CMS introduces new Pre-Claim Review Demonstration proposal

Yesterday, the Centers for Medicare & Medicaid Services (CMS) announced a request for public comment on a new Pre-Claim Review Demonstration proposal. The new demonstration proposal offers home health agencies in the five proposed demonstration states three different options for payment. Under the new proposal, agencies can choose either potential full payment with pre-claim or postpayment reviews, or agencies can choose to forego the review process altogether with a 25 percent reduction in payments on all home health claims submitted. Agencies that choose the third option and payment reduction may still be eligible for review by Recovery Audit Contractors (RACs). The unpublished memo is currently available here, while the published version will appear on Thursday, May 31st in the Federal Register here.

The five states included in the new proposal are: Illinois, Ohio, North Carolina, Florida, and Texas. Ohio and North Carolina are new additions to the current proposal, replacing Massachusetts and Michigan in the original demonstration. The original demonstration did begin in Illinois in 2016 but was paused on April 1, 2017 and never re-started. At the time, CMS provided a brief Q&A on the pause here.

As in the past, the Alliance will be working with our membership as well as colleagues across the industry, to formulate a comment letter to CMS. You can read the Alliance’s comments to the Office of Management and Budget (OMB) from 2016 on the original PCRD proposal here. In those comments, the Alliance highlighted concerns related to the burden on home health agencies, process consideration, and legal authority.

CMS is said to be providing further updates this week so stay tuned for more information.

Alliance members interested in joining the discussion on PCRD and other regulatory and legislative efforts, as well as clinical and quality improvement should reach out to the Alliance’s Director, Policy Communications & Research, Jen Schiller at, to join the Alliance’s monthly Quality & Innovation Work Group.

What’s in A Star Rating?

Co-authored by the Alliance and Visiting Nurse Associations of America

Over the past few months, the Centers for Medicare and Medicaid Services’ (CMS) introduction of patient experience survey star ratings to Home Health Compare, as a way to better understand the overall patient experience with care provided through Medicare-certified home health agencies, has gained a lot media attention.

While the jury is still out on the star ratings as a whole, home health agencies recognize that both quality of care and patient experience are critical. Agencies are learning from the issuance of the star ratings and are committed to improving their performance on both quality of care and patient experience.

Outlined below, the Alliance and VNAA breakdown the top five takeaways from the Patient Survey Star Ratings:

  1. The new patient survey star ratings do not replace, but instead are in addition to, the Quality of Patient Care Star Ratings used to describe the quality of clinical care provided by a Medicare-certified home health agency.
  2. Health care is moving towards a system that rewards value over volume and more readily engages consumers; as such, performance data will become increasingly important.
  3. The Home Health Compare Star Ratings are the first step towards streamlining communication regarding home health quality and patient experience in a way that is digestible to health care consumers.
  4. The discrepancies in the patient and quality ratings among individual agencies stem from several factors, including the limitation of the Medicare home health benefit, as well as the understanding of skilled versus non-skilled home health health services. For example, Medicare home health care provides skilled, clinical care, not services such as meal planning and house cleaning. Unfortunately, there is a disconnect for many patients when those needed non-clinical services are not met by their home health care team, despite receiving excellent clinical care.
  5. The patient experience survey is a positive step in the right direction, and is essential to capturing the overall home health care experience, but CMS must refine its metrics to capture more accurate data.

As organizations committed to advancing home health care, the Alliance and VNAA stand ready to work with the Administration to perfect the use of patient survey data so that it is balanced with necessary quality data.

Celebrating Women in Home Health Care

Happy International Women’s Day!

Women are vital to home health care, both as employees and patients, and today we celebrate the contributions of women in the industry and the patients who benefit from their care.

The National Women’s History Museum credits Lillian D. Wald, founder of what is today the Visiting Nurse Service of New York, with inspiring the New York Board of Health to organize the first public nursing system in the world.

