Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2013, Hospice Quality Reporting Requirements, and Survey and Enforcement Requirements for Home Health Agencies

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 409, 424, 484, 488, 489, and 498

[CMS-1358-F]

RIN 0938-AR18

Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2013, Hospice Quality Reporting Requirements, and Survey and Enforcement Requirements for Home Health Agencies

AGENCY:

Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION:

Final rule.

SUMMARY:

This final rule updates the Home Health Prospective Payment System (HH PPS) rates, including the national standardized 60-day episode rates, the national per-visit rates, the low-utilization payment amount (LUPA), the non-routine medical supplies (NRS) conversion factor, and outlier payments under the Medicare prospective payment system for home health agencies effective January 1, 2013. This rule also establishes requirements for the Home Health and Hospice quality reporting programs. This final rule will also establish requirements for unannounced, standard and extended surveys of home health agencies (HHAs) and sets forth alternative sanctions that could be imposed instead of, or in addition to, termination of the HHA's participation in the Medicare program, which could remain in effect up to a maximum of 6 months, until an HHA achieves compliance with the HHA Conditions of Participation (CoPs) or until the HHA's provider agreement is terminated.

DATES:

This rule is effective on January 1, 2013, except for:

a. The amendments to 42 CFR 488.2, 488.3, 488.26, and 488.28, and the additions of 42 CFR part 488, subparts I and J, which are effective July 1, 2013 (except that § 488.745, § 488.840 and § 488.845 are effective July 1, 2014).

b. The amendments to 42 CFR 489.53 and 498.3, which are effective July 1, 2013.

FOR FURTHER INFORMATION CONTACT:

Hillary Loeffler, (410) 786-0456, for information about the HH PPS.

Kristine Chu, (410) 786-8953, for information about the HH payment reform study and report.

Robin Dowell, (410) 786-0060, for information about HH and Hospice quality improvement and reporting.

Mollie Knight, (410) 786-7948, for information about the HH market basket.

Joan Proctor, (410) 786-0949, for information about the HH PPS Grouper and ICD-10 Conversion.

Lori Teichman, (410) 786-6684, for information about HHCAHPS.

Patricia Sevast, (410) 786-8135 and Peggye Wilkerson, (410) 786-4857, for survey and enforcement requirements for HHAs.

SUPPLEMENTARY INFORMATION:

Table of Contents

I. Executive Summary

A. Purpose

B. Summary of the Major Provisions

C. Summary of Costs and Benefits

II. Background

A. Statutory Background

B. System for Payment of Home Health Services

C. Updates to the HH PPS

III. Summary of Proposed Provisions and Analysis of and Responses to Public Comments

A. Case-Mix Measurement

B. Outlier Policy

C. CY 2013 Rate Update

D. Home Health Face-to-Face Encounter

E. Therapy Coverage and Reassessments

F. Payment Reform: Home Health Study and Report

G. International Classification of Diseases, 10th Edition (ICD-10) Transition Plan and Grouper Enhancements

IV. Quality Reporting for Hospices

A. Background and Statutory Authority

B. Public Availability of Data Submitted

C. Quality Measures for Hospice Quality Reporting Program and Data Submission Requirements for Payment Year FY 2014.

D. Quality Measures for Hospice Quality Reporting Program for Payment Year FY 2015 and Beyond

E. Additional Measures Under Consideration and Standardization of Data Collection

V. Survey and Enforcement Requirements for Home Health Agencies

A. Background and Statutory Authority

B. Summary of Proposed Provisions and Analysis of and Responses to Public Comments

C. Provider Agreements and Supplier Approval

D. Solicitation of Comments

VI. Collection of Information Requirements

VII. Regulatory Impact Analysis

VIII. Federalism Analysis Regulations Text

Acronyms

In addition, because of the many terms to which we refer by abbreviation in this final rule, we are listing these abbreviations and their corresponding terms in alphabetical order below:

ACH LOS Acute Care Hospital Length of Stay

ADL Activities of Daily Living

APU Annual Payment Update

BBA Balanced Budget Act of 1997, Pub. L. 105-33

BBRA Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999, Pub. L. 106-113

CAD Coronary Artery Disease

CAH Critical Access Hospital

CBSA Core-Based Statistical Area

CASPER Certification And Survey Provider Enhanced Reports

CHF Congestive Heart Failure

CMI Case-Mix Index

CMS Centers for Medicare and Medicaid Services

CoPs Conditions of Participation

COPD Chronic Obstructive Pulmonary Disease

CVD Cardiovascular Disease

CY Calendar Year

DM Diabetes Mellitus

DRA Deficit Reduction Act of 2005, Pub. L. 109-171, enacted February 8, 2006

FDL Fixed Dollar Loss

FI Fiscal Intermediaries

FR Federal Register

FY Fiscal Year

HAVEN Home Assessment Validation and Entry System

HCC Hierarchical Condition Categories

HCIS Health Care Information System

HH Home Health

HHABN Home Health Advance Beneficiary Notice

HHCAHPS Home Health Care Consumer Assessment of Healthcare Providers and Systems Survey

HH PPS Home Health Prospective Payment System

HHAs Home Health Agencies

HHRG Home Health Resource Group

HIPPS Health Insurance Prospective Payment System

IH Inpatient Hospitalization

IRF Inpatient Rehabilitation Facility

LTCH Long-Term Care Hospital

LUPA Low Utilization Payment Amount

MEPS Medical Expenditures Panel Survey

MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173, enacted December 8, 2003

MSA Metropolitan Statistical Areas

MSS Medical Social Services

NRS Non-Routine Supplies

OBRA Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-2-3, enacted December 22, 1987

OCESAA Omnibus Consolidated and Emergency Supplemental Appropriations Act, Pub. L. 105-277, enacted October 21, 1998

OES Occupational Employment Statistics

OIG Office of Inspector General

OT Occupational Therapy

OMB Office of Management and Budget

PAC-PRD Post-Acute Care Payment Reform Demonstration

PEP Partial Episode Payment Adjustment

PT Physical Therapy

QAP Quality Assurance Plan

PRRB Provider Reimbursement Review Board

RAP Request for Anticipated Payment

RF Renal Failure

RFA Regulatory Flexibility Act, Pub. L. 96-354

RHHIs Regional Home Health Intermediaries

RIA Regulatory Impact Analysis

SLP Speech Language Pathology Therapy

SNF Skilled Nursing Facility

UMRA Unfunded Mandates Reform Act of 1995

I. Executive Summary

A. Purpose

This rule updates the payment rates for home health agencies (HHAs) for Calendar Year (CY) 2013 as required under section 1895(b) of the Social Security Act (the Act). The update to the prospective payment system addresses the market basket update, case-mix adjustments due to variation in costs among different units of services, adjustments for geographic differences in wage levels, outlier payments, the submission of quality data, and additional payments for services provided in rural areas.

B. Summary of the Major Provisions

In this final rule, we use the methods described in the CY 2012 HH PPS final rule (76 FR 68526) to update the prospective payment rates for CY 2013 using a rebased and revised market basket described in section III.C.1 of this rule. This rule discusses the nominal case-mix growth adjustment, policy changes regarding therapy reassessments and face-to-face encounter requirements, grouper enhancements, and requirements concerning the home health and hospice quality reporting programs. We also provide an update on the transition plan for ICD-10 and the home health study concerning home health care access. Lastly, this rule establishes alternative sanctions, in lieu of termination, for HHAs found not to be in compliance with Medicare Conditions of Participation.

C. Summary of Costs and Benefits

TABLE 1—Cost and Benefits

Provision description

Total costs

Total benefits

Transfers

CY 2013 HH PPS payment rate update

N/A

The benefits of this final rule include paying more accurately for the delivery of Medicare home health services, providing additional regulatory flexibility for HHAs to comply with therapy requirements and face-to-face encounter documentation requirements

The overall economic impact of this final rule is an estimated $10 million in decreased payments to HHAs.

HHA Survey Requirements and Alternative (or Intermediate) Sanctions That May be Imposed when HHAs are Out of Compliance with federal Requirements

The components of the rule, which address survey requirements, codify current Survey and Certification policies and do not represent new costs. We estimate that the costs associated with Informal Dispute Resolution (IDR) will not be significantly greater than current actions related to termination actions. We estimate a onetime $2 million expense for system modifications to monitor Civil Money Penalties and annual operating expenses of $410,972 to maintain the system and provide surveyor training

The benefits of this rule include establishing alternative (or intermediate) sanctions that may be imposed when HHAs are out of compliance with federal requirements, increasing provider participation related to survey findings via the IDR, and incentives for HHAs to maintain or regain compliance with the HHA Conditions of Participation through measures other than termination

N/A.

II. Background

A. Statutory Background

The Balanced Budget Act of 1997 (BBA) (Pub. L. 105-33, enacted August 5, 1997), significantly changed the way Medicare pays for Medicare HH services. Section 4603 of the BBA mandated the development of the HH PPS. Until the implementation of a HH PPS on October 1, 2000, HHAs received payment under a retrospective reimbursement system.

Section 4603(a) of the BBA mandated the development of a HH PPS for all Medicare-covered HH services provided under a plan of care (POC) that were paid on a reasonable cost basis by adding section 1895 of the Social Security Act (the Act), entitled “Prospective Payment For Home Health Services.” Section 1895(b)(1) of the Act requires the Secretary to establish a HH PPS for all costs of HH services paid under Medicare.

Section 1895(b)(3)(A) of the Act requires the following: (1) The computation of a standard prospective payment amount include all costs for HH services covered and paid for on a reasonable cost basis and that such amounts be initially based on the most recent audited cost report data available to the Secretary; and (2) the standardized prospective payment amount be adjusted to account for the effects of case-mix and wage levels among HHAs.

Section 1895(b)(3)(B) of the Act addresses the annual update to the standard prospective payment amounts by the HH applicable percentage increase. Section 1895(b)(4) of the Act governs the payment computation. Sections 1895(b)(4)(A)(i) and (b)(4)(A)(ii) of the Act require the standard prospective payment amount to be adjusted for case-mix and geographic differences in wage levels. Section 1895(b)(4)(B) of the Act requires the establishment of an appropriate case-mix change adjustment factor for significant variation in costs among different units of services.

Similarly, section 1895(b)(4)(C) of the Act requires the establishment of wage adjustment factors that reflect the relative level of wages, and wage-related costs applicable to HH services furnished in a geographic area

compared to the applicable national average level. Under section 1895(b)(4)(C) of the Act, the wage-adjustment factors used by the Secretary may be the factors used under section 1886(d)(3)(E) of the Act.

Section 1895(b)(5) of the Act gives the Secretary the option to make additions or adjustments to the payment amount otherwise paid in the case of outliers due to unusual variations in the type or amount of medically necessary care. Section 3131(b)(2) of the Patient Protection and Affordable Care Act of 2010 (the Affordable Care Act) (Pub. L. 111-148, enacted March 23, 2010) revised section 1895(b)(5) of the Act so that total outlier payments in a given year would not exceed 2.5 percent of total payments projected or estimated. The provision also made permanent a 10 percent agency-level outlier payment cap.

In accordance with the statute, as amended by the BBA, we published a final rule in the July 3, 2000

Federal Register

(65 FR 41128) to implement the HH PPS legislation. The July 2000 final rule established requirements for the new HH PPS for HH services as required by section 4603 of the BBA, as subsequently amended by section 5101 of the Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCESAA) for Fiscal Year 1999, (Pub. L. 105-277, enacted October 21, 1998); and by sections 302, 305, and 306 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999, (Pub. L. 106-113, enacted November 29, 1999). The requirements include the implementation of a HH PPS for HH services, consolidated billing requirements, and a number of other related changes. The HH PPS described in that rule replaced the retrospective reasonable cost-based system that was used by Medicare for the payment of HH services under Part A and Part B. For a complete and full description of the HH PPS as required by the BBA, see the July 2000 HH PPS final rule (65 FR 41128 through 41214).

Section 5201(c) of the Deficit Reduction Act of 2005 (DRA) (Pub. L. 109-171, enacted February 8, 2006) added new section 1895(b)(3)(B)(v) to the Act, requiring HHAs to submit data for purposes of measuring health care quality, and links the quality data submission to the annual applicable percentage increase. This data submission requirement is applicable for CY 2007 and each subsequent year. If an HHA does not submit quality data, the HH market basket percentage increase is reduced 2 percentage points. In the November 9, 2006

Federal Register

(71 FR 65884, 65935), we published a final rule to implement the pay-for-reporting requirement of the DRA, which was codified at § 484.225(h) and (i) in accordance with the statute. The pay-for-reporting requirement was implemented on January 1, 2007.

The Affordable Care Act made additional changes to the HH PPS. One of the changes in section 3131 of the Affordable Care Act is the amendment to section 421(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173, enacted on December 8, 2003) as amended by section 5201(b) of the DRA. The amended section 421(a) of the MMA now requires, for HH services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act) with respect to episodes and visits ending on or after April 1, 2010, and before January 1, 2016, that the Secretary increase, by 3 percent, the payment amount otherwise made under section 1895 of the Act.

B. System for Payment of Home Health Services

Generally, Medicare makes payment under the HH PPS on the basis of a national standardized 60-day episode payment rate that is adjusted for the applicable case-mix and wage index. The national standardized 60-day episode rate includes the six HH disciplines (skilled nursing, HH aide, physical therapy, speech-language pathology, occupational therapy, and medical social services). Payment for NRS is no longer part of the national standardized 60-day episode rate and is computed by multiplying the relative weight for a particular NRS severity level by the NRS conversion factor (See section II.D.4.e). Payment for durable medical equipment covered under the HH benefit is made outside the HH PPS payment system. To adjust for case-mix, the HH PPS uses a 153-category case-mix classification system to assign patients to a home health resource group (HHRG). The clinical severity level, functional severity level, and service utilization are computed from responses to selected data elements in the OASIS assessment instrument and are used to place the patient in a particular HHRG. Each HHRG has an associated case-mix weight which is used in calculating the payment for an episode.

For episodes with four or fewer visits, Medicare pays national per-visit rates based on the discipline(s) providing the services. An episode consisting of four or fewer visits within a 60-day period receives what is referred to as a low utilization payment adjustment (LUPA). Medicare also adjusts the national standardized 60-day episode payment rate for certain intervening events that are subject to a partial episode payment adjustment (PEP adjustment). For certain cases that exceed a specific cost threshold, an outlier adjustment may also be available.

C. Updates to the HH PPS

As required by section 1895(b)(3)(B) of the Act, we have historically updated the HH PPS rates annually in the

Federal Register

. The August 29, 2007 final rule with comment period set forth an update to the 60-day national episode rates and the national per-visit rates under the Medicare prospective payment system for HHAs for CY 2008. The CY 2008 rule included an analysis performed on CY 2005 HH claims data, which indicated a 12.78 percent increase in the observed case-mix since 2000. Case-mix represents the variations in conditions of the patient population served by the HHAs. Subsequently, a more detailed analysis was performed on the 2005 case-mix data to evaluate if any portion of the 12.78 percent increase was associated with a change in the actual clinical condition of HH patients. We examined data on demographics, family severity, and non-HH Part A Medicare expenditures to predict the average case-mix weight for 2005. We identified 8.03 percent of the total case-mix change as real, and therefore, decreased the 12.78 percent of total case-mix change by 8.03 percent to get a final nominal case-mix increase measure of 11.75 percent (0.1278 * (1−0.0803) = 0.1175).

