Home health Regulatory Roundup ---Part 2
Mary Carr, RN MPH, V.P. for Regulatory Affairs,
National Association of Home Care & Hospice
FOCUS
• Value-Based Purchasing Pilot
program
• IMPACT Act
• Joint Replacement Bundling
Value Based Purchase Pilot
 HHS Goal
 30 percent of traditional, or fee-for-service, Medicare
payments to quality or value through alternative payment
models, such as Accountable Care Organizations (ACOs) or
bundled payment arrangements by the end of 2016,
 50 percent of payments to these models by the end of 2018.
 85 percent of all FFS Medicare payments to quality or value
by 2016 and 90 percent by 2018 through programs such as
the Value Based Purchasing and the Hospital Readmissions
Reduction Programs
Value-Based Purchasing Pilot
 Earlier comments to CMS
 Concern on the magnitude of the adjustment
 Encouragement of pay for performance and pay for
reporting
 Measures: exclude 5-Star system, HHCAPS’ rehospitalizations, OASIS measures
 Support risk adjustment strategy, voluntary
participation
Value-Based Purchasing Pilot
 Proposed states: MA, MD, NC, FL, WA, AZ, IA, NE, TN
– 9 regions
– Randomized selection w/in each region
– Subject to change
 Factors considered in setting up regions
 HHA size
– Utilization levels
– Rural
– Dual-eligibles
– Proportion of minorities
Value-Based Purchasing Pilot
 “smaller-volume”—exempt from HHCAPS
 “larger-volume”—HHCAPS participant
Value-Based Purchasing Pilot
 Payment Adjustment Timeline
– 5 performance years beginning in 2016
 2016 > 2018 payment adjustment (5%)
 2017 > 2019 payment adjustment (5%)
 2018 > 2020 payment adjustment (6%)
 2019 > 2021 payment adjustment (8%)
 2020 > 2022 payment adjustment (8%)
– May modify schedule beginning in 2019 with more
frequent adjustments
Value-Based Purchasing Pilot
 Measures
– 10 Process; 15 Outcome; 4 New Measures
– OASIS; Claims; HHCAPS
 Principles:
– Broad set to capture HHA complexities
– Flexibility to include IMPACT Act proposed PAC measures
– Develop second-generation measures of outcomes, health
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and functional status, shared decisionmaking and patient
activation
Balance of process, outcome, and patient experience
Advance ability to measure cost and value
Measures on appropriateness and overuse
Promote infrastructure investments
Value-Based Purchasing Pilot:
Measures
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Outcome
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Improvement in ambulation-locomotion (OASIS)
Improvement in bed transferring
Improvement in Bathing
Improvement in Dyspnea
Discharged to community
Improvement in pain interfering with activity
Improvement in oral medication management
Prior functioning ADL/IADL
Acute care hospitalization (unplanned w/in 60 days; during first 30 days)
(Claims)
Emergency Department use w/o hospitalization
Care of Patients (CAHPS)
Communication between providers and patients (CAHPS)
Specific care Issues (CAHPS)
Overall rating (CAHPS)
Willingness to recommend the agency (CAHPS)
Value-Based Purchasing Pilot:
Measures
 Process
 Depression assessment conducted (OASIS)
 Influenza vaccine data collection
 Influenza immunization received
 Pneumococcal vaccine received
 Reason Pneumococcal vaccine not received
 Drug education
 Timely initiation of care
 Care management: Types and sources of assistance
 Pressure ulcer prevention and care
 Multifactor fall risk assessment /pts who can ambulate
Value-Based Purchasing Pilot:
Measures
 New Measures: HHA reporting through portal
 Influenza vaccination of HH staff
 Herpes zoster )shingles) vaccines for HHA patients
 Advanced Care planning
 Adverse event for improper medication
Value-Based Purchasing Pilot: Scoring
 Quarterly assessment
 Total Performance Score (TPS): higher of
achievement or performance score in each measure
 All Outcome and Process measures have equal
weight and account for 90% of TPS
 New Measure reported accounts for 10% and each
has equal weight
 Points only for “applicable measures” (20 episodes
per year)
– 0 to 10 points on each Outcome and Process measure
– 10 or 0 points on New Measures (report vs. no report)
Value-Based Purchasing Pilot: Scoring
 “Achievement threshold”: median of all HHA
performance in baseline period
 “benchmark”: mean of top decile of all HHA
performance in baseline period
 State specific; separate “smaller” and “larger” HHAs
 Each measure is separately scored
Value-Based Purchasing Pilot: Scoring
 Achievement scoring
– HHA with performance equal to or higher than
benchmark receives 10 points
– HHA with performance equal to or greater than
achievement threshold receives 1-9 points based on
formula:
 9 X (HHA performance score-achievement
threshold) divided by (benchmark-achievement
threshold) + 0.5
– HHA with performance less than achievement
threshold receives 0 points
Value-Based Purchasing Pilot: Scoring
 Improvement scoring
– HHA with performance equal to or higher than
benchmark receives 10 points
– HHA with performance greater than its baseline
period receives 1-9 points based on formula:
 10 X (HHA performance period score-HHA
baseline period score) divided by (benchmark-HHA
baseline period score) - 0.5
– HHA with performance equal or less than baseline
period score receives 0 points
Value-Based Purchasing Pilot: Scoring
