Medicare and Medicaid Programs; CY 2018 Home Health Prospective Payment System Rate Update and Proposed CY 2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 409 and 484

[CMS-1672-P]

RIN 0938-AT01

Medicare and Medicaid Programs; CY 2018 Home Health Prospective Payment System Rate Update and Proposed CY 2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements

AGENCY:

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

ACTION:

Proposed rule.

SUMMARY:

This proposed rule updates the home health prospective payment system (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor, effective for home health episodes of care ending on or after January 1, 2018. This rule also: updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the 3rd-year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014; and discusses our efforts to monitor the potential impacts of the rebasing adjustments that were implemented in CY 2014 through CY 2017. This rule proposes case-mix methodology refinements, as well as a change in the unit of payment from 60-day episodes of care to 30-day periods of care, to be implemented for home health services beginning on or after January 1, 2019; and finally, this rule proposes changes to the Home Health Value-Based Purchasing (HHVBP) Model and to the Home Health Quality Reporting Program (HH QRP).

DATES:

To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on September 25, 2017.

ADDRESSES:

In commenting, please refer to file code CMS-1672-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed):

1.

Electronically.

You may submit electronic comments on this regulation to

http://www.regulations.gov

. Follow the instructions under the “More Search Options” tab.

2.

By regular mail.

You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1672-P, P.O. Box 8016, Baltimore, MD 21244-8016.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3.

By express or overnight mail.

You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1672-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4.

By hand or courier.

If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the following addresses:

a. For delivery in Washington, DC—Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD—Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, please call (410) 786-7195 in advance to schedule your arrival with one of our staff members.

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, see the beginning of the

SUPPLEMENTARY INFORMATION

section.

FOR FURTHER INFORMATION CONTACT:

For general information about the HH PPS, please send your inquiry via email to:

HomehealthPolicy@cms.hhs.gov

.

For information about the HHVBP model, please send your inquiry via email to:

HHVBPquestions@cms.hhs.gov

.

Joan Proctor, (410) 786-0949 for information about the home health quality reporting program.

SUPPLEMENTARY INFORMATION:

Inspection of Public Comments:

All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received:

http://www.regulations.gov

. Follow the search instructions on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. EST. To schedule an appointment to view public comments, phone 1-800-743-3951.

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. Current System for Payment of Home Health Services

C. Updates to the Home Health Prospective Payment System

D. Report to Congress: Home Health Study on Access to Care for Vulnerable Patient Populations and Subsequent Research and Analyses

III. Provisions of the Proposed Rule: Payment Under the Home Health Prospective Payment System (HH PPS)

A. Monitoring for Potential Impacts—Affordable Care Act Rebasing Adjustments

B. Proposed CY 2018 HH PPS Case-Mix Weights

C. Proposed CY 2018 Home Health Payment Rate Update

D. Payments for High-Cost Outliers under the HH PPS

E. Proposed Implementation of the Home Health Groupings Model (HHGM) for CY 2019

IV. Proposed Provisions of the Home Health Value-Based Purchasing (HHVBP) Model

A. Background

B. Quality Measures

C. Quality Measures for Future Consideration

V. Proposed Updates to the Home Health Care Quality Reporting Program (HH QRP)

A. Background and Statutory Authority

B. General Considerations Used for the Selection of Quality Measures for the HH QRP

C. Accounting for Social Risk Factors in the HH QRP

D. Proposed Data Elements for Removal From OASIS

E. Proposed Collection of Standardized Patient Assessment Data Under the HH QRP

F. HH QRP Quality Measures Proposed Beginning With the CY 2020 HH QRP

G. HH QRP Quality Measures and Measure Concepts Under Consideration for Future Years

H. Proposed Standardized Patient Assessment Data

I. Proposals Relating to the Form, Manner, and Timing of Data Submission Under the HH QRP

J. Other Proposals for the CY 2019 HH QRP and Subsequent Years

K. Proposals and Policies Regarding Public Display of Quality Measure Data for the HH QRP

L. Proposed Mechanism for Providing Confidential Feedback Reports to HHAs

M. Home Health Care CAHPS® Survey (HHCAHPS)

VI. Request for Information on CMS Flexibilities and Efficiencies

VII. Collection of Information Requirements

A. Statutory Requirement for Solicitation of Comments

B. Collection of Information Requirements for the HH QRP

C. Submission of PRA-Related Comments

VIII. Response to Public Comments

IX. Regulatory Impact Analysis

A. Statement of Need

B. Overall Impact

C. Detailed Economic Analysis

D. Alternatives Considered

E. Accounting Statement and Table

F. Reducing Regulation and Controlling Regulatory Costs

G. Conclusion

X. Federalism Analysis

Regulation Text

Acronyms

In addition, because of the many terms to which we refer by abbreviation in this proposed 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

AM-PAC Activity Measure for Post-Acute Care

APU Annual Payment Update

ASPE Assistant Secretary for Planning and Evaluation

BBA Balanced Budget Act of 1997, Public Law 105-33

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

BIMS Brief Interview for Mental Status

BLS Bureau of Labor Statistics

CAD Coronary Artery Disease

CAH Critical Access Hospital

CAM Confusion Assessment Method

CARE Continuity Assessment Record and Evaluation

CASPER Certification and Survey Provider Enhanced Reports

CBSA Core-Based Statistical Area

CCN CMS Certification Number

CHF Congestive Heart Failure

CMI Case-Mix Index

CMP Civil Money Penalty

CMS Centers for Medicare & 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, Public Law 109-171, enacted February 8, 2006

DTI Deep Tissue Injury

EOC End of Care

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

HHA Home Health Agency

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

HH PPS Home Health Prospective Payment System

HHGM Home Health Groupings Model

HHQRP Home Health Quality Reporting Program

HHRG Home Health Resource Group

HHVBP Home Health Value-Based Purchasing

HIPPS Health Insurance Prospective Payment System

HVBP Hospital Value-Based Purchasing

IADL Instrumental Activities of Daily Living

ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification

ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modification

IH Inpatient Hospitalization

IMPACT Act Improving Medicare Care Transformation Act of 2014 (Pub. L. 113-185)

IPR Interim Performance Report

IRF Inpatient Rehabilitation Facility

IRF-PAI IRF Patient Assessment Instrument

IV Intravenous

LCDS LTCH CARE Data Set

LEF Linear Exchange Function

LTCH Long-Term Care Hospital

LUPA Low-Utilization Payment Adjustment

MACRA Medicare Access and CHIP Reauthorization Act of 2015

MAP Measure Applications Partnership

MDS Minimum Data Set

MEPS Medical Expenditures Panel Survey

MFP Multifactor productivity

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

MSA Metropolitan Statistical Area

MSS Medical Social Services

NQF National Quality Forum

NQS National Quality Strategy

NRS Non-Routine Supplies

OASIS Outcome and Assessment Information Set

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

OLS Ordinary Least Squares

OT Occupational Therapy

OMB Office of Management and Budget

PAC Post-Acute Care

PAC-PRD Post-Acute Care Payment Reform Demonstration

PAMA Protecting Access to Medicare Act of 2014

PEP Partial Episode Payment Adjustment

PHQ-2 Patient Health Questionnaire-2

PPOC Primary Point of Contact

PPS Prospective Payment System

PRA Paperwork Reduction Act

PRRB Provider Reimbursement Review Board

PT Physical Therapy

PY Performance Year

QAP Quality Assurance Plan

QIES Quality Improvement Evaluation System

QRP Quality Reporting Program

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

ROC Resumption of Care

SAF Standard Analytic File

SLP Speech-Language Pathology

SN Skilled Nursing

SNF Skilled Nursing Facility

SOC Start of Care

SSI Surgical Site Infection

TEP Technical Expert Panel

TPS Total Performance Score

UMRA Unfunded Mandates Reform Act of 1995.

VAD Vascular Access Device

VBP Value-Based Purchasing

I. Executive Summary

A. Purpose

This proposed rule would update the payment rates for home health agencies (HHAs) for calendar year (CY) 2018, as required under section 1895(b) of the Social Security Act (the Act). This proposed rule would update the case-mix weights under section 1895(b)(4)(A)(i) and (b)(4)(B) of the Act for CY 2018 and implement a 0.97 percent reduction to the national, standardized 60-day episode payment amount to account for case-mix growth

unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014, under the authority of section 1895(b)(3)(B)(iv) of the Act. For home health services beginning on or after January 1, 2019, this rule also proposes case-mix methodology refinements under the authority set out at sections 1895(b)(4)(A)(i) and (b)(4)(B) of the Act, and a change in the unit of payment from a 60-day episode of care to a 30-day period of care under the authority set out at section 1895(b)(2) of the Act. Additionally, this rule proposes changes to: The Home Health Value Based Purchasing (HHVBP) model under the authority of section 1115A of the Act; and the Home Health Quality Reporting Program (HH QRP) requirements under the authority of section 1895(b)(3)(B)(v) of the Act.

B. Summary of the Major Provisions

Section III.A of this rule discusses our efforts to monitor for potential impacts due to the rebasing adjustments implemented in CY 2014 through CY 2017, as mandated by section 3131(a) of the Patient Protection and Affordable Care Act of 2010 (Pub. L. 111-148, enacted March 23, 2010) as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152, enacted March 30, 2010), collectively referred to as the “Affordable Care Act”. In the CY 2015 HH PPS final rule (79 FR 66072), we finalized our proposal to recalibrate the case-mix weights every year with the most current and complete data available at the time of rulemaking. In section III.B of this rule, we are recalibrating the HH PPS case-mix weights, using the most current cost and utilization data available, in a budget neutral manner. Also in section III.B of this rule, as finalized in the CY 2016 HH PPS final rule (80 FR 68624), we are implementing a reduction to the national, standardized 60-day episode payment rate for CY 2018 of 0.97 percent to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014.

In section III.C of this proposed rule, we would update the payment rates under the HH PPS by 1 percent for CY 2018 in accordance with section 411(d) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015) which amended section 1895(b)(3)(B) of the Act. Additionally, section III.C of this rule, would update the CY 2018 home health wage index using FY 2014 hospital cost report data. In section III.D of this proposed rule, we note that the fixed-dollar loss ratio would remain 0.55 for CY 2018 to pay up to, but no more than, 2.5 percent of total payments as outlier payments, as required by section 1895(b)(5)(A) of the Act.

In section III.E of this rule we are proposing to implement case-mix methodology refinements and a change in the unit of payment from a 60-day episode of care to a 30-day period of care, effective for home health services beginning on or after January 1, 2019. The proposed home health groupings model (HHGM) relies more heavily on clinical characteristics and other patient information to place patients into meaningful payment categories, while eliminating therapy service use thresholds that are currently used to case-mix adjust payments under the HH PPS. This includes proposed changes in the episode timing categories, the addition of an admission source category, the creation of six clinical groups used to categorize patients based on their primary reason for home health care, revised functional levels and corresponding OASIS items, the addition of a comorbidity adjustment, and a proposed change in the Low-Utilization Payment Adjustment (LUPA) threshold. The LUPA add-on policy, the partial [episode] payment adjustment policy, and the methodology used to calculate payments for high-cost outliers would remain unchanged except for occurring on a 30-day basis rather than a 60-day basis.

In section IV of this rule, we are proposing changes to the Home Health Value-Based Purchasing (HHVBP) Model implemented January 1, 2016. We are proposing to amend the definition of “applicable measure” to specify that the HHA would have to submit a minimum of 40 completed surveys for Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) measures, for purposes of receiving a performance score for any of the HHCAHPS measures, and for performance year (PY) 3 and subsequent years, to remove the Outcome and Assessment Information Set (OASIS)-based measure, Drug Education on All Medications Provided to Patient/Caregiver during All Episodes of Care, from the set of applicable measures. We are also soliciting public comments on composite quality measures for future consideration.

In section V of this rule, we propose updates to the Home Health Quality Reporting Program, including: The replacement of one quality measure, the adoption of two new quality measures, the reporting of standardized patient assessment data in five categories described under the IMPACT Act, data submission requirements, exception and extension requirements, and reconsideration and appeals procedures.

C. Summary of Costs and Benefits

Table 1—Summary of Costs and Transfers

Provision description

Costs

Transfers

CY 2018 HH PPS Payment Rate Update

The overall economic impact of the HH PPS payment rate update is an estimated −$80 million (−0.4 percent) in payments to HHAs.

CY 2018 HHVBP Model

The overall economic impact of the HHVBP Model provision for CY 2018 through 2022 is an estimated $378 million in total savings from a reduction in unnecessary hospitalizations and SNF usage as a result of greater quality improvements in the HH industry (none of which is attributable to the changes proposed in this proposed rule). As for payments to HHAs, there are no aggregate increases or decreases expected to be applied to the HHAs competing in the model.

CY 2019 HH QRP

The overall economic impact of the HH QRP changes is a savings to HHAs of an estimated $44.9 million, beginning January 1, 2019

CY 2019 HH PPS Case-Mix Adjustment Methodology Refinements

The overall impact of the proposed HH PPS case-mix adjustment methodology refinements, including a change in the unit of payment from 60-day episodes to 30-day periods of care, is an estimated −$950 million (−4.3 percent) in payments to HHAs in CY 2019 if the refinements are implemented in a non-budget neutral manner for 30-day periods of care beginning on or after January 1, 2019. The overall impact is an estimated −$480 million (−2.2 percent) in payments to HHAs in CY 2019 if the refinements are implemented in a partially budget-neutral manner.

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 the 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 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 Affordable Care Act 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 for Fiscal Year 1999 (OCESAA), (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 of 1999, (BBRA) (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 by 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. Section 421(a) of the MMA, as amended by section 3131 of the Affordable Care Act, requires that the Secretary increase, by 3 percent, the payment amount otherwise made under section 1895 of the Act, 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.

Section 210 of the MACRA amended section 421(a) of the MMA to extend the rural add-on for 2 more years. Section 421(a) of the MMA, as amended by section 210 of the MACRA, requires that the Secretary increase, by 3 percent, the payment amount otherwise made under section 1895 of the Act, for HH services

provided 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, 2018. Section 411(d) of MACRA amended section 1895(b)(3)(B) of the Act such that for home health payments for CY 2018, the market basket percentage increase shall be 1 percent.

B. Current System for Payment of Home Health Services

Generally, Medicare currently 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 non-routine supplies (NRS) is not part of the national, standardized 60-day episode rate, but is computed by multiplying the relative weight for a particular NRS severity level by the NRS conversion factor. 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. Therapy service use is measured by the number of therapy visits provided during the episode and can be categorized into nine visit level categories (or thresholds): 0-5; 6; 7-9; 10; 11-13; 14-15; 16-17; 18-19; and 20 or more visits.

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 Home Health Prospective Payment System

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 HH PPS for CY 2008. The CY 2008 HH PPS final 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 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, to 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.

In the CY 2012 HH PPS final rule (76 FR 68526), we updated the 60-day national episode rates and the national per-visit rates. In addition, as discussed in the CY 2012 HH PPS 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. At that time, to fully account for the 19.03 percent nominal case-mix growth identified from 2000 to 2009, we finalized a 3.79 percent payment reduction in CY 2012 and a 1.32 percent payment reduction for CY 2013.

In the CY 2013 HH PPS final rule (77 FR 67078), we implemented a 1.32 percent reduction to the payment rates for CY 2013 to account for nominal case-mix growth from 2000 through 2010. When taking into account the total measure of case-mix change (23.90 percent) and the 15.97 percent of total case-mix change estimated as real from 2000 to 2010, we obtained a final nominal case-mix change measure of 20.08 percent from 2000 to 2010 (0.2390 * (1 − 0.1597) = 0.2008). To fully account for the remainder of the 20.08 percent increase in nominal case-mix beyond that which was 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. Although we considered proposing a 2.18 percent reduction to account for the remaining increase in measured nominal case-mix, we finalized the 1.32 percent payment reduction to the national, standardized 60-day episode rates in the CY 2012 HH PPS final rule (76 FR 68532).

