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Final Rule Summary
Medicare Home
Health Prospective
Payment System Calendar Year 2017
November 2016
TABLE OF CONTENTS Overview and Resources ......................................................................................................................... 1
HHPPS Payment Rates ............................................................................................................................ 1
National Per-Visit Amounts ................................................................................................................ 2
Non-Routine Medical Supply Conversion Factor ............................................................................... 2
Wage Index and Labor-Related Share ..................................................................................................... 3
Payment Add-On for Rural Home Health Agencies ............................................................................... 3
Reductions Due To Nominal Case Mix Growth ..................................................................................... 4
Home Health Resource Group Update .................................................................................................... 4
Outlier Payments ..................................................................................................................................... 4
Negative Pressure Wound Therapy Payments ........................................................................................ 5
Update on Research and Analysis of Home Health Groupings Model ................................................... 6
Future Plans To Group HHPPS Claims Centrally ................................................................................... 7
Mandatory Home Health Value-Based Purchasing Model Demonstration Project ................................ 7
Quality Measures ................................................................................................................................. 9
Inclusion/Exclusion Criteria .............................................................................................................. 10
Scoring .............................................................................................................................................. 11
Reporting/Review, Correction and Appeals Process ......................................................................... 12
Updates to the Home Health Quality Reporting Program ..................................................................... 13
Home Health Consumer Assessment of Healthcare Providers and Systems Survey ............................ 15
If you have any questions about this summary, contact Kathy Reep, FHA Vice
President/Financial Services, by email at [email protected] or by phone at (407) 841-6230.
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OVERVIEW AND RESOURCES
On November 3, 2016, the Centers for Medicare & Medicaid Services (CMS) published its
final calendar year (CY) 2017 payment rule for the Medicare home health prospective
payment system (HHPPS). The final rule includes updates of the Medicare fee-for-service
(FFS) HHPPS payment rates based on regulatory changes adopted by CMS and legislative
changes previously adopted by the U.S. Congress. Among the finalized regulatory updates
and policy changes are:
Implementation of the last year of a four-year phase-in for rebasing adjustments to the
HHPPS payment rates mandated by the Patient Protection and Affordable Care Act
(PPACA) of 2010;
Implementation of the second year of the three-year reduction to the national,
standardized, 60-day episode payment rates of 0.97 percent to recoup overpayments
for nominal case mix growth between CY2012 and CY2014;
Updates to the Home Health Resource Group (HHRG) weights;
Changes to the methodology used to calculate outlier payments;
Changes in payment for Negative Pressure Wound Therapy (NPWT) performed using
a disposable device for patients under a home health plan of care;
Changes to the home health value-based purchasing (HHVBP) model with payment
adjustments beginning January 1, 2018, applicable to home health agencies (HHAs) in
selected states; and
Changes to the home health quality reporting program requirements.
A copy of the Federal Register with this final rule and other resources related to the HHPPS
are available on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/HomeHealthPPS/Home-Health-Prospective-Payment-System-Regulations-
and-Notices.html. An online version of the Federal Register with this final rule is available at
https://federalregister.gov/a/2016-26290.
A summary of the final rule is provided below. Program changes adopted by CMS would be
effective for services provided on or after January 1, 2017, unless otherwise noted.
HHPPS PAYMENT RATES Federal Register pages 76705-76718
The tables below show the final CY2017 conversion factor compared to the final CY2016
conversion factor and the components of the update factor:
Final
CY2016
Final
CY2017
Percent
Change
60-Day Episode Rate $2,965.12 $2,989.97
(proposed at
$2,936.68)
0.84
(proposed at
-0.96)
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Final CY2017 Update Factor Component Value
(Percent)
Market Basket Update +2.8
PPACA-Mandated Productivity Market Basket Reduction -0.3 percentage points
(proposed at -0.5 percentage points)
Negative Rebasing Adjustment -$80.95
(-2.70)
Nominal Case Mix Growth Reduction (-0.97)
Case Mix Budget Neutrality Adjustment 2.14
(proposed at 0.62)
Wage Index Budget Neutrality -0.04
(proposed at -0.10)
Overall Final Rate Update 0.84
(proposed at -0.96)
National Per-Visit Amounts
HHPPS payments for episodes with four visits or less are paid on a per visit basis. CMS
uses national per visit amounts by service discipline to pay for these Low-Utilization
Payment Adjustment (LUPA) episodes. The national per visit amounts are also used for
outlier calculations. The final CY2017 per visit amounts include a rebasing increase of 3.5
percent of the CY2010 national per visit payment amounts, an update factor increase of
2.5 percent (proposed at 2.3), and an adjustment for wage index budget neutrality.
