How CMS Stole Home Care Christmas!

December 21, 2018

Every person in Home Care liked caring a lot.
But the Grinches south of Baltimore, they surely did not!
The Grinches hated home care, delivered in any which way.
Now, please don’t ask why. No one knows what to say.

It could be CMS didn’t have a mom or a dad.
It could be their jobs were incredibly sad.
But, the most likely reason was this just this my dear,
Their hearts were hijacked by nasty old fear.

They feared the support, the need and the caring.
“It has to stop now,” they said, nostrils flaring!
“I hate all their teamwork! I despise all they do!
I’ll pick them all off, one-by-one, two-by-two!”

With a laugh and snort, they sneered, “I know just what to do!”
And put pen to paper to plot their evil, awful coup.
They threw it all at us, with the usual glee,
COPs, OASIS changes, and even VBP!
“I’ve ruined them now and forever, I swear,
Let’s see how you cope, how you can possibly still care!”

But across the Land of Home Care, they got down to work.
HCA had their back, a membership perk!
Every worker in home care, the small and the tall,
Still kept making visits, swearing once and for all:
“The families, they need us, and we will be there!
No Grinches in DC can stop us with fear.”

And what happened then? Well… in home they say,
Those Grinches’ hearts grew three sizes that day!
The true meaning of home care shined right on through.
They ripped up their papers, stopped pre-claim review.
“Maybe home care,” they said, “isn’t about regs, or rules.
Maybe home care is bigger, a national jewel!”

“Thank you, home care,” they said, now with a smile.
“For once, in your shoes, maybe I’ll walk a mile.
I’ll make a home visit, I’ll assist with a med.
I’ll listen to stories from clients in bed.”

“I’ve a new understanding why you do what you do.
Let’s make a new year that’s bright with a start that’s brand new!”

Return to www.thinkhomecare.org.


OASIS D-Day: Assess Once, Score Twice

December 11, 2018

In less than three weeks, home health agencies will be transitioning from OASIS-C-2 to the new OASIS D assessment. Given all the regulatory changes this year and with the holiday season upon us, it has really been a sprint to get staff trained.

HCA of MA recently held three training sessions for members and not surprisingly there is concern with staff being ready, especially around the nuanced degrees of functional assessments and specifically related to the new items related to mobility and self-care.  While OASIS-D comes advertised as “dropping 28 previous M-Items” from OASIS-C-2, the additional assessments will require lots of creative patient engagement on the part of the admitting nurse or therapist, according to HCA Director of Regulatory and Clinical Affairs Colleen Bayard.

“OASIS-D is intended to begin to standardize patient assessment and quality measures across all post-acute providers,” said Bayard. “But for us in home care some of the new items ask for very nuanced responses. For example, the mobility item (GG0170) has 17 mobility activities that  the clinician must  ‘code’ with a  6-point scale from independent to dependent or  ‘code’ with 4 possible responses related to ‘activity not attempted.’ he admitting clinician is responsible for assessing a patient’s ability to stair climb, pick up an object from the floor and even make a car transfer.

During the Alliance’s trainings, Bayard warned agencies to expect some productivity issues related to the learning curve,  but stressed that the training message across the industry should be: “assess once, score twice.” In other words, be aware of OASIS M assessment questions which track to newly added  GG assessments and use the same assessment to respond to multiple OASIS items in the same category.  Bayard also recommends close auditing or self-monitoring in the initial months, especially related to the responses “patient refused” or “dash” (not attempted). (Ask:  could the clinician interview a family member as a way to get a response?)

Bayard recommends using the “Expansion of the one Clinician Rule” to your advantage because CMS is encouraging an interdisciplinary team approach with OASIS-D. Bayard’s final advice: “As you focus on your training be aware that your nurses are going to need to have a strong intersection of observational skills with interview skills.”

