February 6, 2105
The Honorable Marilyn Tavenner
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Room 445—G
Hubert H. Humphrey Building,
200 Independence Avenue SW
Washington, DC 20201
RE: CMS–1461–P: Medicare Program: Medicare Shared Savings Program: Accountable Care
Organizations; Proposed Rule
Dear Administrator Tavenner:
The National Association for Home Care & Hospice (NAHC) is the nation’s largest trade association
representing home health and hospice agencies including Visiting Nurse Associations, government-based
agencies, multi-state corporate organizations, health system affiliated providers, and freestanding
proprietary agencies. NAHC members serve over 3 million Medicare home health and hospice
beneficiaries each year.
We appreciate the opportunity to provide comments on the Proposed Rule and to offer recommendations
and considerations to CMS on: waivers for telehealth services; waiver of the homebound requirement and
other payment waivers; and waivers for referrals to post-acute care settings.
NAHC recommends that any waiver should apply to beneficiaries in Track 2 in addition to Track 3 ACO
MSSPs. Limiting to waivers to Track 3 may discourage ACOs that are currently in Track 1 from
participating in a Medicare Shared Savings Program for fear of taking on too much risk unless if wavers
are also applied to Track 2 ACO agreements. Any ACO that assumes some level of risk should have the
flexibility to provide care that achieves the dual goals of positive patient outcomes and Medicare savings.
Waivers for Telehealth Services
NAHC supports CMS’ proposal to waive certain telehealth requirements for beneficiaries in a Medicare
Shared Savings Program (MSSP). Expanding the geographic area and the originating sites for telehealth
services will greatly enhance the Accountable Care Organization’s (ACOs) ability to coordinate care and
improve accessibility and timeliness of needed care. The increased flexibility in the use of telehealth will
also create better efficiencies in providing care to individuals with chronic diseases and the vulnerable
elderly.
NAHC urges that CMS permit the beneficiary’s home to be an approved originating on site for the
telehealth waiver. Permitting payments to ACOs for telehealth services in beneficiaries’ homes would
provide the ACO with a mechanism to readily address the needs of high risk patients, who are often
confined to the home. Practitioners could intervene at critical points, thus avoiding more costly
interventions. In addition, providing telehealth services in the home would go a long way in maintaining
the beneficiary’s health status and prevent unnecessary hospitalizations.
Homebound patients cannot readily avail themselves of useful telehealth services under the current
originating site restrictions. Today’s portable telehealth equipment performs the same functions as
equipment stationed in a hospital or nursing home. As such, the originating site restrictions unnecessarily
limit access to telehealth services and the resulting improvements in care quality and efficiency.
Further, it would be useful to consider waiving the limitation on coverage of telehealth of services
provided only by physicians and certain non-physician practitioners. The multi-disciplinary professional
staff of a home health agency can and do utilize telehealth services for patient monitoring, education, and
check-ups of a patient’s clinical condition. An expanded waiver could encompass both telehealth visits as
part of a Medicare-covered episode of care as well as situations where the patient does not meet home
health services coverage standards. That would permit telehealth visits to be counted in the home health
services payment model along with allowing Part B coverage under appropriate CPT codes for the visits
provided outside the home health benefit.
These services are allowed to be provided as supplemental services by MA plans that manage patient care
while bearing risk similar to that borne by ACOs.
Waiver of Homebound Requirement for Home Health Services
NAHC applauds CMS’ proposal to waive the homebound requirement for certain beneficiaries in MSSPs.
NAHC also appreciates that CMS recognizes that the homebound requirement could impede the ACO’s
ability to effectively care for high risk patients. Home health agencies have been at the forefront of
innovation in caring for patients with multiple chronic conditions with the explicit goal of preventing rehospitalizations. We believe the ACOs, as well as the beneficiaries will benefit tremendously if home
health care can be provided before a patient’s condition deteriorates to the point of rendering a patient
homebound.
CMS proposes to only permit waiver of the homebound requirement for those home health agencies that
have a quality rating of 3 or more stars.
NAHC recommends that CMS not apply a star rating system as a quality metric for home health care for
the MSSP. NAHC has concerns with CMS’ proposed star rating system, particularly, the measure
selection and the rating calculation methodology. In addition, a star rating for home health care has yet to
be fully developed and tested. More importantly, the star rating on an HHA is not a measure of its ability
to achieve Medicare program savings.
The ACO should have the flexibility to determine which partners, participants, and vendors that it feels
best fit within its integration of care as it is at financial risk in such decisions. The star rating model may
provide some guidance to consumers in choosing a home health agency, but health care professionals
directly connected to the local health care community have the ability to evaluate the skills and
proficiencies of local home health agencies far beyond the guidance coming from a narrow, dataaggregated star rating system that relies on limited process and patient outcome measures. The physicians
and health care providers that make up an ACO would have the experience of direct dealings with home
health agencies involving multiple patients over an extended period of time in contrast to one-time
decisions required by the Medicare beneficiaries who likely have no experience with any of the home
health providers.
Other Payment Waivers
NAHC also urges CMS to consider the following additional waivers that could enhance the ACOs ability
to provide needed services more efficiently and effectively.
1) The requirement that only a physician may certify a beneficiary for home health services. Allow
Non-Physician Practitioners (NPPs) to certify patient for home health services.
NPPs increasingly are playing a very important role in health care delivery – both in the direct provision
of care and through coordinating and management efforts, ensuring patients receive access to the care
they need in a safe and efficient manner. NPPs often function as the primary care practitioner for
Medicare beneficiaries. In many instances, NPPS must obtain Medicare certifications from a physician
whose direct care of the patient is far less than the NPP. Allowing NPPs to certify beneficiaries for home
health services will foster continuity of care and care coordination, while maintaining a cost effective
approach to providing primary care services.
