Proposed Rule to Expand Value-Based Payment in Home Healthcare

On July 11, CMS proposed a rule that would start the transition to value-based payment in the home healthcare field and make a home infusion benefit available to Medicare beneficiaries.

 Specifically, the proposed rule includes steps to implement the Patient-Driven Groupings Model, a new value-based payment system for home health agencies that ties Medicare reimbursement to patient characteristics rather than the number of therapy visits.

“We are proud to announce the new permanent home infusion therapy benefit that will give patients the freedom to safely access critical treatments, such as chemotherapy, at home instead of traveling to the hospital or doctor’s office, improving their quality of life,” said CMS Administrator Seema Verma. “We are also proposing updates to payments for home health agencies under the new Patient-Driven Groupings Model, which focuses on patient characteristics to more accurately pay for home health services, rewarding value over volume.”

The 346-page update of the home health prospective payment system is routine, the fact sheet clarifies. However, the changes would be significant, including expanding seniors’ ability to receive care at home and a potential $250 million bump in Medicare payments to home health agencies (HHAs).

In 2014, approximately 3.5 million Medicare beneficiaries received home health services. However, stakeholders like the National Home Infusion Association (NHIA) have argued that those home health services should include infusion therapy, which some patients can administer on their own.

Medicare only covers home healthcare infusion therapy services done in person by a physician or nurse, NHIA noted. Furthermore, many infusion therapies are not covered by Medicare at all.

The new permanent home infusion therapy benefit allows patients to receive a higher level of care in their home environment. The proposed rule would allow providers to use durable medical equipment pumps and provide services at home. Beneficiaries could receive anti-infectives, chemotherapy, immune deficiency treatments, or other critical infusion drug therapies without having to go to the hospital or a provider’s office.

Additionally, the rule addresses value-based payments for home healthcare.

Under the new rule, CMS would implement the Patient-Driven Groupings Model (PDGM), a new case-mix payment methodology. The model emphasizes value-based care that relies on patient outcomes and patient characteristics to ensure accurate reimbursement for home health services.

CMS is also proposing to add two quality measures to the Home Health Quality Reporting Program (HH QRP) related to the transfer of health. Both measures would seek to decrease potentially inaccurate medications (PIMs) at the time of transfer or discharge by double-checking the patient’s list of medications before the patient leaves the care site. These adjustments also promote coordinated care, interoperability, and the transfer of health information.

A newly designed HH QRP standardized patient assessment data elements (SPADEs) would also serve, along with the rest of the Outcome Assessment Information Set, to improve coordination of care with a particular focus on mental health and social determinants of health.

To help stem the opioid epidemic, CMS also proposed to remove the improvement in pain interfering with activity measure, which may have led to the over-prescription of opioids.

CMS would adjust the Home Health Value-Based Purchasing (HH VBP) model to publicize the home health reporting process. For the nine states that qualified for a payment adjustment for CY 2020, the agency would publish the total performance scores (TPS) and TPS percentile ranking from performance year 5 (CY 2020) annual TPS and payment adjustment report. The goal is to increase competition between HHAs to improve quality and to empower beneficiaries to make more knowledgeable provider selections.

The new rule also would allow therapist assistants to perform at the top of their licensure and give maintenance therapy to patients in their homes, which extends the flexibility of home health care under Medicare.

The proposed rule is now available on the Federal Register.