Mandatory Participation Ending for Several CMS Initiatives Related to Home Health

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Rhonda Perrin Oaks, RN, CHP By Rhonda Perrin Oakes, RN, CHPN 
Regulatory Analyst, Change Healthcare
Changing Home Health Care Mandates

Mandatory participation will end for Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) incentive payments, according to a recent filing by the Centers for Medicare & Medicaid Services (CMS). But that doesn’t mean your home health organization should suspend its efforts to partner with hospitals and other care providers.

CMS also proposed several changes for the Comprehensive Care for Joint Replacement (CJR) model:

  • Giving hospitals participating in the model a one-time option on whether to continue
  • Refining certain payment, reconciliation and quality provisions
  • Increasing the number of clinicians who qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track
  • Reducing the number of participation areas from 67 to 33
  • Making participation voluntary for low-volume and rural hospitals

The changes were widely expected, as CMS moves from mandatory participation in care models to voluntary participation. Many providers, especially those in the mandated participation areas, expressed concern over the speed of change to episodic payments. Episodic payment models provide a set dollar amount for care based on a patient diagnosis, leaving hospitals and affiliated providers to divide the money based on the level or intensity of services provided during that episode.

Closer look at CJR

Of the proposed changes, those affecting the CJR model are most likely to hit home health organizations. The model, which went into effect April 1, 2016, relates to episodic payments and quality assessments for certain hip and knee replacement procedures.

As the lowest-cost provider among post-acute care options for CJR procedures, home health remains ideally suited to participate in bundled payment models. It’s also important to mention that patients prefer in-home services to those performed in in-patient rehabilitation facilities or skilled nursing facilities.

Research shows that Medicare paid about $5,000 less per care episode for lower extremity joint replacement when home health was used, compared to other post-acute care settings. What’s more, readmission rates were shown to be less when home health was used (5%), compared to those receiving in-patient rehabilitation (12%-15%).

More good news

Overall, the Bundled Payments for Care Improvement (BCPI) initiative has placed the home health industry in a positive light. Independent analysis on Year 2 of BCPI Models 2-4 demonstrated an increase in the use of home health, coupled with a decrease in the use of institutional post-acute care services. Looking at cardiovascular surgery patients who received post-acute care, those going to institutional settings declined by nearly 20%.

The report covered these models:

  • Model 2, the most comprehensive, includes the hospital stay and all concurrent professional services and post-discharge services for either 30, 60 or 90 days, including readmissions.
  • Model 3 begins when the hospitalization ends with a referral to a post-acute care provider, includes professional services and runs 30, 60 or 90 days, including readmissions.
  • Model 4 includes hospitalization, concurrent professional services and readmissions within 30 days of discharge that are not specifically excluded from the bundle.

You may be breathing a sigh of relief to find that your home health organization no longer has to participate in these bundled payment and episodic payment models. But don’t forget that hospitals still face increased pressure to improve care quality at a lower cost. They still will be looking for care partners who can show demonstrated quality, and home health has been shown time and again to be the lowest-cost post-acute care setting.

One Response to Mandatory Participation Ending for Several CMS Initiatives Related to Home Health

  1. Lorri says:

    Making a care plan for seniors is more necessary now than ever. You can’t expect to jump into hiring a caregiver and go on with it. Health care is a serious and sensitive issue. Thank you for sharing the blog. It’s a nice read.

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