To account for the changes in case-mix that were not related to an underlying change in patient health status, we implemented a reduction over 4 years in the national standardized 60-day episode payment rates. That reduction was to be 2.75 percent per year for 3 years beginning in CY 2008 and 2.71 percent for the fourth year in CY 2011. In the CY 2011 HH PPS final rule (76 FR 68532) we updated our analyses of case-mix change and finalized a reduction of 3.79 percent, instead of 2.71 percent, for CY 2011 and deferred finalizing a payment reduction for CY 2012 until further study of the case-mix change data and methodology was completed.

For CY 2012, we published the November 4, 2011 final rule (76 FR 68526) (hereinafter referred to as the CY 2012 HH PPS final rule) that set forth the update to the 60-day national episode rates and the national per-visit rates under the Medicare prospective payment system for HH services. In

addition, as discussed in the CY 2012 final rule (76 FR 68528), our analysis indicated that there was a 22.59 percent increase in overall case-mix from 2000 to 2009 and that only 15.76 percent of that overall observed case-mix percentage increase was due to real case-mix change. As a result of our analysis, we identified a 19.03 percent nominal increase in case-mix. To fully account for the 19.03 percent nominal case-mix growth which was identified from 2000 to 2009, we finalized a 3.79 percent payment reduction in CY 2012 and 1.32 percent payment reduction for CY 2013.

Following up on our commitment to further study case-mix change over time and the methodology used to determine real versus nominal case-mix change, we procured an independent review of our methodology by a team at Harvard University, lead by Dr. David Grabowski. That review led to a slight enhancement of the case-mix model, but otherwise confirmed the model's accuracy (please see the report located at

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/HHPPS_HHAcasemixgrowthFinalReport.pdf

).

III. Summary of Proposed Provisions and Analysis of and Responses to Public Comments

A. Case-Mix Measurement

As described in the CY 2013 HH PPS proposed rule issued in the July 13, 2012

Federal Register

(77 FR 41548) and in section II.B of this rule, we have implemented payment reductions to the national standardized 60-day episode payment rates over the past 5 years to account for nominal case-mix growth, that is, case-mix growth unrelated to changes in patient acuity.

When including the latest data available, data from 2000 to 2010, we determined that there was a 20.08 percent nominal case-mix change during that time period. To fully account for the remainder of the 20.08 percent increase in nominal case-mix beyond that which has been accounted for in previous payment reductions, we estimated that the percentage reduction to the national standardized 60-day episode rates for nominal case-mix change would be 2.18 percent. We considered proposing a 2.18 percent reduction to account for the remaining increase in measured nominal case-mix, and solicited comments on that proposal. However for CY 2013, we proposed to move forward with the 1.32 percent payment reduction to the national standardized 60-day episode rates as promulgated in the CY 2012 HH PPS final rule. We note that analysis, to date, would seem to indicate a high likelihood of continued growth in nominal case-mix going forward. As such, we will continue to monitor real and nominal case-mix change and make updates as appropriate. We will consider any and all analyses as it continues to address the issue of the increase in nominal case-mix in future rulemaking.

The following is a summary of the comments we received regarding the case-mix measurement proposal.

Comment:

One commenter stated that the payment reductions for nominal case-mix growth are based on the unsubstantiated assertion that HHAs have intentionally “gamed the system” by coding their patients at a higher clinical severity level in order to receive higher payments.

Response:

As we have stated in previous regulations, we believe nominal coding change results mostly from changed coding practices, including improved understanding of the ICD-9 coding system, more comprehensive coding, changes in the interpretation of various items on the OASIS and in formal OASIS definitions, and other evolving measurement issues. Our view of the causes of nominal coding change does not emphasize the idea that HHAs or clinicians in general “gamed the system.” However, since our 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 are unrelated to changes in patient severity.

Comment:

Several commenters stated that CMS should not implement across-the-board reductions in payments, but rather apply the reductions only to HHAs that are abusing the system, or upcoding. Commenters stated that the payment reductions penalize agencies where case-mix increases have been less than average. A commenter stated that those agencies with a low average case-mix should be protected from further cuts since the cuts are based on a high case-mix weight. Other commenters stated that across the board cuts do not directly address problems with upcoding. One commenter stated that instead of implementing an across the board cut, CMS should redirect its focus to approaches that target specific practices that have caused the case-mix increase and that these methods should be implemented in conjunction with rebasing.

Response:

For a variety of reasons, as we have noted in previous regulations, we have not proposed targeted reductions for nominal case-mix change. Many agencies have small patient populations, which would make it practically impossible to reliably measure nominal case-mix change at the agency level. Further, we believe changes and improvements in coding practices have been widespread, making it difficult to clearly categorize agencies into high and low coding-change groups. As discussed in the CY 2012 final rule, when performing an independent review of our case-mix measurement methodology, Dr. David Grabowski and his team at Harvard University agreed with our reasons for not proposing targeted reductions, stating their concerns about the small sample size of many agencies and their findings of significant nominal case-mix increases across different classes of agencies (please see the report located at

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/HHPPS_HHAcasemixgrowthFinalReport.pdf

).

We note that although we have stated in past regulations that a targeted system would be administratively burdensome, the reasons we have just presented go beyond administrative complexity. Certain comments seem to assume that we can use case-mix levels to precisely identify those agencies with inappropriate coding practices. We do not agree that agency-specific case-mix levels can precisely differentiate agencies with inappropriate coding practices from other agencies that are coding appropriately. System wide, case-mix levels have risen over time while data on patient characteristics indicate little change in patient severity over time. That is, the main problem is not the level of case-mix reached over a period of time, but the amount of change in the billed case-mix weights not attributable to underlying changes in actual patient severity. We continue to explore potential changes to the HH PPS which could deter future nominal case-mix growth, such as the recalibration implemented in the CY 2012 final rule, and possible changes in conjunction with rebasing. However, we believe we still need to implement payment reductions to account for nominal case-mix change from the inception of the HH PPS through 2009.

Comment:

A commenter stated that across the board cuts appear to be based on high profit margins of agencies that are not committed to serving all patients.

Response:

We note that the payment reductions are based on our assessment of real and nominal case-mix growth. High profit margins do not play a role

in our calculations of the payment reductions.

Comment:

Commenters recommended that CMS target specific HHAs by reducing case-mix adjustments for HHAs with Medicare margins that are significantly above average for similarly situated HHAs. A commenter cited MedPAC's report of the variation in margins for home health providers and stated that the vast disparity in Medicare margins among HHAs makes across the board payment cuts not only unwarranted and unfair, but also potentially devastating for those whose costs exceed Medicare reimbursement.

Response:

Case-mix adjustments are based on changes in real and nominal case-mix over time. Our analyses of coding change among many classifications of agencies, as described in the CY 2012 proposed and final rules, found relatively little difference across provider types in the amount of coding change. An examination of coding change by profitability may have similar results, as profitability may reflect efficiency rather than upcoding. We further note that a classification by profitability would be complicated by the fact that profitability can vary from year to year.

Comment:

A commenter stated that applying the 1.32 percent payment reduction would be premature and that CMS should wait to apply the reduction until there are more data to review for 2011 and in particular 2012, where there has been a significant shift in the case-mix away from therapy episodes. The commenter stated that the 2012 recalibration will likely change agency behavior and, in turn, have an effect on the average case-mix weight. The commenter urged CMS to wait to make further payment reductions until it can analyze complete data sets from 2011 and 2012.

Response:

As we have stated in previous rulemaking since the start of the HH PPS, we continue to use data samples that represent a 2-year lag in service dates relative to the year in which we conduct the analysis. We note that while we analyzed 2010 data, which showed that we would need to implement a 2.18 percent reduction to account for nominal case-mix growth through 2010, we only proposed to implement a 1.32 percent reduction which would account for nominal case-mix growth from 2000 to 2009. We agree with the commenter that the recalibration in CY 2012 may have an effect on the average case-mix weight and we note that this has been taken into account when considering the 1.32 percent reduction versus than the 2.18 percent reduction. We would like to point out that the 1.32 percent payment reduction was finalized in the CY 2012 rule and we believe that with the steady increases in nominal case-mix growth over the years, there is a need to implement a payment reduction to account for this growth. We plan to continue to analyze data as it becomes available and propose payment adjustments accordingly.

Comment:

A commenter stated that CMS should use the most current metrics in analyzing case-mix growth and that they were willing to help with this effort.

Response:

Currently, we use claims data matched to OASIS assessments and Part A information, as well as HCC data, in the analysis of real and nominal case-mix growth. The commenter did not specify what they consider to be the most current metrics. However, we will continue to solicit concrete suggestions for other metrics that can be incorporated in our analysis.

Comment:

A commenter stated that CMS proposed a 1.32 percent decrease in payments to account for nominal case-mix growth from 2000 to 2010.

Response:

We would like to clarify that the 1.32 percent decrease in payments was finalized in the CY 2012 final rule in order to account for nominal case-mix growth from 2000 to 2009. Our updated analysis shows that in order to account for nominal case-mix growth from 2000 to 2010, we would need to implement a 2.18 percent reduction to payments for CY 2013. Therefore, for this rule, we are finalizing the 1.32 percent case-mix adjustment.

Comment:

A commenter stated that the proposed national standardized 60-day episode payment rate has only increased by a total of 1 percent in 12 years.

Response:

While the national standardized 60-day episode payment rate has not increased substantially in recent years, overall Medicare HH expenditures increased from $10.1 billion in 2003 to $18.6 billion in 2011, an increase of 84 percent, and the number of HH users increased 30 percent during the same time period. However, payment for an episode does not solely rely on the national standardized 60-day episode base payment rate. One must take into account the average case-mix weight when looking at HH PPS payments. The average case-mix weight has continually increased over the years while our analysis shows relatively lower real case-mix growth. The average case-mix weight in 2000 was 1.0959 while the average case-mix weight in 2009 was 1.3435, a total case-mix change from 2000 to 2009 of 22.59 percent ((1.3435−1.0959)/1.0959). When taking into account the 15.76 percent of total case-mix change estimated as real from 2000 to 2009, the nominal case-mix change measure is 19.03 percent (0.2259 * (1−0.1576) = 0.1903) from 2000 to 2009. Therefore, we believe a payment reduction is necessary to align payments with the real case-mix growth we have observed.

Comment:

A commenter stated that a further payment reduction is unwarranted especially with rebasing next year.

Response:

We are finalizing a 1.32 percent payment reduction to the CY 2013 national standardized 60-day episode base payment rate intended to account for increases in billed case-mix weights, resulting in overpayments, that have occurred between 2000 and 2009, above and beyond the real change in case-mix. Since our analysis indicates that margins will remain adequate, and our analysis for purposes of rebasing is still in process, we see no reason to defer the nominal case-mix adjustment in this rule.

Comment:

A commenter recommended that CMS find alternative ways to account for nominal case-mix growth that do not impose payment reductions to the HH PPS.

Response:

Section 1895(b)(3)(B)(iv) of the Act gives CMS the authority to implement payment reductions for nominal case-mix growth by applying reductions to the base payment. We continue to explore ways to prevent future nominal case-mix growth and we welcome any suggestions.

Comment:

Some commenters stated that CMS should increase its program integrity efforts to combat fraud, waste, and abuse. Other commenters stated that CMS should eliminate the proposed payment reduction and instead “conduct targeted claims review and deny payment for claims where the case-mix weight is not supported by the plan of care.” In addition, some commenters recommended that CMS use existing medical review to identify and target specific agencies with abusive coding practices rather than imposing an across the board payment reduction, and one commenter stated that review by Medicare Administrative Contractors and edits can be used to determine if agencies are upcoding; the commenter believes that such a method would encourage accurate coding.

Response:

We have taken various measures to reduce payment vulnerabilities and the federal government has launched actions to directly identify fraudulent and abusive activities. Commenters should be aware of tip lines available that can help

support investigative efforts of the federal government. The Office of the Inspector General, HHS Web site at

http://oig.hhs.gov/fraud/report-fraud/index.asp,

provides information about how to report fraud. Another Web site,

http://www.stopmedicarefraud.gov/index.html,

is oriented to Medicare patients and their families and provides information about recognizing fraud.

In addition, while we appreciate the commenters' suggestion about the claims review, we note that because our resources are not sufficient to conduct claims review on a scale that would be required to counteract the broad-based uptrend in case-mix weights, we cannot perform the review as suggested.

Furthermore, we note that our statistical methods using available administrative data are feasible and sufficiently reliable to utilize for the purpose of case-mix reductions.

Comment:

A commenter requested that CMS adopt the approach outlined in the Home Health Care Access Protection Act of 2012 (H.R. 6059, 112th Cong.), which is sponsored by Rep. James McGovern and Rep. Walter Jones, and involves working with the home health industry to develop criteria and evaluating a medical records sample to determine reductions, rather than relying on hypothetical extrapolations.

Response:

We already have commissioned a review of the case-mix change methodology, as we described in the CY 2012 proposed and final rule. A research team of highly qualified personnel evaluated our case-mix change methodology and found that, overall, our models to assess real and nominal case-mix growth are robust. We have not commissioned work analyzing case-mix change based on information from a medical records sample. We note that a medical records sample could be used to determine payment reductions; however, there are many difficulties and limitations to this analysis. First, to produce reliable results, we would need to collect a large sample, which would require significant financial resources that may not be available. We would need a sizable sample of records from both the IPS period and from a follow-up year (for example, 2009). In addition, based on our past experience in retrieving old records, it is difficult to find enough records to constitute a valid broad-based sample. Further, it is possible that using information from a medical records sample might not return the findings that the proponents suggest, because nominal case-mix increases partly result from reporting practices that have changed throughout time from a state of underreporting to a state of more complete reporting. Therefore, one would expect that the source records would likely reflect underreporting in the early years, just as the OASIS reflected underreporting in the early years.

Comment:

A commenter stated that the CMS case-mix change methodology does not recognize the industry's increasing ability to care for more serious medical conditions in the home (caused by technology improvements, etc.) and ignores changes in patient severity. We received a number of comments stating that home health patients are now more complex with more co-morbidities and chronic conditions than in previous years and that patients that would have previously been referred to health care facilities, such as skilled nursing facilities, are now being cared for at home. Moreover, the commenters stated that other healthcare settings have developed stricter admission requirements, thereby increasing the number of home health patients with high severity levels. A commenter stated that Transitional Care Units (TCUs) and Skilled Nursing Facilities (SNFs) are refusing to accept complex patients from the hospital and implied that those patients were being diverted to home health care.

Response:

To assess whether patients are more complex with more co-morbidities and chronic conditions than previous years, we examined the change in HCC variables over time, examining the average values for 2005 and 2010, the most recent complete data available. We note that our analysis did not find evidence that home health patients have gotten sicker over time as measured by the number of HCC indicators present. The mean number of HCC conditions present was the same in 2005 as in 2010. In addition, our analyses showed that while the prevalence of some HCCs has increased since 2005, the prevalence of others has decreased. Based on the relationship of individual HCC variables to case-mix level, the changes in the HCC indicators that have occurred since 2005 actually lead to a prediction of slightly lower expected case-mix. Furthermore, data we presented in the CY 2011 HH PPS final rule (75 FR 70379) indicate that hospital lengths of stay have been declining slightly and lengths of stay in residential post-acute settings before home health admission have increased between 2001 and 2008. We note that the proportion of initial non-LUPA home health episodes preceded by acute care within the previous 60 days has declined between 2001 and 2008, from 70.0 percent to 62.7 percent. This indicates more patients are being admitted to HHAs from non-institutional settings, such as from the community. Also, we note that acute care stays, which normally precede stays in institutional post-acute care settings, are decreasing in the stay histories of home health patients. Therefore, we question whether there is any evidence showing an increase in home health patient severity as a result of more patients coming to home health as a result of diversion from other post-acute care settings.

