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Members of Congress Ask CMS to Stop Home Health Cuts Based on Behavioral Assumptions

Friday, July 5, 2019   (0 Comments)
Posted by: Kyle Simon

A bipartisan group of U.S. Senators and members of the House of Representatives, including Senators Susan Collins (R-ME), Debbie Stabenow (D-MI), and Reps. Terri Sewell (D-AL-7) and Vern Buchanan (R-FL-16), have written to Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma to ask her to avoid “reductions in payment due to assumptions, without real-world evidence, about how home health agencies may change billing under the new payment model” debuting on January 1, 2020.

Last year, Congress passed the Bipartisan Budget Act (BBA) of 2018. Included in this law were various reforms to the Medicare home health benefit. One such provision called for budget neutrality in any change to the payment model, so that future spending would remain consistent with projections of current spending levels. Additionally, Congress authorized CMS to make changes in reimbursement rates based on assumptions of provider behavior in response to the payment model reforms.

CMS has since taken this authority and incorporated behavior based rate-reductions to take effect in 2020 as included in the final Medicare home health rule. These reductions are based on the assumptions that providers will up-code and also add additional visits to LUPA cases to obtain the full episodic payment. It is notable that these projections significantly differ from their 2017 assumptions in the Home Health Groupings Model (HHGM). Further, in their finalized rule for the Skilled Nursing Facilities payment rule, CMS states that they did “not have any basis on which to assume the approximate nature or magnitude of these behavioral responses.” It is wildly inconsistent for assumptions to be made about one provider type, but not another.

Bipartisan legislation called the Home Health Payment Innovation Act (S. 433/H.R. 2573), sponsored by Collins, Stabenow, Sewell, Buchanan and many others, seeks to remedy these inconsistencies by removing the ability to adjust rates based on assumptions. Under the proposed legislation, rates could only be adjusted response to observed evidence of behavioral changes. The legislation would also allow for waivers to the homebound requirement for beneficiaries in Medicare Advantage plans and innovative Medicare payment models such as Accountable Care Organizations.

“During this year’s home health rulemaking cycle, we urge CMS to revisit those assumptions, which would result in a 6.42 percent cut to home health payments for 2020, based on the agency’s internal analysis and modeling,” write the members of Congress. “The changes to home health payment required by BBA of 2018 were not intended to create significant cuts in 2020. CMS has wide discretion in making assumptions, but we are concerned that CMS has not taken into account what may happen to Medicare beneficiaries and their access to home health services as a result of this substantial cut. In the absence of observed experience and data, CMS should take a cautious approach in its 2020 behavioral assumptions, knowing data-based adjustments can be made in the years that follow.”

While the bipartisan and bicameral legislation would greatly improve the upcoming Patient-Driven Groupings Model (PDGM), these members of Congress want CMS to make their legislation unnecessary by relying only on hard evidence from the very beginning.

“[W]e believe the annual rulemaking cycle offers an opportunity to revise the adjustments and avoid unnecessary disruption to care at a time when providers are already implementing a new payment model,” the Members wrote to Administrator Verma.

The National Association for Home Care & Hospice and HCAF urge you to stand with these allies of home health and tell your own members of Congress to support the Home Health Payment Innovation Act. It is incredibly easy and quick to do. Just go to the HCAF Legislative Action Center, enter your name and contact information, and press a button. With that one click of your mouse, messages are sent to your members of Congress, asking for their support. Millions of home health patients and providers are counting on advocates like you to speak out on their behalf. Please take action now!

Associate Members