Section 3131(a) of the Affordable Care Act requires that, beginning in CY 2014, we apply an adjustment to the national, standardized 60-day episode rate and other amounts that reflect factors such as changes in the number of visits in an episode, the mix of services in an episode, the level of intensity of services in an episode, the average cost of providing care per episode, and other relevant factors. Additionally, we must phase in any adjustment over a 4-year period in equal increments, not to exceed 3.5 percent of the amount (or amounts) as of the date of enactment of the Affordable Care Act, and fully implement the rebasing adjustments by CY 2017. The statute specifies that the maximum rebasing adjustment is to be no more than 3.5 percent per year of the CY 2010 rates. Therefore, in the CY 2014 HH PPS final rule (78 FR 72256) for each year, CY 2014 through CY 2017, we finalized a fixed-dollar reduction to the national, standardized 60-day episode payment rate of $80.95 per year, increases to the national per-visit payment rates per year, and a decrease to the NRS conversion factor of 2.82 percent per year. We also finalized three separate LUPA add-on factors for skilled nursing, physical therapy, and speech-language pathology and removed 170 diagnosis codes from assignment to diagnosis groups in the HH PPS Grouper. In the CY 2015 HH PPS final rule (79 FR 66032), we implemented the 2nd year of the 4 year phase-in of the rebasing adjustments to the HH PPS payment rates and made changes to the

HH PPS case-mix weights. In addition, we simplified the face-to-face encounter regulatory requirements and the therapy reassessment timeframes.

In the CY 2016 HH PPS final rule (80 FR 68624), we implemented the 3rd year of the 4-year phase-in of the rebasing adjustments to the national, standardized 60-day episode payment amount, the national per-visit rates and the NRS conversion factor (as outlined above). In the CY 2016 HH PPS final rule, we also recalibrated the HH PPS case-mix weights, using the most current cost and utilization data available, in a budget neutral manner and finalized reductions to the national, standardized 60-day episode payment rate in CY 2016, CY 2017, and CY 2018 of 0.97 percent in each year to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between CY 2012 and CY 2014. Finally, section 421(a) of the MMA, as amended by section 210 of the MACRA, extended the payment increase of 3 percent for HH services provided in rural areas (as defined in section 1886(d)(2)(D) of the Act) to episodes or visits ending before January 1, 2018.

In the CY 2017 HH PPS final rule (81 FR 76702), we implemented the last year of the 4-year phase-in of the rebasing adjustments to the national, standardized 60-day episode payment amount, the national per-visit rates and the NRS conversion factor (as outlined above). We also finalized changes to the methodology used to calculate outlier payments under the authority of section 1895(b)(5) of the Act. Lastly, in accordance with section 1834(s) of the Act, as added by section 504(a) of the Consolidated Appropriations Act, 2016 (Pub. L. 114-113, enacted December 18, 2015), we implemented changes in payment for furnishing Negative Pressure Wound Therapy (NPWT) using a disposable device for patients under a home health plan of care for which payment would otherwise be made under section 1895(b) of the Act.

D. Report to Congress: Home Health Study on Access to Care for Vulnerable Patient Populations and Subsequent Research and Analyses

Section 3131(d) of the Affordable Care Act required CMS to conduct a study on home health agency costs involved with providing ongoing 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 and submit a report to Congress. As discussed in the CY 2016 HH PPS proposed rule (80 FR 39840) and the CY 2017 HH PPS proposed rule (81 FR 43744), the findings from the Report to Congress on the “Medicare Home Health Study: An Investigation on Access to Care and Payment for Vulnerable Patient Populations”, found that payment accuracy could be improved under the current payment system, particularly for patients with certain clinical characteristics requiring more nursing care than therapy.

1

1

The Report to Congress can be found in its entirety at

https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HomeHealthPPS/Downloads/HH-Report-to-Congress.pdf

.

The research for the Report to Congress, released in December 2014, consisted of extensive analysis of both survey and administrative data. The CMS-developed surveys were given to physicians who referred vulnerable patient populations to Medicare home health and to Medicare-certified HHAs.

2

The response rates were 72 percent and 59 percent for the HHA and physician surveys, respectively. The results of the survey revealed that over 80 percent of respondent HHAs and over 90 percent of respondent physicians reported that access to home health care for Medicare fee-for-service beneficiaries in their local area was excellent or good. When survey respondents reported access issues, specifically their inability to place or admit Medicare fee-for-service patients into home health, the most common reason reported (64 percent of respondent HHAs surveyed) was that the patients did not qualify for the Medicare home health benefit. HHAs and physicians also cited family or caregiver issues as an important contributing factor in the inability to admit or place patients. Only 17.2 percent of HHAs and 16.7 percent of physicians reported insufficient payment as an important contributing factor in the inability to admit or place patients. The results of the CMS-conducted surveys suggested that CMS' ability to improve access for certain vulnerable patient populations through payment policy may be limited. However, we are able to revise the case-mix system to minimize differences in payment that could potentially be serving as a barrier to receiving care. In this rule, we propose to better align payment with resource use so that it reduces HHAs' financial incentives to select certain patients over others.

2

For the purposes of the surveys, “vulnerable patient populations” were defined as beneficiaries who were either eligible for the Part D low-income subsidy (LIS) 27 or residing in a health professional shortage area (HPSA).

However, we also performed an analysis of Medicare administrative data (CY 2010 Medicare claims and cost report data) and calculated margins for episodes of care. This was done because margin differences associated with patient clinical and social characteristics can indicate whether financial incentives exist in the current HH PPS to provide home health care for certain types of patients over others. Lower margins, if systematically associated with care for vulnerable patient populations, may indicate financial disincentives for HHAs to admit these patients, potentially creating access to care issues. The findings from the data analysis found that certain patient characteristics appear to be strongly associated with margin levels, and thus may create financial incentives to select certain patients over others. Margins were estimated to be lower for patients who required parenteral nutrition, who had traumatic wounds or ulcers, or required substantial assistance in bathing. For example, in CY 2010, episodes for patients with parenteral nutrition were, on average, associated with a $178.53 lower margin than episodes for patients without parenteral nutrition. Given that these variables are already included in the HH PPS case-mix system, the results indicated that modifications to the way the current case-mix system accounts for resource use differences may be needed to mitigate any financial incentives to select certain patients over others. Margins were also lower for beneficiaries who were admitted after acute or post-acute stays or who had certain poorly-controlled clinical conditions, such as poorly-controlled pulmonary disorders, indicating that accounting for additional patient characteristic variables in the HH PPS case-mix system may also reduce financial incentives to select certain types of patients over others. More information on the results from the Home Health Study required by section 3131(d) of the Affordable Care Act can be found in the Report to Congress on the “Medicare Home Health Study: An Investigation on Access to Care and Payment for Vulnerable Patient Populations” available at

https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html

.

Section 3131(d)(5) of the Affordable Care Act allowed for the Secretary to determine whether a Medicare demonstration project is appropriate to conduct based on the result of the Home Health Study. If the Secretary determined it was appropriate to conduct the demonstration project under this subsection, the Secretary was to conduct the project for a four year period beginning not later than January

1, 2015. We did not determine that it was appropriate to conduct a demonstration project based on the findings from the Home Health Study. Rather, the findings from the Home Health Study suggested that follow-on work should be conducted to better align payments with costs under the authority of section 1895 of the Act.

In addition to the findings from the Report to Congress on the “Medicare Home Health Study: An Investigation on Access to Care and Payment for Vulnerable Patient Populations”, concerns have also been raised about the use of therapy thresholds in the current payment system. Under the current payment system, HHAs receive higher payments for providing more therapy visits once certain thresholds are reached. As a result, the average number of therapy visits per 60-day episode of care have increased since the implementation of the HH PPS, while the number of skilled nursing and home health aide visits have decreased over the same time period as shown in Figure 3 in section III.A of this rule. A study examining an option of using predicted, rather than actual, therapy visits in the HH found that in 2013, 58 percent of home health episodes included some therapy services, and these episodes accounted for 72 percent of all Medicare home health payments.

3

Figure 1 from that study demonstrates that the percentage of episodes, and the average episode payment by the number of therapy visits for episodes with at least one therapy visit in 2013 increased sharply in therapy provision just over payment thresholds at 6, 7, and 16. According to the study, the presence of sharp increases in the percentage of episodes just above payment thresholds suggests a response to financial incentives in the home health payment system. Similarly, between 2008 and 2013, MedPAC reported a 26 percent increase in the number of episodes with at least 6 therapy visits, compared with a 1 percent increase in the number of episodes with five or fewer therapy visits.

4

CMS analysis demonstrates that the average share of therapy visits across all 60-day episodes of care increased from 9 percent of all visits in 1997, prior to the implementation of the HH PPS (see 64 FR 58151), to 39 percent of all visits in 2015 (see Table 2 in section III.A. of this proposed rule).

3

Fout B, Plotzke M, Christian T. (2016). Using Predicted Therapy Visits in the Medicare Home Health Prospective Payment System.

Home Health Care Management & Practice, 29(2), 81-90.

http://journals.sagepub.com/doi/abs/10.1177/1084822316678384

.

4

Medicare Payment Advisory Commission (MedPAC). “Home Health Care Services.”

Report to Congress: Medicare Payment Policy.

Washington, DC, March 2015. P. 223. Accessed on March 28, 2017 at:

http://www.medpac.gov/docs/default-source/reports/mar2015_entirereport_revised.pdf?sfvrsn=0.

EP28JY17.005

Figure 1 suggests that HHAs may be responding to financial incentives in the home health payment system when making care plan decisions. Additionally, an investigation into the therapy practices of the four largest publically-traded home health companies, conducted by the Senate Committee on Finance in 2010, found that three out of the four companies investigated “encouraged therapists to target the most profitable number of therapy visits, even when patient need alone may not have justified such patterns”.

5

The Committee on Finance

investigation also highlighted the abrupt and dramatic responses the home health industry has taken to maximize reimbursement under the therapy threshold models (both the original 10-visit threshold model and under the revised thresholds implemented in the CY 2008 HH PPS final rule (72 FR 49762)). Under the HH PPS, the report noted that HHAs have broad discretion over the number of therapy visits to provide patients and therefore have control of the single-largest variable in determining reimbursement and overall margins. The report recommended that CMS closely examine a future payment approach that focuses on patient well-being and health characteristics, rather than the numerical utilization measures.

5

Committee on Finance, United States Senate.

Staff Report on Home Health and the Medicare

Therapy Threshold.

Washington, DC, 2011. Accessed on March 28, 2017 at

https://www.finance.senate.gov/imo/media/doc/Home_Health_Report_Final4.pdf.

MedPAC also continues to recommend the removal of the therapy thresholds used for determining payment from the HH PPS, as it believes that such thresholds run counter to the goals of a prospective payment system, create financial incentives that detract from a focus on patient characteristics and care needs when agencies are setting plans of care for their patients, and incentivize unnecessary therapy utilization. For the average HHA, according to MedPAC, the increase in payment for therapy visits rises faster than costs resulting in financial incentives for HHAs to overprovide therapy services.

6

HHAs that provide more therapy episodes tend to be more profitable and this higher profitability and rapid growth in the number of therapy episodes suggest that financial incentives are causing agencies to favor therapy services when possible.

7

Eliminating therapy as a payment factor would base home health payment solely on patient characteristics, which is a more patient-focused approach to payment, as recommended by both MedPAC and previously by the Senate Committee on Finance.

6

Medicare Payment Advisory Commission (MedPAC). “Home Health Services.”

Report to Congress: Medicare Payment Policy.

Washington, DC, March 2011. P. 182-183. Accessed on March 28, 2017 at

http://www.medpac.gov/docs/default-source/reports/Mar11_Ch08.pdf?sfvrsn=0

.

7

Medicare Payment Advisory Commission (MedPAC). “Home Health Care Services.”

Report to Congress: Medicare Payment Policy.

Washington, DC, March 2017. P. 243-244. Accessed on March 28, 2017 at

http://www.medpac.gov/docs/default-source/reports/mar17_medpac_ch9.pdf?sfvrsn=0.

After considering the findings from the Report to Congress and recommendations from MedPAC and the Senate Committee on Finance, CMS, along with our contractor, conducted additional research on ways to improve the payment accuracy under the current payment system. Exploring all options and different models ultimately led us to further develop the Home Health Groupings Model (HHGM) proposal. The HHGM proposal uses 30-day periods, rather than 60-day episodes, and relies more heavily on clinical characteristics and other patient information (for example, principal diagnosis, functional level, comorbid conditions, admission source, and timing) to place patients into meaningful payment categories, rather than the current therapy driven system. We believe this patient-centered approach is consistent with how clinicians differentiate between home health patients and would improve payment accuracy and access for medically complex cases and not just cases receiving therapy. The HHGM proposal leverages many of the same aspects of the current system; however, the major differences between the current system and the HHGM proposal include a change from a 60-day to a 30-day billing cycle and the elimination of the therapy thresholds in the case-mix system.

We shared the analyses and development of the HHGM with both internal and external stakeholders via technical expert panels, clinical workgroups, special open door forums, and in the CY 2016 HH PPS proposed rule (80 FR 39840) and the CY 2017 HH PPS proposed rule (81 FR 43744). Most recently, we posted a detailed technical report on the CMS Web site in December of 2016.

8

After posting the technical report for the public to review, we also held additional technical expert panel and clinical workgroup webinars to garner feedback from the industry and conducted a National Provider call that occurred in January 2017 to solicit feedback from external stakeholders.

9

The feedback we received during the National Provider call on the HHGM was positive. We discuss the HHGM proposal further below, in section III.E, and seek public comment on this proposal and the underlying analyses.

8

Ab Associates.

Medicare Home Health Prospective Payment System: Case-Mix Methodology Refinements. Overview of the Home Health Groupings Model.

Cambridge, MA, November 18, 2016. Accessed on April 27, 2017 at:

https://downloads.cms.gov/files/hhgm%20technical%20report%20120516%20sxf.pdf

.

9

Centers for Medicare & Medicaid Services (CMS). “Home Health Groupings Model Technical Report Call.” Baltimore, MD, January 18, 2017. Accessed on April 27, 2017 at:

https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2017-01-18-Home-Health.html?DLPage=2&DLEntries=10&DLSort=0&DLSortDir=descending

.

III. Provisions of the Proposed Rule: Payment Under the Home Health Prospective Payment System (HH PPS)

A. Monitoring for Potential Impacts—Affordable Care Act Rebasing Adjustments

1. Analysis of FY 2015 HHA Cost Report Data

As part of our efforts in monitoring the potential impacts of the rebasing adjustments finalized in the CY 2014 HH PPS final rule (78 FR 72293), we continue to update our analysis of home health cost report and claims data. Previous years' cost report and claims data analyses and results can be found in the CY 2017 HH PPS proposed rule (81 FR 43719 through 43720). For this proposed rule, we analyzed 2015 HHA cost report data and 2015 HHA claims data. To determine the 2015 average cost per visit per discipline, we applied the same trimming methodology outlined in the CY 2014 HH PPS proposed rule (78 FR 40284) and weighted the costs per visit from the 2015 cost reports by size, facility type, and urban/rural location so the costs per visit were nationally representative according to 2015 claims data. The 2015 average number of visits was taken from 2015 claims data. We estimated the cost of a 60-day episode in CY 2015 to be $2,449.01 using 2015 cost report data as shown in Table 2. However, the national, standardized 60-day episode payment amount in CY 2015 was $2,961.38. For CY 2015, on average, payments were 21 percent higher than costs (($2,961.38—$2,449.01)/$2,449.01).