Comment:

Commenters stated that CMS should suspend or eliminate case-mix payment reductions because the data used to determine the reductions do not recognize real increases in severity due to earlier and sicker hospital discharges.

Response:

Although we recognize that average lengths of stay in acute care settings are in decline, our analysis shows that agencies are, in fact, caring for proportionately fewer, not more, post-acute patients. Since 2001, the average length of stay (LOS) in acute care preceding home health has declined by about one day, from 7 days to 6 days. Between 2008 and 2009, the average length of stay in acute care leading directly to home health admission declined from 6.07 days to 5.85 days. However, agencies are caring for fewer highly acute patients in their caseloads. The proportion of non-LUPA episodes in which the patient went from acute care directly to home health within 14 days of acute hospital discharge declined substantially between 2001 and 2008, from 32 percent to 23 percent. Also, the median acute hospital LOS for these non-LUPA episodes with a 14-day look back period remained unchanged at 5 days between 2002 and 2008 (see 75 FR 70379). In 2009, the median LOS declined to an estimated four days (see Table 2). The distribution of lengths of stay has been fairly stable, with declines since 2006 limited to the upper half of lengths of stay.

We believe the declining proportion of home health cases with a recent acute discharge is due in part to more patients incurring re-certifications after admission to home health care, and also due to more patients entering care from the community. The shortening lengths of stay at the right tail (high percentiles) of the distribution may reflect changing utilization of long-term-care hospitals during recent years. The conclusion we draw from these data is that while patients on average have shorter hospital stays, agencies are also facing a smaller proportion of home health episodes in which the patient has been acutely ill in the very recent past. Also, the detailed data on the distribution of stay lengths suggest that for the most

part lengths of stay for such patients remained fairly stable through 2009.

ER08NO12.000

Furthermore, we think that acuity of patients has been increasingly mitigated by lengthening post-acute stays for the substantial number of home health patients who use residential post-acute care prior to an episode. Our data show that patients who enter residential post-acute care before home health admission have experienced increasing lengths of stay in post-acute care since 2001. Using a 10 percent random beneficiary sample, we computed the total days of stay (including both acute and post-acute care days) for home health episodes with common patterns of pre-admission utilization during the 60 days preceding the beginning of the episode. We included patients whose last stay was an acute care stay, or whose next-to-last stay was an acute care stay with a follow-on residential post-acute care stay, or whose third from last stay was an acute care stay followed by two post-acute care stays. These common patterns accounted for 55 percent of the initial episodes in 2001 and 42 percent in 2008. We found that total days of stay during the 60 days leading up to the episode averaged 12.6 days in 2001, and rose to 12.8 days in 2008. This small change in total days of stay during a period when acute care LOS was declining was due to increasing lengths of stay in residential post-acute care for these patients. For example, within the 30 days before admission, an average LOS in the post-acute care setting for episodes preceded by an acute care stay that was the next-to-last stay, and where the post-acute care stay was the very last stay before the claim from-date, increased from 12.7 to 14.3 days. Our interpretation of these statistics is that patient acuity has been increasingly mitigated by longer post-acute stays for the substantial number of home health patients that use residential post-acute care prior to the start of a home health episode. Patient acuity was also mitigated by growing numbers of home health re-certifications.

Comment:

A commenter stated that the model used to assess real case-mix growth ignores the fact that more individuals are becoming eligible for Medicare services and there is an increasing number of Medicare beneficiaries who are over 85 years of age and need additional services.

Response:

We note that increasing eligibility does not in itself imply more severity. Rather, our statistical analysis shows that there are more patients with about the same severity of illness level. With regards to the comment about the proportion of older patients, we note that we take into account the proportion of home health patients over the age of 85 in our model to estimate real case-mix growth. The results of the model show that while the proportion of patients over age 85 has increased somewhat, this change is only associated with small changes in real case-mix.

Comment:

A commenter stated that relevant data shows that home health care patients have increased functional limitations and more complex clinical conditions than in past years.

Response:

As stated in the CY 2012 proposed rule, a detailed analysis of Medicare Expenditure Panel Survey (MEPS) data (which is independent of our real case-mix model) was performed to examine the severity of the Medicare home health population. The trends in health status from 2000 to 2008 were analyzed.

The analysis showed a slight increase in the overall health status of the Medicare home health population, and in particular, the percent of home health Medicare beneficiaries experiencing “extreme” or “quite a bit” of work-limiting pain decreased substantially, from 56.6 percent in 2000 to 45.4 percent in 2008 (p=0.039). While we recognize that there are some limitations to this analysis, we concluded that the results of this analysis provide no evidence of an increase in patient severity from 2000 to 2008.

In addition, we would like to note that during the CY 2012 rulemaking cycle, we incorporated HCC data, which is used by CMS to risk-adjust payments to managed care organizations in the Medicare program, in our model to assess real case-mix growth. Our findings of real and nominal case-mix growth, even when incorporating HCC data, were consistent with past results. Most of the case-mix change was identified as nominal case-mix change.

We will continue to solicit suggestions for other data that can be

incorporated into our analysis of real and nominal case-mix growth.

Comment:

A commenter stated the models used to determine real case-mix change do not consider increased therapy needs in the home health population.

Response:

The models were intended to analyze real changes in case-mix over time and do not distinguish whether these changes are due to increases in therapy use or other factors. We do not believe that it would be appropriate to include utilization-related variables, such as the number of therapy visits, as predictors in the model, as such variables are provider-determined. In addition, the goal of these analyses was not to develop refinements to the payment system but rather to examine changes in measures of patient acuity that are not affected by any changes in provider coding practices. For example, the models do incorporate information about change in the types of patients more likely to use therapy, such as post-acute joint replacement patients. CMS has access to the claims histories and other administrative data for patients in our samples, and we welcome suggestions about how to better use these resources in finding alternative variables more indicative of the need for therapy, particularly if the suggestions involve the use of data and variables that are not HHA-determined.

Comment:

Some commenters suggested that CMS recognize changes in patient severity, improved patient assessment, and coding and reimbursement changes in its case-mix methodology and work with NAHC to uncover the reasons for case-mix weight changes and to develop a valid methodology for payment reform. A commenter urged CMS to continue to evaluate and refine the case-mix methodology so that it targets drivers of case-mix change and more effectively captures real case-mix change. Another commenter stated that CMS should consult with stakeholders to agree upon factors that should be considered when calculating real and nominal case-mix growth.

Response:

Through the public comment process, we have obtained industry views as to the reasons for coding changes. As we have pointed out in the past, reasons offered, such as improved coding, are not a sufficient basis for raising payment rates, particularly if data does not indicate a significant increase in the severity of home health patients. To the extent case-mix change is due to better methods of assessing patients in the home health setting, this does not justify making reimbursements as though the patients really were different in their case-mix levels of severity. Over the last several years, we have continued to evaluate our data and methods, and in the CY 2012 proposed and final rule, we described that we procured an independent review of our methodology to assess real and nominal case-mix growth performed by a team at Harvard University led by Dr. David Grabowski. The Harvard team was asked to review the appropriateness and strength of evidence from the case-mix change methodology we used. After their examination, they concluded that the methodology was robust and valid. We plan to continue to evaluate the case-mix methodology and potentially refine the methodology as needed. We will continue to solicit suggestions on possible ways to improve our models.

Comment:

Commenters stated that providers have had to absorb several rounds of payment reductions due to upcoding, which have contributed to lower growth in home care spending. They stated that the growth rate in Medicare home care spending has dramatically declined to just 1.0 percent from 2010 to 2011.

Response:

We note that the purpose of the payment reduction is to adjust payments to better reflect real changes in patient severity. In addition, slower Medicare home care spending growth may be due to a number of factors. We note that we have conducted analyses looking at the number of paid claims, both nationally and by state, for 2009 through 2011. Our analyses show that the volume of paid claims is consistent with previous years. Although paid claims generally go up very slightly every year and they did not in 2010, this could be attributed to many factors, including CMS's fraud and abuse efforts, or simply a more general trend in Medicare claims volume.

Comment:

One commenter estimated that over 40 percent of existing HHAs currently operate with negative financial margins on Medicare revenues and that when all patient costs and revenues are considered, overall margins for all freestanding HHAs are estimated to be 3 percent in 2012. Another commenter stated that in the states where they operate, more than half or nearly half of all home health providers are reimbursed less than cost by Medicare. Specifically, the commenter stated that 59 percent of HHAs in Missouri, 45.9 percent of HHAs in Illinois, 59.0 percent of HHAs in Oklahoma, and 67.1 percent of HHAs in Wisconsin are operating with margins less than zero. The commenter urged CMS to eliminate the proposed 1.32 percent reduction so that payments more closely reflect the “economic realities” of HHAs.

Response:

Regarding the commenters' concerns about the effects of the proposed reductions on providers' viability and the resultant access risks, we note that in their March 2012 Report to the Congress, MedPAC projected Medicare margins for home health agencies in 2012 to average 13.7 percent. While it is unclear whether the projection of average Medicare margins of 13.7 percent in 2012 factors in potential changes in the therapy level distribution due to the CY 2012 recalibration, and therefore actual margins could be slightly different, we note that our analysis of payments and costs also projects average margins to be adequate. Furthermore, when examining the impact of the 1.32 percent payment reduction, providers need to take into account all of the other policies in the CY 2013 rule, such as changes to the fixed dollar loss (FDL) ratio as well as the wage index and payment update. When examining all of the CY 2013 policies finalized in this final rule, our data indicates that the impact is minimal, with an average effect on payments of −0.01 percent. In addition, when taking into account all of the CY 2013 policies, Illinois, Wisconsin, and Missouri are expected to have a net increase in payments in CY 2013 (see section IV. Regulatory Impact Analysis). Furthermore, based on the results of our analysis on estimated margins by state, there is no indication that the four states mentioned by the commenter will be more adversely affected by the CY 2013 policies compared to other states.

Comment:

A commenter stated that while the number of HHAs may continue to grow, the growth is limited to certain geographic areas and that the across the board payment reductions are “taking their toll” on HHAs with below average margins. Another commenter stated “Any efficiency available to control the cost of an episode of care has been implemented, and rate cuts are now having a direct, linear impact of providers.”

Response:

We note that our analysis of margins and MedPAC's reported margins for 2010 indicate that payments should be adequate. In addition, we reiterate that the purpose of the payment reduction is to align payment with real, observed changes in patient severity. Moreover, while we considered a 2.18 percent reduction to the national standardized 60-day episode rates based on our analysis using 2010 data, we are finalizing a 1.32 percent payment reduction for this year.

Comment:

A commenter stated that the case-mix model used to determine

real case-mix growth does not account for real case-mix changes in patient severity experienced by hospital-based home health agencies and that the proposed payment reduction would adversely impact hospital-based home health agencies. Commenters stated that the data used to calculate the case-mix reduction is skewed to free-standing facilities and that free-standing HHAs are selective while hospital-based HHAs take on all types of patients discharged from the hospital. The commenters did not think the reduction was appropriate for hospital-based home health care. Another commenter stated that hospital-based HHAs average Medicare margin was -6.29 percent in 2010 and that it can be assumed that overall margins of this HHA sector is well below zero percent given lower-than-cost Medicaid and Medicare Advantage payment rates.

Response:

In the CY 2012 proposed and final rule, we described the results of the independent review of our models to assess case-mix growth performed by a team at Harvard University led by Dr. David Grabowski. We described that the review included an examination of the predictive regression models and data used in CY 2011 rulemaking, and further analysis consisting of extensions of the model to allow a closer look at nominal case-mix growth by categorizing the growth according to provider types and subgroups of patients. Two of the extensions that we examined focused on free standing and facility-based HHAs. The extensions showed a large and not dissimilar rate of nominal case-mix growth from 2000 to 2008 for the two groups, 17.86 percent nominal case-mix increase for free-standing HHAs and 14.17 percent nominal case-mix increase for facility-based increase. Given the results of our analysis, which showed significant nominal case-mix growth for freestanding versus hospital based HHAs, we believe that the model is not skewed to a particular provider type and that an across the board reduction is appropriate given the widespread nominal case-mix growth. We note that our analysis on Medicare Cost Report data for hospital-based HHAs does indicate that Medicare margins are lower than those of freestanding HHAs.

Comment:

Commenters criticized the model's reliance on hospital data, stating that over half of all Medicare home health patients are admitted to care from a setting other than a hospital and many of the patients receive home health care far extended past an initial episode. Commenters implied that the All Patient Refined Diagnosis Related Groups (APR-DRG) variables are less relevant for multiple episode patients.

Response:

We disagree that the use of the hospital information in the case-mix change analysis is so limited. Also, with the addition of HCC data, we have enhanced the robustness of the variable set used for the analysis to include physician diagnoses and diagnoses of other clinicians, as well as Medicaid eligibility. Regardless of whether the patient came directly from a non-hospital-setting (for example, home or an institutional post-acute stay), information from a hospital stay preceding home health is typically relevant to the type of patient being seen by the HHA.

Comment:

A commenter stated that case-mix reductions do not take into account the cost of new regulatory burdens, such as documentation for face-to-face encounters and HHCAHPS.

Response:

We note that the 1.32 percent payment reduction is to account for nominal case-mix increases (increases in case-mix that are not related to real changes in patient acuity). Case-mix reductions are not intended take into account the costs of regulatory burdens. The models used to assess real case-mix growth take into account factors that would affect patient severity.

Comment:

A commenter stated that nominal case-mix growth cannot be assumed using CMS's methodology because of the change from ICD-9 to ICD-10.

Response:

Our analysis of case-mix used data from 2000 to 2010 to determine the amount of real and nominal case-mix growth and did not take into account a change from ICD-9 to ICD-10. The change is currently not relevant to our analysis of case-mix growth. After we transition from ICD-9 to ICD-10, we may examine the effects of the change on case-mix growth as data become available and propose payment adjustments accordingly.

Comment:

One commenter said that the payment reductions to account for nominal case-mix growth are arbitrary and appear to reduce payments without data to show that they are necessary.

Response:

We disagree. The prediction model for real case-mix is an empirical model, the findings of which are based entirely on empirical evidence. The real case-mix prediction model and its application account for changes in the HH patient population by quantifying the relationships between patient demographics, clinical characteristics, and case-mix. The relationships in conjunction with updated measures of patient characteristics are used to quantify real case-mix change. The characteristics in the model include proxy measures for severity, including a variety of measures, namely, demographic variables, hospital expenditures, expenditures on other Part A services, Part A utilization measures, living situation, type of hospital stay, severity of illness during the stay, and risk of mortality during the stay. Last year, additional diagnosis data, based on physician and hospital diagnoses in the patient's claims history, were added in the form of HCC indicators. Measurable changes in patient severity and patient need, factors mentioned by commenters, are an appropriate basis for changes in payment. Our model of real case-mix change has attempted to capture such increases.

