Feds try to steer home care toward technology, value-based care
Expect cheers, complaints or (most likely) both from your home care accounts this year. That’s because changes are coming to the industry in 2019, 2020 and 2021, including:
- “Remote patient monitoring” has been defined under the Medicare home health benefit, and the costs of such monitoring will be an allowable administrative cost. In addition, the Centers for Medicare & Medicaid Services implemented health and safety standards for qualified home infusion therapy suppliers.
- CMS finalized changes to the Home Health Value-Based Purchasing (HHVBP) program.
- The Medicare Advantage program now reimburses for adult day care and other home services.
- Beginning in CY 2020, home health agencies will be reimbursed per the Patient-Driven Groupings Model (PDGM), intended to reimburse providers based on patient characteristics rather than on volume of services offered.
- Medicare’s DMEPOS Competitive Bidding Program will introduce what CMS calls “market-oriented reforms,” though they probably won’t take effect until January 2021.
Remote patient monitoring
CMS Administrator Seema Verma announced in October that Medicare would allow home health agencies to report the cost of remote patient monitoring as allowable costs on the Medicare cost report form. “This is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data are shared among patients, their caregivers and their providers,” she said.
Earlier in the year, CMS had defined remote patient monitoring as the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the home health agency.
In addition to remote monitoring, the final home care rule, issued in November 2018, established a new Medicare home infusion therapy benefit, covering professional services, including: nursing services furnished in accordance with the plan of care; patient training and education (not otherwise covered under the durable medical equipment benefit); and monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier.
The health and safety standards for qualified home infusion therapy providers establish requirements for the plan of care to be initiated and updated by a physician; call for 7-day-a-week, 24-hour-a-day access to services and remote monitoring; and call for patient education and training regarding their home infusion therapy care.
To view the final CMS rule regarding remote patient monitoring and other topics, go to https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24145.pdf.
Home Health Value-Based Purchasing
CMS finalized the following changes to the HHVBP model:
- Removal of two Outcome and Assessment Information Set (OASIS)-based measures from the set of applicable measures: Influenza Immunization Received for Current Flu Season, and Pneumococcal Polysaccharide Vaccine Ever Received.
- Replacement of three OASIS-based measures (Improvement in Ambulation-Locomotion, Improvement in Bed Transferring, and Improvement in Bathing) with two new composite measures based on changes in self-care and mobility.
- Changes to how CMS calculates the Total Performance Scores by changing the weighting methodology for the OASIS-based, claims-based, and Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS).
In the final rule, CMS also provided an update on progress toward developing public reporting of performance under the HHVBP Model.
For more information on changes to the HHVBP, go to https://www.federalregister.gov/documents/2018/11/13/2018-24145/medicare-and-medicaid-programs-cy-2019-home-health-prospective-payment-system-rate-update-and-cy
Medicare Advantage
For 2019, CMS expanded its definition of “primarily health-related” (and therefore reimbursable) benefits for Medicare Advantage enrollees. (Medicare Advantage is Medicare’s private-plan option, which is said to cover about a third of all Medicare beneficiaries. Such plans can include HMOs, PPOs, private fee-for-service plans and medical savings account plans.)
An item or service is now considered “primarily health-related” if it is used to diagnose, compensate for physical impairments, ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization. Examples include:
- Adult day care services.
- Home-based palliative care.
- In-home support services (e.g., to assist individuals with disabilities and/or medical conditions in performing activities of daily living).
- Support for caregivers of enrollees (i.e., respite care for caregivers, including counseling and training courses).
- Medically approved non-opioid pain management, including therapeutic massage furnished by a state-licensed massage therapist.
- Stand-alone memory fitness benefit.
- Home and bathroom safety devices and modifications, including shower stools, hand-held showers, bathroom and stair rails, grab bars, raised toilet seats, temporary/portable mobility ramps, night lights, and stair treads. Plans may also offer installation.