TABLE 2—2015 Estimated Cost per Episode

Discipline

2015 Average

costs per visit

2015 Average

number

of visits

2015 60-day

episode costs

Skilled Nursing

$132.48

8.93

$1,183.05

Physical Therapy

156.32

5.39

842.56

Occupational Therapy

154.64

1.41

218.04

Speech Pathology

170.96

0.29

49.58

Medical Social Services

220.07

0.14

30.81

Home Health Aides

62.80

1.99

124.97

Total

18.15

2,449.01

Source: Medicare cost reports pulled in February 2017 and Medicare claims data from 2014 and 2015 for episodes (excluding low-utilization payment adjusted episodes and partial-episode-payment adjusted episodes), linked to OASIS assessments for episodes ending in CY 2015.

2. Analysis of CY 2016 HHA Claims Data

In the CY 2014 HH PPS final rule (78 FR 72283), some commenters expressed concern that the rebasing of the HH PPS payment rates would result in HHA closures and would therefore diminish access to home health services. In addition to examining more recent cost report data, for this proposed rule we examined home health claims data from the first 3 years of the 4-year phase-in of the rebasing adjustments (CY 2014, CY 2015, and CY 2016), the first calendar year of the HH PPS (CY 2001), and claims data for 2 years before implementation of the rebasing adjustments (CY 2012 and CY2013). Analysis of CY 2016 home health claims data indicates that the number of episodes and the number of home health users that received at least one episode of care remained virtually the same (change of less than 1 percent) from 2015 to 2016, while the number of FFS beneficiaries increased 2 percent from 2015 to 2016. Between 2013 and 2014 there appears to be a net decrease in the number of HHAs billing Medicare for home health services of 1.6 percent, a continued decrease of 1.7 percent from 2014 to 2015, and a decrease of 2.5 percent from 2015 to 2016. The number of home health users, as a percentage of FFS beneficiaries, appears to have slightly decreased from 9.0 percent in 2012 to 8.7 percent in 2016, but remains higher than the 6.9 percent in 2001. In CY 2016, there were 2.9 HHAs per 10,000 FFS beneficiaries, which is still markedly higher than the 1.9 HHAs per 10,000 FFS beneficiaries observed close to the implementation of the HH PPS in 2001 (see Table 3). Therefore, the rebasing adjustments made to the HH PPS payment rates in CYs 2014 through 2016 do not appear to have resulted in significant HHA closures or otherwise diminished

access to home health services.

10

The data used for this table is not publicly available. Providers and researchers have access to similar data via the home health public use files at

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/HHA.html

and through the CMS program statistics Web site at:

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMSProgramStatistics/index.html

.

TABLE 3—Home Health Statistics, CY 2001 and CY 2012 Through CY 2016

10

2001

2012

2013

2014

2015

2016

Number of episodes

3,896,502

6,727,875

6,708,923

6,451,283

6,340,932

6,294,234

Beneficiaries receiving at least 1 episode (Home Health Users)

2,412,318

3,446,122

3,484,579

3,381,635

3,365,512

3,350,174

Part A and/or B FFS beneficiaries

34,899,167

38,224,640

38,505,609

38,506,534

38,506,534

38,555,150

Episodes per Part A and/or B FFS beneficiaries

0.11

0.18

0.17

0.17

0.17

0.16

Home health users as a percentage of Part A and/or B FFS beneficiaries

6.9%

9.0%

9.0%

8.8%

8.8%

8.7%

HHAs providing at least 1 episode

6,511

11,746

11,889

11,693

11,381

11,102

HHAs per 10,000 Part A and/or B FFS beneficiaries

1.9

3.1

3.1

3.0

3.0

2.9

Source:

National claims history (NCH) data obtained from Chronic Condition Warehouse (CCW)—Accessed on May 14, 2014 and August 19, 2014 for CY 2011, CY 2012, and CY 2013 data; accessed on May 7, 2015 for CY 2001 and CY 2014 data; accessed on April 7, 2016 for CY 2015 data; and accessed on March 20, 2017 for CY 2016 data and Medicare enrollment information obtained from the CCW Master Beneficiary Summary File. Beneficiaries are the total number of beneficiaries in a given year with at least 1 month of Part A and/or Part B Fee-for-Service coverage without having any months of Medicare Advantage coverage.

Note(s):

These results include all episode types (Normal, PEP, Outlier, LUPA) and also include episodes from outlying areas (outside of 50 States and District of Columbia). Only episodes with a through date in the year specified are included. Episodes with a claim frequency code equal to “0” (“Non-payment/zero claims”) and “2” (“Interim—first claim”) are excluded. If a beneficiary is treated by providers from multiple states within a year the beneficiary is counted within each state's unique number of beneficiaries served.

In addition to examining home health claims data from the first three years of the implementation of rebasing adjustments required by the Affordable Care Act, we examined trends in home health utilization for all years starting in CY 2001 and up through CY 2016. Figure 2, displays the average number of visits per 60-day episode of care and the average payment per visit. While the average payment per visit has steadily increased from approximately $116 in CY 2001 to $167 for CY 2016, the average total number of visits per 60-day episode of care has declined, most notably between CY 2009 (21.7 visits per episode) and CY 2010 (19.8 visits per episode), which was the first year that the 10 percent agency-level cap on HHA outlier payments was implemented. The average of total visits per episode has steadily decreased from 21.7 in 2009 to 17.9 in 2016.

EP28JY17.000

Figure 3 displays the average number of visits by discipline type for a 60-day episode of care and shows that the number of therapy visits per 60-day episode of care has increased steadily. However, the number of skilled nursing visits has decreased from 10.7 in 2009 to 8.7 in 2016. The number of home health aide visits has decreased from 5.6 average visits in 2009 to 1.5 visits in 2016. The results of the home health study required by section 3131(d) of the Affordable Care Act suggest that the current home health payment system may discourage HHAs from serving patients with clinically complex and/or poorly controlled chronic conditions who do not qualify for therapy but require a large number of skilled nursing visits.

11

The home health study results seem to be consistent with the recent trend in the decreased number of visits per episode of care driven by decreases in skilled nursing and home health aide services evident in Figures 2 and 3.

11

The Report to Congress on the Home Health Study required by Section 3131(d) is available at

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/HH-Report-to-Congress.pdf.

EP28JY17.001

As part of our monitoring efforts, we also examined the trends in episode timing and service use over time. The first and second episodes are considered “early” episodes, while third and later episodes are considered “late” episodes. Specifically, we examined the percentage of early episodes with 0 to 19 therapy visits, late episodes with 0 to 19 therapy visits, and episodes with 20+ therapy visits from CY 2008 to CY 2016. In CY 2008, we implemented refinements to the HH PPS case-mix system. As part of those refinements, we added additional therapy thresholds and differentiated between early and late episodes for those episodes with less than 20+ therapy visits. When the case-mix system first differentiated payments between early and late episodes of care, late episodes of care tended to have higher case-mix weights compared to early episodes of care. Table 4 shows that while there was a substantial increase in the number of late episodes between 2008 and 2009 (8 percentage points), since 2011 the number of late episodes as a percentage of total episodes has decreased over time. In 2015, the case-mix weights for the third and later episodes of care with 0 to 19 therapy visits decreased as a result of the CY 2015 recalibration of the case-mix weights. The recalibration of the HH PPS case-mix weights, beginning in CY 2015, does not seem to have substantially impacted the percentage of early versus late episodes of care.

The case-mix weights for episodes with 20+ therapy visits are not determined based on the timing of the episode of care. The percentage of episodes with 20+ therapy visits increased from 4.6 percent in CY 2008 to 7.0 percent in CY 2016. The increase in the percentage of episodes with 20+ therapy visits is consistent with the overall observed increase in therapy visits provided during a 60-day episode of care (see Figure 3).

TABLE 4—Home Health Episodes by Episode Timing, CY 2008 Through CY 2016

Year

All episodes

Number of

early episodes

(excluding episodes with 20+ therapy visits)

% of early episodes

(excluding episodes with 20+ therapy visits)

Number of late episodes

(excluding episodes with 20+ therapy visits)

% of late episodes

(excluding episodes with 20+ therapy visits)

Number of

episodes

with 20+

therapy

visits

% of

episodes

with 20+

therapy

visits

2008

5,423,037

3,571,619

65.9

1,600,587

29.5

250,831

4.6

2009

6,530,200

3,701,652

56.7

2,456,308

37.6

372,240

5.7

2010

6,877,598

3,872,504

56.3

2,586,493

37.6

418,601

6.1

2011

6,857,885

3,912,982

57.1

2,564,859

37.4

380,044

5.5

2012

6,767,576

3,955,207

58.4

2,458,734

36.3

353,635

5.2

2013

6,733,146

4,023,486

59.8

2,347,420

34.9

362,240

5.4

2014

6,616,875

3,980,151

60.2

2,263,638

34.2

373,086

5.6

2015

6,644,922

4,008,279

60.3

2,205,052

33.2

431,591

6.5

2016

6,294,232

3,802,254

60.4

2,053,972

32.6

438,006

7.0

Source:

National claims history (NCH) data obtained from Chronic Condition Warehouse (CCW)—Accessed on March 21, 2017.

Note(s):

Only episodes with a through date in the year specified are included. Episodes with a claim frequency code equal to “0” (“Non-payment/zero claims”) and “2” (“Interim—first claim”) are excluded.

We also examined trends in admission source for home health episodes over time. Specifically, we examined the admission source for the “first or only” episodes of care (first episodes in a sequence of adjacent episodes of care or the only episode of care) from CY 2008 through CY 2016 (Figure 4). The percentage of first or only episodes with an acute admission source, defined as episodes with an inpatient hospital stay within the 14 days prior to a home health episode, has decreased from 38.6 percent in CY 2008 to 33.9 percent in CY 2016. The percentage of first or only episodes with a post-acute admission source, defined as episodes which had a stay at a skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), or long term care hospital (LTCH) within 14 days prior to the home health episode, slightly increased from 16.5 percent in CY 2008 to 17.5 percent in CY 2016. The percentage of first or only episodes with a community admission source, defined as episodes which did not have an acute or post-acute stay in the 14 days prior to the home health episode, increased from 37.4 percent in CY 2008 to 42.6 percent in CY 2016. Our findings on the trends in admission source are consistent with MedPAC's as outlined in their 2015 Report to the Congress.

12

MedPAC examined admission source trends from 2002 up through 2013 and concluded that “there has been tremendous growth in the use of home health for patients residing in the community, episodes not preceded by a prior hospitalization. The high rates of volume growth for these types of episodes, which have more than doubled since 2001, suggest there is significant potential for overuse, particularly since Medicare does not currently require any cost sharing for home health care.”

12

Medicare Payment Advisory Commission (MedPAC). “Home Health Care Services.”

Report to the Congress: Medicare Payment Policy.

Washington, DC, March 2015. P. 214. Accessed on 3/28/2017 at

http://www.medpac.gov/docs/default-source/reports/chapter-9-home-health-care-services-march-2015-report-.pdf?sfvrsn=0.

EP28JY17.002

We will continue to monitor for potential impacts due to the rebasing adjustments required by section 3131(a) of the Affordable Care Act and other policy changes in the future. Independent effects of any one policy may be difficult to discern in years where multiple policy changes occur in any given year.

B. Proposed CY 2018 HH PPS Case-Mix Weights

In the CY 2015 HH PPS final rule (79 FR 66072), we finalized a policy to annually recalibrate the HH PPS case-mix weights—adjusting the weights relative to one another—using the most current, complete data available. To recalibrate the HH PPS case-mix weights for CY 2018, we will use the same methodology finalized in the CY 2008 HH PPS final rule (72 FR 49762), the CY 2012 HH PPS final rule (76 FR 68526), and the CY 2015 HH PPS final rule (79 FR 66032). Annual recalibration of the HH PPS case-mix weights ensures that the case-mix weights reflect, as accurately as possible, current home health resource use and changes in utilization patterns.

To generate the proposed CY 2018 HH PPS case-mix weights, we used CY 2016 home health claims data (as of March 17, 2017) with linked OASIS data. These data are the most current and complete data available at this time. We will use CY 2016 home health claims data (as of June 30, 2017 or later) with linked OASIS data to generate the CY 2018 HH PPS case-mix weights in the CY 2018 HH PPS final rule. The process we used to calculate the HH PPS case-mix weights are outlined below.

Step 1:

Re-estimate the four-equation model to determine the clinical and functional points for an episode using wage-weighted minutes of care as our dependent variable for resource use. The wage-weighted minutes of care are determined using the CY 2015 Bureau of Labor Statistics national hourly wage plus fringe rates for the six home health disciplines and the minutes per visit from the claim. The points for each of the variables for each leg of the model, updated with CY 2016 home health claims data, are shown in Table 5. The points for the clinical variables are added together to determine an episode's clinical score. The points for the functional variables are added together to determine an episode's functional score.

Table 5—Case-Mix Adjustment Variables and Scores

Episode number within sequence of adjacent episodes

1 or 2

1 or 2

3+

3+

Therapy visits

0-13

14+

0-13

14+

EQUATION:

1

2

3

4

CLINICAL DIMENSION

1

Primary or Other Diagnosis = Blindness/Low Vision

2

Primary or Other Diagnosis = Blood disorders

1

3

Primary or Other Diagnosis = Cancer, selected benign neoplasms

4

4

4

Primary Diagnosis = Diabetes

3

1

5

Other Diagnosis = Diabetes

1

6

Primary or Other Diagnosis = Dysphagia

AND

Primary or Other Diagnosis = Neuro 3—Stroke

2

16

1

10

7

Primary or Other Diagnosis = Dysphagia

AND

M1030 (Therapy at home) = 3 (Enteral)

1

6

6

8

Primary or Other Diagnosis = Gastrointestinal disorders

2

9

Primary or Other Diagnosis = Gastrointestinal disorders

AND

M1630 (ostomy)= 1 or 2

7

10

Primary or Other Diagnosis = Gastrointestinal disorders

AND

Primary or Other Diagnosis = Neuro 1—Brain disorders and paralysis, OR Neuro 2—Peripheral neurological disorders, OR Neuro 3—Stroke, OR Neuro 4—Multiple Sclerosis

11

Primary or Other Diagnosis = Heart Disease OR Hypertension

1

3

2

12

Primary Diagnosis = Neuro 1—Brain disorders and paralysis

2

9

6

9

13

Primary or Other Diagnosis = Neuro 1—Brain disorders and paralysis

AND

M1840 (Toilet transfer) = 2 or more

4

4

14

Primary or Other Diagnosis = Neuro 1—Brain disorders and paralysis

OR

Neuro 2—Peripheral neurological disorders

AND

M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3

2

4

1

4

15

Primary or Other Diagnosis = Neuro 3—Stroke

3

9

2

4

16

Primary or Other Diagnosis = Neuro 3—Stroke

AND

M1810 or M1820 (Dressing upper or lower body)= 1, 2, or 3

2

17

Primary or Other Diagnosis = Neuro 3—Stroke

AND

M1860 (Ambulation) = 4 or more

18

Primary or Other Diagnosis = Neuro 4—Multiple Sclerosis

AND AT LEAST ONE OF THE FOLLOWING:

M1830 (Bathing) = 2 or more

OR

M1840 (Toilet transfer) = 2 or more

OR

M1850 (Transferring) = 2 or more

OR

M1860 (Ambulation) = 4 or more

3

7

5

10

19

Primary or Other Diagnosis = Ortho 1—Leg Disorders or Gait Disorders

AND

M1324 (most problematic pressure ulcer stage)= 1, 2, 3 or 4

7

1

7

20

Primary or Other Diagnosis = Ortho 1—Leg OR Ortho 2—Other orthopedic disorders

AND

M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

3

3

7

21

Primary or Other Diagnosis = Psych 1—Affective and other psychoses, depression

22

Primary or Other Diagnosis = Psych 2—Degenerative and other organic psychiatric disorders