2)
The face to face requirement as part of the home health certification
Complying with the Medicare home health face to face requirement has proven to be
extremely burdensome and complex for both physicians and home health agencies. Even after
implementing several “flexibilities” and eliminating the narrative portion of the requirement, physicians
and agencies remain unsure of what is required to comply.
In addition, concerns continue within the home health industry regarding barriers to care this requirement
may cause for beneficiaries. Further, CMS had not demonstrated that the F2F requirement has achieved
its intended purpose, which is to decrease fraud and increase physician involvement.
With an ACO at risk of negative financial consequences if home health services are over-utilized,
program integrity concerns are more than adequately addressed without the costly F2F paperwork burden
imposed on physicians and home health agencies.
It is important to note that CMS policy permits an MA plan to waive the F2F requirements if the plan has
sufficient alternative utilization and program integrity measures in place. The same standard should be
applied to ACOs.
3)
The “intermittent” requirement for home health services
CMS defines intermittent nursing as “skilled nursing care that is either provided or needed on fewer than
7 days each week, or less than 8 hours each day for periods of 21 days or less”. The “Intermittent" rule
also requires that the patient have a medically predictable recurring need for skilled nursing services at
least every 60 days with some exceptions. Therefore, skilled nursing may not be provided daily for more
than 21 days unless there is a documented exception and there is a predictable and finite end point.
Additionally, one-time nursing visits are not generally covered.
The intermittent care requirement can interfere with achieving the goals of an ACO, which is to provide
effective and efficient health care services that are patient centered. Because of the “intermittent” nursing
requirement, beneficiaries that have extended care needs are often not eligible for home health care even
if the care is less costly and/or more effective than alternative care in a hospital or institutional setting. As
a result, beneficiaries may be placed in more expensive, less clinically effective care settings that could
trigger higher direct costs along with extended costs resulting from the risks occurring in such settings.
Similarly, beneficiaries who may need home health very infrequently such as one time nursing visit are
not eligible for home health services, leaving the beneficiary to seek an alternative method for care or not
receive the service at all when a single home nursing visit could have significant cost and clinical
benefits.
As with our recommendations on the homebound waiver, NAHC recommends that CMS not apply a star
rating metric as a condition of any permissible waiver.
4) The limitation on coverage of Occupational Therapy as a qualifying skilled service
Current Medicare law permits the coverage of occupational therapy only if other skilled care disciplines
are provided or when OT is a service continuing after the cessation of other skilled services. In recent
years, OT has grown in importance in the rehabilitation of Medicare home health patients with more OT
services provided today than Speech-Language Pathology services. The benefits of OT to returning
patients to self-care are tremendous. However, those benefits are limited by the coverage restriction.
Waiver of the OT coverage restriction would foster improved clinical outcomes and result in
programmatic savings to Medicare by expanding the class of Medicare beneficiaries who could avail
themselves of this valuable rehabilitative service.
5.) The 6 month terminal illness prognosis for the Medicare hospice benefit
Medicare hospice has established itself as one of the most cost efficient services covered under the
program. Hospice brings dynamic savings to Medicare while providing a consumer-driven end-of-life
care. However, the restriction of coverage to individuals with a prognosis of a life expectancy of 6 months
or less has been a barrier to effective palliative care at the time appropriate for and chosen by the
Medicare beneficiary. Instead, high cost ineffective curative services are rendered to such individuals who
would elect hospice care if it was covered by Medicare.
6.) The hospice face-to-face physician encounter requirements
Medicare requires that hospice beneficiaries have a face-to-face encounter with a physician when the
length of stay extends past 180 days. As with the recommendation offered on the home health F2F
requirements, hospice patients in an ACO are subject to ongoing utilization oversight that renders the F2F
requirement unnecessary and burdensome.
Waivers of process requirements in discharges to Post Acute Care Settings
CMS proposes to waive the requirement that the hospital may “not specify or otherwise limit the
qualified provider which may provide post-hospital home services’’ when providing the beneficiary with
a list of qualified post-acute care providers. The ACO would be permitted to recommend preferred
providers. However, the beneficiary’s freedom of choice would be maintained when selecting a postacute provider.
Recommendations: NAHC supports the waiver to permit the ACO to list and recommend preferred
providers on the hospital post-acute care provider list under certain conditions:
First, patients in the ACO realm should be notified in advance that participation in the ACO may mean
that the ACO directs patients to certain pre-identified post-acute care providers.
Second, hospitals participating in the ACOs should be required to provide written and verbal notice to the
individuals in need of post-acute care of their right to choose any qualified provider in advance of making
a recommendation. Along with the notice, the hospital should provide detailed information about any
qualified provider that the patient wishes to consider and arrange for an in-hospital visit with the patient
for that post-acute provider.
Third, the hospital must disclose to patients and providers the criteria applied in making provider-specific
recommendations.
Fourth, CMS must closely monitor the waiver to ensure beneficiaries maintain full freedom of choice.
A patient’s freedom to choose any qualified provider of services is a right that was established in the
original Medicare law. It exemplifies the essential principle that the patients are in charge of their care
decisions, not health care providers with strong financial interests in care decisions. That principle is of
utmost importance in circumstances where a provider can share in Medicare savings that can be affected
by care provider choices. It is especially important where the Medicare beneficiary may not even know of
or has limited understanding of his/her involvement in an ACO.
Thank you again for the opportunity to submit these comments.
Very truly yours,
Mary K. Carr
Vice President for Regulatory Affairs