Nationally, women are tremendous assets to our healthcare industry, and this is especially true for home health care. In 2014, a whopping 88.6% of persons employed in home health services were women; that’s over a million women employed in the industry! Nationwide, women make up roughly 47% of the workforce, and while women are more likely to work in the health care industry writ large (78.6%), home health care is still even more female-dominated than the industry as a whole. Within the Bureau of Labor Statistics’ “health care and social assistance” industry marker, home health care services employ the second greatest percentage of women.

It’s not just in the workforce where women are prominent. Looking at information from the 2015 Home Health Chartbook, home health patients are also more likely to be women, with females comprising 61.5% of home health users (compared with 54.6% of all Medicare beneficiaries). Women actually comprise a smaller percentage of home health users than males under age 85, but over a quarter of female home health users are over 85.

Diving deeper into the demographics, women are three times more likely than their male counterparts to be widowers, while less than a third are married. Women who receive Medicare home health services are also much more likely than male users to have an income below $25,000 a year.

According to the Kaiser Family Foundation’s 2009 fact sheet on “Medicare’s Role for Women” across the Medicare population, women are more likely than men to suffer from arthritis, hypertension, and osteoporosis. Almost 50% of women, compared with 38% of men, suffer from three or more chronic conditions. That same paper noted that while Medicare plays a critical role for women, women are still more likely than men to spend a greater share of their incomes on medical care. It is therefore crucial to continue finding ways to both ensure funding of the program and new innovation and models to help women face the challenges posed by a rapidly aging population.

Home health care is shaped very much by women, as patients, providers, and innovators. Today we thank them, and look forward to their continued role in molding the home health care delivery system of the future.

CMS Continues Advancing Alternative Payment Models

Alternative models of payment are a trending topic for the Centers for Medicare and Medicaid (CMS) as the agency hits the half-century mark. Given that the Secretary of Health and Human Services has specified a goal of moving 50 percent of Medicare payments to alternative payment models within the next two years, the health care system—and home health care as part of it—lies at a critical juncture. It is more important than ever to understand these new models, and several recent publications shed critical light.

In the November 19th issue of The New England Journal of Medicine, Paul Ginsburg and Alice Rivlin explored the challenges facing CMS in a changing healthcare delivery environment (available here). Given CMS’s commitment to alternative payment models and quality care initiatives, the health care delivery landscape of the future appears to be approaching more quickly than ever, and Ginsburg and Rivlin see this as an opportunity to improve both quality and efficiency.

Though CMS has been clear about making bundled payment arrangements a high priority alternative payment model, there are multiple programs and approaches that are testing bundled payments. The Center for Medicare and Medicaid Innovation’s (CMMI) Bundled Payment for Care Improvement (BPCI) initiative. BPCI aims to change both the delivery and payment of health care services, and consists of four different models under which the initiative operates. Models 1 and 4 refer to inpatient acute care hospital stays alone, but models 2 and 3 include either inpatient stay plus post acute or post acute care only. Health Affairs recently issued their policy brief focused on BPCI and the opportunities, concerns, and early findings from the program. The full brief is available online here.

Although BPCI is still underway, the newly finalized Comprehensive Care for Joint Replacement (CJR) Model will quickly disseminate bundled payments across the country. Starting on April 1, 2016, hospitals in 67 geographic, or metropolitan statistical areas (MSAs), will be mandated to bundle payments for all traditional Medicare MS-DRG 469 and 470 cases. The episode begins with the admission to a participating hospital and includes the 90 days of care post-discharge for all services paid under Medicare Parts A and B, with limited exceptions. The final rule for the CJR Model is available in the Federal Register here. The CJR model does not apply to those already in BPCI Models 1, 2, or 4.

Bundled payment and other alternative models of payment provide unique challenges and opportunities for home health care. The focus on higher quality, lower cost care puts home health care in a critical place in the health care delivery system. In general, home health care is least costly and patient preferred in post-acute care, and therefore of increasingly recognized importance.

As the healthcare landscape, and especially Medicare, continues to reinvent itself and push toward alternative models of payment and delivery, providers, policymakers, and those at CMS must continue to work together to ensure that quality care is not sacrificed for cost-effectiveness, and that patient-centered care remains at the forefront of this mission.