23

Primary or Other Diagnosis = Pulmonary disorders

2

1

24

Primary or Other Diagnosis = Pulmonary disorders

AND

M1860 (Ambulation) = 1 or more

25

Primary Diagnosis = Skin 1-Traumatic wounds, burns, and post-operative complications

3

17

6

17

26

Other Diagnosis = Skin 1—Traumatic wounds, burns, post-operative complications

6

13

8

13

27

Primary or Other Diagnosis = Skin 1-Traumatic wounds, burns, and post-operative complications

OR

Skin 2—Ulcers and other skin conditions AND M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

2

28

Primary or Other Diagnosis = Skin 2—Ulcers and other skin conditions

2

16

8

17

29

Primary or Other Diagnosis = Tracheostomy

2

17

17

30

Primary or Other Diagnosis = Urostomy/Cystostomy

17

12

31

M1030 (Therapy at home) = 1 (IV/Infusion) or 2 (Parenteral)

15

5

15

32

M1030 (Therapy at home) = 3 (Enteral)

15

8

33

M1200 (Vision) = 1 or more

34

M1242 (Pain)= 3 or 4

3

2

35

M1311 = Two or more pressure ulcers at stage 3 or 4

4

6

4

6

36

M1324 (Most problematic pressure ulcer stage)= 1 or 2

4

19

7

16

37

M1324 (Most problematic pressure ulcer stage)= 3 or 4

8

31

10

25

38

M1334 (Stasis ulcer status)= 2

4

13

7

13

39

M1334 (Stasis ulcer status)= 3

7

17

9

17

40

M1342 (Surgical wound status)= 2

2

7

6

13

41

M1342 (Surgical wound status)= 3

6

5

10

42

M1400 (Dyspnea) = 2, 3, or 4

1

1

43

M1620 (Bowel Incontinence) = 2 to 5

3

2

44

M1630 (Ostomy)= 1 or 2

4

11

2

8

45

M2030 (Injectable Drug Use) = 0, 1, 2, or 3

FUNCTIONAL DIMENSION

46

M1810 or M1820 (Dressing upper or lower body) = 1, 2, or 3

1

47

M1830 (Bathing) = 2 or more

6

5

5

2

48

M1840 (Toilet transferring) = 2 or more

1

49

M1850 (Transferring) = 2 or more

3

1

2

50

M1860 (Ambulation) = 1, 2 or 3

7

4

51

M1860 (Ambulation) = 4 or more

8

9

6

7

Source:

CY 2016 Medicare claims data for episodes ending on or before December 31, 2016 (as of December 31, 2016) for which we had a linked OASIS assessment. LUPA episodes, outlier episodes, and episodes with PEP adjustments were excluded.

Note(s):

Points are additive; however, points may not be given for the same line item in the table more than once. Please see Medicare Home Health Diagnosis Coding guidance at

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/coding_billing.html

for definitions of primary and secondary diagnoses.

In updating the four-equation model for CY 2018, using 2016 home health claims data (the last update to the four-equation model for CY 2017 used CY 2015 home health claims data), there were few changes to the point values for the variables in the four-equation model. These relatively minor changes reflect the change in the relationship between the grouper variables and resource use between CY 2015 and CY 2016. The CY 2018 four-equation model resulted in 120 point-giving variables being used in the model (as compared to the 124 variables for the CY 2017 recalibration). There were 8 variables that were added to the model and 12 variables that were dropped from the model due to the absence of additional resources associated with the variable. Of the variables that were in both the four-equation model for CY 2017 and the four-equation model for CY 2018, the points for 14 variables increased in the CY 2018 four-equation model and the points for 48 variables decreased in the CY 2018 4-equation model. There were 50 variables with the same point values.

Step 2:

Re-defining the clinical and functional thresholds so they are reflective of the new points associated with the CY 2018 four-equation model. After estimating the points for each of the variables and summing the clinical and functional points for each episode, we look at the distribution of the clinical score and functional score, breaking the episodes into different steps. The categorizations for the steps are as follows:

• Step 1: First and second episodes, 0-13 therapy visits.

• Step 2.1: First and second episodes, 14-19 therapy visits.

• Step 2.2: Third episodes and beyond, 14-19 therapy visits.

• Step 3: Third episodes and beyond, 0-13 therapy visits.

• Step 4: Episodes with 20+ therapy visits.

We then divide the distribution of the clinical score for episodes within a step such that a third of episodes are classified as low clinical score, a third of episodes are classified as medium clinical score, and a third of episodes are classified as high clinical score. The same approach is then done looking at the functional score. It was not always possible to evenly divide the episodes within each step into thirds due to many episodes being clustered around one particular score.

13

Also, we looked at the average resource use associated with each clinical and functional score and used that as a guide for setting our thresholds. We grouped scores with similar average resource use within the same level (even if it meant that more or less than a third of episodes were placed within a level). The new thresholds, based off the CY 2018 four-equation model points are shown in Table 6.

13

For Step 1, 45.4% of episodes were in the medium functional level (All with score 14).

For Step 2.1, 87.3% of episodes were in the low functional level (Most with scores 5 to 7).

For Step 2.2, 81.9% of episodes were in the low functional level (Most with score 1).

For Step 3, 46.4% of episodes were in the medium functional level (Most with score 9).

For Step 4, 48.6% of episodes were in the medium functional level (Most with score 5 or 6).

Table 6—CY 2018 Clinical and Functional Thresholds

1st and 2nd episodes

0 to 13

therapy visits

14 to 19

therapy visits

3rd+ episodes

0 to 13

therapy visits

14 to 19

therapy visits

All Episodes

20+ therapy

visits

Grouping Step

1

2

3

4

5

Equations used to calculate points (see Table B1)

1

2

3

4

(2&4)

Dimension

Severity Level

Clinical

C1

0 to 1

0 to 1

0 to 1

0 to 1

0 to 3

C2

2 to 3

2 to 7

2

2 to 9

4 to 16

C3

4+

8+

3+

10+

17+

Functional

F1

0 to 13

0 to 7

0 to 6

0 to 2

0 to 2

F2

14

8 to 15

7 to 10

3 to 7

3 to 6

F3

15+

16+

11+

8+

7+

Step 3:

Once the clinical and functional thresholds are determined and each episode is assigned a clinical and functional level, the payment regression is estimated with an episode's wage-weighted minutes of care as the dependent variable. Independent variables in the model are indicators for the step of the episode as well as the clinical and functional levels within each step of the episode. Like the four-equation model, the payment regression model is also estimated with robust standard errors that are clustered at the beneficiary level. Table 7 shows the regression coefficients for the variables in the payment regression model updated with CY 2016 home health claims data. The R-squared value for the payment regression model is 0.5073 (an increase from 0.4919 for the CY 2017 recalibration).

Table 7—Payment Regression Model

Payment

regression

from 4-

equation

model for

CY2018

Step 1, Clinical Score Medium

$24.35

Step 1, Clinical Score High

54.10

Step 1, Functional Score Medium

71.10

Step 1, Functional Score High

104.74

Step 2.1, Clinical Score Medium

47.79

Step 2.1, Clinical Score High

133.50

Step 2.1, Functional Score Medium

30.46

Step 2.1, Functional Score High

55.93

Step 2.2, Clinical Score Medium

39.93

Step 2.2, Clinical Score High

192.15

Step 2.2, Functional Score Medium

17.99

Step 2.2, Functional Score High

53.34

Step 3, Clinical Score Medium

14.03

Step 3, Clinical Score High

92.83

Step 3, Functional Score Medium

56.27

Step 3, Functional Score High

86.76

Step 4, Clinical Score Medium

78.75

Step 4, Clinical Score High

260.68

Step 4, Functional Score Medium

25.95

Step 4, Functional Score High

58.66

Step 2.1, 1st and 2nd Episodes, 14 to 19 Therapy Visits

497.79

Step 2.2, 3rd+ Episodes, 14 to 19 Therapy Visits

508.40

Step 3, 3rd+ Episodes, 0-13 Therapy Visits

-67.30

Step 4, All Episodes, 20+ Therapy Visits

883.46

Intercept

382.25

Source: CY 2016 Medicare claims data for episodes ending on or before December 31, 2016 (as of March 17, 2017) for which we had a linked OASIS assessment.

Step 4:

We use the coefficients from the payment regression model to predict each episode's wage-weighted minutes of care (resource use). We then divide these predicted values by the mean of the dependent variable (that is, the average wage-weighted minutes of care across all episodes used in the payment regression). This division constructs the weight for each episode, which is simply the ratio of the episode's predicted wage-weighted minutes of care divided by the average wage-weighted minutes of care in the sample. Each episode is then aggregated into one of the 153 home health resource groups (HHRGs) and the “raw” weight for each HHRG was calculated as the average of the episode weights within the HHRG.

Step 5:

The raw weights associated with 0 to 5 therapy visits are then increased by 3.75 percent, the weights associated with 14-15 therapy visits are decreased by 2.5 percent, and the weights associated with 20+ therapy visits are decreased by 5 percent. These adjustments to the case-mix weights were finalized in the CY 2012 HH PPS final rule (76 FR 68557) and were done to address MedPAC's concerns that the HH PPS overvalues therapy episodes and undervalues non-therapy episodes and to better align the case-mix weights with episode costs estimated from cost report data.

14

14

Medicare Payment Advisory Commission (MedPAC),

Report to the Congress: Medicare Payment Policy.

March 2011, P. 176.

Step 6:

After the adjustments in Step 5 are applied to the raw weights, the weights are further adjusted to create an increase in the payment weights for the therapy visit steps between the therapy thresholds. Weights with the same clinical severity level, functional severity level, and early/later episode status were grouped together. Then within those groups, the weights for each therapy step between thresholds are gradually increased. We do this by interpolating between the main thresholds on the model (from 0-5 to 14-15 therapy visits, and from 14-15 to 20+ therapy visits). We use a linear model to implement the interpolation so the payment weight increase for each step between the thresholds (such as the increase between 0-5 therapy visits and 6 therapy visits and the increase between 6 therapy visits and 7-9 therapy visits) are constant. This interpolation is identical to the process finalized in the CY 2012 HH PPS final rule (76 FR 68555).

Step 7:

The interpolated weights are then adjusted so that the average case-

mix for the weights is equal to 1.0000.

15

This last step creates the proposed CY 2018 case-mix weights shown in Table 8.

15

When computing the average, we compute a weighted average, assigning a value of one to each normal episode and a value equal to the episode length divided by 60 for PEPs.

Table 8—Proposed CY 2018 Case-Mix Payment Weights

Pay group

Description

Clinical and

functional

levels

(1 = low;

2 = medium;

3 = high)