We recognize that models are potentially limited in their ability to pick up more subtle changes in a patient population such as those alluded to by various commenters. Yet in previous regulations we presented additional types of data suggestive of only minor changes in the population admitted to home health, and very large changes in case-mix over a short period. We included among these pieces of evidence information about the declining proportion of home health episodes associated with a recent acute stay for hip fracture, congestive heart failure, stroke, and hip replacement, which are four situations often associated with high severity and high resource intensity (72 FR 49762, 49833 (August 2007)). We presented information showing that resource use did not increase along with case-mix increases (72 FR 49833). We also analyzed changes in OASIS item guidance that clarified definitions and could have led to progress in coding practice (72 FR 25356, 25359 (May 2007)). We found some small and scattered changes indicative of worsening severity but these changes did not commensurate with the increase in case-mix weights (72 FR 25359). In our discussion, we cited specific instances where agencies' changing understanding of coding could have contributed to the adverse changes. However, as previously stated, Medicare payments should be based on patient level of severity, and not on coding practices.

In the CY 2011 HH PPS proposed rule, we identified a very large, sudden 1-year change (+0.0533) in the average case-mix weight between 2007 and 2008. This increase is partly attributable to the reporting of secondary diagnosis codes (see 75 FR 43242 (July 23, 2010)). The use of secondary diagnosis codes in the case-mix algorithm was introduced

in 2008 as part of the new case-mix system.

In summary, we believe the payment reductions to account for nominal case-mix growth are not arbitrary and data used in our model as well as other data indicate only small changes in patient severity while we have observed large changes in the average case-mix weight over time. Therefore, in order to better align payment with real changes in patient severity, we are finalizing a 1.32 percent payment reduction for CY 2013.

Comment:

One commenter stated that the actual program spending on home health is generally less than the Congressional Budget Office estimates between 1996 to 2009. Therefore they questioned CMS's authority to implement payment reductions for nominal case-mix growth. They stated that in home health, Medicare expenditures have been equal to or lower than projections and estimates by CBO since the beginning of the HH PPS and therefore, there is no increase in aggregate expenditures that warrants application of the statutory authority under section 1895(b)(3)(B)(iv) of the Act.

Response:

Section 1895(b)(3)(B)(iv) of the Act gives CMS the authority to implement payment reductions if there are changes in aggregate payments that are a result of nominal case-mix growth. Our data show changes in actual aggregate payments due to nominal case-mix growth, and therefore in the CY 2013 HH PPS proposed rule, we proposed to move forward with a 1.32 percent reduction to the HH PPS rates.

Comment:

A commenter stated that across the board reduction can cause or exacerbate access issues for high-cost patients. Another commenter stated that they are seeing access problems for higher-cost patients. The commenter suggested that CMS evaluate the payment model to determine whether changes are needed to address the unintended impact of the across the board rates on providers and evaluate the payment model based on its ability to maintain access to care for all eligible Medicare beneficiaries. Commenters urged CMS to make modifications to the payment system so that there are not financial disincentives to accepting a disproportionate number of high cost patients.

Response:

We appreciate the commenter's concerns. To address concerns that some beneficiaries are at risk of not having access to Medicare home health services and that the current HH PPS may encourage providers to adopt selective admission patterns, section 3131(d) of the Affordable Care Act requires the Secretary to conduct a study on home health agency costs involved with providing access to care to low-income Medicare beneficiaries or beneficiaries in medically underserved areas, and in treating beneficiaries with varying levels of severity of illness (specifically, beneficiaries with “high levels of severity of illness”). Pending results of the study, CMS may make recommendations for revisions to the HH PPS and recommendations for legislation and/or administrative action which may address any access issues identified in the study. In addition, we will continue to monitor for unintended consequences of the payment reductions and we will seek information from other government agencies on access. Finally, we will use Open Door Forums and other venues to solicit information from agencies on any actual access issues they witness.

Comment:

A commenter stated that CMS should use information from the home health study under section 3131(d) of the Affordable Care Act to determine a fair payment rate rather than imposing across the board payment reductions.

Response:

The home health study under section 3131(d) of the Affordable Care Act allows CMS to not only look at access for vulnerable populations, but also look at other issues with the payment system and payment vulnerabilities. In this study, we plan to examine ways to better align payment with patient needs. The Report to Congress describing the findings of our study is projected to be available in 2014. In the meantime, while examining ways to better improve the case-mix system, we believe that it is appropriate to adjust payment rates to reflect real, observed changes in patient severity.

Comment:

One commenter stated that they were concerned with the 1.32 percent payment reduction since it is combined with the Affordable Care Act mandated 1 percent reduction to the market basket update. The commenter urged CMS to recognize home health as a critical part of the health care continuum and that it requires adequate reimbursement to succeed in a reformed health care delivery system. The commenter stated that home health agencies should be reimbursed adequately for their services and that home health services are less expensive than acute care alternatives. Another commenter stated that overall Medicare spending has increased much more than Medicare payments to home health agencies and that the payment reductions to home health care spending “represents negative health policy at a time when we should be encouraging the provision of health care outside of facilities.” The commenter continued to say that hospital inpatient and long-term acute care hospitals will see increases in their payments for CY 2013. The commenter stated that CMS should not be cutting the most cost effective portions of the health care system to provide greater reimbursement to the most expensive ones. The commenters asked CMS to reconsider the 1.32 percent coding adjustment and other payment reduction changes in the 2013 HH PPS rule.

Response:

We thank the commenters for their comments. However, we note that the 1 percent reduction to the market basket update is a mandated payment reduction, not intended to be offset by other policies, such as the 1.32 percent payment reduction. In addition, the Regulatory Impact section of our rule (see section VII.) shows that when combined with the market basket update and the wage index update, this rule will have a minimal impact on payment in comparison with previous years. In addition, while we updated our analysis to include 2010 data, which would have resulted in a 2.18 percent payment reduction, we are finalizing a 1.32 percent reduction for this final rule. We would also like to remind commenters that the goal of the payment reduction is to better align payment with real changes in patient severity. That is, the payment reduction is to ensure appropriate payment given the real changes in the Medicare home health population we observe. We would also like to point out that the 1.32 percent payment reduction is not related to the increase in payments for hospital inpatient and long term acute care hospitals; that is, the payment reduction does not free up money to pay for other settings. The goal of the payment reduction is to pay appropriately for the home health services provided to Medicare home health beneficiaries.

Comment:

Several commenters stated that they support and appreciate CMS's proposal to withhold any further increase in the payment reduction to account for nominal case-mix growth. Commenters stated that the 1.32 percent payment reduction, rather than the full 2.18 percent reduction is a welcome action from CMS as providers have experienced significantly increased costs with the face-to-face encounter and therapy assessment requirements. Another commenter stated that the restraint in the payment reduction to account for nominal case-mix growth is warranted because the 2010 data does not yet fully reflect changes in CMS

policy that were intended to reduce some of the nominal increases in case-mix weights. Commenters stated that they would like CMS to limit the 2013 adjustment for nominal case-mix growth to 1.32 percent as proposed in the CY 2013 proposed rule.

Response:

We appreciate the commenters' support of our proposal. We would like to clarify that the reason the 1.32 percent payment reduction, rather than the full 2.18 percent reduction, was proposed was not because of any potential additional costs associated with the face-to-face encounter and therapy assessment rules. We believe the 2.18 percent payment reduction would allow CMS to fully account for the nominal case-mix growth from 2000 to 2010 and we may consider accounting for more nominal case-mix growth in future rulemaking. However, given certain factors, such as the recent recalibration in CY 2012 and potential effect on the average case-mix, for this final rule, we are finalizing a 1.32 percent reduction to account for nominal case-mix growth, as described in the CY 2012 final rule.

Comment:

One commenter stated that unwarranted overpayments attributable to changes in coding practices should be recovered and that payment increases unrelated to patient severity also occur in other payment systems. The commenter stated that the proposed adjustment would not account for all of the coding increase CMS has identified and that the proposed adjustment would result in overpayments to home health agencies, increasing home health expenditures for the federal government and beneficiaries. The commenter stated that aggregate Medicare margins in 2012 are projected to exceed 13 percent and that with the full reduction of 2.18 percent, most HHAs would be paid well in excess of costs. The commenter stated that implementing a small reduction in 2013 will require that a larger reduction occur in future years and therefore, CMS should reduce payments by 2.18 percent in 2013.

Response:

We thank the commenter for the comments. We agree that the 2.18 percent reduction would allow CMS to fully account for the nominal case-mix growth through 2010. However, due to certain factors such as the recalibration in CY 2012, the average case-mix weights may have lowered and therefore, for this final rule, we are finalizing a more conservative payment reduction of 1.32 percent. It is unclear whether the projection of average Medicare margins of 13 percent in 2012 factors in potential changes in the therapy level distribution due to the CY 2012 recalibration. We will continue to assess nominal case-mix growth and propose reductions in future rulemaking as necessary.

Comment:

One commenter stated that the yearly recalculation of revision of the payment reduction to account for nominal case-mix undermines the stability of the payment system and CMS's proposals have made it hard for HHAs to predict the payment amounts.

Response:

We disagree there has been instability. Since 2008, agencies have been informed that payments would be reduced over time to offset unwarranted reimbursement growth due to nominal case-mix growth and every year since 2008, we have applied a payment reduction to account for nominal case-mix growth. Also, every year since CY 2011 rulemaking, we have updated our analysis of real and nominal case-mix growth as data have become available and in CY 2011 and CY 2012 rulemaking, our updated analysis resulted in further payment reductions to the national standardized 60-day episode rates. We note that for CY 2013, we are finalizing a 1.32 percent reduction, as described in the CY 2012 final rule. In addition, we reiterate that the purpose of the payment reduction is to adjust payments to better reflect real changes in patient severity and our goal is to pay appropriately for the home health services provided to Medicare home health beneficiaries.

Comment:

Commenters were concerned with the impact of the 1.32 percent payment reduction on quality of care.

Response:

Commenters did not provide specific information about why they believe payment reductions might impact quality of care. Our simulation of margins under the payment policies in this rule suggests that margins will remain adequate, and thereby not have an adverse effect on quality of care. We also believe that policymaking in the quality improvement area should help to ensure quality advances. OASIS-C outcome reports and HHCAHPS data are two important recent developments that we anticipate will support high-quality services. Over time, value-based purchasing policies will be developed, further enhancing quality-related incentives. We encourage agencies to work to their full professional potential to deliver a high standard of care to their patients.

Comment:

A commenter stated that payment reductions will decrease the agencies' ability to educate, focus on quality care, implement electronic systems of documentation, and focus on savings to the Medicare program such as decreasing hospitalizations. They stated that payment reductions would mean fewer resources to develop quality and compliance programs.

Response:

A reduction in margins as a result of our payment changes may have an effect on the availability of resources for various types of investments. However, our analysis indicates that payments to HHAs will still be more than adequate under our payment changes and would still allow for investments. We do not have sufficient data to evaluate the effect on technology-specific investments from the unusually large margins that have been in existence under the HH PPS, but we welcome information about whether the numerous agencies that operated with high margins under the HH PPS made investments during those years, and the nature of those investments. Other areas, such as education, quality improvement, and decreasing hospitalizations, are the focus of investment in human capital that agencies should be currently undertaking in view of program initiatives underway or being tested (HHCAHPS, HH P4P demo). We reiterate that our analysis of payments indicates that payments are adequate enough to allow for different types of quality-strengthening investments, whose costliness would depend on the agency's individual situation, including how efficiently the agency operates in general. We would also like to note that the pay for performance (P4P) demonstration did not find strong evidence that changes participating agencies made along the lines of better care coordination to improve quality and reduce hospitalizations were necessarily expensive (

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/Downloads/HHP4P_Demo_Eval_2008_Vol3.pdf

).

In the CY 2012 final rule, we finalized a 3.79 percent payment reduction to the CY 2012 national standard 60-day episode rates and a 1.32 percent payment reduction to the CY 2013 national standardized 60-day episode rates to account for nominal case-mix growth we identified from 2000 to 2009. In the CY 2013 proposed rule, we updated our analysis using data from 2000 to 2010, estimating that the percentage reduction to account for nominal case-mix change would be 2.18 percent. However, we proposed a 1.32 percent payment reduction as described in the CY 2012 rule. For this final rule, we are finalizing a 1.32 percent payment reduction for CY 2013 to the national standardized 60-day episode rates. This reduction enables us to account for nominal case-mix growth which we have identified through CY 2009 and to

collect additional data on case-mix change, such as data on the effects of the CY 2012 recalibration of the HH PPS case-mix weights.

B. Outlier Policy

1. Background

Section 1895(b)(5) of the Act allows for the provision of an addition or adjustment to the national standardized 60-day case-mix and wage-adjusted episode payment amounts in the case of episodes that incur unusually high costs due to patient home health (HH) care needs. Prior to the enactment of the Affordable Care Act, this section of the Act stipulated that projected total outlier payments could not exceed 5 percent of total projected or estimated HH payments in a given year. In the July 2000 final rule (65 FR 41188 through 41190), we described the method for determining outlier payments. Under this system, outlier payments are made for episodes whose estimated costs exceed a threshold amount for each Home Health Resource Group (HHRG). The episode's estimated cost is the sum of the national wage-adjusted per-visit payment amounts for all visits delivered during the episode. The outlier threshold for each case-mix group or partial episode payment (PEP) adjustment is defined as the 60-day episode payment or PEP adjustment for that group plus a fixed dollar loss (FDL) amount. The outlier payment is defined to be a proportion of the wage-adjusted estimated cost beyond the wage-adjusted threshold. The threshold amount is the sum of the wage and case-mix adjusted PPS episode amount and wage-adjusted fixed dollar loss amount. The proportion of additional costs paid as outlier payments is referred to as the loss-sharing ratio.

2. Regulatory Update

In the CY 2010 HH PPS final rule (74 FR 58080 through 58087), we discussed excessive growth in outlier payments, primarily the result of unusually high outlier payments in a few areas of the country. Despite program integrity efforts associated with excessive outlier payments in targeted areas of the country, we discovered that outlier expenditures still exceeded the 5 percent target and, in the absence of corrective measures, would have continued do to so. Consequently, we assessed the appropriateness of taking action to curb outlier abuse. To mitigate possible billing vulnerabilities associated with excessive outlier payments and adhere to our statutory limit on outlier payments, we adopted an outlier policy that included a 10 percent agency level cap on outlier payments. This cap was implemented in concert with a reduced FDL ratio of 0.67. These policies resulted in a projected target outlier pool of approximately 2.5 percent. (The previous outlier pool was 5 percent of total HH expenditures.)

For CY 2010, we first returned 5 percent of these dollars back into the national standardized 60-day episode rates, the national per-visit rates, the low utilization payment adjustment (LUPA) add-on payment amount, and the non-routine supplies (NRS) conversion factor. Then, we reduced the CY 2010 rates by 2.5 percent to account for the new outlier pool of 2.5 percent. This outlier policy was adopted for CY 2010 only.

3. Statutory Update

As we noted in the CY 2011 HH PPS final rule (75 FR 70397 through 70399), section 3131(b)(1) of the Affordable Care Act amended section 1895(b)(3)(C) of the Act. As revised, “Adjustment for outliers,” states that “The Secretary shall reduce the standard prospective payment amount (or amounts) under this paragraph applicable to home health services furnished during a period by such proportion as will result in an aggregate reduction in payments for the period equal to 5 percent of the total payments estimated to be made based on the prospective payment system under this subsection for the period.” In addition, section 3131(b)(2) of the Affordable Care Act amended section 1895(b)(5) of the Act by re-designating the existing language as section 1895(b)(5)(A) of the Act, and revising it to state that the Secretary, “subject to [a 10 percent program-specific outlier cap], may provide for an addition or adjustment to the payment amount otherwise made in the case of outliers because of unusual variations in the type or amount of medically necessary care. The total amount of the additional payments or payment adjustments made under this paragraph with respect to a fiscal year or year may not exceed 2.5 percent of the total payments projected or estimated to be made based on the prospective payment system under this subsection in that year.”