Per Visit Amounts Final
CY2016
Final
CY2017
Percent
Change
Final CY2017
With LUPA Add-On *
Home Health Aide $60.87 $64.23
+5.5
N/A
Medical Social Services $215.47 $227.36 N/A
Occupational Therapy $147.95 $156.11 N/A
Physical Therapy (PT) $146.95 $155.05 $258.38 (1.6700 adj.)
Skilled Nursing (SN) $134.42 $141.84 $261.71 (1.8451 adj.)
Speech Language Pathology (SLP) $159.71 $168.52 $274.11 (1.6266 adj.)
* For SN, PT, or SLP visits in LUPA episodes that occur as the only episode or an initial episode in a
sequence of adjacent episodes, CMS will continue the use of the LUPA add-on factors established in the
CY2014 final rule.
Non-Routine Medical Supply Conversion Factor
In CY2008, CMS carved out the Non-Routine Medical Supply (NRS) component from
the 60-day episode rate and established a separate national NRS conversion factor with six
severity group weights to provide more adequate reimbursement for episodes with a high
utilization of NRS. The final CY2017 NRS conversion factor includes a rebasing
reduction -2.82 percent and an update factor increase of 2.5 percent.
Final
CY2016
Final
CY2017 Percent Change
NRS Conversion Factor $52.71
$52.50
(proposed at
$52.40)
-0.40 percent
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Severity Level Points
(Scoring)
Relative Weight
(no change from prior years)
CY2017 Final
Payment Amount
1 0 0.2698 $14.16
2 1 to 14 0.9742 $51.15
3 15 to 27 2.6712 $140.24
4 28 to 48 3.9686 $208.35
5 49 to 98 6.1198 $321.29
6 99+ 10.5254 $552.58
WAGE INDEX AND LABOR-RELATED SHARE Federal Register page 76714-76715, 76719-76721
CMS is maintaining the labor-related share at 78.535 percent for CY2017. The labor-related
portion of the home health payment rate is adjusted for differences in area wage levels using a
wage index. CMS is not making any major changes to the calculation of Medicare home
health wage indexes. As has been the case in prior years, CMS is using the most recent
inpatient hospital wage index, the FY2017 pre-rural floor and pre-reclassified hospital wage
index, to adjust payment rates under the HHPPS for CY2017. A complete list of the finalized
wage indexes for payment in CY2017 is available on the CMS Web site at
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Home-
Health-Prospective-Payment-System-Regulations-and-Notices-Items/CMS-1625-
F.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
PAYMENT ADD-ON FOR RURAL HOME HEALTH AGENCIES Federal Register pages 76719
By amending the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(MMA), PPACA mandated a 3.0 percent increase to the payments for HHPPS episodes and
visits provided in rural areas between April 1, 2010 and January 1, 2016. The Medicare
Access and CHIP Reauthorization Act of 2015 (MACRA) amended the MMA again,
extending the 3.0 percent increase to payments for HHPPS episodes and visits in rural areas
for another two years. The 3.0 percent rural add-on now applies to payments for episodes and
visits ending on or after April 1, 2010, and before January 1, 2018.
This 3.0 percent add-on is not subject to budget neutrality and is applied to the 60-day episode
rate, the national per-visit amounts, LUPA add-on payments, and the NRS conversion factor.
