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News Roundup: June 10, 2016

Experts Recommend Changes to Home Health Star Ratings

Published by Home Health Care News
By Mary Kate Nelson
June 10, 2016

There’s plenty of room for improvement when it comes to the methodology, clarity and accessibility of Home Health Quality of Patient Care star ratings.

That was the consensus among the Home Health Quality of Patient Care Star Ratings Technical Expert Panel (TEP), convened by Abt Associates in early May. The Centers for Medicare & Medicaid Services (CMS) contracted with Abt to convene the panelists, a group of home health executives, consultants and academics tasked with reviewing the first year of data on the performance of the Quality of Patient Care star ratings—as well as making recommendations for revising them.

The Quality of Patient Care star ratings, separate from the Patient Survey Star Ratings, summarize home health agencies’ performance on nine quality measures that indicate how well they help their patients in regaining or maintaining important functional abilities, and how frequently they adhere to evidence-based processes of care.

Among their recommendations, the TEP proposed revamping the way the Quality of Patient Care star ratings are calculated, reconsidering which data sources are included in the rating methodology and clarifying the ratings’ meaning for consumers.

Keeping end-goals in mind

Specifically, the TEP expressed concern that the current methodology for calculating the star ratings may not be properly taking into consideration the diversity of home health patients, including patients whose end goal is to remain stable, not to improve.

The recommendation to explore this distinction has been met with enthusiasm from industry stakeholders.

“I feel this will truly allow home health care agencies to be accurately differentiated from each other,” Michele Berman, director of rehabilitation at BAYADA Home Health Care, told Home Health Care News. “Of all the recommendations, this is the biggest win.” BAYADA is a privately held, New-Jersey based company that operates in 22 states.

The TEP also raised concerns about consumers’ general understanding of the Quality of Patient Care star ratings, noting that while the ratings are a tool meant to help patients and their families pick a home health agency, consumers may confuse the ratings with the Patient Survey star ratings, and they may not realize the Quality of Patient Care star ratings are essentially rated on a curve, so there aren’t 4- or 5-star agencies in every market.

The experts also poked holes in the star ratings’ methodology. The payer mix at a home health agency appears to be driving the agency’s star ratings performance, the TEP explained. Specifically, patients who are the easiest to manage are reimbursed at the highest Medicare fee-for-service rates, and agencies that serve patients who are more difficult to treat typically have lower ratings.

These trends may disincentives providers to care for difficult-to-treat populations, the TEP said.

“I do absoltely agree that we can see that, and that is absolutely worth exploring,” Gina Mazza, partner and director of regulatory and compliance services at Fazzi Associates, told HHCN.

The star ratings should also incorporate changing payment and care delivery initiatives, such as value-based purchasing, the TEP said. New measures emerging from the IMPACT Act would be beneficial for inclusion in the Quality of Patient Care star rating methodology, the TEP explained.

Mazza agreed.

“I think that makes a lot of sense,” she said. “The burden on agencies is tremendous if they have to keep track of different programs with different requirements, even though they all have the same goal.”

Clearing up confusion

Though there has been some confusion among consumers about the different types of star ratings in the past, TEP members recommended against combining the Quality of Patient Care and Patient Survey star ratings. Instead, TEP agreed, there should be a focus on clarifying the difference between the two types of ratings to consumers.

Mazza, however, has complicated feelings on the matter.

“I have mixed reviews on that, because i think it is hard for the consumer as well as the agency to understand data collection periods between the two, and they have different methodologies,” Mazza said. “I do think adding clarity to the definitions is very much needed.”

The functionality of the Home Health Compare website should also be improved, the TEP said. To start, Home Health Compare should enable the comparison of more than three agencies at once, and enable consumers to search and sort agencies based on star ratings and categories of interest.

Overall, the TEP’s recommendations accurately reflect the desires of home health agencies across the country, Berman said.

“I feel like the TEP really did a good job in identifying a lot of the issues that really echo what many of the home health agencies feel,” Berman said. “I think it really represents the gamut well of what we would like to see.”

