After CMS Issues Final PDGM Rule, Advocates Ask: “What Now?”

Washington, D.C. (November 6, 2019)—Days after the Centers for Medicare & Medicaid Services (CMS) issued its final rule governing the new payment model for home health care, industry advocates are asking for guidance from the community on what to do next.

Bill Dombi, president of the National Association for Homecare & Hospice (NAHC), asked participants on a webinar on Wednesday, November 6, to submit comments on whether the organization should keep pushing back on specifics in the final rule for the Patient-Driven Groupings Model (PDGM)—or whether to take a breath and move forward.

“This is not a black and white kind of thing,” Dombi said. “Congress is at the moment is overloaded with items to deal with, everything from the budget for 2020 … to health care matters involving drug pricing and price transparency, to a series of other issues including the impeachment proceedings that are going on and taking a lot of the air out of Washington, D.C. … Concerns have been raised about whether members of Congress really have enough gas in the tank to take this forward given other activities.”

There are two pieces of legislation pending with a combined 166 co-sponsors that would alter the approach to PDGM, especially regarding a rate reduction due to assumed behavior on the part of billers. Dombi said he had spoken with some of their staff members that day and they queried him about what the next steps should be.

On the one hand, he said, parts of the final rule are moves in the right direction—especially an increase in the 2020 payment rates, which he called “a significant plus for home health agencies.”

“When you calculate this out as to the benefits coming to the home health agencies, that change itself comes with a value of over $700 million,” Dombi said.

Also positive is a near-halving of the behavioral adjustment that CMS proposed to reduce payments by first 6.4%, then by 8.01%. Dombi said that it appeared the agency intended to revise that upwards again to 8.389% in the final rule issued October 31–but then quickly changed course, dropping the final adjustment to 4.36%, saying that not all behaviors would occur immediately and they would only apply to about half of cases.

“It’s very obvious that CMS had written the final rule with an 8.389% adjustment and then, somewhere late in the process, CMS leadership stepped in and said, ‘let’s drop that down to 4.36,’” he said. “There was a late intervention that led to that. We believe the late intervention was due to our advocacy and also advocacy coming from Senate and House legislative sponsors.”

However, there are still significant issues in the final rule, including new rules for therapy utilization that may bring harsh penalties if therapy volume changes abruptly; a restriction and eventually elimination of requests for anticipated payment (RAPs) that Dombi said could cause serious cashflow problems for home health agencies; new penalties for filing late RAPs and late notice of admission, which begins in 2022 and would cost agencies as much as 1/30th of their monthly rates for each day they are late; and the phasing out of the rural add-on.

He urged NAHC members and webinar listeners to let the organization know which direction it should take. For more information, visit NAHC.org.

“There are a lot of pros and cons,” Dombi said. “We do have a concern that CMS could be in a position to make assumptions in 2021 for behavioral adjustments, or in 2022 before full data is available.” Also, Congress may be pulled elsewhere by elections next year and unable to focus on additional legislation.

This article was written by HomeCare Editor Hannah Wolfson.