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September 8, 2019The Honorable Seema Verma, Administrator Centers for Medicare and Medicaid ServicesU.S. Department of Health and Human ServicesAttn: CMS-1689-PP.O. Box 80137500 Security BoulevardBaltimore, Maryland 21244-8013Submitted via: . Re: CMS–1711-P: Medicare and Medicaid Programs: CY 2020 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; Home Health Quality Reporting Requirements; and Home Infusion Therapy RequirementsDear Administrator Verma:On behalf of the Massachusetts providers of Medicare home health services, I write with comments regarding the payment and programmatic reforms in the Notice of Proposed Rulemaking (NPRM). 84 Fed. Reg. 34598 (July 18, 2019). Our membership includes agencies that are non-profit, proprietary, hospital affiliated and independent. They provide services across the entire state of Massachusetts. Many of our agencies are actively engaged in value-based demonstration projects, such as ACOs and bundling, as well as Value Based Purchasing, which we believe are advancing both the quality and efficiency of care to Medicare beneficiaries. We present our comments specifically on changes in this proposed rule that we believe will be a destabilizing force to our sector and its critical role in continuing to advance positive change in how we care for and what outcomes we expect for our Medicare population. While we support the transition to the Patient Driven Groupings Model, we are specifically concerned about the timing, magnitude and scope of some of the associated changes and ask that CMS reconsider the following proposals. Payment Reform: Patient Driven Groupings Model (PDGM) – Behavioral Adjustment The most recent proposal of an 8.01% reduction in payment based on assumed, projected changes that may occur when the PGDM is implemented, we believe to be both unsustainable and unjustified. We further do not see that the calculation of the behavior adjustment to be supported in a necessary and fully transparent manner. CMS seems to have calculated this adjustment based primarily on an assumption of up-coding of the primary diagnosis. Such an assumption seems unsupported by any public analytics, past industry behavior or other rationale. The downside impact of eliminating the increased therapy visits payment incentive that existed in HHPPS seems unaccounted for. Without much more definitive justifications, we believe it entirely unreasonable for CMS to assume over four (4) times the average annual change that was experienced in the 2000 transition to the current HHPPS model, especially given that PDGM has fewer meaningful areas of behavior change risk than existed in the 2000 model. In both overstating the risk of behavior change and implementing such a radically different payment model requiring considerable training and operational resources at every agency, CMS is particularly threatening the viability of smaller, local agencies that are thinly capitalized, but that in some areas of our state are essential community providers. Recommendations:In the interest of making for a smooth transition (without incentivizing undesired behavior changes), we urge a more cautious approach for the first year of PDGM. We believe that CMS should instead take a more data-driven approach to rate adjustments based on observed and reported behavior changes in future years. At a minimum, we ask CMS to consider moderating the impact of the 8.01% by implementing any behavior adjustment over a period of years. This type of multi-year phase-in will ensure that the impact on the home health community is mitigated and will allow for the industry to adjust appropriately to the new system. Additionally, it must be noted and factored into any payment adjustment, that upcoding and other provider behaviors are not the sole influencers on Medicare home health spending. Medicare enrollment, modification/improvement of enforcement of coverage standards (e.g. maintenance therapy; home infusion therapy), behavior changes in other PAC services that affect home health utilization are among the most common. Given these, CMS must take all reasonable steps to ensure that it does not modify payment rates under its ongoing behavior adjustment and reconciliation authority based on factors other than those directly triggered by the transition from HHPPs-HHRG to PDGM, we further recommend that CMS convene a Technical Expert Panel (TEP) to develop the necessary standards and processes on an expedited basis as new data may be needed that currently is not collected.Medicare Home Health Services Proposed Rule: RAP Phase-Out HCA believes that reduction in the split payment amount to 20% in 2020 and the elimination of RAPs in 2021 will present serious cash flow challenges for a number of our member agencies. While the application of a 30-day payment unit reduces the length of time that HHAs incur costs prior to receiving payment on a claim, an extended period of time still remains. Typically, a final claim for a 30-day episode will not be paid until around 50-60 days following the start of care. This delay occurs as it is necessary - after the close of the 30-day payment period - for an HHA to secure all the necessary paperwork (especially from physicians who, despite our best efforts, remain notoriously slow) required as part of a compete claim. In addition, most HHAs engage in some form of quality control on the completeness and appropriateness of each claim. All told, these processes can take a minimum of two to three weeks. With the complications of a new payment model added to the mix, further delays are likely. When a claim is submitted to Medicare, the Medicare Administrative Contractor (MAC) can begin processing it immediately. However, the MAC cannot issue payment any earlier than the 15th day following receipt of a “clean claim” under Medicare law. Together, these process steps and payment restrictions are likely to lead to a normal payment receipt cycle of 50-60 days from the start of the period.For nearly 20 years, HHAs have managed their finances consistent with a Medicare payment model that provides 60% or 50% of the anticipated episodic payment within a matter of days or weeks from of the start of the episode. The reduction of the split payment from 60% to 20% in 2020 may require costly bridge financing either by way of tapping any existing reserves or borrowing in order to meet payroll obligations that do not get suspended while waiting for Medicare to pay its bills. Recommendation: Given the time and costs associated with PDGM payment transition, CMS should withdraw its proposed modification and termination of the RAP model for at least one year. Instead, CMS should explore targeted approaches and predictive analytics to manage the