Despite stakeholder outcry, CMS launches home health prior-authorization demo

Published by Modern healthcare
By Virgil Dickson
June 10, 2016

Despite outcry from industry stakeholders, advocates and beneficiaries, the CMS is moving forward with a three-year demonstration in which beneficiaries from five states would need to get prior approval before they get home health services.

The demonstration will launch in Florida, Illinois, Massachusetts, Michigan and Texas—states that are all tagged by the CMS as having high levels of improper payments.

The pre-claim review demonstration will begin in Illinois on Aug. 1, and the remaining states will phase in this year and next.

Under this demonstration, once home health services are ordered by physicians, the Medicare beneficiary can still immediately receive Medicare's home health services. However, the home health agencies must submit supporting written evidence earlier than they normally would.

"CMS will help make sure that home health services are medically necessary without delaying or disrupting patient care or access," the agency says of the approach.

Medicare will review the documentation to determine if all coverage requirements for home health services are met and will issue a pre-claim review decision generally within 10 days. If a claim is ultimately rejected, the agency can appeal.

In 2015, 59% of home healthcare payments, or more than $9 billion, were “improper.” The improper payment rate was 17.3% or $3 billion in 2013.

An improper payment can occur when funds go to the wrong recipient, the right recipient receives the incorrect amount of funds, documentation is not available to support a payment or the recipient uses funds in an improper manner. The tally includes fraudulent claims but is not a measure of fraud.

Prior to formally launching the effort, the CMS received comments from the public and the response was generally negative.

The pre-claim review “might be one more disincentive for home health agencies to provide services to people with more than the usual short-term, limited-service need," said Matthew Shepard, spokesperson for the Center for Medicare Advocacy.

Industry stakeholders have said the proposed demonstration could punish home health agencies that don't have a history of fraud.

The CMS estimates that administrative costs for industry will be $21.6 million for the first three years. However, getting the project off the ground will cost the federal government more than $300 million.

Home care services can keep people out of hospital

Published by Carroll County Times
By Jon Kelvey
June 10, 2016

Skilled health services provided at home, or home health care, can be an important tool for people who have recently had surgery or have health issues that make it difficult to leave the home, but people first need to know what services are available, said Jennifer Windesheim, director of home care operations at HomeCare Maryland.

"It's prescribed by a physician and paid for by Medicare or commercial health insurance," Windesheim said. "The most common services are nursing care or physical therapy, but we also have occupational therapy, speech therapy, home health aids and social worker services."

While home care services typically do not provide custodial services, such as bathing or feeding, Windesheim said they can do a wide variety of other tasks aimed at helping people recover from surgery or illness.

"Therapists can provide services for any patient who has a joint replacement or has deconditioning while they are in the hospital, so they can do strength building and develop a home exercise program for them to help them get back to their baseline," she said. "Our goal is to keep patients out of the hospital, to educate them on ways to care for themselves in their home, to prevent any readmissions if they came from the hospital or even an admission to a hospital."

This can lead not only to better health outcomes, but to less expensive care, according to Windesheim, especially since Medicare typically covers the full cost of doctor prescribed home care services and most commercial plans include benefits as well.

"The goal is for patients not to spend as much time in the hospital, and to also look at our population and our community needs," she said. "It's been found that home care can provide the best service at the least cost to individuals and to be able to meet their needs where they are, in their environment."

While the population served by home care services tends to be older adults, Windesheim said there are also pediatric and behavioral health services available.

"People just need to understand that we are here, that we are available to them, and we are willing to come out and evaluate patients," she said. "[They should] discuss it with their physician if they feel like they need services."

More information about HomeCare Maryland, which offers home care services in Carroll County, can be found at

MedPAC, CBO urged to use commercial data in judging telehealth's effectiveness

Published by Modern Healthcare
By Joseph Conn
June 10, 2016

A host of healthcare organizations and individual healthcare providers that advocated for expanded telemedicine want federal budget and Medicare payment advisers to look outside the Medicare program for evidence of the benefits of telehealth.