As such, beginning in CY 2011, our HH PPS outlier policy is that we reduce payment rates by 5 percent and target up to 2.5 percent of total estimated HH PPS payments to be paid as outliers. To do so, we first returned the 2.5 percent held for the target CY 2010 outlier pool to the national standardized 60-day episode rates, the national per visit rates, the LUPA add-on payment amount, and the NRS conversion factor for CY 2010. We then reduced the rates by 5 percent as required by section 1895(b)(3)(C) of the Act, as amended by section 3131(b)(1) of the Affordable Care Act. For CY 2011 and subsequent calendar years we target up to 2.5 percent of estimated total payments to be paid as outlier payments, and apply a 10 percent agency-level outlier cap.

4. Loss-Sharing Ratio and Fixed Dollar Loss (FDL) Ratio

For a given level of outlier payments, there is a trade-off between the values selected for the FDL ratio and the loss-sharing ratio. A high FDL ratio reduces the number of episodes that can receive outlier payments, but makes it possible to select a higher loss-sharing ratio and, therefore, increase outlier payments for outlier episodes. Alternatively, a lower FDL ratio means that more episodes can qualify for outlier payments, but outlier payments per episode must then be lower.

The FDL ratio and the loss-sharing ratio must be selected so that the estimated total outlier payments do not exceed the 2.5 percent aggregate level (as required by section 1895(b)(5)(A) of the Act). In the past, we have used a value of 0.80 for the loss-sharing ratio, which is relatively high, but preserves incentives for agencies to attempt to provide care efficiently for outlier cases. With a loss-sharing ratio of 0.80, Medicare pays 80 percent of the additional estimated costs above the outlier threshold amount. In the CY 2011 HH PPS final rule (75 FR 70398), in targeting total outlier payments as 2.5 percent of total HH PPS payments, we implemented an FDL ratio of 0.67, and we maintained that ratio in CY 2012. The national standardized 60-day episode payment amount is multiplied by the FDL ratio. That amount is wage-adjusted to derive the wage-adjusted FDL, which is added to the case-mix and wage-adjusted 60-day episode payment amount to determine the outlier threshold amount that costs have to exceed before Medicare will pay 80 percent of the additional estimated costs. We did not propose a change to the loss-sharing ratio in the CY 2013 HH PPS proposed rule issued in the July 13, 2012

Federal Register

(77 FR 41548).

For the proposed rule, based on simulations using CY 2010 claims data, we estimated that outlier payments in 2012 will comprise approximately 2.12 percent of total HH PPS payments. However, we did not propose a change to the FDL ratio in the CY 2013 HH PPS proposed rule. This was, in part, because we were not able to verify these projections in our paid claims files since

implementing the 10 percent agency-level cap on outlier payments on January 1, 2010. Two claims processing errors were identified in our implementation of the 10 percent agency-level cap on outlier payments. These errors resulted in inaccuracies in outlier payment amounts in our paid claims files for CY 2010 and 2011. One error allows for certain HHAs to be paid beyond the cap, resulting in overpayments. The other applies the cap to HHAs who have not reached it yet, resulting in underpayments. System changes were currently underway, and thus the CY 2010 data file used in our analysis for the CY 2013 HH PPS proposed rule reflected outlier payments with these claims processing errors. In the CY 2013 HHS PPS proposed rule we stated that we would update our estimate of the FDL ratio for the final rule using the best analysis the most current and complete year of HH PPS data.

5. Outlier Relationship to the HH Payment Study

As we discussed in the CY 2013 HH PPS proposed rule, section 3131(d) of the Affordable Care Act requires us to conduct a study and report on developing HH payment revisions that will ensure access to care and payment for HH patients with high severity of illness. Our Report to Congress containing this study's recommendations is projected to be available in 2014. Section 3131(d)(1)(A)(iii) of the Affordable Care Act, in particular, states that this study may include analysis of potential revisions to outlier payments to better reflect costs of treating Medicare beneficiaries with high levels of severity of illness.

The following is a summary of the comments we received regarding the outlier policy in the CY 2013 HH PPS proposed rule.

Comment:

A commenter stated that CMS's policy of reducing the outlier pool from 5 percent to 2.5 percent and capping, per provider, outlier revenues at 10 percent has negatively impacted HH providers. The commenter stated that in certain areas, HHAs provide services to predominantly high-cost beneficiaries with chronic conditions like HIV/AIDS or with mental health needs and developmental disabilities. HHAs that provide services to a high-cost population have reported being negatively impacted by the 10 percent outlier cap. The commenter requested that CMS exempt special-needs HHAs that serve high-cost patients with multiple clinical issues from the 10 percent outlier cap. The commenter also believes that CMS should raise the outlier cap so that all HHAs that serve high-cost beneficiaries can continue to do so without losing outlier funding.

Response:

We do not have the statutory authority to change the 2.5 percent outlier pool, the 5 percent reduction to the HH PPS payment rates to fund the outlier pool, or the 10 percent outlier cap. Section 3131(b)(2) of the Affordable Care Act amended section 1895(b)(5)(A) of the Act to require that the total amount of the additional payments or payment adjustments made with respect to outliers in a fiscal year or year may not exceed 2.5 percent of the total payments projected or estimated to be made based on the prospective payment system in that year. Section 3131(b)(2)(C) of the Affordable Care Act added section 1895(b)(5)(B) of the Act so that CMS is required to apply a 10 percent agency-level outlier cap in each year. The statute does not provide for exemptions to the 10 percent cap based on resource use or otherwise.

Comment:

A commenter requested that CMS develop a remedy to the limitations in the current outlier policy in actually addressing high cost cases.

Response:

We reiterate that we intend to analyze alternatives to our current outlier policy as part of the home health study mandated by section 3131 of the Affordable Care Act. The study calls for us to investigate improvements to the HH PPS to account for patients with varying severity of illness.

Comment:

Several commenters supported CMS's proposal to maintain the current FDL ratio in determining outlier payments, while several others were disappointed that the CY 2013 HH PPS proposed rule did not include any adjustments to the FDL ratio, especially given the analysis that projects that total outlier payments in 2011 and 2012 have been significantly below the 2.5 percent target. Commenters stated that CMS should recalculate outlier payment levels for 2011 and 2012 now that the claims processing errors for outliers have been corrected, and consider revising the CY 2013 FDL ratio in the event that total outlier spending is less than 2.5 percent. One commenter believed that recent outlier claims processing flaws, when resolved, are likely to affect the total outlier spending in 2011 such that outlier payments will comprise more than the estimated 2.12 percent of total HH PPS payments in outlier payments.

Response:

Since the publication of the CY 2013 HH PPS proposed rule, we were able to correct the two claims processing errors that resulted in inaccuracies in outlier payment amounts in our paid claims files for CY 2010 and 2011. Analysis of corrected claims data and updated simulations using CY 2010 claims data show that outlier payments in 2013 are estimated to comprise approximately 2.18 percent of total HH PPS payments. As a result, in order to pay up to, but no more than 2.5 percent of total HH PPS payments as outlier payments, the FDL ratio would need to be revised to 0.45 for CY 2013.

Analysis of corrected claims data and updated simulations using CY 2010 claims data show that outlier payments in 2013 are estimated to comprise approximately 2.18 percent of total HH PPS payments. As a result, we are finalizing an FDL ratio of 0.45 percent in order to pay up to, but no more than 2.5 percent of total HH PPS payments as outlier payments. We believe that our new outlier policy for CY 2013 of using an FDL ratio of 0.45 and a loss-sharing ratio of 0.80 strikes an effective balance of compensating for high cost episodes while allowing more episodes to qualify for outlier payments.

C. CY 2013 Rate Update

1. Rebasing and Revising of the Home Health Market Basket

a. Background

Section 1895(b)(3)(B) of the Act requires that the standard prospective payment amounts for CY 2013 be increased by a factor equal to the applicable home health market basket update for those HHAs that submit quality data as required by the Secretary.

Effective for cost reporting periods beginning on or after July 1, 1980, we developed and adopted an HHA input price index (that is, the home health “market basket”). Although “market basket” technically describes the mix of goods and services used to produce home health care, this term is also commonly used to denote the input price index derived from that market basket. Accordingly, the term “home health market basket” used in this document refers to the HHA input price index.

The percentage change in the home health market basket reflects the average change in the price of goods and services purchased by HHAs in providing an efficient level of home health care services. We first used the home health market basket to adjust HHA cost limits by an amount that reflected the average increase in the prices of the goods and services used to furnish reasonable cost home health care. This approach linked the increase in the cost limits to the efficient utilization of resources. For a greater

discussion on the home health market basket, see the notice with comment period published in the February 15, 1980

Federal Register

(45 FR 10450, 10451), the notice with comment period published in the February 14, 1995

Federal Register

(60 FR 8389, 8392), and the notice with comment period published in the July 1, 1996

Federal Register

(61 FR 34344, 34347). Beginning with the FY 2002 HH PPS payments, we used the home health market basket to update payments under the HH PPS. We last rebased the home health market basket effective with the CY 2008 update. For more information on the HH PPS home health market basket, see our proposed rule published in the May 4, 2007

Federal Register

(72 FR 25435 through 25442).

The home health market basket is a fixed-weight Laspeyres-type price index; its weights reflect the cost distribution for the base year while current period price changes are measured. The home health market basket is constructed in three major steps. First, a base period is selected and total base period expenditures are estimated for mutually exclusive and exhaustive spending categories based upon the type of expenditure. Then the proportion of total costs that each spending category represents is determined. These proportions are called cost or expenditure weights.

The second step essential for developing an input price index is to match each expenditure category to an appropriate price/wage variable, called a price proxy. These proxy variables are mainly drawn from publicly available statistical series published on a consistent schedule, preferably at least quarterly.

In the third and final step, the price level for each spending category is multiplied by the expenditure weight for that category. The sum of these products for all cost categories yields the composite index level in the market basket in a given year. Repeating the third step for other years will produce a time series of market basket index levels. Dividing one index level by an earlier index level will produce rates of growth in the input price index.

We described the market basket as a fixed-weight index because it answers the question of how much more or less it would cost, at a later time, to purchase the same mix of goods and services that was purchased in the base period. As such, it measures “pure” price changes only. The effects on total expenditures resulting from changes in the quantity or mix of goods and services purchased subsequent to the base period are, by design, not considered.

b. Rebasing and Revising the Home Health Market Basket

We believe that it is desirable to rebase the home health market basket periodically so that the cost category weights reflect changes in the mix of goods and services that HHAs purchase in furnishing home health care. We based the cost category weights in the current home health market basket on CY 2003 data. In the CY 2013 HH PPS proposed rule (77 FR 41548), we proposed to rebase and revise the home health market basket to reflect CY 2010 Medicare cost report (MCR) data, the latest available and most complete data on the actual structure of HHA costs.

The terms “rebasing” and “revising,” while often used interchangeably, actually denote different activities. The term “rebasing” means moving the base year for the structure of costs of an input price index (that is, in this exercise, we proposed to move the base year cost structure from CY 2003 to CY 2010) without making any other major changes to the methodology. The term “revising” means changing data sources, cost categories, and/or price proxies used in the input price index.

For the rebasing and revising, we modified the wages and salaries and benefits cost categories to reflect revised occupational groupings of BLS Occupational Employment Statistics (OES) data of HHAs. As a result of the revised groupings, we also proposed changes to the wage and benefit price proxies used in the HH market basket. We also proposed to break out the Administration and General (A&G), Operations and Maintenance, and All Other (residual) cost category weight into more detailed cost categories, based on the 2002 Benchmark U.S. Department of Commerce, Bureau of Economic Analysis (BEA) Input-Output (I-O) Table for HHAs. We proposed to revise the price proxies for the Insurance and Transportation cost categories. Finally, we proposed the use of four new price proxies for the four additional cost categories.

The major cost weights for the revised and rebased home health market basket are derived from the Medicare Cost Reports (MCR) data for freestanding HHAs, whose cost reporting period began on or after January 1, 2010 and before January 1, 2011. Using this methodology allowed our sample to include HHA facilities with varying cost report years including, but not limited to, the federal fiscal or calendar year. We referred to the market basket as a calendar year market basket because the base period for all price proxies and weights are set to CY 2010.

We proposed to maintain our policy of using data from freestanding HHAs because we have determined that they better reflect HHAs' actual cost structure. Expense data for hospital-based HHAs can be affected by the allocation of overhead costs over the entire institution. Due to the method of allocation, total expenses will be correct, but the individual components' expenses may be skewed; therefore, if data from hospital-based HHAs were included, the resulting cost structure could be unrepresentative of the average HHA costs.

Data on HHA expenditures for nine major expense categories (Wages and Salaries, Employee Benefits, Transportation, Operation and Maintenance, A&G, Professional Liability Insurance (PLI), Fixed Capital, Movable Capital, and a residual “All Other”) were tabulated from the CY 2010 Medicare HHA cost reports. As prescription drugs and DME are not payable under the HH PPS, we excluded those items from the home health market basket and from the expenditures. Expenditures for contract services were also tabulated from these CY 2010 Medicare HHA cost reports and allocated to Wages and Salaries, Employee Benefits, A&G, and Other Expenses. After totals for these cost categories were edited to remove reports where the data were deemed unreasonable (for example, when total reported costs were less than zero), we then determined the proportion of total costs that each category represented. The proportions represent the major rebased home health market basket weights.

Next, we disaggregated the costs for the A&G, Operations and Maintenance and “All Other” cost weights using the latest available (2002 Benchmark) U.S. Department of Commerce, Bureau of Economic Analysis (BEA) Input-Output (I-O) Table, from which we extracted data for HHAs. The BEA I-O data, which are updated at 5-year intervals, were most recently described in the Survey of Current Business article, “Benchmark Input-Output Accounts of the U.S., 2002” (December 2002). These data were aged from 2002 to 2010 using relevant price changes. The methodology we used to age the data applied the annual price changes from the price proxies to the appropriate cost categories. We repeated this practice for each year. This methodology reflects a slight revision from the methodology used to derive the 2003-based HHA market basket index. For the 2003-based index, we only disaggregated the A&G

and “All Other” cost categories using BEA I-O data. For the 2010-based index, we proposed to also disaggregate the Operations and Maintenance cost categories using the BEA I-O data. Our proposal is based on our examination of the MCR data which indicated that some providers may be including some operations and maintenance costs in the A&G category and/or other cost categories. The Operations and Maintenance cost category (which we previously proxied with the CPI for Fuel and Other Utilities) from the MCR showed a decrease in the cost weight obtained directly from the MCR data from 2003 to 2010, despite rapid increases in utility costs over this time period. The revised method would rely on the 2002 I-O data, aged by the relevant price proxy, to determine the Utilities cost weight. The resulting methodology shows an increase in the Utilities cost weight over the same time period, which we believe to be a more reasonable result. We believe this change in the methodology for estimating utility costs for HHAs better reflects the 2010 cost structures of HHAs.