Final
CY2017 60-Day
Episode Rate
Multiply by the 3.0
Percent Rural Add-on
Final
Rural CY2017 60-
Day Episode Rate
Rural Add-On Payment $2,989.97 X 1.03 $3,079.67
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REDUCTIONS DUE TO NOMINAL CASE MIX GROWTH Federal Register pages 76716
Previously, CMS accounted for nominal case mix growth through HHRG weight reductions,
implemented from 2008 through 2013, in order to better align payment with real changes in
patient severity. In CY2015, there was no nominal case mix growth reduction. In the CY2016
final rule, CMS finalized a total reduction of 2.88 percent to account for nominal case mix
growth from CY2012 to CY2014, implemented and distributed evenly over a three-year
period. This means that in CY2016 there was a 0.97 percent reduction to the national,
standardized 60-day episode payment rate, which will also occur in both CY2017 and
CY2018. CMS’ goal is to have Medicare pay more accurately for the delivery of home health
services and this reduction will remain separate from the CY2014 rebasing adjustments.
HOME HEALTH RESOURCE GROUP UPDATE Federal Register pages 76706-76714
The HHPPS program uses a 153-category case mix classification called Home Health
Resource Groups (HHRGs). Patients’ clinical severity level, functional severity level, and
service utilization are extracted from the Outcome and Assessment Information Set (OASIS)
instrument and used to assign HHRGs. Each HHRG has an associated case mix weight which
is used in calculating the payment for an episode. According to CMS, the HHRG weights
were designed to maintain an average case mix of about 1.0 for the nation.
In the CY2015 HHPPS final rule, CMS implemented a recalibration of case mix weights to
occur each year using the most current data available. This annual recalibration guarantees
that the case mix weights will reflect the current status of home health resource use and
changes in utilization. For CY2017, CMS is recalibrating the HHPPS case mix weights using
cost and utilization data from CY2015. Overall the impact of the change is negative;
therefore, CMS is increasing the 60-day episode rate by 2.14 percent in order to maintain
budget neutrality for the HHPPS program.
OUTLIER PAYMENTS Federal Register pages 76724-76730
Outlier payments are intended to mitigate the risk of caring for extremely high-cost cases. An
outlier payment is provided whenever a HHA’s cost for an episode of care exceeds a fixed-
loss threshold (the HHPPS payment amount for the episode plus a fixed dollar loss [FDL]
amount). The cost for an episode of care is currently calculated using the number of visits in
the episode multiplied by a wage index-adjusted national per visit amount. CMS is concerned
that the current methodology for calculating the cost for an episode of care may create a
financial disincentive for providers to treat medically complex beneficiaries who require
longer visits. CMS is finalizing to instead calculate the cost of an episode of care using a cost-
per-unit calculation. The cost-per-unit calculation takes into account the visit length, which
the current calculation does not.
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CMS is also implementing a cap of eight hours or 32 units per day (1 unit = 15 minutes,
summed across the six disciplines of care) on the amount of time per day that would be
counted toward the estimation of an episode’s costs for outlier claims. This is not limiting the
amount of care that can be provided on any given day, but instead limiting the time per day
that can be credited towards the estimated cost of an episode when determining if that episode
should receive outlier payments and calculating the amount of that payment. The rural add-on
will still apply in this calculation as in the previous methodology.
The discipline of care with the lowest associated cost per unit will be discounted first in the
calculation of episode cost, in order to cap the estimation of an episode’s cost at eight hours of
care per day. CMS estimates that approximately 13 percent of episodes will be impacted due
to the eight hour cap.
The FDL amount is calculated as a FDL ratio multiplied by the wage index-adjusted 60-day
episode payment rate. This is then added to the HHPPS payment amount for that episode. If
the calculated cost exceeds the threshold, the HHA receives an additional outlier payment
equal to 80 percent of the calculated excess costs over the fixed-loss threshold.