integrity of RAPs. Note that acceptance of this recommendation precludes the need for a Notice of Admission from HHAs, see comments below. Proposal Changes to Therapist Assistants to Perform Maintenance Therapy (Section IIII. H) CMS proposes to modify the regulation to permit therapy assistants to perform maintenance therapy. However, the proposed regulation at §409.44(C) only addresses physical therapy assistants. Recommendation: HCA supports that CMS also revise the regulation to clarify that occupational therapy assistants may also perform maintenance therapy. Proposed Changes to the Split-Percentage Payment Approach for HHAs in CY 2020 and Subsequent Years (Section IIII.G) Notice of admission (NOA) CMS proposes to require a NOA when the request for anticipated payment (RAP) is eliminated. The NOA will be required to update the common working file (CWF) in order to enforce consolidated billing rules for home health agencies. CMS proposes to mirror the process for the notice of election (NOE) submission that is currently in place for hospice providers. HHAs will be required to submit the NOA within 5 days of the start of care date. Failure to submit the NOA timely will result in a payment reduction for each day the NOA is submitted late.Given our position that the RAP be retained for at least one more year, HCA of MA sees no reason for moving forward with this NOA. However, should CMS proceed we have very strong concerns with the NOA content and timing. The NOA does not generate a payment, as did the RAP, so there remains no rationale for the NOA to have the same requirements for the NOA submission as for the RAP submission. Quite simply, agencies will not be able to meet the 5-day time frame for submission of the NOA if CMS moves forward with its proposed list of requirements. There are well developed reasons, related to practice and quality control, why current regulations allow that agencies begin care with a verbal order and that give agencies 5 days from the start of care (SOC) date to complete the comprehensive assessment and from that time point develop the Plan of Care (POC). Before the POC is sent to the physician agencies will conduct quality reviews and any other administrative actions required to ensure the POC is complete and ready for the physician’s signature. This process may explain why the median number of days for a RAP submission is twelve, as noted by CMS in the proposed rule. Recommendation: CMS should withdraw the NOA in favor of continuing with RAP payments for another year. Subsequently, CMS should convert to an NOA that would require only what is necessary to begin home health, i.e., a verbal order that is signed and dated by the registered nurse or qualified therapist who is responsible for furnishing or supervising the ordered service in the plan of care signed by the clinician. As an alternative, CMS should allow at least 14 days for the agency to submit the NOA. Proposed Updates to the Home Health Care Quality Reporting Program (HH QRP)The new measure and SPADEs that CMS is proposing would significantly increase the number of assessment items to the Outcome and Assessment Information Set (OASIS) instrument, resulting in a very different data set in 2021 from what agencies are currently using. Any changes in the OASIS assessment data set increases resource use for agencies in terms of staff training and altered productivity associated with the learning curve required for collecting new material. The HCA believes these changes will initially be extremely burdensome for agencies to implement due to the number of new items and the fatigue agencies are experiencing related to having to accommodate multiple alterations to the OASIS assessment over the past several years. Adding to the burden is the time it takes for CMS to receive final approval from the Office of Management and Budget for the modified data set.Recommendation: Given these concerns, HCA would support the proposed changes to the OASIS data set for CY 2021 provided that CMS issue a final version of the assessment tool no later than 6 months prior to the implementation date to allow for staff training and other necessary preparations required for agency implementation. This may well require that CMS use the authority permitted by the IMPACT Act to waive the Paperwork Reduction Act (PRA) requirements related to modification of the assessment tools for providers subject to the IMPACT Act. Waiving the PRA may expedite CMS’ ability to issue a final version of the revised OASIS instrument in a timely manner. We also recommend CMS commit to refraining from issuing any revisions to the OASIS instrument for at least 5 years after the 2021 implementation of the proposed changes. Input Sought To Expand the Reporting of OASIS Data Used for the HHQRP To Include Data on all Patients Regardless of Their Payer (Section I.4) CMS requested input on its proposal to collect and report OASIS data on all patients served by the home health agency regardless of payer. A survey of HCA members indicates no support for this change for the following reasons:At present there is no difference in care delivery between the patients for whom OASIS collection and reporting applies and for those for whom the OASIS is not requiredThere is a financial burden associated with this data collection, with zero chance of additional reimbursement from payers, who themselves have indicated no interest in these data. Case in Point: our multiple Medicare Advantage plans have at no time indicated that they use this data as part of their outcome assessment processes.There are concerns about collecting and aggregating into an agency’s score OASIS data on patients that have different demographics, health care needs, insurance coverage policies, and possibly expected outcomes than the Medicare and Medicaid population. At present, some agencies with high Medicaid chronic long-term patients believe that their OASIS based outcome scores may not be appropriately reflective of the quality of their care, and that they might not be fairly compared to an agency engaged almost exclusively in providing post-acute services. We appreciate CMS’s efforts to reform the home health payment system, to focus on value, and align payment with patient characteristics and quality. We believe the improvements to the PDGM, and the program regulations suggested herein are necessary to ensure the continued availability of home health services to all who require them. We appreciate the opportunity to submit comments on this Proposed Rule and are ready to work with CMS to ensure that home health policy works for CMS, providers, and patients alike. Sincerely, Maureen Bannan Patricia KelleherPresidentExecutive Director ................
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