Alliance and Peers Announce Formation of Home Health and Hospice ICD-10 Transition Workgroup

On October 8th, leading home health and hospice associations, including the Alliance, joined with the Centers for Medicare and Medicaid Services (CMS) ICD-10 Ombudsman Dr. William Rogers to form the Home Health and Hospice ICD-10 Transition Workgroup.

The purpose of the workgroup is to streamline the process for ICD-10 transition and act as a conduit for addressing questions and concerns regarding the transition.

ICD-10 is the latest coding set for the diagnoses of all patients protected under the Health Insurance Portability Accountability Act (HIPAA), and is used across the U.S. healthcare continuum. It is a seven-digit coding structure, which replaced ICD-9 on October 1, 2015.

Last month, the Alliance submitted comments to CMS regarding concerns with the transition to ICD-10, including concerns about the lack of “transition flexibility” for home health agencies and other post-acute care providers, and confusion over coding of the seventh character for home health.

In addition to the Alliance, the group will include the Association for Home Care Coding and Compliance (AHCC), the National Association of Home Care & Hospice (NAHC), the National Hospice and Palliative Care Organizations (NHPCO), and the Visiting Nurses Association of America (VNAA) will also serve on the workgroup. AHCC will serve as the main conduit between this workgroup and CMS, consulting with the Board of Medical Specialty Coding (BMSC) to resolve ICD-10 issues. AHCC and BMSC are both part of Decision Health, a company that provides news, analysis resources and training for home health and hospice professionals.

The Alliance would like to invite all community members to reach out with questions and concerns for the workgroup. You can reach the Alliance’s Executive Director Teresa Lee at

Dr. Rogers is welcoming all industry members to reach out with questions and concerns individually, however, those previewed by the workgroup first may see accelerated response times. Dr. Rogers can be reached directly at

For more information on ICD-10, check out CMS’s website:

Optimizing Home Health Care: Enhanced Value and Improved Outcomes

This spring, the Alliance for Home Health Quality and Innovation released an electronic supplement to the Cleveland Clinic Journal of Medicine, “Optimizing Home Health Care: Enhanced Value and Improved Outcomes.” The supplement features six research articles from leading home health experts, and can be read in its entirety here.  Physicians can also seek Continuing Medical Education (CME) credit online related to three of the journal articles and free of charge, by clicking here.

In a continuing effort to educate the care community on the value of home health, the Alliance is issuing a series of one-page documents for each article. The first in the series summarizes the article, “Home-based care for heart failure: Cleveland Clinic’s ‘Heart Care at Home’ transitional care program.” The article focuses on potential value for home care in treating patients with chronic heart failure (HF).

Article Highlights

  • Heart Care at Home, a program initiated by the Cleveland Clinic in 2010, seeks to minimize possible risks in the transition of HF patients from inpatient to home care.
  • As part of the program, home care liaisons visit HF patients approximately two days following discharge from the hospital into the home to teach patients how to use their telehealth equipment.
  • HF patients, in the Heart Care at Home program, receive weekly contact and monitoring from telehealth nurses for 30-40 days after the program begins.
  • Home care nurses are trained specifically to work with HF patients and telehealth technologies.
  • The program yielded high success in 30 day readmissions rate, which were nearly four percent lower for first-time enrollees in Heart Care at Home versus publicly reported Cleveland Clinic rates.

To access the one pager please click here.

Connecting Home Health Care to the Care Continuum: Thoughts from Pamela Duncan, Wake Forest Baptist Medical Center

Recently, the Alliance for Home Health Quality and Innovation profiled healthcare innovator Pamela W. Duncan, Ph.D. as part of the new Revolutionizing Healthcare-at-Home series, in an article titled, “Connecting Home Health Care to the Care Continuum.” One of the goals of this new series is to showcase how the innovative use of home health can improve the lives of patients and improve healthcare outcomes.

