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  • APTA: CMS Proposal for Home Health Creates 'Perverse Financial Incentives' to Reduce Care

    APTA delivered comments to the US Centers for Medicare and Medicaid Services (CMS) that make no bones about the agency's proposed changes to the home health payment system. The bottom line, according to the association: The plan contains "significant flaws" that "will have a harsh and dramatic effect on patient care." And what's more, APTA says, CMS may not have the legal authority to do what it wants to do, at least in the way it hopes to do it.

    The letter from APTA provides a detailed deconstruction of a CMS proposal to radically change the payment environment for home health (HH) in ways that would directly impact patients, physical therapists (PTs), and physical therapist assistants (PTAs)—and not for the better. Those proposed changes would move episodes of care from 60 to 30 days, and would include the adoption of a new case-mix model, known as the Home Health Grouping Model (HHGM), that removes physical therapy service-use thresholds from the mix.

    All told, the changes being proposed could result in a $950 million payment reduction to home health, according to CMS. And CMS wants to roll out the new system in 2019. The CMS proposal generated a strong reaction in the HH community in general, and within APTA in particular, resulting in a record-breaking number of individual comment letters submitted to CMS, facilitated by template text that APTA made available online.

    In its letter to CMS, APTA provides comments on the entire package of proposals, but focuses particular attention on the HHGM, which it describes as a system that "undervalues the important role of rehabilitation and creates perverse financial incentives to deliver less than appropriate care." APTA's letter acknowledges the importance of creating health care delivery systems that are "better, smarter, and healthier," but argues that the HHGM moves things in the opposite direction.

    APTA writes that as a whole, the HHGM "lacks person-centeredness and…fails to support proven interventions to address behavioral, social, and environmental determinants of health. While CMS has committed to putting first the best interest of the people it serves, the motivation behind the HHGM appears to focus solely on reducing Medicare spending."

    On top of that, says APTA, CMS may be going about its proposal in a way that exceeds its authority. The association's argument is based on statutory limitations that require CMS to implement changes in a "budget neutral" manner, meaning that only Congress has the authority to impose changes that significantly impact the HH budget, down or up. APTA writes that while CMS was provided with a temporary window to make non-budget-neutral adjustments under the Affordable Care Act (ACA), that window closed this year.

    "Unless the statute says otherwise, changes to elements of [home health payment systems] must be made in a budget-neutral manner across the system," APTA writes. "If the HHGM unintentionally causes access problems through rate cuts instituted by regulation, Congress would then be tasked with finding budget offsets to cover the 'cost' of fixing the mistake."

    Making matters even worse, according to APTA, is the CMS proposal to begin implementing the HHGM in 2019. The association asserts that if it moves forward, the new model shouldn't be rolled out any earlier than 2020, and that more dialogue and education take place before a finalized system is put in place.

    Among other elements of APTA's comments:

    • APTA encourages CMS not to eliminate rural add-on payments in 2018, citing concerns that the change would worsen workforce shortages in rural areas.
    • The association supports proposed modifications to the HH Quality Reporting Program and Value-Based Purchasing Program, and is in favor of "overarching" CMS strategies around assessing and adjusting for social risk factors.
    • APTA urges CMS to move away from its proposal to use a single diagnosis to categorize an episode into a clinical grouping, and instead allow for combinations of diagnoses to ensure proper therapy interventions. Similarly, the association recommends that CMS expand its list of comorbidity subcategories "to better capture diagnoses that cause higher resource allocation."

    Still, the association's most significant concerns are linked directly to the HHGM.

    "The HHGM would not improve patient care or aid CMS in aligning home health [prospective payment systems] with its overarching…policy goals," APTA writes. "We believe the HHGM would create new program integrity issues, compliance challenges for providers, and new access issues for beneficiaries."


    • Such a well thought out insightful letter..makes m proud to be a member of the APTA!

      Posted by Carol Zehnacker -> BMX[@ on 9/27/2017 5:50 PM

    • Thank god for APTA looking out for the residents and PTs & PTAs. I am a retired PT and Ombudsman in 4 SNFs and as HMOs discharge residents prior to them reaching their PLF the really need and rely on PT. It would be a huge disservice to reduce availability and opportunity to thrive. Well done!

      Posted by Elizabeth Voigt on 9/27/2017 8:57 PM

    • Let's hope they read it and give some thought to what the letter says . Good job to the folks who wrote the letter.

      Posted by Jan Warne on 9/28/2017 11:02 PM

    • PTA here with a decade of home health experience. Home Rehabilition Clinicians and the Home Health Agencies we work for are dredful in terms of outcome, waste, and abuse. Registered Nurses are our Supervisors, yet they have no expertise and in most cases not even basic knowledge in Rehbilitation. I have read thousand of PT Evals, >95% are materially and substantially incorrect, PT impairments are misidentified or missed, very basic assessments like MMT's are not even close. Gait deviations, once again, almost always wrong. Most PT/PTA's in HH Care have the patient stnd at the kitchen sink and perform rudimentary, basic exercises that are laughably ineffective. Home Helathcare Rehab is a joke and SHOULD be slashed and cut. Ask yourself this about homecare, how much would the patient pay for PT in the home per visit? If they were charged just $5 per visit, Home Healthcare PT utilization would fall by at least 80%...Homecare PT's in the real world do NOT practice evidence based interventions or POC's, most just make stuff up, literally, they make up nonsense exercises..Many PT's do more harm than good by confusing or misinformaing the patient with a lot incorrect and nonsenical advice. Home Health deserves to be slashed and you PTs and PTAs that are bad and lazy at your job are the reason...

      Posted by Ronnie Coffey on 9/30/2017 10:14 PM

    • Shame on you! How dare you make these broad generalizations about home heath therapists and nurses!! I am a long time Home Health PT and work with some of the most caring group of PTs/PTAs/OTs/STs/RNs/etc. They spend their own money on things their patient's insurance doesn't cover and gasoline and unreimbursed time on running after groceries, meds, etc the homebound are not able to get for themselves. In a time when home health agencies are struggling to pay the bills and stay open while being the current "goat" for Medicare beatings!! I have practiced 32 years as a PT and seen it all! Never has healthcare been so difficult to provide with the overregulation, cuts, difficult and ridiculous paper trail required. You need to find another profession, one you love and appreciate!!

      Posted by Cindi Jarrett on 10/2/2017 11:09 AM

    • Is there any sort of petition to sign to help fight against CMS implementing their HHGM in 2019?

      Posted by Elissa Ranes on 10/3/2017 1:31 PM

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