Twenty-two health systems and other organizations and individuals sent a letter to Keith Hall, director of the Congressional Budget Office and Mark Miller, executive director of the Medicare Payment Advisory Commission. They asked the two officials influential in setting Medicare program reimbursement policies “to look to evidence of telemedicine's effectiveness from the commercial sector, the Department of Veterans Affairs, Medicaid, and other programs when producing future cost estimates and analyses of telemedicine utilization in the Medicare program.”

While more specialties and regions that have staffing shortages are adopting the practice of telemedicine and more insurers are paying for it, its expansion has been slowed by both medical licensing laws and overall reimbursements.

But in 2014, the Federation of State Medical Boards cautiously expanded support for using certain technologies for remote patient-physician encounters, including initial visits.

Those recommendations, though not binding on its member states' medical licensing boards, have helped serve as a catalyst for wider acceptance of telemedicine nationally by medical regulators and state legislatures.

Today, 29 states and the District of Columbia have private telehealth coverage laws. That number is expected to grow to 32 states by 2017, according to a National Conference of State Legislatures estimate.

Medicare, the 800-pound gorilla of healthcare bill payers, is moving slower. In 2014, it proposed adding a slight expansion of payment rules to include telehealth wellness and behavioral health visits, and for telehealth services in rural areas nearer big cities than previously allowed.

But in 2015, Medicare paid out just $17.6 million for telemedicine services, a miniscule amount compared against the $546 billion in total Medicare expenditures that year.

As a result, there's simply not a lot of data within the Medicare program about the cost and clinical effectiveness of telehealth, a fact the letter writers both acknowledge and propose to address.

“The lack of Medicare data is understandable given the outdated statutory restrictions on telemedicine: since federal law prevents many providers from being paid when they use telemedicine to serve Medicare beneficiaries, obviously, little data is available,” they said. “There is, however, substantial experience utilizing telemedicine outside Medicare. Combined, we have authored many studies showing its quality and cost-effectiveness in fee-for-service as well as managed care environments.

“We hope CBO and MedPAC will consider these alternative sources of evidence in producing future cost estimates and analyses of telemedicine utilization in Medicare,” they wrote.

Organizations that signed on to the missive include Ascension Health, Christus Health, the Evangelical Lutheran Good Samaritan Society, the Scripps Translational Science Institute, Stanford Health Care, the University of Virginia Medical Center and the telehealth centers at the University of Mississippi and the UMPC system.

Individual signatories include Dr. Joseph Kvedar, vice president of the Connected Health program at Partners HealthCare, Boston; and Dr. Jack Lewin, CEO of the Cardiovascular Research Foundation and chairman of the National Coalition on Health Care, a not-for-profit coalition of healthcare and other organizations attempting to rein in soaring healthcare costs.

A few years ago, recalls Kvedar, Partners conducted a year-long study using telemonitoring to stay connected in the first two months of the program with about 300 of its congestive heart failure patients. The study provides a good example of telehealth efficacy that CBO and MedPAC officials might want to know about and consider.

“We have shown that a well-run heart telemonitoring program in our hands reduces readmissions by 50% and mortality by another 40%,” Kvedar said.

“The skeptics might say, (while) you may be avoiding readmissions, you may be driving up other costs,” Kvedar said. But the Partners study team covered that base, calculating that even with increased visits and the cost of running the monitoring program, the total medical expenses of the monitored patients was 14% lower than a similarly sized cohort of CHF patients without the early monitoring.

In cardiology, “I think we're going to transform a lot of what's going on over the next decade” to bio-monitoring and other remote communication techniques, Lewin said.

Even today, follow-up care after a discharge for an angioplasty or by-pass surgery is “really important,” Lewin said. “One of the most dramatic problems we have is adherence to medications.” But 60% of heart patients prescribed antiplatelet drugs to reduce blood clotting aren't taking them two months later, Lewin said.

“At some point or another asynchronous medicine may be the way to go,” Lewin said.

As Medicare and other payers continue to move toward value-based reimbursement, where readmissions produce penalties, not added revenue, “The motivations to do these things will be very strong, but we need to have it reimbursed,” Lewin said.