HCA has several places members can come to share and learn as they move past Jan 1. Our Clinical Directors and Quality Improvement list serves and networking groups will be highly focused on OASIS-D as winter turns to spring.  The Clinical Directors next meet Thursday, January 10 and the QI Managers will next meet on January 9th. Meeting information is here. Our email groups are here.

If you haven’t already studied it – here is a list of more than 100 answers to OASIS questions received by CMS from the industry during recent CMS in-person trainings and webinars.

Return to www.thinkhomecare.org.


HCA Submits Comment on Medicare Changes; Submit Your Comments Now!

August 30, 2018

On July 1st, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule which includes several changes to the home health benefit for 2019 and beyond. The public comment period closes this Friday August 31, 2018, at 11:59 p.m. As of this blog posting, 760 comments have been submitted to CMS which is encouraging, but far from the more than 1,300 comments submitted last year in response to the HHGM proposal which was ultimately withdrawn.

You can view the HCA’s written comments here and can download the word document here.

You may submit your own comments to CMS here.

Here are some of the key changes proposed, and an overview of HCA’s response:

Home Health Wage Index Changes

  • The 2019 proposed payment rates increase by 2.1% which represents a $400 million increase.
  • HCA of MA has long expressed concerns to CMS over inequities in how the wage index is calculated for home health agencies compared to hospitals. HCA urges CMS to adjust the 2019 home health agency wage index to reflect a policy to limit the wage index disparity between provider types within a given CBSA.

Proposed Patient Driven Groupings Model (PDGM) for CY 2020

  • Implementation: As the proposed PDGM would mark a major change in the way home health agencies will be reimbursed, the HCA urges CMS to delay implementation by one year to ensure that there is no disruption in access to services for beneficiaries and evaluate the accuracy of the model and its effect.

  • LUPA Thresholds: CMS proposes to set the LUPA visit threshold at the 10th percentile for each payment group. HCA believes this is complex and will complicate the care planning process for home health agencies. HCA urges CMS to retain the current LUPA thresholds and revisit them in future years.

  • Behavioral Assumptions: CMS proposed three ‘behavioral assumptions’ in the PDGM totaling -6.42%. However, these assumptions are not based in data or evidence. HCA believes that two of the three assumptions already exist in the current PPS methodology including; that agencies are already incentivized to both report the highest playing diagnosis codes and to develop and deliver plans of care that exceed the LUPA threshold. This could result in an over estimated impact of behavioral assumptions and the HCA urges CMS to eliminate the Clinical Group Coding and LUPA threshold assumptions.

  • Split percentage payment approach: HCA believes that changing from a 60 to 30 day billing period will be very disruptive to agencies’ operations and increase back-office costs. Therefore, HCA urges CMS to continue the split payment approach at the current 60/40 and 50/50 splits for early and late periods, respectively, to give agencies cash flow breathing room.

  • Certification and Re-certification of Patient Eligibility: HCA has long advocated for regulatory language to align with sub-regulatory guidance as it relates to documentation of the patient’s eligibility. HCA is encouraged by CMS’ proposal to eliminate the requirement that the physician provide an estimate of how much longer skilled services are required and we request that CMS consider revisions to the physician’s burden of the F2F encounter as a condition of payment. 
  • Remote Patient Monitoring: HCA strongly supports the proposal to recognize remote patient monitoring costs as an administrative cost on the HHA cost report. HCA does recommend however that CMS remove the regulation that does not allow remote patient monitoring to be used as a substitute for in-person home health services. 
  • Home Health Value Based Purchasing Model: HCA has long supported the HHVBP model aiming to improve quality by giving HHAs incentives to provide better quality care. However, HCA urges CMS to modify the HHVBP to recognize stabilization in the scoring because in many cases, stabilization (instead of improvement) is an appropriate goal for some patients.

MA Legislative/Regulatory Preview for 2018

January 11, 2018
On Wednesday January 3rd , the Massachusetts Legislature returned for the second year of its two-year session. After a seven-week recess, the body is looking at a traditionally busier second half than the first. The nearly 170 bills that passed in 2017 marked the lowest total in twenty years.