This process resulted in the identification of 16 separate cost categories, which is four more cost categories than presented in the 2003-based home health market basket. The additional cost categories (Administrative and Support Services, Financial Services, Medical Supplies, and Rubber and Plastics) stem from further disaggregating the Other Products and Other Services cost categories presented in the 2003-based index into more detail. The Administrative and Support Services cost weight would include expenses for a range of day-to-day office administrative services including but not limited to billing, recordkeeping, mail routing, and reception services. The Financial Services cost weight would reflect expenses for services including but not limited to banking services and security and commodity brokering. The Medical Supplies cost weight would reflect expenses for medical and surgical instruments as, well as laboratory analysis equipment. The Rubber and Plastics cost weight would reflect expenses for products such as plastic trash cans, and carpeting. We proposed these additional cost categories in order to proxy price inflation in a more granular fashion. We provide our proposed price proxies in more detail below.

The differences between the major categories for the 2010-based index and those used for the current 2003-based index are summarized in Table 3. We have allocated the Contract Services weight to the Wages and Salaries Employee Benefits, A&G, and Other Expenses cost categories in the 2010-based index as we did in the 2003-based index.

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The complete 2010-based cost categories and weights are listed in Table 4.

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After we computed the CY 2010 cost category weights for the rebased home health market basket, we selected the most appropriate wage and price

indexes to proxy the rate of change for each expenditure category. With the exception of the price index for professional liability insurance costs, the price proxies are based on Bureau of Labor Statistics (BLS) data and are grouped into one of the following BLS categories:

•

Employment Cost Indexes

—Employment Cost Indexes (ECIs) measure the rate of change in employee wage rates and employer costs for employee benefits per hour worked. These indexes are fixed-weight indexes and strictly measure the change in wage rates and employee benefits per hour. They are not affected by shifts in skill mix. ECIs are superior to average hourly earnings as price proxies for input price indexes for two reasons: (a) They measure pure price change; and (b) they are available by occupational groups, not just by industry.

•

Consumer Price Indexes

—Consumer Price Indexes (CPIs) measure change in the prices of final goods and services bought by the typical consumer. Consumer price indexes are used when the expenditure is more similar to that of a purchase at the retail level rather than at the wholesale level, or if no appropriate Producer Price Indexes (PPIs) were available.

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Producer Price Indexes

—PPIs measures average changes in prices received by domestic producers for their goods and services. PPIs are used to measure price changes for goods sold in other than retail markets. For example, a PPI for movable equipment is used rather than a CPI for equipment. PPIs in some cases are preferable price proxies for goods that HHAs purchase at wholesale levels. These fixed-weight indexes are a measure of price change at the producer or at the intermediate stage of production.

We evaluated the price proxies using the criteria of reliability, timeliness, availability, and relevance. Reliability indicates that the index is based on valid statistical methods and has low sampling variability. Widely accepted statistical methods ensure that the data were collected and aggregated in way that can be replicated. Low sampling variability is desirable because it indicates that sample reflects the typical members of the population. (Sampling variability is variation that occurs by chance because a sample was surveyed rather than the entire population.) Timeliness implies that the proxy is published regularly, preferably at least once a quarter. The market baskets are updated quarterly and therefore it is important the underlying price proxies be up-to-date, reflecting the most recent data available. We believe that using proxies that are published regularly helps ensure that we are using the most recent data available to update the market basket. We strive to use publications that are disseminated frequently because we believe that this is an optimal way to stay abreast of the most current data available. Availability means that the proxy is publicly available. We prefer that our proxies are publicly available because this will help ensure that our market basket updates are as transparent to the public as possible. In addition, this enables the public to be able to obtain the price proxy data on a regular basis. Finally, relevance means that the proxy is applicable and representative of the cost category weight to which it is applied. The CPIs, PPIs, and ECIs selected by us in this regulation meet these criteria. Therefore, we believe that they continue to be the best measure of price changes for the cost categories to which they would be applied.

As part of the revising and rebasing of the home health market basket, we proposed to revise and rebase the home health blended Wage and Salary index and the home health blended Benefits index. We proposed to use these blended indexes as price proxies for the Wages and Salaries and the Employee Benefits portions of the 2010-based home health market basket, as we did in the 2003-based home health market basket. A more detailed discussion is provided below.

c. Price Proxies Used To Measure Cost Category Growth

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Wages and Salaries

For measuring price growth in the 2010-based home health market basket, we proposed to apply six price proxies to six occupational subcategories within the Wages and Salaries component, that reflect the HHA occupational mix.

The 2003-based blended wage index was comprised of four occupational subcategories proxied by five wage proxies. For the 2010 blended wage index, we proposed to further disaggregate the service workers occupations into health and social assistance service and other service occupational groups. We also proposed to explicitly disaggregate professional and technical (P&T) workers into health-related P&T and non health-related P&T workers. We proposed to continue to use the National Industry-Specific Occupational Employment and Wage estimates for North American Industrial Classification System (NAICS) 621600, Home Health Care Services, published by the BLS Office of Occupational Employment Statistics (OES) as the data source for the cost shares of the home health specific blended wage and benefits proxy. Detailed information on the methodology for the national industry-specific occupational employment and wage estimates survey can be found at

http://www.bls.gov/oes/current/oes_tec.htm.

The needed data on HHA expenditures for the six occupational subcategories (managerial, health-related P&T, non health-related P&T, health and social assistance service, other service occupations, and administrative/clerical) for the wages and salaries component were tabulated from the May 2010 OES data for NAICS 621600, Home Health Care Services. Table 5 compares the 2010 occupational assignments of the six CMS designated subcategories to the 2003 occupational assignments of the four CMS designated subcategories.

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Total expenditures by occupation were calculated by taking the OES number of employees multiplied by the OES annual average salary. The wage and salary expenditures were aggregated based on the groupings in Table 6. We determined the proportion of total wage costs that each subcategory represents. These proportions listed in Table 6 represent the major rebased and revised home health blended Wage and Salary index weights.

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A comparison of the yearly changes from CY 2010 to CY 2013 for the 2003-based HH wage and salary blend and the 2010-based home health wage and salary blend is shown in Table 7. The average annual increase in the two price proxies is similar, and in no year is the difference greater than 0.2 percentage point.

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Employee benefits:

For measuring employee benefits price growth in the 2010-based home health market basket, we proposed to apply applicable price proxies to the six occupational subcategories that are used for the wage blend listed in Table 8. The percentage change in the blended price of home health employee benefits is applied to this component, which is described in Table 8.

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There is no available data source that exists for benefit expenditures by occupation for the home health industry. Thus, to construct weights for the home health occupational benefits index we calculated the ratio of benefits to wages and salaries for CY 2010 for the six BLS ECI series we proposed to use in the blended wage and benefit indexes. To derive the relevant benefit weight, we applied the benefit-to-wage ratios to each of the six occupational subcategories from the 2010 OES wage and salary weights, and normalized. For example, the ratio of benefits to wages from the 2010 home health occupational wage and benefit indexes for home health managers is 0.976. We apply this ratio to the 2010 OES weight for wages and salaries for home health managers, 8.260, and then normalize those weights relative to the other five benefit occupational categories to obtain a benefit weight for home health managers of 8.029.

A comparison of the yearly changes from CY 2010 to CY 2013 for the 2003-based HH benefit blend and the 2010-based home health benefit blend is shown in Table 9. The average annual increase in the two price proxies is similar, and in no year is the difference greater than 0.3 percentage point.

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Administrative and Support:

We proposed to use the ECI for Compensation for Office and Administrative Support Services (private industry) (BLS series code #CIU2010000220000I) to measure price growth of this cost category. The 2003-based index did not reflect this detailed cost category.

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Financial Services:

We proposed to use the ECI for Compensation for Financial Activities (private industry) (BLS series code #CIU201520A000000I) to measure price growth of this cost category. The 2003-based index did not reflect this detailed cost category.

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Medical Supplies:

We proposed to use the PPI for Medical Surgical & Personal Aid Devices (BLS series code #WPU156) to measure price growth of this cost category. The 2003-based index did not reflect this detailed cost category.

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Rubber and Plastics:

We proposed to use the PPI for Rubber and Plastic Products (BLS series code #WPU07) to measure price growth of this cost

category. The 2003-based index did not reflect this detailed cost category.

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Operations and Maintenance:

We proposed to use CPI for Fuel and Utilities (BLS series code #CUUR0000SAH2) to measure price growth of this cost category. The same proxy was used for the 2003-based market basket.

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Professional Liability Insurance:

We proposed to use the CMS Physician Professional Liability Insurance price index to measure price growth of this cost category. The 2003-based index used the CPI for Household Insurance as the price proxy for this component. We proposed to revise the price proxy for this category as we believe that it is more technically appropriate to proxy PLI price changes by an index specific to medical liability insurance. We currently do not have a PLI index specific to the HHA industry so we proposed to use the CMS Physician Liability Insurance Index as we believe this would reasonably reflect the price changes associated with medical liability insurance purchased by home health agencies.

To accurately reflect the price changes associated with physician PLI, each year, we solicit PLI premium data for physicians from a sample of commercial carriers. This information is not collected through a survey form, but instead is requested directly from, and provided by (on a voluntary basis), several national commercial carriers. As we require for our other price proxies, the PLI price proxy is intended to reflect the pure price change associated with this particular cost category. Thus, it does not include changes in the mix or level of liability coverage. To accomplish this result, we obtain premium information from a sample of commercial carriers for a fixed level of coverage, currently $1 million per occurrence and a $3 million annual limit. This information is collected for every state by physician specialty and risk class. Finally, the state-level, physician-specialty data are aggregated by effective premium date to compute a national total, using counts of physicians by state and specialty as provided in the AMA publication,

Physician Characteristics and Distribution in the U.S.

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Telephone:

We proposed to use CPI for Telephone Services (BLS series code #CUUR0000SEED) to measure price growth of this cost category. The same proxy was used for the 2003-based market basket.

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Postage:

We proposed to use CPI for Postage (BLS series code #CUUR0000SEEC01) to measure price growth of this cost category. The same proxy was used for the 2003-based market basket.

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Professional Fees:

We proposed to use the ECI for Compensation for Professional and Related Workers (private industry) (BLS series code # CIS2010000120000I) to measure price growth of this category. The same proxy was used for the 2003-based market basket.

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Other Products:

We proposed to use the PPI for Finished Goods Less Food and Energy (BLS series code #) to measure price growth of this category. For the 2003-based market basket we used the CPI for All Items Less Food and Energy to proxy this category. We believe that the PPI better reflects business input costs than the CPI index which better reflects cost faced by consumers.

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Other Services:

We proposed to use the ECI for Compensation for Service Occupations (private) (BLS series code #CIU2010000300000I) to measure price growth of this category. The same proxy was used for the 2003-based market basket.

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Transportation:

We proposed to use the CPI for Transportation (BLS series code #CUUR00000SAT) to measure price growth of this category. The 2003-based market basket used the CPI for Private Transportation (BLS series code #CUUS0000SAT1). We proposed to revise the price proxy to reflect price inflation of both private and public transportation costs. We proposed this change as further investigation of the MCR instructions request providers to include both private and public transportation costs.

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Fixed capital:

We proposed to use the CPI for Owner's Equivalent Rent (BLS series code #CUUS0000SEHC) to measure price growth of this cost category. The same proxy was used for the 2003-based market basket.

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Movable Capital:

We proposed to use the PPI for Machinery and Equipment (BLS series code #WPU11) to measure price growth of this cost category. The same proxy was used for the 2003-based market basket.

As we did in the 2003-based home health market basket, we allocated the Contract Services' share of home health agency expenditures among Wages and Salaries, Employee Benefits, A&G and Other Expenses.

d. Rebasing Results

A comparison of the yearly changes from CY 2010 to CY 2013 for the 2003-based home health market basket and the 2010-based home health market basket is shown in Table 10.

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Table 10 shows that the forecasted rate of growth for CY 2013, beginning January 1, 2013, for the rebased and revised home health market basket is 2.3 percent, while the forecasted rate of growth for the current 2003-based home health market basket is 2.1 percent. The higher growth rate for the 2010-based HHA market basket for CY 2013 is primarily attributable to the wage blended price proxies. The revised wage blended index reflects a larger weight associated with health P&T occupations (which is proxied by the ECIs for Hospital Workers) compared to the 2003-based index. The wage ECI for hospital workers is currently projected to grow faster than the other ECIs in the blended indexes.

e. Labor-Related Share

In the 2003-based home health market basket the labor-related share was 77.082 percent while the remaining non-labor-related share was 22.918 percent. In the revised and rebased home health market basket, the labor-related share is 78.535 percent. The labor-related share includes wages and salaries and employee benefits, as well as allocated contract labor costs. The non-labor-related share is 21.465 percent. The increase in the labor-related share using the 2010-based HH market basket is primarily due to the increase in costs associated with contract labor. Table 11 details the components of the labor-related share for the 2003-based and 2010-based home health market baskets.

ER08NO12.010

f. CY 2013 Market Basket Update for HHAs

For CY 2013, we proposed to use an estimate of the 2010-based HHA market basket to update payments to HHAs based on the best available data. Consistent with historical practice, we estimate the HHA market basket update for the HHA PPS based on IHS Global Insight, Inc.'s (IGI's) forecast using the most recent available data. IGI is a nationally recognized economic and financial forecasting firm that contracts with CMS to forecast the components of the market baskets.

In the proposed rule, based on IGI's second quarter 2012 forecast with history through the first quarter of 2012, the HHA market basket update for CY 2013 was projected to be 2.5 percent. Consistent with historical practice, we also proposed that if more recent data are subsequently available (for example, a more recent estimate of the market basket), we would use such data, if appropriate, to determine the CY 2013 annual update in the final rule. Therefore, we are finalizing a CY 2013 market basket update of 2.3 percent for CY 2013, which is based on IGI's third quarter 2012 forecast with history through the 2nd quarter 2012.

2. CY 2013 Home Health Payment Update Percentage

Section 3401(e) of the Affordable Care Act amended section 1895(b)(3)(B) of the Act by adding a new clause (vi) which states, “After determining the home health market basket percentage increase * * * the Secretary shall reduce such percentage * * * for each of 2011, 2012, and 2013, by 1 percentage point. The application of this clause may result in the home health market basket percentage increase under clause (iii) being less than 0.0 for a year, and may result in payment rates under the system under this subsection for a year being less than such payment rates for the preceding year.” Therefore, the final CY 2013 market basket update of 2.3 percent must be reduced by 1 percentage point. Thus, the CY 2013 home health payment update is 1.3 percent.

The following is a summary of the comments we received regarding the CY 2013 Rate Update proposal.

Comment:

Several commenters supported the proposed effort to rebase and revise the market basket in order to update the cost shares from a 2003 base year to a 2010 base year. One commenter believed that future rebasings and revisions may be needed every 5 years or less due to the rapidly changing landscape of health care and home health services.

Response:

We appreciate the commenters' support for the proposed rebasing and revising of the market basket to reflect 2010 cost data. We also acknowledge the public's concern regarding the changing landscape of costs. We will monitor the market basket's cost categories and their respective weights in order to ensure they remain contemporary and representative of the industry's cost structure.

Comment:

One commenter expressed concerns about the quality of the cost report data that are submitted to CMS. The commenter noted that they are hopeful that the recent audits of the cost reports that CMS has initiated will improve the quality of the data. The commenter noted that although they have concerns about the quality of the cost report data they still support the proposed rebasing and revising of the market basket to 2010.

Response:

In regards to the commenter's concern on the quality of the cost report data, when we calculate the market basket cost weights, we run various trimming scenarios to be sure the final market basket cost weights are not adversely impacted by outliers. We also run matched samples and compare trends and cost shares over time. Therefore, we believe our resulting market basket cost weights are representative of the national average of freestanding home health agencies.