 Total Performance Score (TPS)
 Use only those measures out of the 25 with 20 or
more episodes
 Use higher of improvement or achievement score
 Divide total earned points by total possible points
multiplied by 90
 Add New Measure points (points earned/possible
points X 10)
Value-Based Purchasing Pilot: Preview
 Opportunity to review quarterly quality reports
– 10 days to request recalculation
– July 2016 first report
 Opportunity to review TPS and payment adjustment
calculations
– August 1, 2017 first notification
– 10 days to request recalculation
– Final report no later than November 1, 2017
VALUE BASED PURCHASING PILOT:
IMPACT
 10% of HHAs would experience a -5% or greater
reduction under the 8% withhold level (2021-2022)
NAHC ADVOCACY PLAN
 Contest Value-Based Purchasing Pilot design
 5-8% at risk is unsustainable
 Lost resources prevent performance improvement
 Use of public comment process by all stakeholders
 Secure beneficiary advocate support
 Congressional intervention
HHQRP - IMPACT ACT
 Passed Sept 2014
 Requires PAC provider report standardized assessment data
and quality, resource, and
other measures
 HHAs, SNFs, IRFs, and LTCHs
 Time line
 Quality measure on domains between 2016-2019
 Assessment data HHA 2019; others 2018
IMPACT ACT
 Domains (HH)
 Functional and cognitive status and changes in functional and
cognitive status (2019)
 Skin integrity and changes (2017)
 Medication reconciliation (2017)
 Incident of falls (2019)
 Transition of care (2019)
 Resource use measures, including total estimated Medicare
spending per beneficiary(2017)
 Discharge to community (2017)
 Measures to reflect all-condition risk- adjusted potentially
preventable hospital readmission rates (2017)
IMPACT ACT
Standardized Data Assessment
 Data Categories
 Functional status
 Cognitive function and mental status
 Special services, treatments, and interventions
 Medical conditions and co-morbidities
 Impairments
 Other categories required by the Secretary
 HH 2019
Quality Measures (IMPACT)
 Functional status, cognitive function, and changes in function and
cognitive function
 Percent of patients/residents with an admission and discharge
functional assessment and a care plan that addresses function
 Skin integrity and changes in skin integrity
 Percent of Residents or Patients with Pressure Ulcers That Are New or
Worsened (NQF #0678 )
 Incidence of major falls
 Percent of Residents Experiencing One or More Falls with Major Injury
(NQF #0674)
IMPACT ACT
 2016 HH Proposed rule included:
 Skin integrity and changes in skin integrity
 Percent of Residents or Patients with Pressure Ulcers
That Are New orWorsened (NQF #0678 )
 Uses OASIS C-1 data set items M01308 and M01309
 Feedback on this measure and future measures to implement
the IMPACT Act
IMPACT ACT
 CMS measures under consideration (MUC) list
 Measure Application Partnership(MAP)-National Quality
Forum (NQF)
 Guides HHS in measure selection for Federal programs
 Public - private partnership
IMPACT ACT
 CMS Measure Management web page
 Call for Measures
 Public comments on measures
 Technical Expert Panel nominations
https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/MMS/index.html
IMPACT ACT
 NQF Calendar of activities:
http://www.qualityforum.org/EventList.aspx
 •MAP Coordinating committee project page:
http://www.qualityforum.org/Project_Pages/MAP_Coordin
ating_Committee.aspx
 •MAP PAC-LTC workgroup project page:
http://www.qualityforum.org/Project_Pages/MAP_PostAcute_CareLong-Term_Care_Workgroup.aspx
 •CMS’s Pre-Rulemaking page:
https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityMeasures/Pre-RuleMaking.html
IMPACT Act
 Open Door Forums (ODFs): SNF, LTC: October 29 and December 1
 HH, Hospice, DME: November 4 and December 16
 •Special Open Door Forum (SODF): Understanding The IMPACT Act-
Patient and Family Focused for Informed Decision Making. Wednesday,
October 28, 2015, from 1:00 p.m. –3:00p.m. Eastern Time
 CMS Quality Conference Presentation: December 1 –3, 2015
(planned)
 CMS National Training Program Partner Update Webinar:
January 2016 (planned)
CMS Proposed Joint Replacement
Bundling
 CMS proposes to “bundle” payment for joint replacement services under
1115A waiver
 MS-DRG 469 (Major joint replacement or reattachment of lower
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extremity with Major Complications or Comorbidities (MCC)) or
MS-DRG 470 (Major joint replacement or reattachment of lower
extremity without MCC).
75 geographic areas
Mandatory participation with some exclusions
Includes hospitalization plus all Part A and Part B related services for
90 days post-discharge
Begins January 1, 2016; 5 performance years
 https://www.federalregister.gov/public-inspection/2015/07/13
CMS Proposed Joint Replacement
Bundling
 Hospital as the risk bearing participant
 Encourages, but does not dictate care and financial integration
 Retains patient freedom of choice of providers
 No direct care control
 Reconciliation process on shared savings payment or overpayment recovery
 Phase-in with no recovery until year 2
 Certain rule waivers
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3-day hospitalization pre-SNF
Post-discharge home visits where no home health coverage
Telehealth site of service (permits service in home)
Rejects a “homebound” waiver