Lawmakers have until July 31 to complete all substantial legislative debate. In addition, all 200 members are up for election in 2018, which is expected to be a distraction from normal legislative work as a result of a polarized political landscape. Here’s what the Alliance will be focused on in 2018:

Workforce Issues:

Prior to the Holiday break, the Alliance met with its ‘Enough Pay to Stay’ partners to strategize coordinated efforts to attain wage relief for direct care workers and ASAP case managers. The coalition has pending legislation which would take steps toward this initiative, but we will pursue other legislative vehicles to fight for our workforce.

Worker Registry:

In November, Governor Baker signed into law the Home Care Worker Registry. This law will establish a worker registry that requires agencies contracting with ASAPs to submit workers’ private information to the state. The law is enacted and subject to regulations. The Alliance and its partners are in active communication regarding next steps toward protecting our members and their workers’ rights.

Licensure:

The FY 2018 State Budget included language that will establish a licensure process for home health agencies providing skilled services. It is unclear at this point when the process to promulgate regulations will begin, but the Alliance will be providing input to the Department of Public Health as these parameters are developed. In addition, Alliance-sponsored legislation that would license private care agencies is still making its way through the legislative process. Under procedural rules, the legislature has until February to report legislation out of committee. The Alliance will continue to advocate for passage of this legislation.

Continuous Skilled Nursing:

In late 2017, MassHealth announced two rate increases for the Continuous Skilled Nursing (CSN) program that totaled nearly 11 million. This was welcomed news, but there remains work to be done. The CSN provider/parent coalition will continue to advocate for the CSN Bill of Rights legislation that would mandate bi-annual reviews of the workforce to ensure safeguards against future crises.

MassHealth Rates:

The Alliance has been informed that MassHealth will conduct a long-overdue review of rates for per-visit nursing, therapies, and home health aide services.  The Alliance will be working to gather data to demonstrate that the current low rates are interfering with agencies’ ability to attract and retain enough workers to meet the demand for services.

MassHealth Reorganization:

MassHealth’s initiative to enroll the majority of members into managed care programs this coming spring will dramatically change the way MassHealth members access home health services, and disrupt many existing provider referral relationships.  The Alliance will continue to work to ensure that MassHealth members retain access to needed home health services, and that agencies are adequately reimbursed for those services.

House of Representative Health Care Bill:

Late last year the Senate passed a health care cost containment bill aimed at curbing costs while maintaining access. It has long been rumored that the House will be embarking on similar initiatives. Though the details are scarce, this legislation could be a vehicle for many of the Alliances priorities in 2018 and we will continue to advocate where necessary.

If you have any questions about the year ahead for advocacy or would like to get involved, reach out to Jake Krilovich, the Alliance’s Director of Legislative and Public Affairs.


Alliance Quoted in Article on Worker Training, Background Checks

December 28, 2016

James Fuccione, former Director of Legislative and Public Affairs for the Home Care Alliance, was extensively quoted in an article in the Springfield Republican today.  The article, “Personal care attendants have less training, checks than other home care workers,” by Shira Schoenberg, Statehouse reporter for the Republican, compares background checks and training requirements for workers in the state Personal Care Attendant program with workers employed by home care agencies that provide services under the Executive Office of Elder Affairs home care program.


State Budget Cuts Impact Home Health Care

December 8, 2016

The Home Care Alliance participated in several calls with MassHealth and Health and Human Services on planned budget cuts from Governor Baker’s administration. In total, the Governor announced $98 million in cuts from the $39.25 billion state budget.

Although there are reductions in home health, there are positive rates increases to report.

After years of advocacy by the Alliance and more recent efforts from a coalition of continuous skilled nursing providers as well as a family-based network called the Mass. Pediatric Nursing Campaign, MassHealth informed the HCA that payment rates for Continuous Skilled Nursing will increase by 2.6%. According to MassHealth, this equates to a $2.2 million bump in rates, which will become effective January 1st, 2017.