Dr. Duncan currently serves as a professor of neurology at the Sticht Center on Aging, Geriatrics & Gerontology at Wake Forest Baptist Medical Center and an Innovation Advisor for The Center for Medicare & Medicaid Innovation. Her most recent project for the CMS Innovation Advisors Program focuses on transitions for patients with congestive heart failure, looking at streamlining the transition between hospital and home health.

Article Highlights

  • Dr. Duncan’s work looks at health care in the context of a cohesive community of care, with home health playing a significant role in a patient’s disease management and the transition from hospital to home.
  • As the intermediary in the transition, home health offers both clinical care and connections to community resources—critically linking acute care treatment with at-home recovery.
  • While the data from the program is still new, Dr. Duncan says she has seen significant reductions in rehospitalizations using cross-continuum collaboration.
  • Creating transitional care programs like the one implemented by Dr. Duncan may help providers and health systems save time, energy, and money while improving patient outcomes.
  • In order to better utilize home health for care transitions to primary care and community-based resources, Dr. Duncan suggests that home health providers should place a greater emphasis on education and improving relationships with other members of the care continuum.

To read the full profile, please click here.

Alliance and Cleveland Clinic Journal of Medicine Host Capitol Hill Briefing

Guest Author: Steven Landers, MD, MPH
President and CEO, VNA Health Group
Board of Directors Chairman, Alliance for Home Health Quality and Innovation 

This past Tuesday, I had the privilege to moderate a Capitol Hill briefing as part of a collaboration between the Alliance for Home Health Quality and Innovation and the Cleveland Clinic Journal of Medicine. The briefing focused on home health and its overall value to the health care delivery system, through a discussion on a supplement and corresponding Clinical Medical Education (CME) program in partnership with the Cleveland Clinic.

The supplement, titled, “Optimizing Home Health Care: Enhanced Value and Improved Outcomes”, compiles articles from distinguished physicians, nurses and academics, who are experts in delivering health care at home. This research represents the Alliance’s support of peer-reviewed work demonstrating how home health can be used more effectively to address patient needs, improve outcomes, and lower costs in the Medicare system.

Fellow panelists included:

  • Peter Boling, MD, Chair, Division of Geriatric Medicine, Virginia Commonwealth University
  • Michael Fleming, MD, FAAFP, Chief Medical Officer, Amedisys, Inc.
  • Mark Froimson, MD, MBA, President, Euclid Hospital, Cleveland Clinic Health System
  • Eiran Gorodeski, MD, MPH, Heart and Vascular Institute, Cleveland Clinic Executive Director
  • Margherita Labson, RN, MSHSA, CPHQ, CCM, Executive Director, Home Care Program, The Joint Commission

Below are a few highlights and key points from the information packed hour:

  •  The Amedisys care transitions initiative decreased the average 12-month readmission rate from 17 percent to 12 percent.
  • The VCU Medical Center implemented a hospital-based transitional care program (TCP) 12 years ago that has served more than 500 patients.  This program resulted in a decreased use of hospital resources— including fewer inpatient days, shorter lengths of stay, and fewer intensive care unit days— after enrollment in the TCP.
  • A home-based care path following Total Knee Replacement reduces the patient’s hospital stay and lowers readmission rates.
  • The Heart Care at Home program helps patients avoid the “black hole” of returning home after hospital discharge with complicated medication regimes and restrictions through visits with home care nurses and the use of telehealth.
  • Palliative care and home health can work in tandem to reduce pain and manage symptoms while still pursing curative or life-prolonging treatments. Two programs- Kaiser Permanente’s In-Home Palliative Care Program and Sutter Health’s Advanced Illness Management (AIM) program have been successful in their efforts. The Kaiser program delivers all service into the home and contributed to increased patient satisfaction and an average cost savings of $8,000 per person and a 52% reduction in readmission rates heart failure patients.

If you missed the briefing, please visit to view the webcast and materials. We will also be bringing you a detailed blog post on each of the author’s articles in the coming weeks, so please be sure to check back here for updates!