Proposed

CY 2018

weight

10111

1st and 2nd Episodes, 0 to 5 Therapy Visits

C1F1S1

0.5617

10112

1st and 2nd Episodes, 6 Therapy Visits

C1F1S2

0.6925

10113

1st and 2nd Episodes, 7 to 9 Therapy Visits

C1F1S3

0.8232

10114

1st and 2nd Episodes, 10 Therapy Visits

C1F1S4

0.9539

10115

1st and 2nd Episodes, 11 to 13 Therapy Visits

C1F1S5

1.0846

10121

1st and 2nd Episodes, 0 to 5 Therapy Visits

C1F2S1

0.6662

10122

1st and 2nd Episodes, 6 Therapy Visits

C1F2S2

0.7845

10123

1st and 2nd Episodes, 7 to 9 Therapy Visits

C1F2S3

0.9027

10124

1st and 2nd Episodes, 10 Therapy Visits

C1F2S4

1.0209

10125

1st and 2nd Episodes, 11 to 13 Therapy Visits

C1F2S5

1.1392

10131

1st and 2nd Episodes, 0 to 5 Therapy Visits

C1F3S1

0.7157

10132

1st and 2nd Episodes, 6 Therapy Visits

C1F3S2

0.8311

10133

1st and 2nd Episodes, 7 to 9 Therapy Visits

C1F3S3

0.9464

10134

1st and 2nd Episodes, 10 Therapy Visits

C1F3S4

1.0618

10135

1st and 2nd Episodes, 11 to 13 Therapy Visits

C1F3S5

1.1772

10211

1st and 2nd Episodes, 0 to 5 Therapy Visits

C2F1S1

0.5975

10212

1st and 2nd Episodes, 6 Therapy Visits

C2F1S2

0.7343

10213

1st and 2nd Episodes, 7 to 9 Therapy Visits

C2F1S3

0.8711

10214

1st and 2nd Episodes, 10 Therapy Visits

C2F1S4

1.0078

10215

1st and 2nd Episodes, 11 to 13 Therapy Visits

C2F1S5

1.1446

10221

1st and 2nd Episodes, 0 to 5 Therapy Visits

C2F2S1

0.7020

10222

1st and 2nd Episodes, 6 Therapy Visits

C2F2S2

0.8263

10223

1st and 2nd Episodes, 7 to 9 Therapy Visits

C2F2S3

0.9506

10224

1st and 2nd Episodes, 10 Therapy Visits

C2F2S4

1.0749

10225

1st and 2nd Episodes, 11 to 13 Therapy Visits

C2F2S5

1.1991

10231

1st and 2nd Episodes, 0 to 5 Therapy Visits

C2F3S1

0.7514

10232

1st and 2nd Episodes, 6 Therapy Visits

C2F3S2

0.8729

10233

1st and 2nd Episodes, 7 to 9 Therapy Visits

C2F3S3

0.9943

10234

1st and 2nd Episodes, 10 Therapy Visits

C2F3S4

1.1157

10235

1st and 2nd Episodes, 11 to 13 Therapy Visits

C2F3S5

1.2372

10311

1st and 2nd Episodes, 0 to 5 Therapy Visits

C3F1S1

0.6412

10312

1st and 2nd Episodes, 6 Therapy Visits

C3F1S2

0.7929

10313

1st and 2nd Episodes, 7 to 9 Therapy Visits

C3F1S3

0.9446

10314

1st and 2nd Episodes, 10 Therapy Visits

C3F1S4

1.0963

10315

1st and 2nd Episodes, 11 to 13 Therapy Visits

C3F1S5

1.2480

10321

1st and 2nd Episodes, 0 to 5 Therapy Visits

C3F2S1

0.7457

10322

1st and 2nd Episodes, 6 Therapy Visits

C3F2S2

0.8850

10323

1st and 2nd Episodes, 7 to 9 Therapy Visits

C3F2S3

1.0242

10324

1st and 2nd Episodes, 10 Therapy Visits

C3F2S4

1.1634

10325

1st and 2nd Episodes, 11 to 13 Therapy Visits

C3F2S5

1.3026

10331

1st and 2nd Episodes, 0 to 5 Therapy Visits

C3F3S1

0.7952

10332

1st and 2nd Episodes, 6 Therapy Visits

C3F3S2

0.9315

10333

1st and 2nd Episodes, 7 to 9 Therapy Visits

C3F3S3

1.0679

10334

1st and 2nd Episodes, 10 Therapy Visits

C3F3S4

1.2043

10335

1st and 2nd Episodes, 11 to 13 Therapy Visits

C3F3S5

1.3406

21111

1st and 2nd Episodes, 14 to 15 Therapy Visits

C1F1S1

1.2154

21112

1st and 2nd Episodes, 16 to 17 Therapy Visits

C1F1S2

1.3780

21113

1st and 2nd Episodes, 18 to 19 Therapy Visits

C1F1S3

1.5406

21121

1st and 2nd Episodes, 14 to 15 Therapy Visits

C1F2S1

1.2574

21122

1st and 2nd Episodes, 16 to 17 Therapy Visits

C1F2S2

1.4176

21123

1st and 2nd Episodes, 18 to 19 Therapy Visits

C1F2S3

1.5779

21131

1st and 2nd Episodes, 14 to 15 Therapy Visits

C1F3S1

1.2926

21132

1st and 2nd Episodes, 16 to 17 Therapy Visits

C1F3S2

1.4558

21133

1st and 2nd Episodes, 18 to 19 Therapy Visits

C1F3S3

1.6189

21211

1st and 2nd Episodes, 14 to 15 Therapy Visits

C2F1S1

1.2814

21212

1st and 2nd Episodes, 16 to 17 Therapy Visits

C2F1S2

1.4573

21213

1st and 2nd Episodes, 18 to 19 Therapy Visits

C2F1S3

1.6332

21221

1st and 2nd Episodes, 14 to 15 Therapy Visits

C2F2S1

1.3234

21222

1st and 2nd Episodes, 16 to 17 Therapy Visits

C2F2S2

1.4970

21223

1st and 2nd Episodes, 18 to 19 Therapy Visits

C2F2S3

1.6705

21231

1st and 2nd Episodes, 14 to 15 Therapy Visits

C2F3S1

1.3586

21232

1st and 2nd Episodes, 16 to 17 Therapy Visits

C2F3S2

1.5351

21233

1st and 2nd Episodes, 18 to 19 Therapy Visits

C2F3S3

1.7116

21311

1st and 2nd Episodes, 14 to 15 Therapy Visits

C3F1S1

1.3997

21312

1st and 2nd Episodes, 16 to 17 Therapy Visits

C3F1S2

1.6178

21313

1st and 2nd Episodes, 18 to 19 Therapy Visits

C3F1S3

1.8359

21321

1st and 2nd Episodes, 14 to 15 Therapy Visits

C3F2S1

1.4418

21322

1st and 2nd Episodes, 16 to 17 Therapy Visits

C3F2S2

1.6575

21323

1st and 2nd Episodes, 18 to 19 Therapy Visits

C3F2S3

1.8732

21331

1st and 2nd Episodes, 14 to 15 Therapy Visits

C3F3S1

1.4770

21332

1st and 2nd Episodes, 16 to 17 Therapy Visits

C3F3S2

1.6956

21333

1st and 2nd Episodes, 18 to 19 Therapy Visits

C3F3S3

1.9142

22111

3rd+ Episodes, 14 to 15 Therapy Visits

C1F1S1

1.2300

22112

3rd+ Episodes, 16 to 17 Therapy Visits

C1F1S2

1.3877

22113

3rd+ Episodes, 18 to 19 Therapy Visits

C1F1S3

1.5455

22121

3rd+ Episodes, 14 to 15 Therapy Visits

C1F2S1

1.2549

22122

3rd+ Episodes, 16 to 17 Therapy Visits

C1F2S2

1.4159

22123

3rd+ Episodes, 18 to 19 Therapy Visits

C1F2S3

1.5770

22131

3rd+ Episodes, 14 to 15 Therapy Visits

C1F3S1

1.3037

22132

3rd+ Episodes, 16 to 17 Therapy Visits

C1F3S2

1.4632

22133

3rd+ Episodes, 18 to 19 Therapy Visits

C1F3S3

1.6226

22211

3rd+ Episodes, 14 to 15 Therapy Visits

C2F1S1

1.2852

22212

3rd+ Episodes, 16 to 17 Therapy Visits

C2F1S2

1.4598

22213

3rd+ Episodes, 18 to 19 Therapy Visits

C2F1S3

1.6345

22221

3rd+ Episodes, 14 to 15 Therapy Visits

C2F2S1

1.3100

22222

3rd+ Episodes, 16 to 17 Therapy Visits

C2F2S2

1.4880

22223

3rd+ Episodes, 18 to 19 Therapy Visits

C2F2S3

1.6660

22231

3rd+ Episodes, 14 to 15 Therapy Visits

C2F3S1

1.3588

22232

3rd+ Episodes, 16 to 17 Therapy Visits

C2F3S2

1.5352

22233

3rd+ Episodes, 18 to 19 Therapy Visits

C2F3S3

1.7117

22311

3rd+ Episodes, 14 to 15 Therapy Visits

C3F1S1

1.4954

22312

3rd+ Episodes, 16 to 17 Therapy Visits

C3F1S2

1.6816

22313

3rd+ Episodes, 18 to 19 Therapy Visits

C3F1S3

1.8678

22321

3rd+ Episodes, 14 to 15 Therapy Visits

C3F2S1

1.5202

22322

3rd+ Episodes, 16 to 17 Therapy Visits

C3F2S2

1.7098

22323

3rd+ Episodes, 18 to 19 Therapy Visits

C3F2S3

1.8993

22331

3rd+ Episodes, 14 to 15 Therapy Visits

C3F3S1

1.5690

22332

3rd+ Episodes, 16 to 17 Therapy Visits

C3F3S2

1.7570

22333

3rd+ Episodes, 18 to 19 Therapy Visits

C3F3S3

1.9449

30111

3rd+ Episodes, 0 to 5 Therapy Visits

C1F1S1

0.4628

30112

3rd+ Episodes, 6 Therapy Visits

C1F1S2

0.6163

30113

3rd+ Episodes, 7 to 9 Therapy Visits

C1F1S3

0.7697

30114

3rd+ Episodes, 10 Therapy Visits

C1F1S4

0.9232

30115

3rd+ Episodes, 11 to 13 Therapy Visits

C1F1S5

1.0766

30121

3rd+ Episodes, 0 to 5 Therapy Visits

C1F2S1

0.5455

30122

3rd+ Episodes, 6 Therapy Visits

C1F2S2

0.6874

30123

3rd+ Episodes, 7 to 9 Therapy Visits

C1F2S3

0.8293

30124

3rd+ Episodes, 10 Therapy Visits

C1F2S4

0.9711

30125

3rd+ Episodes, 11 to 13 Therapy Visits

C1F2S5

1.1130

30131

3rd+ Episodes, 0 to 5 Therapy Visits

C1F3S1

0.5903

30132

3rd+ Episodes, 6 Therapy Visits

C1F3S2

0.7330

30133

3rd+ Episodes, 7 to 9 Therapy Visits

C1F3S3

0.8757

30134

3rd+ Episodes, 10 Therapy Visits

C1F3S4

1.0183

30135

3rd+ Episodes, 11 to 13 Therapy Visits

C1F3S5

1.1610

30211

3rd+ Episodes, 0 to 5 Therapy Visits

C2F1S1

0.4835

30212

3rd+ Episodes, 6 Therapy Visits

C2F1S2

0.6438

30213

3rd+ Episodes, 7 to 9 Therapy Visits

C2F1S3

0.8041

30214

3rd+ Episodes, 10 Therapy Visits

C2F1S4

0.9645

30215

3rd+ Episodes, 11 to 13 Therapy Visits

C2F1S5

1.1248

30221

3rd+ Episodes, 0 to 5 Therapy Visits

C2F2S1

0.5662

30222

3rd+ Episodes, 6 Therapy Visits

C2F2S2

0.7149

30223

3rd+ Episodes, 7 to 9 Therapy Visits

C2F2S3

0.8637

30224

3rd+ Episodes, 10 Therapy Visits

C2F2S4

1.0125

30225

3rd+ Episodes, 11 to 13 Therapy Visits

C2F2S5

1.1612

30231

3rd+ Episodes, 0 to 5 Therapy Visits

C2F3S1

0.6110

30232

3rd+ Episodes, 6 Therapy Visits

C2F3S2

0.7605

30233

3rd+ Episodes, 7 to 9 Therapy Visits

C2F3S3

0.9101

30234

3rd+ Episodes, 10 Therapy Visits

C2F3S4

1.0597

30235

3rd+ Episodes, 11 to 13 Therapy Visits

C2F3S5

1.2093

30311

3rd+ Episodes, 0 to 5 Therapy Visits

C3F1S1

0.5993

30312

3rd+ Episodes, 6 Therapy Visits

C3F1S2

0.7785

30313

3rd+ Episodes, 7 to 9 Therapy Visits

C3F1S3

0.9577

30314

3rd+ Episodes, 10 Therapy Visits

C3F1S4

1.1369

30315

3rd+ Episodes, 11 to 13 Therapy Visits

C3F1S5

1.3162

30321

3rd+ Episodes, 0 to 5 Therapy Visits

C3F2S1

0.6820

30322

3rd+ Episodes, 6 Therapy Visits

C3F2S2

0.8496

30323

3rd+ Episodes, 7 to 9 Therapy Visits

C3F2S3

1.0173

30324

3rd+ Episodes, 10 Therapy Visits

C3F2S4

1.1849

30325

3rd+ Episodes, 11 to 13 Therapy Visits

C3F2S5

1.3526

30331

3rd+ Episodes, 0 to 5 Therapy Visits

C3F3S1

0.7268

30332

3rd+ Episodes, 6 Therapy Visits

C3F3S2

0.8952

30333

3rd+ Episodes, 7 to 9 Therapy Visits

C3F3S3

1.0637

30334

3rd+ Episodes, 10 Therapy Visits

C3F3S4

1.2321

30335

3rd+ Episodes, 11 to 13 Therapy Visits

C3F3S5

1.4006

40111

All Episodes, 20+ Therapy Visits

C1F1S1

1.7032

40121

All Episodes, 20+ Therapy Visits

C1F2S1

1.7381

40131

All Episodes, 20+ Therapy Visits

C1F3S1

1.7821

40211

All Episodes, 20+ Therapy Visits

C2F1S1

1.8091

40221

All Episodes, 20+ Therapy Visits

C2F2S1

1.8440

40231

All Episodes, 20+ Therapy Visits

C2F3S1

1.8881

40311

All Episodes, 20+ Therapy Visits

C3F1S1

2.0539

40321

All Episodes, 20+ Therapy Visits

C3F2S1

2.0889

40331

All Episodes, 20+ Therapy Visits

C3F3S1

2.1329

To ensure the changes to the HH PPS case-mix weights are implemented in a budget neutral manner, we then apply a case-mix budget neutrality factor to the proposed CY 2018 national, standardized 60-day episode payment rate (see section III.C.3. of this proposed rule). The case-mix budget neutrality factor is calculated as the ratio of total payments when the CY 2018 HH PPS case-mix weights (developed using CY 2016 home health claims data) are applied to CY 2016 utilization (claims) data to total payments when CY 2017 HH PPS case-mix weights (developed using CY 2015 home health claims data) are applied to CY 2016 utilization data. This produces a case-mix budget neutrality factor for CY 2018 of 1.0159.

C. Proposed CY 2018 Home Health Payment Rate Update

1. Proposed CY 2018 Home Health Market Basket Update

Section 1895(b)(3)(B) of the Act requires that the standard prospective payment amounts for CY 2018 be increased by a factor equal to the applicable HH market basket update for those HHAs that submit quality data as required by the Secretary. The home health market basket was rebased and revised in CY 2013. A detailed description of how we derive the HHA market basket is available in the CY 2013 HH PPS final rule (77 FR 67080 through 67090).

Section 1895(b)(3)(B)(vi) of the Act, requires that, in CY 2015 (and in subsequent calendar years, except CY 2018 (under section 411(c) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10, enacted April 16, 2015)), the market basket percentage under the HHA prospective payment system as described in section 1895(b)(3)(B) of the Act be annually adjusted by changes in economy-wide productivity. Section 1886(b)(3)(B)(xi)(II) of the Act defines the productivity adjustment to be equal to the 10-year moving average of change in annual economy-wide private nonfarm business multifactor productivity (MFP) (as projected by the Secretary for the 10-year period ending with the applicable fiscal year, calendar year, cost reporting period, or other annual period) (the “MFP adjustment”). The Bureau of Labor Statistics (BLS) is the agency that publishes the official measure of private nonfarm business MFP. Please see

http://www.bls.gov/mfp

, to obtain the BLS historical published MFP data.

Prior to the enactment of the MACRA, which amended section 1895(b)(3)(B) of the Act, the proposed home health update percentage for CY 2018 would have been based on the estimated home health market basket update of 2.7 percent (based on IHS Global Insight Inc.'s first-quarter 2017 forecast with historical data through fourth-quarter 2016). Due to the requirements specified at section 1895(b)(3)(B)(vi) of the Act prior to the enactment of MACRA, the estimated CY 2018 home health market basket update of 2.7 percent would have been reduced by a MFP adjustment as mandated by the Affordable Care Act (currently estimated to be 0.5 percentage point for CY 2018). In effect, the proposed home health payment update percentage for CY 2018 would have been 2.2 percent. However, section 411(c) of the MACRA amended section 1895(b)(3)(B) of the Act, such that for home health payments for CY 2018, the market basket percentage increase is required to be 1 percent.

Section 1895(b)(3)(B) of the Act requires that the home health update be decreased by 2 percentage points for those HHAs that do not submit quality data as required by the Secretary. For HHAs that do not submit the required quality data for CY 2018, the home health payment update would be -1 percent (1 percent minus 2 percentage points).

2. Proposed CY 2018 Home Health Wage Index

Sections 1895(b)(4)(A)(ii) and (b)(4)(C) of the Act require the Secretary to provide appropriate adjustments to the proportion of the payment amount under the HH PPS that account for area wage differences, using adjustment

factors that reflect the relative level of wages and wage-related costs applicable to the furnishing of HH services. Since the inception of the HH PPS, we have used inpatient hospital wage data in developing a wage index to be applied to HH payments. We propose to continue this practice for CY 2018, as we continue to believe that, in the absence of HH-specific wage data, using inpatient hospital wage data is appropriate and reasonable for the HH PPS. Specifically, we propose to continue to use the pre-floor, pre-reclassified hospital wage index as the wage adjustment to the labor portion of the HH PPS rates. For CY 2018, the updated wage data are for hospital cost reporting periods beginning on or after October 1, 2013, and before October 1, 2014 (FY 2014 cost report data). We would apply the appropriate wage index value to the labor portion of the HH PPS rates based on the site of service for the beneficiary (defined by section 1861(m) of the Act as the beneficiary's place of residence).

To address those geographic areas in which there are no inpatient hospitals, and thus, no hospital wage data on which to base the calculation of the CY 2018 HH PPS wage index, we propose to continue to use the same methodology discussed in the CY 2007 HH PPS final rule (71 FR 65884) to address those geographic areas in which there are no inpatient hospitals. For rural areas that do not have inpatient hospitals, we would use the average wage index from all contiguous Core Based Statistical Areas (CBSAs) as a reasonable proxy. Currently, the only rural area without a hospital from which hospital wage data could be derived is Puerto Rico. However, for rural Puerto Rico, we would not apply this methodology due to the distinct economic circumstances that exist there (for example, due to the close proximity to one another of almost all of Puerto Rico's various urban and non-urban areas, this methodology would produce a wage index for rural Puerto Rico that is higher than that in half of its urban areas). Instead, we would continue to use the most recent wage index previously available for that area. For urban areas without inpatient hospitals, we would use the average wage index of all urban areas within the state as a reasonable proxy for the wage index for that CBSA. For CY 2018, the only urban area without inpatient hospital wage data is Hinesville, GA (CBSA 25980).

On February 28, 2013, OMB issued Bulletin No. 13-01, announcing revisions to the delineations of MSAs, Micropolitan Statistical Areas, and CBSAs, and guidance on uses of the delineation of these areas. In the CY 2015 HH PPS final rule (79 FR 66085 through 66087), we adopted the OMB's new area delineations using a 1-year transition. The most recent bulletin (No. 15-01) concerning the revised delineations was published by the OMB on July 15, 2015.

The proposed CY 2018 wage index is available on the CMS Web site at

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-and-Notices.html

.