Each HHA’s outlier payments are capped at 10 percent of total PPS payments. By law, a limit
of 2.5 percent of total HHPPS payments are set aside for outliers. Under the new
methodology, which uses a cost per unit rather than a cost per visit when calculating episode
costs, CMS is increasing the FDL ratio from 0.45 in CY2016 to 0.55 (proposed at 0.56) in
CY2017. The change in the methodology will be budget neutral as CMS will still target to pay
up to, but no more than, 2.5 percent of total payments as outlier payments.
NEGATIVE PRESSURE WOUND THERAPY PAYMENTS Federal Register pages 76730-76736
Negative Pressure Wound Therapy (NPWT) is a medical procedure in which a vacuum
dressing is used to enhance and promote healing in acute, chronic, and burn wounds. The
therapy involves using a sealed wound dressing attached to a pump to create a negative
pressure environment in the wound. This conventional NPWT system is classified as durable
medical equipment (DME). However, NPWT can also be performed with a disposable device
that is a single-use integrated system that consists of a non-manual vacuum pump, a
receptacle for collecting exudate, and dressings for the purpose of wound therapy. These
disposable systems consist of a small pump, which eliminates the need for a bulky canister.
HHPPS includes payment for all covered home health services. However, the national,
standardized 60-day episode payment amount does not include costs for DME. Therefore,
DME is currently paid outside of the HHPPS. Medical supplies, however, both routine and
non-routine, are included in the definition of home health services and are included in the
national, standardized 60-day episode amount. A disposable NPWT system would be
considered a non-routine supply for home health.
The Consolidated Appropriations Act of 2016 requires a separate payment, based on the
outpatient prospective payment system (OPPS) amount to a HHA for an applicable disposable
device when furnished on or after January 1, 2017, to an individual who receives home health
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services for which payment is made under the Medicare home health benefit. CMS, as
proposed for instances where the sole purpose for an HHA visit is to furnish NPWT using a
disposable device, is implementing Medicare will not pay for the visit under the HHPPS.
Instead, the HHA must bill these visits separately under the type of bill 34x under the
appropriate HCPCS code (97607 or 97608). This bill is used for patients not under a home
health plan of care, Part B medical and other health services, and osteoporosis injection.
If NPWT using a disposable device is performed during the course of an otherwise covered
HHA visit, the HHA must not include the time spent furnishing NPWT in their visit charge
for the length of time reported for the visit on the HHPPS claim. This will be paid separately
based on the OPPS payment.
CMS clarified in this final rule that furnishing NPWT using a disposable device means the
HHA is furnishing a new disposable NPWT device. That is, the HHA provider is either
initially applying an entirely new disposable NPWT device or removing a disposable NPWT
device and replacing it with an entirely new one.
In order for a beneficiary to receive NPWT using a disposable device under the home health
benefit, a physician must certify that the Medicare beneficiary meets the following criteria:
Is confined to the home;
Needs skilled nursing care on an intermittent basis or physical therapy or speech
language pathology; or
Has a continuing need for occupational therapy;
Is under the care of a physician;
Receives services under a plan of care established and reviewed by a physician; and
Has had a face-to-face encounter related to the primary reason for home health care
with a physician or allowed Non-Physician Practitioner within a required timeframe.
Additionally, care must be deemed as “reasonable and necessary” based on information
reflected in the home health plan of care.
UPDATE ON RESEARCH AND ANALYSIS OF HOME HEALTH GROUPINGS MODEL Federal Register pages 76736
The Secretary of Health and Human Services conducted a study on home health agency costs
involved with providing ongoing access to low-income Medicare beneficiaries or
beneficiaries in medically underserved areas in treating beneficiaries with high levels of
severity of illness. This study included an analysis of methods to potentially revise the
HHPPS. In the CY2016 proposed rule, CMS provided information on the initial research and
analysis to address the study findings. In the CY2017 proposed rule, CMS provided an update
to this research and analysis on the Home Health Groupings Model (HHGM).