For the RN and LPN day and night rates, the increase hovers around a $1 boost in what those agencies currently receive. The Alliance, along with the provider coalition and family-based campaign, will continue to advocate for further adjustments to continuous skilled nursing rates in the upcoming FY18 state budget cycle.

As for home health skilled nursing rates outside of CSN, payment will be reorganized by the length of service of the MassHealth member. As of July 1, 2017, MassHealth is planning to break up the current skilled nursing rate for home health agencies into three separate tiers. The first tier will be for patients on services from day 1 through 30, which will be increased from $86.99 to $89.21. The second rate tier will be 31-180 days and the third rate tier is any home health service beyond 180 days.

MassHealth has indicated that the rates in the second tier will remain relatively static and the third tier will be decreased, but post 30-day rates as of 7/1/17 will be budget neutral from the changes taking effect on January 1st. An announcement from EOHHS will specifically outline the new tiered rates, but according to MassHealth, anything regarding rates that is seen before the New Year is not finalized and therefore subject to change.

The other notable decrease will take effect on January 1st when MassHealth plans to approximate the budget impact of those proposed second and third rate tiers into the current post 60-rate. The cut in the post 60-day rate from 1/1/17 to 7/1/17 will be a 6.75% reduction. This means the current post 60-day rate of $69.59 will be roughly $64.89 for the first six months of 2017. (This rate remains higher than the medication administration rate originally considered by MassHealth.)

Laid out in another way, this will be how rates are currently planned to change:

January 1 – July 1:

Home health services post 60-day rate will be roughly $64.89 (6.75% reduction)

July 1:

Service days 1-30: $89.21

Service days 31-180: Rates will remain roughly the same, but are not yet finalized

Service days 180: Rates will be slightly reduced from the current post 60-day rate, but are not yet finalized.

MassHealth is also streamlining enrollment in the Independent Nursing program to cut their application process from 8 weeks down to one week.

The net state cut for home health is approximately $3.8 million out of $758 million in MassHealth spending on home health care services.

Most of the other cuts announced by the administration are restoring vetoes previously proposed by the Governor in the FY2017 budget, but that were overridden by the legislature. At that time, the Governor vetoed $255 million and the legislature overrode $231 million. Included in these cut overrides are certain hospital supplementary payments (particularly to pediatric and Western MA hospitals) as well as $1.1 million in cuts to public health hospitals.

Other impacted accounts include supplemental payments to nursing homes, which will be reduced by $2.8 million, as well as a $2.8 million cut to adult foster care (AFC).

The Pediatric Palliative Care account (4590-1503) is being reduced by $400,000.

The legislature has already announced their view that Governor Baker went too far with some of the announced cuts and they will be working on restoring some of the funding reductions.

HCA of MA has an upcoming meeting with MassHealth to review the Governor’s proposal.  Also on the agenda are issues with ICD-10 changes that are impacting agency billing and payment.

Return to www.thinkhomecare.org.


CMS to Delay Expansion of Pre-Claim Review Demo

September 20, 2016

CMS announced yesterday afternoon that they are delaying the expansion of the Pre-Claim Review Demonstration for Home Health Services which began in Illinois on August 3, 2016.

According a notice on CMS’s website, based on early information from the problems encountered in Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, they will not move forward with initiating the demonstration in Florida in October.  This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.

According to the notice, CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program. CMS will therefore take additional time prior to expanding to other states.   The start dates for Florida, Texas, Michigan, and Massachusetts have not been announced; however, CMS will provide at least 30 days’ notice on this website prior to beginning in any state.  CMS continues to expect a staggered start, beginning with Florida.

The Alliance has been working closely with the state associations in the other demonstration states and national home health groups to advocate for major changes to the project.  Building off of this short-term victory, HCA will continue those efforts and is also briefing our Congressional delegation on the issue. HCA will, of course, keep members informed of any changes in the demonstration.

Return to www.thinkhomecare.org.


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