Comment:

One commenter questioned the accuracy with which the market basket accounts for transportation costs, currently, as well as under the proposed methodology. They note that transportation costs have become more unpredictable with the increasing and fluctuating cost of gasoline.

Response:

We believe the Transportation cost weight within this market basket accurately captures the relative costs faced by home health providers as we obtain these costs directly from the Medicare cost reports. Additionally, this particular category's cost weight has been notably consistent, ranging from between 2.5 percent and 2.8 percent over the last several years.

For the price proxy used to estimate price changes for this category of costs, although we agree that there is volatility in the price of gasoline, we feel that the CPI-U for Transportation price index, developed and published by the Bureau of Labor Statistics appropriately reflects these costs. Within this particular CPI, motor fuel represents approximately 1/3rd of its cost weight (with new and used motor vehicles and motor vehicle insurance comprising most of the remaining share). This index also appropriately meets CMS's guidelines for price proxies (relevance, reliability, timeliness, and public availability).

Comment:

Several commenters expressed concern that CMS only uses data from freestanding home health agencies to determine the market basket cost shares. One commenter also specifically noted the possible difference in the labor portion of the market basket and the impact on the payments based on the geographic differences. They noted that while there is concern about the attribution of costs to hospital-based providers, those shifts would appear in the indirect cost centers. They also noted that wages and salaries and benefits should be comparable across freestanding and hospital-based providers since they are direct costs and therefore the hospital-based data should be incorporated into the calculation of the labor-related share.

Response:

Presently, all of CMS's market baskets, or input prices indexes, incorporate data from only freestanding providers. We monitor the costs and cost structures of both freestanding and hospital-based providers in the home health industry, as well as other industries. Despite controlling for the differing characteristics of both provider types, including their respective patient case mix, their geographic locations, and other relevant factors, we were not able to adequately explain the variation in costs between the two provider types. Consequently, we believe that it is appropriate to base the market basket's structure on free-standing providers only. We will continue to monitor and attempt to better understand these differences going forward.

Comment:

One commenter believed that the market basket should be based on 2011 cost report data and that 2010 cost reports do not reflect the increases in costs to providers of the face-to-face and therapy reassessment requirements.

Response:

The market baskets are always based on the most current and complete set of cost report data. At the time of this rebasing, the most current and complete set of data was for 2010. We will monitor the 2011 cost reports as they become available and, if the cost structure of the industry is materially different than it was in 2010, we would consider proposing a subsequent rebasing.

Comment:

Several commenters support the resulting increase to the labor-related share which results from the rebasing of the market basket cost shares.

Response:

We believe the cost shares that are determined based on this rebasing represent the current national average cost shares of the industry. Thus, we are finalizing those cost shares in this final rule.

Comment:

Several commenters expressed concerns with the proposal to increase the labor-related share from 77.082 percent to 78.535 percent for CY 2013 and asked CMS to provide more clarity on the calculation methodology. One commenter notes that the resulting increase to the labor-related share will have a significant negative impact on providers, particularly those in rural areas.

Response:

The home health market basket's labor-related share is based on the sum of the weights for Wages & Salaries and Benefits. The labor-related share is estimated based on actual data submitted on the home health Medicare cost report for both rural and urban freestanding home health facilities and is intended to reflect the national average. The proposed change in the labor-related share is primarily attributable to the update of the base year to reflect 2010 data. The 2010 data, the most recent and comprehensive data available at the time of the rebasing, show that labor-related costs have increased faster than aggregate non-labor-related costs since 2003. Although we will continue to analyze the home

health Medicare cost report data on a regular basis to ensure it accurately reflects the cost structures facing home health providers, we believe the proposed 78.535 percent labor-related share appropriately reflects the current national average.

Comment:

One commenter believed the market basket should reflect cost changes in an episode of care rather than annual total costs for the home health agency. The commenter requested that CMS provide an explanation of how the market basket index and the changes in episode costs relate to one another. They noted that the average episode of care in 2010 could include a different mix of disciplines than an average episode of care in 2003.

Response:

Section 1895(b)(3)(B) of the Act requires that the standard prospective payment amounts for CY 2013 be increased by a factor equal to the applicable home health market basket. Specifically the statute states: “The standard prospective payment amount (or amounts) shall be adjusted for fiscal year 2002 and for fiscal year 2003 and for each subsequent year (beginning with 2004) in a prospective manner specified by the Secretary by the home health applicable increase percentage (as defined in clause (ii)) applicable to the fiscal year or year involved.” Given that the weighted changes in episode costs, including the changing mix of disciplines required to provide home health services, all flow into the Medicare cost report, they are thus reflected in the market basket's respective cost weights.

As a result of the comments, we are finalizing all of the proposed changes to the home health market basket. The base year will reflect the 2010 cost shares as proposed and all of the price proxies that were proposed will be implemented. Therefore, consistent with our historical practice of estimating market basket increases based on the best available data, we are finalizing a CY 2013 market basket update of 2.3 percent for CY 2013, which is based on IGI's third quarter 2012 forecast with history through the 2nd quarter 2012. Additionally, we are finalizing the labor-related share that reflect the 2010 wage and benefit cost shares of the market basket, which is 78.535 percent.

Comment:

A commenter expressed concern about the impact of the reduction to the market basket update.

Response:

The reduction to the market basket update is legislated by section 1895(b)(3)(B) of the Act, as amended by section 3401(e) of the Affordable Care Act, which states that the Secretary shall reduce the market basket percentage by 1 percentage point for 2011, 2012, and 2013.

Comment:

We received several comments regarding CMS's efforts in rebasing the HH payment rates as mandated by the Affordable Care Act. We also received comments pertaining to the automatic, across-the-board cuts, known as sequestration, that are included in the Budget Control Act of 2011.

Response:

The comments are outside the scope of this rule. However, we will consider the comments concerning rebasing in our future rebasing efforts.

3. Home Health Quality Reporting Program (QRP)

a. Background and Quality Reporting Requirements

Section 1895(b)(3)(B)(v)(II) of the Act states that “each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.”

In addition, section 1895(b)(3)(B)(v)(I) of the Act states that “for 2007 and each subsequent year, in the case of a HHA that does not submit data to the Secretary in accordance with subclause (II) with respect to such a year, the HH market basket percentage increase applicable under such clause for such year shall be reduced by 2 percentage points.” This requirement has been codified in regulations at § 484.225(i). HHAs that meet the quality data reporting requirements are eligible for the full home health market basket percentage increase. HHAs that do not meet the reporting requirements are subject to a 2 percentage point reduction to the home health market basket increase.

Section 1895(b)(3)(B)(v)(III) of the Act further states that “[t]he Secretary shall establish procedures for making data submitted under sub clause (II) available to the public. Such procedures shall ensure that a home health agency has the opportunity to review the data that is to be made public with respect to the agency prior to such data being made public.”

As codified at § 484.250(a), we established that the quality reporting requirements could be met by the submission of OASIS assessments and Home Health CAHPS. In the CY 2012 HH PPS final rule (76 FR 68576), we listed selected measures for the HH QRP and also established procedures for making the information available to the public by placing the information on the Home Health Compare Web site. The selected measures that are made available to the public can be viewed on the Home Health Compare Web site located at

http://www.medicare.gov/HHCompare/Home.asp.

In the CY 2012 HH PPS final rule (76 FR68575), we finalized that we will also use measures derived from Medicare claims data to measure home health quality.

b. OASIS Data Submission and OASIS Data for Annual Payment Update

The Home Health Conditions of Participation (CoPs) at § 484.55(d) require that the comprehensive assessment must be updated and revised (including the administration of the OASIS) no less frequently than: (1) The last five days of every 60 days beginning with the start-of-care date, unless there is a beneficiary elected transfer, significant change in condition, or discharge and return to the same HHA during the 60-day episode; (2) within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests; and (3) at discharge.

It is important to note that to calculate quality measures from OASIS data, there must be a complete quality episode, which requires both a Start of Care or Resumption of Care OASIS assessment and a Transfer or Discharge OASIS assessment. Failure to submit sufficient OASIS assessments to allow calculation of quality measures, including transfer and discharge assessments, constitutes failure to comply with the CoPs.

Home Health Agencies do not need to submit OASIS data for those patients who are excluded from the OASIS submission requirements under the Home Health Conditions of Participation (CoPs) § 484.1 through § 484.265. As described in the Medicare and Medicaid Programs: Reporting Outcome and Assessment Information Set Data as Part of the Conditions of Participation for Home Health Agencies Final Rule (70 FR 76202), these are:

• Those patients receiving only nonskilled services;

• Those patients for whom neither Medicare nor Medicaid is paying for home health care (patients receiving care under a Medicare or Medicaid Managed Care Plan are not excluded from the OASIS reporting requirement);

• Those patients receiving pre- or post-partum services; or

• Those patients under the age of 18 years.

As set forth in the Medicare Program; Home Health Prospective Payment

System Refinement and Rate Update for Calendar Year 2008 Final Rule (72 FR 49863), HHAs that become Medicare-certified on or after May 31 of any year are not subject to the OASIS quality reporting requirement nor any payment penalty for quality reporting purposes for the following calendar year. For example, HHAs certified on or after May 31, 2012 are not subject to the 2 percentage point reduction to their market basket update for CY 2013. These exclusions only affect quality reporting requirements and do not affect the HHA's reporting responsibilities under the Conditions of Participation and Conditions of Payment (70 FR 76202).

c. Home Health Care Quality Reporting Program Requirements for CY 2014 Payment and Subsequent Years

(1) Submission of OASIS data

In the CY 2013 HH PPS proposed rule (77 FR 41548), we proposed to consider OASIS assessments submitted by HHAs to CMS in compliance with HHA Conditions of Participation and Conditions for Payment for episodes beginning on or after July 1, 2011 and before July 1, 2012 as fulfilling one portion of the quality reporting requirement for CY 2013. This time period will allow for 12 full months of data collection and would provide us with the time necessary to analyze and make any necessary payment adjustments to the payment rates for CY 2013. We proposed to continue this pattern for each subsequent year beyond CY 2013, considering OASIS assessments submitted for episodes beginning in the time frame between July 1 of the calendar year two years prior to the calendar year of the Annual Payment Update (APU) effective date and June 30 of the calendar year one year prior to the calendar year of the APU effective date, and received timely by CMS (that is, within 30 days of the end of that time period), as fulfilling the OASIS portion of the quality reporting requirement for the subsequent APU.

Comment:

We received one comment which supported both of these proposals. We received no comments in opposition.

Response:

We appreciate the supportive comments.

As a result of the comments received, we are finalizing these two proposals as proposed.

(2) Acute Care Hospitalization Claims-Based measure

In August 2003, we began to publicly report on Home Health Compare a number of OASIS-C outcome measures, including Acute Care Hospitalization. Since that time, we have determined that claims data are a more robust source of data for accurately measuring acute care hospitalizations. For this reason we proposed that the claims-based Acute Care Hospitalization measure replace the OASIS-based measure on Home Health Compare. The OASIS-based measure will continue to be reported on the agency-specific Certification and Survey Provider Enhanced Reporting system (CASPER) reports.

At the time of the publication of the proposed rule, there were technical issues with Home Health Compare files which resulted in our plan to delay the reporting of the two claims-based measures “Emergency Department Use Without Hospitalization” and “Acute Care Hospitalization” until such time as the technical issues were resolved. We stated that the OASIS-based Acute Care Hospitalization measure would continue to be made available to the public via Home Health Compare until it is replaced with the claims-based measure.

To summarize, for the CY 2013 payment update and for subsequent annual payment updates, we proposed to continue to use a HHA's submission of OASIS assessments between July 1 and June 30 as fulfilling one portion of the quality reporting requirement for each payment year. Medicare claims data and HHCAHPS data will also be used to measure home health care quality.

Comment:

We received nine comments supportive of the proposal and the use of claims-based measures in general. One commenter clearly prefers the OASIS-based Acute Care Hospitalization measure, stating it provides more granularity. Two commenters opposed publicly reporting the claims-based Acute Care Hospitalization measure until measure specifications and measure detail are made available and requested to preview the measure before public reporting. Several commenters question how observation stays will be addressed in the measure. We also received comment regarding the restriction of claims-based measures to Medicare FFS patients, the need to harmonize with other reporting programs, the need to retain OASIS items related to these two measures, and the resolution of technical issues referenced in the proposed rule.

Response:

We have resolved the technical challenges that we noted in the proposed rule and in August, the CASPER reports included Acute Care Hospitalization and Emergency Department Use Without Hospitalization measure rates that we calculated using claims data. We will also begin to publicly report the claims-based measure rates for these measures on Home Health Compare.

We wish to clarify that when we referred to the Acute Care Hospitalization and Emergency Department Use Without Hospitalization measures as “replacing” the OASIS-based measures, what we meant is that the measures will be calculated using a new source of data. The measure concept has not changed. The revised technical specifications were provided to the National Quality Forum (NQF), and after a public comment period, the NQF endorsed the revised measures in August 2012. The Acute Care Hospitalization measure is NQF #0171 and the ED Use Without Hospitalization measure is NQF #0173. The technical specifications for the claims-based measures been available since September 12 on the CMS Home Health Quality Initiative web page at

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html.

HHAs can currently view their performance on both measures (calculated using claims data) on their agency-specific CASPER reports. To further respond to the commenters who requested more detail on the measures, these measures evaluate the utilization of emergency department use without hospitalization and acute care hospitalization during the 60 days after the start of the home health stay. Thus, the measures address outcomes of HHA patients in a fixed interval after the start of their home health care, regardless of the length of their home health stay. Home health agencies are most often paid in a 60-day payment bundle which covers all home health services for 60 days. As a result, the claims-based measures address outcomes of home health patients during the time period in which their home health agency receives payment from Medicare, (that is, for the 60-day period beginning with the start of care date). This is in contrast to the OASIS-based measures which calculate outcomes based on the time period from start of care to discharge, a period which may be greater or less than 60 days.

Similarly, the measurement begins at home health start of care (rather than at hospital discharge) as the home health agency cannot be held responsible for hospitalizations or emergency department visits that occur before home health care begins. Home Health Compare will continue to display these

measures using a rolling twelve months of data updated on a quarterly basis.

As with the OASIS-based measure, planned hospitalizations are excluded from the acute care hospitalization claims-based measure numerator. In addition, though some hospitalizations may be avoidable, it is difficult to determine if a hospitalization was out of the home health agency's control or not. As a result, agency rates on this measure are not expected to reach zero percent. Instead, the measure rates can be used as guidelines for comparing agencies to each other and can be used by agencies to improve their quality of care.

Observation stays that begin in a hospital emergency department but do not result in an inpatient stay within the 60 days after the start of home health care are counted in the ED Use without Hospitalization measure. Observation stays that result in an inpatient stay within the 60 days after the start of home health care are counted in the Acute Care Hospitalization measure. By comparing HHAs on both utilization measures, consumers can gain an accurate picture of how often patients of each HHA receive care in an emergency department or hospital in the 60 days following the start of home health care.

Medicare claims data are reliable because home health agencies are required to submit claims in order to receive payment for Medicare beneficiaries. Claims data are extremely detailed and include patient identifiers, provider identifiers, services rendered, diagnoses, and payment, as well as additional information. Because encounter claims data are only readily available for Medicare FFS beneficiaries, the measure rates generated from claims for both the Acute Care Hospitalization and Emergency Department Use Without Hospitalization measures will only reflect Medicare FFS data.