3. Proposed CY 2018 Annual Payment Update

a. Background

The Medicare HH PPS has been in effect since October 1, 2000. As set forth in the July 3, 2000 final rule (65 FR 41128), the base unit of payment under the Medicare HH PPS is a national, standardized 60-day episode payment rate. As set forth in § 484.220, we adjust the national, standardized 60-day episode payment rate by a case-mix relative weight and a wage index value based on the site of service for the beneficiary.

To provide appropriate adjustments to the proportion of the payment amount under the HH PPS to account for area wage differences, we apply the appropriate wage index value to the labor portion of the HH PPS rates. The labor-related share of the case-mix adjusted 60-day episode rate would continue to be 78.535 percent and the non-labor-related share would continue to be 21.465 percent as set out in the CY 2013 HH PPS final rule (77 FR 67068). The CY 2018 HH PPS rates would use the same case-mix methodology as set forth in the CY 2008 HH PPS final rule with comment period (72 FR 49762) and would be adjusted as described in section III.B of this rule. The following are the steps we take to compute the case-mix and wage-adjusted 60-day episode rate:

(1) Multiply the national 60-day episode rate by the patient's applicable case-mix weight.

(2) Divide the case-mix adjusted amount into a labor (78.535 percent) and a non-labor portion (21.465 percent).

(3) Multiply the labor portion by the applicable wage index based on the site of service of the beneficiary.

(4) Add the wage-adjusted portion to the non-labor portion, yielding the case-mix and wage adjusted 60-day episode rate, subject to any additional applicable adjustments.

In accordance with section 1895(b)(3)(B) of the Act, this document proposes the annual update of the HH PPS rates. Section 484.225 sets forth the specific annual percentage update methodology. In accordance with § 484.225(i), for a HHA that does not submit HH quality data, as specified by the Secretary, the unadjusted national prospective 60-day episode rate is equal to the rate for the previous calendar year increased by the applicable HH market basket index amount minus 2 percentage points. Any reduction of the percentage change would apply only to the calendar year involved and would not be considered in computing the prospective payment amount for a subsequent calendar year.

Medicare pays the national, standardized 60-day case-mix and wage-adjusted episode payment on a split percentage payment approach. The split percentage payment approach includes an initial percentage payment and a final percentage payment as set forth in § 484.205(b)(1) and (b)(2). We may base the initial percentage payment on the submission of a request for anticipated payment (RAP) and the final percentage payment on the submission of the claim for the episode, as discussed in § 409.43. The claim for the episode that the HHA submits for the final percentage payment determines the total payment amount for the episode and whether we make an applicable adjustment to the 60-day case-mix and wage-adjusted episode payment. The end date of the 60-day episode as reported on the claim determines which calendar year rates Medicare would use to pay the claim.

We may also adjust the 60-day case-mix and wage-adjusted episode payment based on the information submitted on the claim to reflect the following:

• A low-utilization payment adjustment (LUPA) is provided on a per-visit basis as set forth in §§ 484.205(c) and 484.230.

• A partial episode payment (PEP) adjustment as set forth in §§ 484.205(d) and 484.235.

• An outlier payment as set forth in §§ 484.205(e) and 484.240.

b. Proposed CY 2018 National, Standardized 60-Day Episode Payment Rate

Section 1895(3)(A)(i) of the Act requires that the 60-day episode base rate and other applicable amounts be standardized in a manner that eliminates the effects of variations in relative case-mix and area wage adjustments among different home health agencies in a budget neutral manner. To determine the CY 2018 national, standardized 60-day episode payment rate, we would apply a wage

index budget neutrality factor; a case-mix budget neutrality factor described in section III.B. of this proposed rule; a reduction of 0.97 percent to account for nominal case-mix growth from 2012 to 2014, as finalized in the CY 2016 HH PPS final rule (80 FR 68646); and the home health payment update percentage discussed in section III.C.1 of this proposed rule.

To calculate the wage index budget neutrality factor, we simulated total payments for non-LUPA episodes using the proposed CY 2018 wage index and compared it to our simulation of total payments for non-LUPA episodes using the CY 2017 wage index. By dividing the total payments for non-LUPA episodes using the proposed CY 2018 wage index by the total payments for non-LUPA episodes using the CY 2017 wage index, we obtain a wage index budget neutrality factor of 1.0001. We would apply the wage index budget neutrality factor of 1.0001 to the calculation of the proposed CY 2018 national, standardized 60-day episode rate.

As discussed in section III.B. of this proposed rule, to ensure the changes to the case-mix weights are implemented in a budget neutral manner, we would apply a case-mix weight budget neutrality factor to the CY 2018 national, standardized 60-day episode payment rate. The case-mix weight budget neutrality factor is calculated as the ratio of total payments when CY 2018 case-mix weights are applied to CY 2016 utilization (claims) data to total payments when CY 2017 case-mix weights are applied to CY 2016 utilization data. The case-mix budget neutrality factor for CY 2018 would be 1.0159 as described in section III.B of this proposed rule.

Next, we would apply a reduction of 0.97 percent to the national, standardized 60-day payment rate for CY 2018 to account for nominal case-mix growth between CY 2012 and CY 2014. Lastly, we would update the proposed payment rates by the proposed CY 2018 home health payment update percentage of 1 percent as mandated by section 1895(b)(3)(B)(iii) of the Act. The proposed CY 2018 national, standardized 60-day episode payment rate is calculated in Table 9.

Table 9—Proposed CY 2018 60-day National, Standardized 60-day Episode Payment Amount

CY 2017 national, standardized 60-day

episode payment

Wage index budget

neutrality

factor

Case-mix

weights

budget

neutrality

factor

Nominal

case-mix

growth

adjustment

(1-0.0097)

Proposed

CY 2018 HH

payment

update

Proposed

CY 2018

national,

standardized

60-day

episode

payment

$2,989.97

× 1.0001

× 1.0159

× 0.9903

× 1.01

$3,038.43

The proposed CY 2018 national, standardized 60-day episode payment rate for an HHA that does not submit the required quality data is updated by the proposed CY 2018 home health payment update of 1 percent minus 2 percentage points and is shown in Table 10.

Table 10—Proposed CY 2018 National, Standardized 60-day Episode Payment Amount for HHAs That DO NOT Submit the Quality Data

CY 2017 national, standardized 60-day

episode payment

Wage index

budget

neutrality

factor

Case-mix

weights

budget

neutrality

factor

Nominal

case-mix growth

adjustment

(1-0.0097)

Proposed

CY 2018 HH

payment

update minus

2 percentage

points

Proposed

CY 2018

national,

standardized

60-day episode payment

$2,989.97

× 1.0001

× 1.0159

× 0.9903

× 0.99

$2,978.26

c. Proposed CY 2018 National Per-Visit Rates

The national per-visit rates are used to pay LUPAs (episodes with four or fewer visits) and are also used to compute imputed costs in outlier calculations. The per-visit rates are paid by type of visit or HH discipline. The six HH disciplines are as follows:

• Home health aide (HH aide);

• Medical Social Services (MSS);

• Occupational therapy (OT);

• Physical therapy (PT);

• Skilled nursing (SN); and

• Speech-language pathology (SLP).

To calculate the proposed CY 2018 national per-visit rates, we start with the CY 2017 national per-visit rates. We then apply a wage index budget neutrality factor to ensure budget neutrality for LUPA per-visit payments. We calculate the wage index budget neutrality factor by simulating total payments for LUPA episodes using the proposed CY 2018 wage index and comparing it to simulated total payments for LUPA episodes using the CY 2017 wage index. By dividing the total payments for LUPA episodes using the proposed CY 2018 wage index by the total payments for LUPA episodes using the CY 2017 wage index, we obtain a wage index budget neutrality factor of 1.0005. We would apply the wage index budget neutrality factor of 1.0005 in order to calculate the CY 2018 national per-visit rates.

The LUPA per-visit rates are not calculated using case-mix weights. Therefore, there is no case-mix weights budget neutrality factor needed to ensure budget neutrality for LUPA payments. Lastly, the per-visit rates for each discipline are updated by the proposed CY 2018 home health payment update percentage of 1 percent. The national per-visit rates are adjusted by the wage index based on the site of service of the beneficiary. The per-visit payments for LUPAs are separate from the LUPA add-on payment amount, which is paid for episodes that occur as the only episode or initial episode in a sequence of adjacent episodes. The proposed CY 2018 national per-visit rates are shown in Tables 11 and 12.

Table 11—Proposed CY 2018 National Per-Visit Payment Amounts for HHAs That DO Submit the Required Quality Data

HH discipline type

CY 2017

per-visit

payment

Wage index

budget

neutrality

factor

Proposed

CY 2018

HH payment update

Proposed

CY 2018

per-visit

payment

Home Health Aide

$64.23

× 1.0005

× 1.01

$64.90

Medical Social Services

227.36

× 1.0005

× 1.01

229.75

Occupational Therapy

156.11

× 1.0005

× 1.01

157.75

Physical Therapy

155.05

× 1.0005

× 1.01

156.68

Skilled Nursing

141.84

× 1.0005

× 1.01

143.33

Speech- Language Pathology

168.52

× 1.0005

× 1.01

170.29

The proposed CY 2018 per-visit payment rates for HHAs that do not submit the required quality data are updated by the proposed CY 2018 HH payment update percentage of 1 percent minus 2 percentage points and are shown in Table 12.

Table 12—Proposed CY 2018 National Per-Visit Payment Amounts for HHAs That DO NOT Submit the Required Quality Data

HH discipline type

CY 2017

per-visit

rates

Wage index budget

neutrality

factor

Proposed CY 2018 HH

payment update minus 2

percentage

points

Proposed CY 2018 per-visit rates

Home Health Aide

$64.23

× 1.0005

× 0.99

$63.62

Medical Social Services

227.36

× 1.0005

× 0.99

225.20

Occupational Therapy

156.11

× 1.0005

× 0.99

154.63

Physical Therapy

155.05

× 1.0005

× 0.99

153.58

Skilled Nursing

141.84

× 1.0005

× 0.99

140.49

Speech- Language Pathology

168.52

× 1.0005

× 0.99

166.92

d. Low-Utilization Payment Adjustment (LUPA) Add-On Factors

LUPA episodes that occur as the only episode or as an initial episode in a sequence of adjacent episodes are adjusted by applying an additional amount to the LUPA payment before adjusting for area wage differences. In the CY 2014 HH PPS final rule, we changed the methodology for calculating the LUPA add-on amount by finalizing the use of three LUPA add-on factors: 1.8451 for SN; 1.6700 for PT; and 1.6266 for SLP (78 FR 72306). We multiply the per-visit payment amount for the first SN, PT, or SLP visit in LUPA episodes that occur as the only episode or an initial episode in a sequence of adjacent episodes by the appropriate factor to determine the LUPA add-on payment amount. For example, in the case of HHAs that do submit the required quality data, for LUPA episodes that occur as the only episode or an initial episode in a sequence of adjacent episodes, if the first skilled visit is SN, the payment for that visit would be $264.46 (1.8451 multiplied by $143.33), subject to area wage adjustment.

e. Proposed CY 2018 Non-Routine Medical Supply (NRS) Payment Rates

Payments for NRS are computed by multiplying the relative weight for a particular severity level by the NRS conversion factor. To determine the proposed CY 2018 NRS conversion factor, we update the CY 2017 NRS conversion factor ($52.50) by the proposed CY 2018 home health payment update percentage of 1 percent. We do not apply a standardization factor as the NRS payment amount calculated from the conversion factor is not wage or case-mix adjusted when the final claim payment amount is computed. The proposed NRS conversion factor for CY 2018 is shown in Table 13.

Table 13—Proposed CY 2018 NRS Conversion Factor for HHAs That DO Submit the Required Quality Data

CY 2017 NRS

conversion

factor

Proposed CY 2018 HH

payment

update

Proposed CY 2018 NRS conversion factor

$52.50

× 1.01

$53.03

Using the CY 2018 NRS conversion factor, the payment amounts for the six severity levels are shown in Table 14.

Table 14—Proposed CY 2018 NRS Payment Amounts for HHAs That DO Submit the Required Quality Data

Severity level

Points

(scoring)

Relative weight

Proposed

CY 2017

NRS payment amounts

1

0

0.2698

$ 14.31

2

1 to 14

0.9742

51.66

3

15 to 27

2.6712

141.65

4

28 to 48

3.9686

210.45

5

49 to 98

6.1198

324.53

6

99+

10.5254

558.16

For HHAs that do not submit the required quality data, we update the CY 2017 NRS conversion factor ($52.50) by the proposed CY 2018 home health payment update percentage of 1 percent minus 2 percentage points. The proposed CY 2018 NRS conversion factor for HHAs that do not submit quality data is shown in Table 15.

Table 15—Proposed CY 2018 NRS Conversion Factor for HHAs That DO NOT Submit the Required Quality Data

CY 2017 NRS

conversion

factor

Proposed CY 2018

HH payment update

percentage

minus 2 percentage points

Proposed CY 2018 NRS conversion factor

$52.50

× 0.99

$51.98

The payment amounts for the various severity levels based on the updated conversion factor for HHAs that do not submit quality data are calculated in Table 16.

Table 16—Proposed CY 2018 NRS Payment Amounts for HHAs That DO NOT Submit the Required Quality Data

Severity level

Points

(scoring)

Relative weight

Proposed

CY 2018

NRS payment amounts

1

0

0.2698

$ 14.02

2

1 to 14

0.9742

50.64

3

15 to 27

2.6712

138.85

4

28 to 48

3.9686

206.29

5

49 to 98

6.1198

318.11

6

99+

10.5254

547.11

f. Rural Add-On

Section 421(a) of the MMA required, for HH services furnished in a rural areas (as defined in section 1886(d)(2)(D) of the Act), for episodes or visits ending on or after April 1, 2004, and before April 1, 2005, that the Secretary increase the payment amount that otherwise would have been made under section 1895 of the Act for the services by 5 percent.

Section 5201 of the DRA amended section 421(a) of the MMA. The amended section 421(a) of the MMA required, for HH services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act), on or after January 1, 2006, and before January 1, 2007, that the Secretary increase the payment amount otherwise made under section 1895 of the Act for those services by 5 percent.

Section 3131(c) of the Affordable Care Act amended section 421(a) of the MMA to provide an increase of 3 percent of the payment amount otherwise made under section 1895 of the Act for HH services furnished in a rural area (as defined in section 1886(d)(2)(D) of the Act), for episodes and visits ending on or after April 1, 2010, and before January 1, 2016.

Section 210 of the MACRA amended section 421(a) of the MMA to extend the rural add-on by providing an increase of 3 percent of the payment amount otherwise made under section 1895 of the Act for HH services provided in a rural area (as defined in section 1886(d)(2)(D) of the Act), for episodes and visits ending before January 1, 2018. Therefore, for episodes and visits that end on or after January 1, 2018, a rural add-on payment will not apply.

D. Payments for High-Cost Outliers Under the HH PPS

1. Background

Section 1895(b)(5) of the Act allows for the provision of an addition or adjustment to the home health payment amount in the case of outliers because of unusual variations in the type or amount of medically necessary care. Prior to the enactment of the Affordable Care Act, section 1895(b)(5) 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 3, 2000 Medicare Program; Prospective Payment System for Home Health Agencies 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 was established as the sum of the national wage-adjusted per-visit payment amounts 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 FDL amount. The proportion of additional costs over the outlier threshold amount paid as outlier payments is referred to as the loss-sharing ratio.