The HHGM groups home health episodes by primary diagnosis based on what home health
interventions would be required during the episode of care. The HHGM also incorporates
information from claims data to further group the episodes for payment. Each episode is
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categorized into different sub-groups, where an episode is placed into one of the categories
within each sub-group:
In total, there would be 324 possible payment groupings into which an episode can be
grouped. Unlike the current payment model, the HHGM does not rely on the number of
therapy visits performed to influence payment. The HHGM addresses marginal differences
across beneficiary characteristics that the current model does not provide. Also, the HHGM
aligns with how clinicians generally identify the types of patients seen in home health. CMS
plans to release a Technical Report which will provide more detail as to the research and the
analysis conducted on the HHGM.
FUTURE PLANS TO GROUP HHPPS CLAIMS CENTRALLY Federal Register pages 76736-76737
Currently, HHAs use the HHPPS Grouper to calculate HHRGs for submission on the claim.
In the CY2011 HHPPS proposed rule, CMS stated possible plans to group HHPPS claims
centrally during claim processing potentially using the treatment authorization field to group
the HHPPS claims and received many comments in support of this initiative. However, in
conducting further analysis CMS determined that the use of the treatment authorization field
was not a viable option and the information that CMS planned to report in this field was not
permitted by the Health Insurance Portability and Accountability Act (HIPAA).
In the CY2017 proposed rule, CMS solicited comments on a different process whereby all the
information necessary to group HHPPS claims occurs centrally during claims processing.
This would consist of embedding the HHPPS Grouper within the claims processing system to
mitigate a provider’s vulnerability and improve payment accuracy. An HHA would no longer
have to maintain a separate process outside of CMS’ claims processing system, reducing the
costs and burden to HHAs.
Several commenters were in support of centralized grouping of HHPPS claims. Some
requested that CMS still continue to provide the grouper software and/or algorithm in order
for providers to be able to determine the expected reimbursement amount for each claim.
Lastly, commenters requested CMS provide agencies the ability to review and correct their
data submissions, similar to what occurs now.
MANDATORY HOME HEALTH VALUE-BASED PURCHASING MODEL
DEMONSTRATION PROJECT Federal Register pages 76737-76752
Sub-Group Categories Within Sub-Group
Timing Early or late
Referral Source Community, acute, or post-acute admission source
Clinical Grouping Musculoskeletal rehab, neuro/stroke rehab, wounds, medication
management, teaching and assessment, behavioral, or complex
Functional/Cognitive Level Low, medium, or high
Comorbidity Adjustment First, second, or third (tier based on secondary diagnoses)
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Background: CMS implemented a PPACA-mandated Home Health Value-based Purchasing
(HHVBP) demonstration model for certain Medicare-certified HHAs, starting January 1, 2016
and concluding December 31, 2022. The Medicare-certified HHAs required to participate are
from nine randomly selected states, each from one of nine regional groupings determined by
CMS. The demonstration program resembles the VBP program for inpatient acute care
hospitals.
Finalized in the CY2016 rule, random states were selected through grouping states by
geographic proximity to one another and accounting for certain evaluation characteristics. The
nine states are Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa,
Nebraska, and Tennessee.
Medicare-certified HHAs that are included in the HHVBP model would be required to
compete for payment adjustments to their current PPS reimbursements based on their quality
performance. A competing Medicare-certified HHA is defined as “an agency having a current
Medicare certification that is being reimbursed by CMS for home health care delivered in the
boundaries of any of the randomly selected states to participate.”
The HHVBP model compares a competing HHA’s performance on quality measures against
the performance of other competing HHAs within the same state and size cohort, either the
smaller-volume cohort or the larger-volume cohort. The larger-volume cohort is made up of
HHAs that participate in Home Health Consumer Assessment of Healthcare Providers and
Systems Survey (HHCAHPS), while the smaller-volume cohort is made up of HHAs that are
exempt from participation in HHCAHPS (less than 60 eligible unique HHCAHPS patients
annually).