We are considering whether to begin calculating other OASIS-C outcome measures using claims data and we are also considering the feasibility of proposing to adopt readmission measures, which might include a 30-day measure of rehospitalization that would apply to home health patients who begin home health immediately after an inpatient hospital stay. We note that this measure would be similar to “Hospital-Wide All-Cause Unplanned Readmission” measure that we recently adopted for the Hospital Inpatient Quality Reporting Program.

We believe that the OASIS items related to acute care hospitalization and emergency department use should remain in the OASIS dataset. It is important for agencies to be aware of their patient's hospitalizations and emergency department visits in order to adjust care plans in response to changes in the patient's condition, medication regimen, and care needs. Maintaining the items in the OASIS also allows agencies to monitor their hospitalization and ED use rates in real-time rather than waiting for a claims-based measure to be calculated and reported in CASPER. The OASIS item related to emergency department use is still used for the Emergency Department Use With Hospitalization measure reported on CASPER. Agencies can approximately compare their rates on the OASIS-based and claims-based Acute Care Hospitalization measures, as reported on the CASPER reports, to gauge if their patients received treatment in an emergency department or hospital significantly more often than they were aware of. This comparison could be useful in HHAs' performance improvement activities.

As a result of the comments received, we are finalizing that the claims-based Acute Care Hospitalization measure replace the OASIS-based measure on Home Health Compare as proposed.

d. Home Health Care CAHPS Survey (HHCAHPS)

In the HH PPS Rate Update for CY 2012 Final Rule (76 FR 68577), we stated that the expansion of the home health quality measures reporting requirements for Medicare-certified agencies includes the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Care (HHCAHPS) Survey for the CY 2012 annual payment update (APU). In CY 2012 we moved forward with the HHCAHPS linkage to the pay-for-reporting (P4R) requirements affecting the HH PPS rate update for CY 2012. We are maintaining the stated HHCAHPS data requirements for CY 2013 that were set out in the CY 2012 HH PPS final rule, for the continuous monthly data collection and quarterly data submission of HHCAHPS data.

(1) Background and Description of HHCAHPS

As part of the United States Department of Health and Human Services' (DHHS) Transparency Initiative, we have implemented a process to measure and publicly report patient experiences with home health care, using a survey developed by the Agency for Healthcare Research and Quality's (AHRQ's) CAHPS® program, and endorsed by the National Quality Forum (NQF) (number 0517). The HHCAHPS survey is part of a family of CAHPS® surveys that asks patients to report on and rate their experiences with health care. The HHCAHPS survey presents home health patients with a set of standardized questions about their home health care providers and about the quality of their home health care.

Prior to this survey, there was no national standard for collecting information about patient experiences that would enable valid comparisons across all home health agencies (HHAs). The history and development process for HHCAHPS has been given in previous rules, but it is also available on our Web site

https://homehealthcahps.org

and also, in the annually updated

HHCAHPS Protocols and Guidelines Manual,

which is downloadable from

https://homehealthcahps.org.

For public reporting purposes, we present five measures—three composite measures and two global ratings of care—from the questions on the HHCAHPS survey. The publicly reported data are adjusted for differences in patient mix across home health agencies. Each of the three composite measures consists of four or more questions on one of the following related topics:

• Patient care (Q9, Q16, Q19, and Q24);

• Communications between providers and patients (Q2, Q15, Q17, Q18, Q22, and Q23); and

• Specific care issues on medications, home safety, and pain (Q3, Q4, Q5, Q10, Q12, Q13, and Q14).

The two global ratings are the overall rating of care given by the HHA's care providers (Q20), and the patient's willingness to recommend the HHA to family and friends (Q25).

The HHCAHPS survey is not supposed to measure the aspects of home health clinical care that can be captured through a medical record. Rather, the HHCAHPS survey focuses on areas where the home health patient is the best or only source for the information. We believe that the HHCAHPS survey is a valid measure of a patient's perspectives of home health care. The developmental work for the HHCAHPS survey began in mid-2006, and the first HHCAHPS survey was field-tested (to validate the length and content of the survey) in 2008 by the AHRQ and the CAHPS® grantees, and the final HHCAHPS survey was used in a national randomized mode experiment in 2009 through 2010.

The HHCAHPS survey is currently available in several languages. At the time of the CY 2010 HH PPS final rule, HHCAHPS was only available in English and Spanish translations. In the proposed rule for CY 2010, we stated

that we would provide additional translations of the survey over time in response to suggestions for any additional language translations. We now offer HHCAHPS in English, Spanish, Chinese, Russian, and Vietnamese languages. We will continue to consider additional translations of the HHCAHPS in response to the needs of the home health patient population.

All of the requirements about home health patient eligibility for the HHCAHPS survey and conversely, which home health patients are ineligible for the HHCAHPS survey are delineated and detailed in the

HHCAHPS Protocols and Guidelines Manual,

which is downloadable from

https://homehealthcahps.org.

Home health patients are eligible for HHCAHPS if they received at least two skilled home health visits in the past two months, which are paid for by Medicare or Medicaid.

Home health patients are ineligible for inclusion in HHCAHPS surveys if one of these conditions pertains to them:

• Are under the age of 18;

• Are deceased prior to pulling sample;

• Receive hospice care;

• Received routine maternity care only;

• Are not considered survey eligible because the state in which the patient lives restricts release of patient information for a specific condition or illness that the patient has; or

• Requested that their names not be released to anyone.

We stated in previous rules that Medicare-certified agencies are required to contract with an approved HHCAHPS survey vendor. This requirement is also codified. Beginning in summer 2009, interested vendors applied to become approved HHCAHPS survey vendors. HHCAHPS survey vendors are required to attend introductory and all update trainings conducted by CMS and the HHCAHPS Survey Coordination Team, as well as to pass a post-training certification test. We now have approximately 40 approved HHCAHPS survey vendors. The list of approved HHCAHPS survey vendors is available at

https://homehealthcahps.org.

(2) HHCAHPS Oversight Activities

We stated in prior final rules that vendors would be required to participate in HHCAHPS oversight activities to ensure compliance with HHCAHPS protocols, guidelines, and survey requirements. The purpose of the oversight activities is to ensure that approved survey vendors follow the

HHCAHPS Protocols and Guidelines Manual.

As stated previously in the CY 2010, CY 2011, and CY 2012 final rules, all approved survey vendors must develop a Quality Assurance Plan (QAP) for survey administration in accordance with the

HHCAHPS Protocols and Guidelines Manual.

An HHCAHPS survey vendor's first QAP must be submitted within 6 weeks of the data submission deadline date after the vendor's first quarterly data submission. The QAP must be updated and submitted annually thereafter and at any time that changes occur in staff or vendor capabilities or systems. A model QAP is included in the

HHCAHPS Protocols and Guidelines Manual.

The QAP should include the following:

• Organizational Background and Staff Experience

• Work Plan

• Sampling Plan

• Survey Implementation Plan

• Data Security, Confidentiality and Privacy Plan

• Questionnaire Attachments

As part of the oversight activities, the HHCAHPS Survey Coordination Team conducts on-site visits to the approved HHCAHPS survey vendors. The purpose of the site visits is to allow the HHCAHPS Coordination Team to observe the entire Home Health Care CAHPS Survey implementation process, from the sampling stage through file preparation and submission, as well as to assess how the HHCAHPS data are stored. The HHCAHPS Survey Coordination Team reviews the survey vendor's survey systems, and assesses administration protocols based on the

HHCAHPS Protocols and Guidelines Manual

posted at

https://homehealthcahps.org.

The systems and program review includes, but is not limited to the following:

• Survey management and data systems;

• Printing and mailing materials and facilities;

• Telephone call center facilities;

• Data receipt, entry and storage facilities; and

• Written documentation of survey processes.

After the site visits, HHCAHPS vendors are given a defined time period in which to correct any identified issues and provide follow-up documentation of corrections for review. HHCAHPS survey vendors are subject to follow-up site visits on an as-needed basis.

We proposed to codify the current guideline that all approved HHCAHPS survey vendors fully comply with all HHCAHPS oversight activities at § 484.250(c) of our regulations.

(3) HHCAHPS Requirements for CY 2014

For the CY 2014 APU, we proposed to continue monthly HHCAHPS data collection and reporting for four quarters. The data collection period for CY 2014 would include the second quarter 2012 through the first quarter 2013 (the months of April 2012 through March 2013). HHAs would be required to submit their HHCAHPS data files to the Home Health CAHPS Data Center for CY 2014 for the second quarter 2012 by 11:59 p.m., Eastern Time on October 18, 2012; for the third quarter 2012 by 11:59 p.m., Eastern Time on January 17, 2013; for the fourth quarter 2012 by 11:59 p.m., Eastern Time on April 18, 2013; and for the first quarter 2013 by 11:59 p.m., Eastern Time on July 18, 2013.

We would exempt HHAs receiving Medicare certification on or after April 1, 2012 from the full HHCAHPS reporting requirement for the CY 2014 APU, because these HHAs were not Medicare-certified in the period of April 1, 2011 through March 31, 2012. These HHAs would not need to complete a Participation Exemption Request Form for the CY 2014 Annual Payment Update. We proposed to maintain this stated exemption for new HHAs.

HHAs that had fewer than 60 HHCAHPS-eligible unduplicated or unique patients in the period of April 1, 2011 through March 31, 2012 would be exempt from the HHCAHPS data collection and submission requirements for the CY 2014 APU. Such agencies would be required to submit their patient counts for the period of April 1, 2011 through March 31, 2012 on the Participation Exemption Request form posted at

https://homehealthcahps.org

by 11:59 p.m., Eastern Time on January 17, 2013. This deadline would be firm, as would be all of the quarterly data submission deadlines.

(4) HHCAHPS Requirements for CY 2015

For the CY 2015 APU, we proposed to continue to require the continuous monthly HHCAHPS data collection and reporting for four quarters. The data collection period for CY 2015 would include the second quarter 2013 through the first quarter 2014 (the months of April 2013 through March 2014). HHAs would be required to submit their HHCAHPS data files to the Home Health CAHPS Data Center for CY 2014 for the second quarter 2013 by 11:59 p.m., Eastern Time on October 17, 2013; for the third quarter 2013 by 11:59 p.m., Eastern Time on January 16, 2014; for the fourth quarter 2013 by 11:59 p.m., Eastern Time on April 17, 2014; and for

the first quarter 2014 by 11:59 p.m., Eastern Time on July 17, 2014.

We proposed to continue to exempt HHAs receiving Medicare certification on or after April 13, which is after the period in which HHAs do their patient count (April 1, 2012 through March 31, 2013) on or after April 1, 2013 from the full HHCAHPS reporting requirement for the CY 2015 APU, because these HHAs are not Medicare-certified throughout the period of April 1, 2012 through March 31, 2013. These HHAs do not need to complete a Participation Exemption Request Form for the CY 2015 Annual Payment Update. We proposed to maintain this stated exemption for new HHAs.

Likewise, all HHAs that had fewer than 60 HHCAHPS-eligible unduplicated or unique patients in the period of April 1, 2012 through March 31, 2013 would be exempt from the HHCAHPS data collection and submission requirements for the CY 2015 APU. Agencies with fewer than 60 HHCAHPS-eligible, unduplicated or unique patients in the period of April 1, 2012 through March 31, 2013 would be required to submit their patient counts on the Participation Exemption Request form for CY 2015 posted at

https://homehealthcahps.org

by 11:59 p.m., Eastern Time on January 16, 2014. This deadline would be firm, as would be all of the quarterly data submission deadlines.

(5) HHCAHPS Reconsiderations and Appeals Process

We believe that HHAs should monitor their respective HHCAHPS survey vendors to ensure that vendors submit their HHCAHPS data on time, by accessing their HHCAHPS Data Submission Reports on

https://homehealthcahps.org.

This will help HHAs ensure that their data are submitted in the proper format for data processing to the HHCAHPS Data Center.

We believe that the reconsiderations process for HHCAHPS should not be burdensome to HHAs. We have modeled the HHCAHPS reconsiderations process after the one that is used for Hospital CAHPS, in use for nearly 7 years. We have described the HHCAHPS reconsiderations process requirements in the notification memorandum that the RHHIs/MACs sent to the affected HHAs, on behalf of CMS. HHAs have 30 days to send their reconsiderations to CMS. CMS has and will continue to fully examine all HHA reconsiderations.

(6) Summary of Proposed Changes in CY 2013

We proposed one change in the CY 2013 HH PPS proposed rule issued in the July 13, 2012

Federal Register

(77 FR 41548). We proposed to codify the current guideline that all approved HHCAHPS survey vendors fully comply with all HHCAHPS oversight activities, and include this at § 484.250(c).

(7) For Further Information on the HHCAHPS Survey

We strongly encourage HHAs to learn about the survey and view the HHCAHPS Survey Web site at the official Web site for the HHCAHPS at

https://homehealthcahps.org.

Home health agencies can also send an email to the HHCAHPS Survey Coordination Team at

HHCAHPS@rti.org,

or telephone toll-free (1-866-354-0985) for more information about HHCAHPS.

The following is a summary of the comments we received regarding the Home Health Care CAHPS Survey (HHCAHPS) proposal.

Comment:

We received several comments that expressed confusion over CMS's statement that we would codify the HHCAHPS guideline that home health agencies ensure that survey vendors are fully compliant with all HHCAHPS requirements because vendors are approved by CMS. These commenters noted that an agency should accept CMS's approval as verification that the vendor meets all HHCAHPS requirements and should not be held responsible for any compliance failures of a CMS-approved vendor.

Response:

In the proposed rule, we proposed to codify the current guideline that all approved HHCAHPS survey vendors fully comply with all HHCAHPS oversight activities. We proposed to include this survey requirement at § 484.250(c). This was correct. However, we were not clear in the proposed rule about the HHA's role. HHAs do not need to participate in vendor oversight activities. We have corrected this in the final rule. We have clarified this language in the preamble of the final rule based on comments, that the HHCAHPS approved vendors have to comply with HHCAHPS oversight activities. We in error noted in the preamble of the proposed rule that HHAs have to comply with HHCAHPS oversight activities. However, HHAs are responsible for monitoring their vendors to ensure that vendors submit their data on time, using the information that is available to them on the HHCAHPS data submission reports accessible through

https://homehealthcahps.org.

If we become aware of a significant vendor issue that would put HHAs at risk for not meeting the APU requirements, we will immediately alert the affected HHAs. If we find that a vendor does not comply with HHCAHPS protocols and guidelines, or correct in a timely manner any deficiencies that are found during oversight activities, then we will remove that vendor from the approved list of HHCAHPS survey vendors.

Comment:

One commenter believed that there needs to be enough flexibility within the reconsideration process to provide relief to HHA providers that have made reasonable efforts to ensure that their survey vendors have complied with the HHCAHPS requirements.

Response:

We review each HHA submission for the reconsideration process in a standardized manner so that all HHAs are treated fairly in the review process. If we become aware of a significant vendor issue that would put HHAs at risk for not meeting the APU requirements, we will immediately alert the affected HHAs. If we find that a vendor does not comply with HHCAHPS protocols and guidelines, or correct in a timely manner any deficiencies that are found during oversight activities, then we will remove that vendor from the approved list of HHCAHPS survey vendors.

Comment:

One commenter stated that there is continued concern that the HHCAHPS survey places another unfunded administrative burden on HHAs—a mandate that requires significant time to work with CMS's approved vendor selected by the HHA provider.

Response:

The collection of the patient's perspectives of care data for similar CAHPS surveys, such as Hospital CAHPS, follow

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