In the CY 2010 HH PPS proposed rule (74 FR 40948, 40957), we stated that outlier payments increased as a percentage of total payments from 4.1 percent in CY 2005, to 5.0 percent in CY 2006, to 6.4 percent in CY 2007 and that this excessive growth in outlier payments was primarily the result of unusually high outlier payments in a few areas of the country. In that discussion, we noted that 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 in CY 2007 and, in the absence of corrective measures, would continue do to so. Consequently, we assessed the appropriateness of taking action to curb outlier abuse. As described in the CY 2010 HH PPS final rule (74 FR 58080 through 58087), to mitigate possible billing vulnerabilities associated with excessive outlier payments and adhere to our statutory limit on outlier payments, we finalized 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 home health expenditures). For CY 2010, we first returned the 5 percent held for the previous target 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. 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.

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, and required the Secretary to reduce the HH PPS payment rates such that aggregate HH PPS payments were reduced by 5 percent. In addition, section 3131(b)(2) of the Affordable Care Act amended section 1895(b)(5) of the Act by redesignating the existing language as section 1895(b)(5)(A) of the Act, and revising the language to state that the total amount of the additional payments or payment adjustments for outlier episodes may not exceed 2.5 percent of the estimated total HH PPS payments for that year. Section 3131(b)(2)(C) of the Affordable Care Act also added section 1895(b)(5)(B) of the Act which capped outlier payments as a percent of total payments for each HHA at 10 percent.

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.

In the CY 2017 HH PPS proposed and final rules (81 FR 43737 through 43742 and 81 FR 76702), we described our concerns regarding patterns observed in home health outlier episodes. Specifically, we noted that the methodology for calculating home health outlier payments may have created a financial incentive for providers to increase the number of visits during an episode of care to surpass the outlier threshold and simultaneously created a disincentive for providers to treat medically complex beneficiaries who require fewer but longer visits. Given these concerns, in the CY 2017 HH PPS final rule (81 FR 76702), we finalized changes to the methodology used to calculate outlier payments, using a cost-per-unit approach rather than a cost-per-visit approach. This change in methodology allows for more accurate payment for outlier episodes, accounting for both the number of visits during an episode of care and also the length of the visits provided. Using this approach, we now convert the national per-visit rates into per 15-minute unit rates. These per 15-minute unit rates are used to calculate the estimated cost of an episode to determine whether the claim will receive an outlier payment and the amount of payment for an episode of care. In conjunction with our finalized policy to change to a cost-per-unit approach to estimate episode costs and determine whether an outlier episode should receive outlier payments, in the CY 2017 HH PPS final rule we also finalized the implementation of a cap on the amount of time per day that would be counted toward the estimation of an episode's costs for outlier calculation purposes (81 FR 76725). Specifically, we limit the amount of time per day (summed across the six disciplines of care) to 8 hours (32 units) per day when estimating the cost of an episode for outlier calculation purposes.

2. 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 qualifying 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). Historically, we have used a value of 0.80 for the loss-sharing ratio which, we believe, 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.

Simulations based on CY 2015 claims data (as of June 30, 2016) completed for the CY 2017 HH PPS final rule showed that outlier payments were estimated to represent approximately 2.84 percent of total HH PPS payments in CY 2017, and as such, we raised the FDL ratio from 0.45 to 0.55. We stated that raising the FDL ratio to 0.55, while maintaining a loss-sharing ratio of 0.80, struck an effective balance of compensating for high-cost episodes while still meeting the statutory requirement to target up to, but no more than, 2.5 percent of total payments as outlier payments (81 FR 76726). 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 amount, 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 would pay 80 percent of the additional estimated costs.

For this proposed rule, using preliminary CY 2016 claims data (as of March 17, 2017) and the proposed CY 2018 payment rates presented in section III.C of this proposed rule, we estimate that outlier payments would constitute

approximately 2.47 percent of total HH PPS payments in CY 2018 under the current outlier methodology. Given the statutory requirement to target up to, but no more than, 2.5 percent of total payments as outlier payments, we are not proposing a change to the FDL ratio for CY 2018 as we believe that maintaining an FDL ratio of 0.55 with a loss-sharing ratio of 0.80 is still appropriate given the percentage of outlier payments projected for CY 2018. Likewise, we are not proposing a change to the loss-sharing ratio (0.80) for the HH PPS to remain consistent with payment for high-cost outliers in other Medicare payment systems (for example, IRF PPS, IPPS, etc.). While we are not proposing to change the FDL ratio of 0.55 for CY 2018, we note that in the final rule, we will update our estimate of outlier payments as a percent of total HH PPS payments using the most current and complete year of HH PPS data (CY 2016 claims data as of June 30, 2017 or later). This may result in changes to the FDL ratio in the final rule.

E. Proposed Implementation of the Home Health Groupings Model (HHGM) for CY 2019

1. Overview, Data, and File Construction

Under the home health prospective payment system (HH PPS), Medicare pays for home health services provided during a 60-day episode of care. Episodes are case-mix adjusted based on the timing of the episode within a sequence of episodes, the patient's clinical status and functional status as determined using information from the Outcome and Assessment Information Set (OASIS), and the amount of therapy service provided during the episode. Therapy service use is measured by the number of therapy visits provided during the episode and can be categorized into nine visit level categories (or thresholds): 0-5; 6; 7-9; 10; 11-13; 14-15; 16-17; 18-19; and 20 or more visits. The combinations of episode timing, clinical and functional levels, and therapy service use categories result in 153 home health resource groups (HHRGs) into which home health episodes are categorized. Each HHRG is assigned a relative weight reflecting the average resource use of patients in that group compared with average resource use across all Medicare home health patients; this weight is then used to case mix adjust the episode's payment (with an additional adjustment for geographic variation in wages). Additional payment adjustments are made for very resource intensive (outlier) episodes, episodes with very few visits, transfers to other HHAs or to hospitals with a return to home health during the episode, and the expected use of non-routine medical supplies (NRS).

As discussed in section II.D of this proposed rule, the Report to Congress, required by section 3131(d) of the Affordable Care Act, found that payment accuracy could be improved under the current payment system, particularly for patients with certain clinical characteristics.

16

Findings from the report suggest that the current home health payment system may discourage HHAs from serving patients with clinically complex and/or poorly controlled chronic conditions who do not need therapy services, but require skilled nursing care. In addition, MedPAC believes that the Medicare home health benefit is ill-defined and the current reliance on therapy service thresholds for determining payment is counter to the goals of a prospective payment system. Under the current payment system, HHAs receive higher payments for providing more therapy visits, which may incentivize unnecessary utilization. MedPAC reitereated their recommendation in the March 2017 Report to Congress that CMS eliminate the use of the number of therapy vists as a payment factor in the home health PPS beginning in 2019.

17

16

Report to Congress. Medicare Home Health Study: An Investigation on Access to Care and Payment for Vulnerable Patient Populations.

Available at

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/HH-Report-to-Congress.pdf

.

17

Medicare Payment Advisory Commission (MedPAC). “Home Health Care Services.”

Report to Congress: Medicare Payment Policy.

Washington, DC, March 2015. P. 233. Accessed on March 28, 2017 at

http://www.medpac.gov/docs/default-source/reports/mar2015_entirereport_revised.pdf?sfvrsn=0

.

To better align payment with patient care needs and better ensure that clinically complex and ill beneficiaries have adequate access to home health care, we are proposing for CY 2019 case-mix methodology refinements through the implementation of the Home Health Groupings Model (HHGM). We propose to implement the HHGM for home health periods of care beginning on or after January 1, 2019. The implementation of the HHGM will require provider education and training, updating and revising relevant manuals, and changing claims processing systems. Implementation starting in CY 2019 would provide an opportunity for CMS, its contractors, and the agencies themselves to prepare. This patient-centered model groups periods of care in a manner consistent with how clinicians differentiate between patients and the primary reason for needing home health care. The HHGM uses 30-day periods rather than the 60-day episode used in the current payment system, eliminates the use of the number of therapy visits provided to determine payment, and relies more heavily on clinical characteristics and other patient information (for example, diagnosis, functional level, comorbid conditions, admission source) to place patients into clinically meaningful payment categories. In total, there are 144 different payment groups in the HHGM.

Costs during an episode/period of care are estimated based on the concept of resource use, which measures the costs associated with visits performed during a home health episode/period. For the current HH PPS case-mix weights, we use Wage Weighted Minutes of Care (WWMC), which uses data from the Bureau of Labor Statistics (BLS) reflecting the Home Health Care Service Industry. For the HHGM, we propose shifting to a Cost-Per-Minute plus Non-Routine Supplies (CPM + NRS) approach, which uses information from the Medicare Cost Report. The CPM + NRS approach incorporates a wider variety of costs (such as transportation) compared to the BLS estimates and the costs are available for individual HHA providers while the BLS costs are aggregated for the Home Health Care Service industry. The proposed methodology used to calculate the cost of an episode/period of care is discussed in detail in section III.E.2. of this proposed rule.

We propose using the 30-day periods rather than the 60-day episodes in the current payment system. Episodes have more visits, on average, during the first 30 days compared to the last 30 days.

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Costs are much higher earlier in the episode and lesser later on, therefore we believe that dividing a single 60-day episode into two 30-day periods more accurately apportions payments. Overall, we found that the average length of an episode of care was 47 days, but roughly a quarter of all 60 days episodes lasted 30 days or less. The proposed change from 60-day billing to 30-day billing under the HHGM is discussed in detail in section III.E.3. of this proposed rule.

18

Abt Associates. “Overview of the Home Health Groupings Model.”

Medicare Home Health Prospective Payment System: Case-Mix Methodology Refinements.

Cambridge, MA, November 18, 2016. Available at

https://downloads.cms.gov/files/hhgm%20technical%20report%20120516%20sxf.pdf

.

Similar to the current payment system, 30-day periods under the HHGM would be classified as “early” or “late” depending on when they occur within a sequence of 30-day periods. Under the current HH PPS, the first two 60-day episodes of a sequence of adjacent 60-day episodes are considered early, while the third 60-day episode of that sequence and any subsequent episodes are considered late. Under the HHGM, the first 30-day period is classified as early. All subsequent 30-day periods in the sequence (second or later) are classified as late. We propose to adopt this episode timing classification for 30-day periods with the implementation of the HHGM. Similar to the current payment system, we propose that a 30-day period could not be considered early unless there was a gap of more than 60 days between the end of one period and the start of another. The comprehensive assessment would still be completed within 5 days of the start of care date and completed no less frequently than during the last 5 days of every 60 days beginning with the start of care date, as currently required by § 484.55, Condition of participation: Comprehensive assessment of patients. The proposed episode timing classification is discussed in detail in section III.E.4. of this proposed rule.

Under the HHGM, each period would be classified into one of two admission source categories—community or institutional—depending on what healthcare setting was utilized in the 14 days prior to home health. The 30-day period would be categorized as institutional if an acute or post-acute care stay occurred in the prior 14 days to the start of the 30-day period of care. The 30-day period would be categorized as community if there was no acute or post-acute care stay in the 14 days prior to the start of the 30-day period of care. We propose to adopt this categorization by admission source with the implementation of the HHGM. The proposed admission classification source is discussed in detail in section III.E.5. of this proposed rule.

The HHGM would group 30-day periods into categories based on a variety of patient characteristics. Within the HHGM, one of the steps in case-mix adjusting the 30-day payment amount would include grouping periods into one of six clinical groups based on the principal diagnosis listed on the home health claim. We propose grouping periods into one of six clinical groups based on the principal diagnosis with the implementation of the HHGM. The principal diagnosis reported would provide information to describe the primary reason for which patients are receiving home health services under the Medicare home health benefit. The proposed six clinical groups, which are discussed in detail in section III.E.6. of this proposed rule, are as follows:

• Musculoskeletal Rehabilitation.

• Neuro/Stroke Rehabilitation.

• Wounds—Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care.

• Complex Nursing Interventions.

• Behavioral Health Care.

• Medication Management, Teaching and Assessment (MMTA).

Under the HHGM, each 30-day period would be placed into one of three functional levels. The level would indicate if, on average, given its responses on certain functional OASIS items, a 30-day period is predicted to have higher costs or lower costs. We propose classifying 30-day periods according to functional level. For each of the six clinical groups, we propose that periods would be further classified into one of three functional levels with roughly 33 percent of periods in each level. The creation of this functional level is very similar to how the functional level is created in the current payment system. The proposed functional levels and corresponding OASIS items are discussed in detail in section III.E.7. of this proposed rule.

Exploratory analyses determined that comorbidities—that is, secondary diagnoses—provide additional information that can further explain resource use differences across 30-day periods of care even after controlling for the primary diagnosis. Comorbidities are tied to poorer health outcomes, more complex medical need and management, and higher costs. The HHGM would include a comorbidity adjustment category based on the presence of secondary diagnoses. We propose that 30-day periods would receive a comorbidity adjustment if any diagnosis codes listed on the home health claim are included on a list of comorbidities that occurred in at least 0.1 percent of 30-day periods and associated with increased average resource use. The proposed comorbidity adjustment is discussed in detail in section III.E.8. of this proposed rule.

Currently, if an HHA provides four visits or less in an episode, they will be paid a standardized per visit payment instead of an episode payment for a 60-day episode of care. These payment adjustments are called Low-Utilization Payment Adjustments (LUPAs). While the HHGM would still include LUPAs, the approach to calculating the LUPA thresholds would need to change in the HHGM because of the switch to 30-day periods from 60-day episodes. Whereas there is a single LUPA threshold of 4 visits for all episodes under the current payment system, we propose the LUPA threshold would vary for a 30-day period under the HHGM depending on the HHGM payment group to which it was assigned. To create LUPA thresholds, 30-day periods (including those that were LUPAs in the current payment system) were grouped into the 144 different HHGM payment groups. For each payment group, we propose to use the 10th percentile value of visits to create a payment group specific LUPA threshold with a minimum threshold of at least 2 for each group. The proposed LUPA thresholds are discussed in more detail in section III.E.9. of this proposed rule.

Figure 5 represents how each 30-day period of care would be placed into one of 144 home health resource groups (HHRGs) under the proposed HHGM.

EP28JY17.003

While the proposed HHGM would reflect a change in the case-mix adjustment methodology, the conditions for payment would remain the same for Medicare home health services, meaning all requirements would still

need to be met in accordance with § 424.22. This includes physician certification that: (1) The individual is in need or needed intermittent skilled nursing care, or physical therapy or speech-language pathology services, and is confined to the home; (2) a plan of care has been established and will be periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine; (3) the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine; and, (4) a face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner. Likewise, under the HHGM, the Medicare beneficiary would retain all rights that currently exist under the current HH PPS, including those related to beneficiary liability for services or any reduction or termination of services. These would include the issuance of the Advanced Beneficiary Notice (ABN) and the Home Health Change of Care Notice (HHCCN), when appropriate. Medicare home health agencies are required to issue an ABN when a HHA believes Medicare will not pay for some or all of the patient's Medicare home health care. In these circumstances, if the beneficiary chooses to receive the items/services in question and Medicare does not cover the home health care, HHAs may use the ABN to shift liability for the non-covered home health care to the beneficiary. The HHCCN is a written notice that the HHA provides a beneficiary when his/her home health plan of care is changing because the home health agency makes a business decision to reduce or stop providing the patient some or all of the home health services or supplies OR the beneficiary's physician changed orders which may reduce or stop certain Medicare covered home health services or supplies.

To create the HHGM proposed model and related analyses, a data file based on home health episodes of care as reported in Medicare home health claims was utilized. The claims data provide episode-level data (for example, episode From and Through Dates, total number of visits, HHRG, diagnoses), as well as visit-level data (visit date, visit length in 15-minute units, discipline of the staff, etc.). The claims also provide data on whether NRS was provided during the episode and total charges for NRS.