CMS determined in the CY2016 final rule that payment adjustments for each year of the
model would be calculated based on a comparison of how well each of the competing
Medicare-certified HHAs performed during each one year performance period, beginning in
CY2016, compared to the baseline year CY2015, as well as performance of their peers. The
contribution amount is equal to the maximum payment adjustment. The payment adjustments
will be applied beginning in CY2018.
Payment Period Performance Period
Aggregate HHVBP
Payment Adjustment
(Percent)
CY2018 January 1, 2016 – December 31, 2016 3 max
CY2019 January 1, 2017 – December 31, 2017 5 max
CY2020 January 1, 2018 – December 31, 2018 6 max
CY2021 January 1, 2019 – December 31, 2019 7 max
CY2022 January 1, 2020 – December 31, 2020 8 max
The goals of the HHVBP model are to improve the overall quality of home health care and
deliver it to the Medicare population in a more efficient manner. The HHVBP demonstration
program recognizes both the achievement of high quality standards and the improvement in
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quality performance. HHAs in the selected states will be subject to upward and downward
payment adjustments based on performance on the measures chosen.
The HHVBP model will adjust Medicare HHA payments over the course of the model by up
to eight percent depending on the applicable performance year and the degree of quality
performance demonstrated by each competing Medicare-certified HHA. The HHVBP
program will be budget neutral by state. Similar to the hospital VBP program, this is
redistributive and all HHAs in the mandated state will contribute to the VBP pool; some will
then get their contribution back or even more than what they contributed, and some may get
less.
Quality Measures
Federal Register pages 76742-76747
In the CY2016 rule, CMS finalized the initial set of measures for the first performance year of
the HHVBP demonstration. CMS is removing four of the measures in the CY2017 final rule
since they need further consideration before inclusion in the HHVBP model measure set.
These measures are:
Care Management: Types and Sources of Assistance;
Prior Functioning ADL/IADL;
Influenza Vaccine Data Collection Period; and
Reason Pneumococcal Vaccine Not Received.
The quality measures that would remain in the HHVBP measure set include:
NQS Domain Measure
Type Measure Title Data Source
Clinical Quality
of Care
Outcome Improvement in Ambulation-Locomotion (NQF0167) OASIS (M1860)
Outcome Improvement in Bed Transferring (NQF0175) OASIS (M1850)
Outcome Improvement in Bathing (NQF0174) OASIS (M1830)
Outcome Improvement in Dyspnea OASIS (M1400)
Process Drug Education on All Medications Provided to
Patient/Caregiver during all Episodes of Care OASIS (M2015)
Communication
& Care
Coordination
Outcome Discharged to Community OASIS (M2420)
Efficiency &
Cost Reduction
Outcome Acute Care Hospitalization: Unplanned Hospitalization
during first 60 days of Home Health (NQF0171); CCW (Claims)
Outcome Emergency Department Use Without Hospitalization
(NQF0173) CCW (Claims)
Patient Safety
Outcome Improvement in Pain Interfering with Activity
(NQF0177) OASIS (M1242)
Outcome Improvement in Management of Oral Medications
(NQF0176) OASIS (M2020)
Population/
Community
Health
Process Influenza Immunization Received for Current Flu
Season (NQF0522) OASIS (M1046)
Process Pneumococcal Polysaccharide Vaccine Ever Received
(NQF0525) OASIS (M1051)
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NQS Domain Measure
Type Measure Title Data Source
Patient &
Caregiver
Centered
Experience
Outcome Willingness to Recommend the Agency HHCAHPS
Outcome Communications between Providers and Patients HHCAHPS
Outcome Care of Patients HHCAHPS
Outcome Specific Care Issues HHCAHPS
Outcome Overall Rating of Home Health Care HHCAHPS
The new measures are:
NQS Domain Measure
Type Measure Title Data Source
Population/
Community
Health
Process Influenza Vaccination Coverage for Home
Health Care Personnel (NQF0431)
Reported by HHAs
through Web-based portal
beginning October 2016
for PY1 and April 2017 for
PY2 (annually thereafter)
Process Herpes Zoster (Shingles) Vaccination Received
by HHA Patients Reported by HHAs
through Web-based portal
beginning no later than
October 7, 2016
Communication
& Care
Coordination
Process Advance Care Plan (NQF0326)
In the CY2016 final rule, CMS finalized that HHAs will be required to begin reporting data
on each of the three new measures no later than October 7, 2016 for the period July 2016
through September 2016 and quarterly thereafter. As proposed, CMS is changing the
requirement to annual, rather than quarterly reporting for the Influenza Vaccination Coverage
for Home Health Personnel with the first annual submission in April 2017 for the second
performance year and annually in April thereafter. This submission is for the reporting period
October 1, 2016 – March 31, 2017 to coincide with flu season. For performance Year 1, the
HHA would report on this measure in October 2016 and January 2017.