- Transportation, including rides to physician office visits. The plan may include a health aide to assist the enrollee to and from the destination. (Transportation is limited to the provision of medical services – not for items and services such as groceries or banking.)
- Over-the-counter benefits, including assistive devices, such as pill cutters, pill crushers, pill bottle openers, and personal electronic activity trackers.
For more information on changes to Medicare Advantage, go to https://www.aarp.org/content/dam/aarp/ppi/2018/10/reinterpretation-of-primarily-health-related-for-supplemental-benefits.pdf
PDGM
Beginning on Jan. 1, 2020, CMS will implement a new, budget-neutral case-mix system called the Patient-Driven Groupings Model (PDGM), intended to focus on patient needs rather than volume of care.
The current home care payment system pays for 60-day episodes of care and relies on the number of therapy visits a patient receives to determine payment, according to CMS. The PDGM eliminates the use of “therapy thresholds” in determining payment, and changes the unit of payment to 30-day periods of care.
The 30-day periods are categorized into 432 case-mix groups, which are calculated based on the following criteria:
- Admission source (i.e., community or institutional).
- Timing of the 30-day period (i.e., early or late).
- Clinical grouping. The 12 subgroups are: musculoskeletal rehabilitation; neuro/stroke rehabilitation; wounds; medication management, teaching, and assessment (MMTA) – surgical aftercare; MMTA – cardiac and circulatory; MMTA – endocrine; MMTA – gastrointestinal tract and genitourinary system; MMTA – infectious disease, neoplasms, and blood-forming diseases; MMTA – respiratory; MMTA – other; behavioral health; or complex nursing interventions.)
- Functional impairment level (low, medium, high).
- Comorbidity adjustments (none, low or high, based on secondary diagnoses).
For an overview of the Patient-Driven Groupings Model, go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Overview-of-the-Patient-Driven-Groupings-Model.pdf.
DMEPOS competitive bidding
In November, CMS Administrator Verma announced that upcoming changes to the DMEPOS competitive bidding program “will reduce burden on suppliers by simplifying the bidding process.” (“DMEPOS” is an acronym for Durable Medical Equipment, Prosthetics, Orthotics and Supplies.)
The new rule on DMEPOS competitive bidding – expected to become effective in January 2021 – establishes lead item bidding, which means suppliers will only need to submit one bid per product category. The rule also finalizes increases in DMEPOS fee schedule rates, using a blend of adjusted and unadjusted fee amounts, “in order to protect access to needed durable medical equipment in rural areas that are not subject to the DMEPOS CBP,” said Verma.
All Medicare DMEPOS competitive bidding program contracts were set to expire on Dec. 31, 2018. A temporary gap in the program began on Jan. 1, 2019, and was expected to last until Dec. 31, 2020.
During the temporary gap, suppliers are required to furnish:
- Capped rental items (such as wheelchairs, hospital beds, and continuous positive airway pressure devices) through the remainder of the 13-month rental period. Title to the equipment must be transferred from the supplier to the person with Medicare using the equipment after the end of the 13th month.
- Oxygen and oxygen equipment through the remainder of the 36-month rental period. After the 36th continuous month of Medicare payment, the supplier is required to continue providing the oxygen and oxygen equipment during any period of medical need for the remainder of the five-year reasonable useful lifetime of the oxygen equipment.
For more information on changes to DMEPOS competitive bidding, go to https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/DMEPOS-Temporary-Gap-Period-Fact-Sheet.pdf
Editor’s note: To view the final home care rule (“Medicare and Medicaid Programs; CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; Home Health Quality Reporting Requirements; Home Infusion Therapy Requirements; and Training Requirements for Surveyors of National Accrediting Organizations,”), go to https://www.federalregister.gov/documents/2018/11/13/2018-24145/medicare-and-medicaid-programs-cy-2019-home-health-prospective-payment-system-rate-update-and-cy