The core file for most of the analyses for this proposed rule includes 100 percent of home health episode claims with Through Dates in Calendar Year (CY) 2016, processed by March 17, 2017, accessed via the Chronic Conditions Data Warehouse (CCW). Original or adjustment claims processed after March 17, 2017, would not be reflected in the core file. The claims-based file was supplemented with additional variables that were obtained from the CCW, such as information regarding other Part A and Part B utilization.

The data were cleaned by processing any remaining adjustments and by excluding duplicates and claims that were Requests for Anticipated Payment (RAP). In addition, visit-level variables needed for the analysis were extracted from the revenue center trailers (that is, the line items that describe the visits) and downloaded as a separate visit-level file, with selected episode-level variables merged onto the records for visits during those episodes. To account for potential data entry errors, the visit-level variables for visit length were top-censored at eight hours.

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Less than 0.1 percent of all visits were recorded as having greater than 8 hours of service.

A set of data cleaning exclusions were applied to the episode-level file, which resulted in the exclusion of the following:

• Episodes with no covered visits.

• Episodes with any missing units or visit data.

• Episodes with zero payments.

• Episodes with no charges.

• Non-LUPA episodes missing an HHRG.

The analysis file also includes data on patient characteristics obtained from the OASIS assessments conducted by HHA staff at the start of each episode. The assessment data are electronically submitted by home health agencies (HHAs) to a central CMS repository. In constructing the core data file, 100 percent of the OASIS assessments submitted October 2015, through December 2016 from the CMS repository were uploaded by CMS to the CCW. A CCW-derived linking key (Bene_ID) was used to match the OASIS data with CY 2016 episodes of care. Episodes that could not be linked with an OASIS assessment were excluded from the analysis file, as they included insufficient patient-level data to create the HHGM.

To construct measures of resource use, a variety of data sources were used (see section III.E.2 of this proposed rule for the proposed methodology used to calculate the cost of care under the HHGM). First, BLS data on average wages and fringe benefits were used to produce one version of the wage-weighted cost per minute for each home health discipline. The wage data are for North American Industry Classification System (NAICS) 621600—Home Health Care Services. The wage data are broken down by the following occupations:

Table 17—BLS Standard Occupation Classification (SOC) Codes for Home Health Providers

Standard Occupation Code (SOC) No.

Occupation title

29-1141

Registered Nurses.

29-2061

Licensed Practical and Licensed Vocational Nurses.

29-1123

Physical Therapists.

31-2021

Physical Therapist Assistants.

31-2022

Physical Therapist Aides.

29-1122

Occupational Therapists.

31-2011

Occupational Therapist Assistants.

31-2012

Occupational Therapist Aides.

29-1127

Speech-Language Pathologists.

21-1022

Medical and Public Health Social Workers.

21-1023

Mental Health and Substance Abuse Social Workers.

31-1011

Home Health Aides.

For visits where the service provided—as indicated by the Healthcare Common Procedure Coding System (HCPCS) code—can be provided by only a single standard occupation classification code; for example, establishment or review of a plan of care by a registered nurse (RN; HCPCS = G0162), the wage (and fringe) rate for that standard occupation classification is used to calculate the cost of the minutes for the visit. For visits where the service provided can potentially be provided by different standard occupation classification, such as observation and assessment by an RN or a Licensed Practical Nurse (LPN; HCPCS = G0163), a blended rate is applied, with the rate for each standard occupation classification code weighted by the total home health employment for that standard occupation classification code. The employment data are available from the same BLS table as the wage data.

Home Health Agency Medicare Cost Report (MCR) data were also used to construct a measure of resource use after trimming out HHAs whose costs were outliers. These data are used to provide a representation of the average costs of visits provided by HHAs in the six Medicare home health disciplines: Skilled nursing; physical therapy; occupational therapy; speech-language pathology; medical social services; and home health aide services. Cost report

data are publicly available at

https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports/

.

The 2016 analytic file included 6,293,442 episodes. Of these, 469,346 (7.5 percent) were excluded because they could not be linked to OASIS assessments or because of the reasons listed above. This yielded an analysis file including 5,824,096 episodes. Those episodes are 60-day episodes under the current payment system, but for the HHGM those 60-day episodes were converted into two 30-day periods. This yielded a final HHGM analytic file that included 10,231,507, 30-day periods. Certain 30-day periods were excluded for the following reasons:

• Periods missing a diagnosis code or where the diagnosis code did not link to a clinical group to case-mix adjust the period's payment (after exclusions, n = 10,177,949).

• Inability to merge to certain OASIS items to create the episode's functional level that is used for risk adjustment. For all the periods in the analytic file, there was a look-back through CY 2015 for a Start of Care or Resumption of Care assessment that preceded the period being analyzed and was in the same sequence of periods. If such an assessment was found, it was used to impute responses for OASIS items that were not included in the follow-up assessment. Periods which did not link to a Start of Care or Resumption of Care assessment were dropped (after exclusions, n = 9,477,856).

• No nursing visits or therapy visits (after exclusions, n = 9,290,340).

• LUPAs were excluded from the analysis. Periods that are identified as LUPAs in the current payment system are excluded in the creation of the functional score. Following the creation of the score (and the corresponding levels), case-mix group specific LUPA thresholds were created and episodes/periods were excluded that were below the new LUPA threshold when computing the case-mix weights.

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Therefore, the final analytic sample included 8,642,107 30-day periods that were used for the analyses in the HHGM.

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The case-mix group specific LUPA thresholds were determined using episodes that were considered LUPAs under the current payment system.

As noted in section II.D of this proposed rule, the analyses and the ultimate development of Home Health Groupings Model (HHGM) have been shared with both internal and external stakeholders via technical expert panels, clinical workgroups, special open door forums, and in the CY 2017 HH PPS final rule (81 FR 76702). Technical expert panel and clinical workgroup webinars on the technical report were held in December 2016 and a detailed technical report was posted on the CMS home health agency Web page in December, providing opportunity for stakeholder feedback.

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We also held a National Provider call in January 2017, to further solicit feedback from the public.

22

21

Abt Associates. “Overview of the Home Health Groupings Model.”

Medicare Home Health Prospective Payment System: Case-Mix Methodology Refinements.

Cambridge, MA, November 18, 2016. Available at

https://downloads.cms.gov/files/hhgm%20technical%20report%20120516%20sxf.pdf

.

22

Centers for Medicare & Medicaid Services (CMS). “Certifying Patients for the Medicare Home Health Benefit.” MLN Connects

TM

National Provider Call. Baltimore, MD, December 16, 2016. Slides, examples, audio recording and transcript available at

https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2017-01-18-Home-Health.html?DLPage=2&DLEntries=10&DLSort=0&DLSortDir=descending

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2. Methodology Used To Calculate the Cost of Care

To construct the case-mix weights for the HHGM proposal, the costs of providing care needed to be determined. A Wage-Weighted Minutes of Care (WWMC) approach is used in the current payment system based on data from the BLS. However, we are proposing to adopt a Cost-per-Minute plus Non-Routine Supplies (CPM + NRS) approach, which uses information from Medicare Cost Reports (MCR). We used the following data sources and methodology for calculating these measures of resource use:

•

BLS Wage Estimates:

For the WWMC method of calculating home health resource use, wage and fringe data was obtained from the BLS by industry code from the NAICS and occupation code from the Standard Operation Classification. These data provide nationwide average wage rates and the average value of fringe benefits per hour of work for specific occupations.

•

Home Health Medicare Cost Report Data:

All Medicare-certified HHAs must report their own costs through publicly-available home health cost reports maintained by the Healthcare Cost Report Information System (HCRIS). Freestanding HHAs report HHA-specific cost reports while HHAs that are hospital-based report on the HHA component of the hospital cost reports. These cost reports enable estimation of the cost per visit by provider and the estimated NRS cost to charge ratios. To obtain a more robust estimate of cost, a trimming process was applied to remove cost reports with missing or questionable data and extreme values.

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The trimming methodology is described in the report “Analyses in Support of Rebasing & Updating Medicare Home Health Payment Rates” (Morefield, Christian, and Goldberg 2013). See

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Analyses-in-Support-of-Rebasing-and-Updating-the-Medicare-Home-Health-Payment-Rates-Technical-Report.pdf

.

•

Home Health Claims Data:

Medicare home health claims data are used in both the WWMC and CPM+NRS methods to obtain minutes of care by discipline of care.

•

Wage-Weighted Minutes of Care (WWMC) Approach:

Used in the current payment system, this approach determines resource use for each episode by multiplying utilization (in terms of the number of minutes of direct patient care provided by each discipline) by the corresponding opportunity cost of that care (represented by wage and fringe benefit rates from the BLS).

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Table 18 shows the occupational titles and corresponding mean hourly wage rates from the BLS. The employer cost per hour worked shown in the fifth column is calculated by adding together the mean hourly wage rates and the fringe benefit rates from the BLS (generally around 37 percent of wages). For home health disciplines that include multiple occupations (such as skilled nursing), the opportunity cost is generated by weighting the employer cost by the proportions of the labor mix.

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Otherwise, the opportunity cost is the same as the employer cost per hour.

24

Opportunity costs represent the foregone resources from providing each minute of care versus using the resources for another purpose (the next best alternative). Generally, opportunity costs represent more than the monetary costs, but in these analyses, they are proxied using hourly wage rates.

25

Labor mix represents the percentage of employees with a particular occupational title (as obtained from the BLS) within a home health discipline.

Table 18—Occupational Employment and Wages Provided by the Federal Bureau of Labor Statistics

Occupation

title

National

employment

counts

Mean

hourly

wage

Estimate

of benefits as a % of

wages

Estimated

employer

cost

per hour

worked

Labor

mix

Home

health

discipline

Opportunity

cost

Registered Nurses

173,590

$32.94

43.76

$47.36

0.68

Skilled Nursing

$42.21

Licensed Practical and Licensed Vocational Nurses

82,860

21.86

43.76

31.43

0.32

Physical Therapists

25,700

46.42

39.91

64.95

0.76

Physical Therapy

59.18

Physical Therapist Assistants

7,460

30.81

35.75

41.83

0.22

Physical Therapist Aides

500

15.85

35.75

21.52

0.01

Occupational Therapists

10,780

44.17

39.91

61.80

0.82

Occupational Therapy

58.46

Occupational Therapist Assistants

2,220

32.03

35.75

43.48

0.17

Occupational Therapist Aides

110

25.20

35.75

34.21

0.01

Speech-Language Pathologists

5,340

46.83

39.91

65.52

Speech Therapy

65.52

Medical and Public Health Social Workers

17,270

28.16

39.91

39.40

0.97

Medical Social Service

39.35

Mental Health and Substance Abuse Social Workers

450

26.87

39.91

37.59

0.03

Home Health Aides

385,440

10.93

35.75

14.84

Home Health Aide

14.84

Source: May 2015 National Industry-Specific Occupational Employment and Wage Estimates NAICS 621600—Home Health Care Services.

For each home health period of care, the number of minutes of care provided (obtained from the home health claims) is weighted by the corresponding opportunity cost for each discipline providing the minutes. The resulting wage-weighted minutes of care are summed for the 30-day period to obtain total costs. Table 19 shows these costs overall for 30-day periods in CY 2016 (n = 8,642,107). On average, total period costs were $374.52. The distribution ranged from a 5th percentile value of $73.87 to a 95th percentile value of $912.10.

Table 19—Distribution of Average Resource Use Using WWMC Approach

[30 day periods]

Statistics

Mean

N

5th

Percentile

10th

Percentile

25th

Percentile

50th

Percentile

75th

Percentile

90th

Percentile

95th

Percentile

Average Resource Use (WWMC)

$374.52

8,642,107

$73.87

$94.97

$158.29

$303.19

$517.063

$749.22

$912.10

In the current HH PPS, all episodes without a LUPA payment receive payment for NRS, regardless of whether or not the HHA provided NRS during that episode. NRS payment amounts are determined through a payment model separately from the one used to construct the episode's case-mix weight. The current payment system determines NRS payment using the presence of clinical factors associated with NRS provision from the OASIS. Two-thirds of episodes do not include provision of NRS, yet those episodes still receive an NRS payment.

We are proposing to calculate resource use under the HHGM using a Cost-per-Minute plus Non-Routine Supplies (CPM + NRS) approach. It determines resource use using information from Medicare cost reports. Under the proposed HHGM, we would group episodes into their case-mix

groups taking into account admission source, timing, clinical group, functional level, and comorbidity adjustment. From there, the average resource use for each case-mix group dictates the group's case-mix weight. Resource use is the estimated cost of visits recorded on the home health claim plus the cost of NRS recorded on the claims. The cost of NRS is generated by taking NRS charges on claims and converting them to costs using a NRS cost to charge ratio that is specific to each HHA. When NRS is factored into the average resource use, NRS costs are reflected in the average resource use that drives the case-mix weights. CMS would return $53.03 to the base rate (that is, the NRS conversion factor). If there is a high amount of NRS cost for all episodes in a particular group (holding all else equal), the resource use will be higher relative to the average and the case-mix weight will correspondingly be higher. Similar to the current system, NRS would still be paid prospectively under the HHGM, but the HHGM eliminates the separate case-mix adjustment model for NRS. Incorporating the NRS cost into the measure of overall resource use (that is, the dependent variable of the payment model) requires adjusting the NRS charges submitted on claims based on the NRS cost-to-charge ratio from cost report data.

The following steps would be used to generate the measure of resource use under this CPM + NRS approach:

(1) From the cost reports, obtain total costs for each of the six home health disciplines for each HHA.

(2) From the cost reports, obtain the number of visits by each of the six home health disciplines for each HHA.

(3) Calculate discipline-specific cost per visit values by dividing total costs [1] by number of visits [2] for each discipline for each HHA. For HHAs that did not have a cost report available (or a cost report that was trimmed from the sample), imputed values were used as follows:

• A state-level mean was used if the HHA was not hospital-based. The state-level mean was computed using all non-hospital based HHAs in each state.

• An urban nationwide mean was used for all hospital-based HHAs located in a Core-based Statistical Area (CBSA). The urban nation-wide mean was computed using all hospital-based HHAs located in any CBSA.

• A rural nationwide mean was used for all hospital-based HHAs not in a CBSA. The rural nation-wide mean was computed using all hospital-based HHAs not in a CBSA.

(4) From the home health claims data, obtain the average number of minutes of care provided by each discipline across all episodes for a HHA.

(5) From the home health claims data, obtain the average number of visits provided by each discipline across all episodes for each HHA.

(6) Calculate a ratio of average visits to average minutes by discipline by dividing average visits provided [5] by average minutes of care [4] by discipline for each HHA.

(7) Calculate costs per minute by multiplying the HHA's cost per visit [3] by the ratio of average visits to average minutes [6] by discipline for each HHA.

(8) Obtain 30-day period costs by multiplying costs per minute [7] by the total number of minutes of care provided during a 30-day period by discipline. Then, sum these costs across the disciplines for each period.

This approach accounts for variation in the length of a visit by discipline. NRS costs are added to the resource use calculated in [8] in the following way:

(9) From the cost reports, determine the NRS cost-to-charge ratio for each HHA. The NRS ratio is trimmed if the value falls in the top or bottom 1 percent of the distribution across all HHAs from the trimmed sample. Imputation for missing or trimmed values is done in the same manner as it was done for cost per visit (see [3] above).

(10) From the home health claims data, obtain NRS charges for each period.

(11) Obtain NRS costs for each period by multiplying charges from the home health claims data [10] by the cost-to-charge ratio from the cost reports [9] for each HHA.

Resource use is then obtained by:

(12) Summing costs from [8] with NRS costs from [11] for each 30-day period.

Table 20 shows these costs overall for 30-day periods in CY 2015 (n = 8,642,107). On average, total 30-day period costs are $1,585.48. The distribution ranges from a 5th percentile value of $300.03 to a 95th percentile val

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