CMS is also increasing the timeframe for submitting new measures from seven to 15 calendar
days following the end of the reporting period to account for holidays and weekends.
Inclusion/Exclusion Criteria
Federal Register pages 76738, 76741-76742
Although every HHA in a selected state must participate in the HHVBP model, each HHA
may not receive a payment adjustment every period due to an inadequate number of episodes
of care to generate sufficient quality measure data. The minimum threshold for a HHA to
receive a score on a given measure is 20 home health episodes of care per year for HHAs that
have been certified for at least six months. In order to receive a payment adjustment, the HHA
must meet this threshold in at least five of the Clinical Quality of Care, Care Coordination and
Efficiency, and Person and Caregiver-Centered Experience measures. Otherwise a payment
adjustment will not be made for that particular HHA. If the HHA has greater volume during
later performance years, the HHA will be subject to future payment adjustments. The HHA
will still receive quality reports on any measures for which they have 20 episodes of care.
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When there are fewer than eight HHAs in the smaller-volume cohort in a state to compete in a
fair manner and mitigate outliers, these specific HHAs would be included in the state’s larger-
volume cohort without being measured on HHCAHPS. This is for purposes of calculating the
total performance score and payment adjustment for those HHAs.
Scoring
Federal Register pages 76738-76742
Background: The quality measures are aligned with six National Quality Strategy (NQS)
domains. For the HHVBP, CMS is grouping these NQS domains into four classifications in
order to correctly calculate payment adjustments based on the other measures. Measure
distribution from the six NQS domains into the four classifications has not yet been
determined. However, measures within each classification will be weighted the same for the
purpose of payment adjustments. The model also includes the HHCAHPS for the competing
Medicare-certified HHAs.
HHAs are scored on their quality of care based on performance compared to both the
performance of HHAs in the same size cohort (achievement) and also their own past
performance (improvement). Points on individual measures are aggregated across the four
classifications to calculate the Total Performance Scores (TPS).
Classification Possible
Points
Measure Weight
for each Classification
(Percent)
Clinical Quality of Care
0-10 points
30
Care Coordination and Efficiency 30
Person- and Caregiver-Centered Experience 30
New Measures 10
For the new measures, HHAs will receive 10 points for each new measure they report and 0
points for each they do not. In total, the new measures will account for 10 percent of the TPS
regardless of the number of measures applied to an HHA in the other three classifications.
TPS and payment adjustments would be calculated based on an HHA’s CMS Certification
Number (CCN) and would be based only on services provided to beneficiaries in the selected
nine states. However, HHAs that provide services in a state that had a reciprocal agreement
with the HHA’s home state would have those services included in the TPS. A reciprocal
agreement is when an HHA has an agreement to provide services across state lines. CMS will
calculate a score for achievement and another score for improvement. The higher of the two
scores is used as the TPS for each measure.
