Talking Home Care: PDGM’s First 30 Days

Pat Kelleher moderates a discussion among three leading experts about the first month of PDGM. Slides available at https://www.thinkhomecare.org/pdgm-slides

Attaya, Ashworth, Seabrook, and Kelleher

Medicare’s Patient-Driven Groupings Model (PDGM) system went into effect on January 1, 2020. How has the industry fared in the month since the “most significant regulatory and reimbursement reform” in recent memory?

For the 12th episode of the Talking Home Care podcast, we put that question to a live panel of three of the nation’s leading experts at the Northeast Home Health Leadership Summit: Chris Attaya of Strategic Healthcare Programs, Stacy Ashworth of Select Data, and Nick Seabrook of BlackTree Consulting. Slides from the discussion are available for download.

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You may listen to the podcast by clicking any of the platform images above, clicking “play,” or downloading it directly (Length: 70 minutes; Size: 31 MB). If you enjoy the podcast, please give us a five-star review so others can find it.

Host: Patricia Kelleher is the Executive Director of the Home Care Alliance of Massachusetts.

GuestsChris Attaya is the Vice President, Product Strategy of Strategic Healthcare Programs. Stacy Ashworth is the Executive Vice President of Clinical Innovation of Select Data. Nick Seabrook is the Managing Director & a Founding Member of BlackTree Consulting.

Return to www.thinkhomecare.org.

Behavioral Adjustments Under Early PDGM

NAHC’s Bill Dombi replies to reports that patients across the country are being told they no longer qualify for certain Medicare services or that services have been cut or discontinued.

Kaiser Health News and other health care media outlets are reporting that patients across the country are being told they no longer qualify for certain Medicare home health services or that services have to be cut back or discontinued due to changes in Medicare scope of benefits.  On a call with state home care association executives this week, Bill Dombi, President of the National Association for Home Care and Hospice confirmed that they are hearing of such cases from patient advocacy groups, such as the Center for Medicare Advocacy.  If such behavior gives the industry “a reputation for putting bottom line ahead of patient care, it’s going to be bad long term for the home care industry,” said Dombi.

In terms of any shortcoming with the PDGM model, he said,  we want to be able to lay these at the feet of the model’s crafters at CMS, not having them come back at us for over adjusting behaviors even beyond what was built into the model. He further suggested that until proven otherwise it might be case of managers and field staff inaccurately translating direction from management as to what has changed. He suggested CMS might need to do some more education around what has changed (payment) and what has not (coverage).

NAHC will present a series of six new webinars – free to members and non-members – on PDGM in Real Time featuring an open forum in which attendees can share and gain insights with Home Care & Hospice Financial Managers Association (HHFMA) experts about what is working and not working in the early weeks of PDGM.

These webinars are designed to enable home health agencies to achieve “high performer” status through continuous operational improvements in financial, clinical, business analytics, and administrative operations as PDGM unfolds.

The schedule for the Wednesday webinars at 1 PM ET is as follows:

  1. February 12 at 1:00 PM ET Info Tech/EMR readiness
  2. February 19 at 1:00 PM ET PDGM coding
  3. February 26 at 1:00 PM ET PDGM cash flow & LUPAs
  4. March 4 at 1:00 PM ET Therapy in PDGM
  5. March 11 at 1:00 PM ET Clinical management of patient episode
  6. March 18 at 1:00 PM ET PDGM data analytics

Registration information can be found here.

Advocate and Engage on PDGM

There are many ways that home health agencies will need to prepare their agencies for the radical changes coming from PDGM in January 2020. The Alliance is here to help.

Last month, the Centers for Medicare & Medicaid Services (CMS) issued its proposed rule for 2019 home health payment rates and policy changes, which includes significant provisions that will impact your organization, staff, and the patients you serve.

Between now and when the Patient Driven Grouping Model (PDGM) goes into effect on January 1, 2020, there are multiple ways that home health agencies will need to prepare their agencies for the radical change. (See Coding and Billing webinars coming in September, at the bottom of this page) At the same time, home care must take action to mitigate the impact of what PDGM will look like and how it will impact organizational viability.

Home care’s collective advocacy efforts have undeniably made a difference in the past, including putting a stop (at least in Massachusetts) to the Pre-Claim Review Demonstration and scrapping the Home Health Groupings Model thanks to more than 1,200 comments submitted to CMS last year. The more that CMS and lawmakers hear from home health professionals, the better our chances are at reducing the severe cuts that accompany PDGM in its proposed form.

As currently proposed, the 2020 rule will:

  • Reduce the Medicare base rate by 8.01% next year, which amounts to a $1.298 billion reduction in home health payments in 2020 alone. CMS proposes the reduction to account for anticipated changes in provider behavior that are unrelated to changes in patients served or services delivered that increase payments. This newly proposed “behavioral adjustment” reduction is up from the 6.42% reduction that CMS initially proposed, and the reduction would start before any actual behavioral changes occur.
  • Phasing out RAPS over 2020 with total elimination of RAPs in 2021. Next year, CMS proposed reducing RAPs from 60/50% to 20% for existing home health agencies (HHAs), while new agencies would get no RAP. CMS claims that RAPs create fraud risks.
  • Starting in 2021, a Notice of Admission (NOA) must be submitted Notice of Admission must be submitted within five days of the start of care. For every day late, CMS plans to reduce base-rate reimbursements for the unit of care.

The Solution: Pass S.433/H.R.2573

This month, Congress is in recess and back in the states, which presents a pivotal opportunity for home health industry professionals to engage with lawmakers about a key legislative priority – the Home Health Payment Innovation Act (S.433/H.R.2573).

This legislation prohibits CMS’s ability to adjust payment based on “behavioral assumptions” as opposed to observed evidence of behavioral changes, thus rescinding the proposed 8.01% adjustment.
Additionally, this important legislation would:

  1. Achieve full budget neutrality over the period of 2020-2029.
  2. Require behavioral adjustments based on real, actual changes in provider behavior in response to the new payment model.
  3. Permit a phase-in of rate adjustments (up or down) when an annual adjustment would be greater than 2 percent. However, the phase-in would operate to ensure full budget neutrality by 2029.

Email your Members of Congress

It’s not too late to get members of Congress informed and engaged on this important legislation. You can send an email directly from HCA’s member advocacy center.

At this point, Congressman Jim McGovern is the only member of the MA delegation signed on as a cosponsor. We must do better.

Fact Sheet: Senate 433 & HR 2573

Advocate in Person

Join home health industry advocates next month in Washington, D.C. for The Council of State Home Care Associations’ Third Annual Public Policy Summit and Advocacy Day!  On September 9, participate in a full-day summit featuring speakers including Hillary Loeffler, Director of the CMS’ Division of Home Health & Hospice.  On September 10, we be on Capitol Hill meeting with members of Congress to convey the critical need to pass S.433/H.R.2357.

Program details can be found here and registration information can be found at The Council’s website.

Submit Comments to CMS by September 9

Click here to submit comments to CMS in response to the 2020 proposed rule by 5:00 PM ET on Monday, September 9, 2019.

HCA and other industry organizations will provide more thorough comments on other problematic areas of the proposed rule. As previously stated, there is strength in numbers, so the more business-focused comments from providers – both large and small – are critical to giving CMS a full and clear picture of how devastating PDGM will be should it be implemented as proposed. Watch Update for draft comments.

Return to www.thinkhomecare.org.