available on FR pages 40,281-40,283. CMS plans to update the factor to adjust the case-mix weights and the 60-day episode rate for the final rule. CMS is also proposing to reduce the number of International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis codes recognized under the HH PPS for CY CMS is proposing to remove 170 diagnosis codes from the HH PPS. CMS believes that these conditions could not be appropriately cared for in the HH setting and have either progressed to a less acute state or have been completely resolved before the patient could be cared for in the home setting. CMS believes the inclusion of theses diagnoses is currently producing overpayments within the HH payment system. The list of ICD-9-CM CMS is proposing to remove from the HH PPS is available on FR pages 40,276-40,279. Outlier Payments for CY 2014 FR pages 40,301-40,302 Outlier payments provide additional payment for extremely high-cost cases. Currently, if a HHA s costs for an episode of care (measured by the number of visits multiplied by the wage index-adjusted national per-visit amount) exceeds the fixed-loss threshold (measured by the case-mix and wage-adjusted payment for the episode plus a 0.45 fixed-dollar loss [FDL] ratio multiplied by the 60-day episode payment rate), the agency receives an outlier payment equal to 80% of the HHA s costs over the fixed-loss threshold. Outlier payments are capped at 10% per HHA. By law, a target of 2.5% of total HH PPS payments are set aside for outliers. To maintain total outlier payments at 2.5% of total HH PPS payments, CMS is proposing to maintain an FDL ratio of 0.45 for CY P age

5 Updates to the HHQRP FR pages 40,290-40,295 The Deficit Reduction Act (DRA) of 2005 required CMS to implement a quality data pay-for-reporting program for providers paid under the HH PPS. HH providers that fail to successfully participate in the HH Quality Reporting Program (HHQRP) receive reduced payments through a reduction of 2.0 percentage points to the HH marketbasket update. A subset of the quality data collected under the HHQRP is made available to the public on the HH Compare Web site at Currently, process and outcomes measures used under the HHQRP are derived from the OASIS assessment instrument. HH Conditions of Participation (CoPs) require that all HH providers participating in Medicare and Medicaid collect and report OASIS data. Therefore, HH providers that meet the current HH CoPs during defined time periods are deemed to have successfully participated in one portion of the HHQRP. HH providers must also collect patient experience of care data using the HH Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey. For CY 2014 payment determinations, HH providers must have met the OASIS reporting requirements for episodes beginning on or after July 1, 2012 and before July 1, In addition, HH providers must have submitted, through an approved HHCAHPS survey vendor, HHCAHPS survey data collected between April 1, 2012 and March 31, HH providers that met these requirements are deemed to have successfully participated in the CY 2014 HHQRP. Each year, CMS updates the HH pay-for-reporting program measures and policies. CMS is using the CY 2014 rulemaking process to propose new measures for CY 2015 HHQRP and beyond and update the data submission timelines for existing program measures. CMS is proposing to add the following two claims-based measures to the HHQRP for CY 2015 payment determinations and beyond: Rehospitalization during the first 30 days of HH According to CMS, this measure would estimate the risk-standardized rate of unplanned, all-cause hospital readmissions for cases in which patients who had an acute inpatient hospitalization in the 5 days before the start of their HH stay were admitted to an acute care hospital during the 30 days following the start of the HH stay. Emergency Department (ED) Use without Hospital Readmission during the first 30 days of HH According to CMS, this measure would estimates the risk-standardized rate of unplanned, all-cause hospital readmissions for cases in which patients had an acute inpatient hospitalization in the 5 days before the start of a HH stay used an ED but were not admitted to an acute care hospital during the 30 days following the start of a HH stay. Additional details on these measures, including technical specifications, can be found on CMS HH Quality Web page at Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html. For the process and outcome measures collected using the OASIS tool, CMS would continue to reconcile the OASIS submissions with claims data to verify full compliance with this portion of the quality reporting requirements on an annual cycle July 1 through June P age

6 For the HHCAHPS measures, CMS will continue the April through March data collection timeframe. The table below lists the HHCAHPS data collection and submission timeframes for CY 2015 and 2016 payment determinations. CY 2015 Collection and Submission Requirements Submission Deadline to HHCAHPS Data the HHCAHPS Data Collection Period Center CY 2016 Collection and Submission Requirements Submission Deadline to HHCAHPS Data the HHCAHPS Data Collection Period Center 2 nd Quarter 2012 Data October 17, nd Quarter 2013 Data October 16, rd Quarter 2012 Data January 16, rd Quarter 2013 Data January 15, th Quarter 2012 Data April 17, th Quarter 2013 Data April 16, st Quarter 2013 Data July 17, st Quarter 2014 Data July 16, 2015 As is the case for CY 2014 payment determinations, certain HH providers will be exempt from the HHCAHPS reporting requirements for CY 2015 and CY 2016 payment determinations. CMS exempts the following HH providers from the HHCAHPS reporting requirements (the CY 2014 exemption criteria was established last year): HH providers receiving Medicare certification on or after April 1, 2013 for CY 2015 payment determinations (April 1, 2014 for CY 2016 payment determinations); or HH providers that have fewer than 60 HHCAHPS eligible unduplicated or unique patients in the period April 1, 2012 through March 31, 2013 for CY 2015 payment determinations (April 1, 2013 through March 31, 2014 for CY 2016 payment determinations). For HHAs with fewer than 60 HHCAHPS eligible unique patients, the deadline to apply for a survey exemption is January 16, 2014 for CY 2015 payment determinations (January 15, 2015 for CY 2016 payment determinations). The form HH providers must use to submit patient counts for this exemption is available online at #### 6 P age