Plus: Be heard on proposed PDGM changes
by NAHC Policy Staff; Edited by Tom Threlkeld
August 29, 2019

The legal, regulatory and legislative landscape confronting home health and hospice operators is growing increasingly complicated, but three big issues have emerged in recent months and the National Association for Home Care & Hospice (NAHC) believes they will continue to be critical for some time to come.

1. Patient-Driven Groupings Model

The Patient-Driven Groupings Model (PDGM) represents the biggest change to the payment system in the 21st century. The PDGM model devised by the Centers for Medicare & Medicaid Services (CMS) will subject home health providers to an 8.01% cut in the base rate derived from entirely unproven assumptions about how providers might respond to its implementation. The cut translates to a nearly $1.3 billion reduction in home health payments in 2020 alone—a staggering number and one that if implemented as proposed would heavily impact the home health community when demand for its services are growing.

These arbitrary reimbursement cuts that accompany PDGM will create barriers to providing the full scope of the home health Medicare benefit, one important reason why NAHC believes CMS should not be permitted to rely on speculation and assumptions about how a home health agency might alter care delivery under a new payment system. It sets a dangerous precedent that needlessly puts care in jeopardy.

Legislation currently pending in Congress, the Home Health Payment Innovation Act (S 433/HR 2573), would prevent CMS from adjusting payment rates based on assumptions. The legislation would also allow for waivers to the homebound requirement for beneficiaries in Medicare Advantage (MA) plans and innovative Medicare payment models such as accountable care organizations. To show your support, visit the NAHC Advocacy Center online and click “Take Action Now.” Click on the Home Health Payment Innovation Act, enter your information and hit send to contact your legislators.

2. Hospice Carve-in

Since creation of the hospice benefit more than 35 years ago it has been excluded (carved out) from MA plans; however, MA enrollees may opt to receive hospice care. Under those circumstances, and for the duration of hospice care, all standard benefits are covered by fee-for-service Medicare. The MA plan continues to cover supplemental benefits and Part D, if applicable.

CMS plans to test the inclusion of hospice under MA as part of the Value-Based Insurance Design model program for calendar year 2021. CMS said the change “is designed to increase access to hospice services and facilitate better coordination between patients’ hospice providers and their other clinicians.” Additional details are anticipated in the coming months.

Carving hospice into the MA benefit package would subject hospice care decisions to an additional layer of financial and utilization controls that could fragment the existing hospice benefit and diminish its value. Areas of particular concern include:

  • Patient choice of hospice would be limited to the hospices with which the MA plan has a contract, rather than based on a patient’s personal preference.
  • Admission to care, levels of care and services could be subject to prior authorization requirements, resulting in service delays.
  • MA plans may override hospice care decisions, undermining the professional integrity of the hospice medical director and interdisciplinary team.

3. Report on Hospice Quality of Care

In July, the Department of Health and Human Services’ Office of the Inspector General (OIG) issued two reports representing in-depth study of findings from Medicare hospice recertification and complaint surveys. One, “Hospice Deficiencies Pose Risks to Medicare Beneficiaries,” provides broad findings on frequencies of deficiencies and makes recommendations to strengthen oversight, transparency and enforcement. The second report, “Safeguards Must Be Strengthened to Protect Medicare Hospice Beneficiaries From Harm,” describes 12 cases that represent significant harm to hospice patients and provides recommendations for increasing hospice responsibility related to potential incidence of abuse.

NAHC supports action taken in recent years to increase hospice providers’ accountability for delivery of high-quality care, including the imposition of a mandate for more frequent surveys. However, the OIG’s findings send a clear message that more action is required to safeguard vulnerable hospice patients. CMS, states, accrediting organizations, hospice associations and hospice providers must all address existing gaps in oversight of hospice quality of care so the problems cited in the report are eliminated. The safety of hospice patients cannot be compromised.

While a methodical and comprehensive approach to this issue is clearly warranted, corrective efforts should be tailored (and prioritized) based on the nature of a hospice’s deficiency. The egregious examples of harm discovered by the OIG require an immediate focus on the small number of providers with incidents of jeopardizing patient safety. CMS should employ a variety of methods to address these agencies’ failings, including subjecting them to the closest of scrutiny until they are able to demonstrate the ability to meet quality standards and the conditions of participation on an ongoing basis.

Most hospice providers are able to meet the vast majority of quality of care standards; in cases where deficiencies are identified, virtually all of these deficiencies are addressed in short order by hospice providers. However, NAHC believes that some of the OIG’s proposed recommendations may help some providers avoid these issues on the front end and could contribute to improvements in the overall quality of care.

NAHC strongly supports the OIG’s recommendation that CMS provide hospices education about common deficiencies and those that pose particular risks to beneficiaries. Historically, there has been limited education available to providers, and information directly from CMS is vital to maintaining a continuing understanding of quality of care requirements. Direct educational offerings also provide a unique opportunity for give and take between CMS and the hospice community around quality and survey issues.

A number of the OIG’s recommendations center on increased public availability of hospice survey data for use by consumers, referring providers and others. NAHC recognizes the value of transparency and the benefit this type of information can supply, but strongly believes that such action should only be taken when data from all survey entities is available for posting in a uniform way to allow for comparison across hospice providers, and the data is displayed in a clear and understandable way. NAHC looks forward to working with its members to thoroughly examine and respond to the OIG’s recommendations, as well as to work with CMS and other stakeholders to ensure quality care for hospice patients.