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by Tim Rowan, Editor

In recent years, CMS has vetted 54 proposals to improve patient outcomes while lowering costs. Most of them did not show either result, and many actually increased costs. The one that did show positive results is Value Based Purchasing. In trials, it showed a 4.6 percent improvement in quality scores and, according to the CMS Innovation Center, was one of only five proposed programs to show any cost savings at all.

After testing it for five years in nine states, CMS is confident that VBS is ready to expand nationwide. In fact, they are ready to start in just over four months. Exactly how VBP will affect HHAs immediately on January 1, 2022 requires some detailed unpacking.

At NAHC's Financial Managers meeting in Chicago, SHP's Chris Attaya shared his research into VBP for Home Health. The gist of his message is that HHAs need to be prepared, and they should have started a year ago. Though payment adjustments will not happen until calendar year 2024, baseline measurements that will determine whether those payments will be rewards or punishments begin on January 1. 

Lessons Learned

Changes made to VBP during the 5-year demonstration project are more than what might be called "tweaks."

• HHCAHPS will be based on 40 completed surveys instead of 20
• Drug Education was removed from the measurement list
• Five OASIS measures are no longer "applicable' measures
• Two new "composite" measures were added, for a total of 14:
  • Total Normalized Composite for Mobility
  • Total Normalized Composite for Self-Care
• Weighting was changed for the calculation of TPS scores:
  • 35% for the OASIS-based measures (6 outcomes)
  • 35% for the Claims-based measures (2 outcomes)
  • 30% for the HHCAHPS measures (5 outcomes)
• The program began with a maximum of 10 points to 9 to measure improvement in patient quality outcomes
• One last change was forced by the Public Health Emergency. No payment adjustments were made for program year 5.

From Nine States to 50

While VBP for all HHAs technically begins at the dawn of 2022, payment adjustments will not commence for another two years. After building on lessons learned during the demonstration, CMS published a proposed rule on June 28 that included:

• All HHAs that became Medicare certified prior to January 1, 2021 will be required to participate.
• HHAs will be scored on two scales, 10 points will be available for achievement and 9 points for agency improvement.
• 2019 will be used as the baseline year for calculating improvement.
• 2022 will be the performance year, with points awarded for improvements over 2019. Then, in 2024:
  • Agencies fewer points will have up to 5% of Medicare revenues deducted from their payments.
  • Agencies with the most points will have up to 5% added to their Medicare payments.
  • ONLY Medicare episodes will be included in both equations. Medicare Advantage payments will not be affected.
• HHAs will be compared against other agencies of similar size, but nationally, not regionally or by state.
• TPE rankings will be public, but probably not until 2025.
• CMS will provide quarterly and annual reports so HHAs will know where they stand. The first quarterly report will be released in July, 2022.

In reference to the periodic reports, Attaya underscored the importance of reviewing them as soon as they are delivered. "You can only appeal and request corrections until your payment adjustment year begins," he warned.

The "What-If's"

Obviously, newly certified HHAs cannot have a 2019 baseline. CMS proposes a kind of sliding scale of dates and deadlines. Agencies with Medicare certification dates:

• Prior to 1/1/19 will be under the standard schedule, described in the bullet points above.
• During 2019 or 2020 (1/1/19 - 12/31/20) will have 2021 as their baseline year, 2022 as their performance comparison year, and payment adjustments will still begin in 2024.
• During 2021 (1/1 - 12/31): baseline year will be 2022, performance year 2023, and payment adjustment year 2025.

Key Preparation Steps

Attaya and his co-presenter Sue Payne, a Home Care Strategies Advisor for Corridor, concluded with lessons learned from pre- and post-demonstration interviews with the same 63 agencies in 2017 and 2021, minus those no longer in business. 

Interviewers found that agency owners had fewer concerns about specifics of the VBP model in 2020 than in 2017. They said whatever the model was, it dovetailed into their other performance and documentation improvement initiatives.

One anonymous interviewee said, "The Star ratings, TPE, HHVBP all happened at the same time. Sometimes, in the beginning, it was a little like a tug-of-war, until we figured out that there was much overlap."

Demonstration providers reported that staff retention and recruitment continues to be an issue. They also felt that HHVBP had a positive impact on improving patient outcomes. Many bemoaned the time lag between improvement activities and TPS scores. They said real-time software would make it easier to see the correlation.

One datum Sue Payne found interesting was that all states improved in quality scores during the demonstration, but the nine states in the VBP demonstration improved more.

Based on the data and the interviews, Attaya and Payne recommended HHAs begin now, if not sooner to:

• Identify agency 2019 outcome scores.
• Examine 2021 scores and compare to your own 2019 scores.
• Examine 2021 scores and compare to national 2019 outcome scores.
• Your VBP steering committee must have executive level leadership.
• Conduct at least monthly -- weekly is better -- dashboard reviews with branch leadership.
• Make each branch own where it should focus effort, but with executive support.
• Provide monthly data to each office location.
• Require local branch management to develop local action plans for 1-2 items at a time.
• In branches that specialize in patient functional improvements, PT should lead.
• Use a familiar QAPI model, with a feedback loop and outcomes data, to ensure that actions are working.

Lastly, Attaya and Payne detailed areas for clinical and operational best practices.

Clinical

1. Documentation: get risk adjustment OASIS items exactly right; make sure completion and submission is timely and all answers are accurate.
2. Communication: with on-call staff; between clinician and patient; between office and clinician. "Ask clinicians to 'Take 5' at the beginning of every visit, to get to know patient and family, hear their questions, develop a relationship that will eventually result in better HHCAHPS scores," they said. "And share outcomes data with your clinicians and the reason outcomes matter once the payment year comes."
3. Preparedness: focus on medication reconciliation and continuity of care. "Patients who do not understand their meds and do not take them correctly, and patients who fall through the cracks in the system, have worse outcomes on average."
4. Initiate technology to enable instant telehealth visits with ED physicians.

Operational

1. Know the right place and right time for patient referrals. Set guidelines for how to know the appropriate care setting. Use your Social Worker to help with these.
2. Up your patient engagement efforts. Take time each visit to get to know them. Use key words that may foreshadow their HHCAHPS report.
3. Develop partnerships with other providers who can help you enhance continuity of care. This might be palliative care centers and hospices, or skilled nursing facilities.
4. Pass the baton handoff with hospitalists prior to discharge.
5. Institute a "Complex Care Council." Include Social Worker, Behavioral Health specialist, wound care and other nurse specialties.

Final Comments and Resources

They recommended some study materials to help HHAs prepare for VBP.

• "Evaluation of the HHVBP Model 4 Annual Report" -CMS
• "CMS Innovation Center at 10 Years: Progress and lessons Learned" -Brad Smith, New England Journal of Medicine
• "CMS Proposes Payment Rate Update to Home Health in 2022" -NAHC Report, 6/28/21
• "Nine Payer and State Medicaid Managed Care Investments in Social Determinants" -FutureFocus, Remington Report, 7/7/21

CMS will be asking for comments when the proposed rule appears. They are anticipating getting rid of the 60-day rehospitalization measure and the ED utilization measure. They may replace it with a different calculation and are asking for suggestions.

 

©2021 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Home Care Technology: The Rowan Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com