Achievement: [9 x ( 𝐇𝐇𝐀 𝐏𝐞𝐫𝐟𝐨𝐫𝐦𝐚𝐧𝐜𝐞 𝐒𝐜𝐨𝐫𝐞 – 𝐀𝐜𝐡𝐢𝐞𝐯𝐞𝐦𝐞𝐧𝐭 𝐓𝐡𝐫𝐞𝐬𝐡𝐨𝐥𝐝
𝐁𝐞𝐧𝐜𝐡𝐦𝐚𝐫𝐤 – 𝐀𝐜𝐡𝐢𝐞𝐯𝐞𝐦𝐞𝐧𝐭 𝐓𝐡𝐫𝐞𝐬𝐡𝐨𝐥𝐝 ) + 0.5]
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Improvement: [10 x (𝐇𝐇𝐀 𝐏𝐞𝐫𝐟𝐨𝐫𝐦𝐚𝐧𝐜𝐞 𝐒𝐜𝐨𝐫𝐞 – 𝐇𝐇𝐀 𝐁𝐚𝐬𝐞𝐥𝐢𝐧𝐞 𝐏𝐞𝐫𝐢𝐨𝐝 𝐒𝐜𝐨𝐫𝐞
𝐁𝐞𝐧𝐜𝐡𝐦𝐚𝐫𝐤 – 𝐇𝐇𝐀 𝐁𝐚𝐬𝐞𝐥𝐢𝐧𝐞 𝐏𝐞𝐫𝐢𝐨𝐝 𝐒𝐜𝐨𝐫𝐞) - 0.5]
In the CY2016 final rule, CMS finalized that the achievement threshold and benchmark will
be calculated separately for each selected state and each HHA cohort size. Therefore, CMS
would have individual benchmarks and achievement thresholds for both larger-volume and
smaller-volume cohorts of HHAs. However, CMS is concerned that because some smaller-
volume cohorts are so small, these cohorts could be required to meet performance standards
that are greater than the level of performance that HHAs in the larger-volume cohorts would
be required to achieve. Therefore, CMS will calculate the benchmarks and achievement
thresholds at the state level rather than at the cohort level for all model years, beginning with
CY2016. The thresholds and benchmarks will be defined in each state based on a CY2015
baseline period.
Duration
Achievement Threshold Median of HHA’s performance on each
measure Baseline Period
Benchmark
Mean of top decile of HHA’s
performance on each measure
CMS will use a linear exchange function (LEF) to calculate HHA payment adjustments. The
LEF translates an HHA’s TPS into a percentage of the value-based payment adjustment
earned by each HHA under the HHVBP model. The intercept of LEF will be zero percent,
meaning HHAs that are average in relationship to other HHAs in their cohort would receive
no payment adjustment.
In the CY2016 final rule, CMS set the slope for CY2016 so that the estimated aggregate
value-based payment adjustments for CY2016 are equal to three percent of the total amount
of episode payments made to all HHAs by Medicare in each individual state’s larger- and
smaller-volume cohorts for CY2018. Instead, CMS will no longer calculate the LEF for
larger- and smaller-volume cohorts but only at the state level.
Reporting/Review, Correction and Appeals Process
Federal Register pages 76747-76752
A quarterly report, Interim Performance Report, will be provided to each Medicare certified
HHA containing information on their performance during the quarter:
Report First Release Releases Thereafter Final Release
Quarterly July 2016 October, January, and April April 2021
An Annual TPS and Payment Adjustment Report will be released once a year in August
containing payment adjustment percentages, an explanation of when the adjustment will be
applied and how the adjustment was calculated. This report will be specific to each HHA and
accessible only to that HHA. A final annual report will then be publicly available that will
provide home health stakeholders with information about their home health services quality of
care. The first quarterly performance report in July 2016 will not account for any of the new
measures.
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CMS is implementing an Appeals Process for Home Health Value-Based Purchasing Model
that will codify the recalculation request process and the reconsideration request process. The
first level of the appeals process would be the recalculation process, as stated in the CY2016
final rule. The reconsideration process for the annual report would only be available when an
HHA has first submitted a recalculation request for that report. The annual report will be
released again in November with any changes made due to recalculation requests.
In the CY2016 final rule, CMS stated that HHAs will have a 30-day period to review and
correct information after quarterly reports and annual reports are released. CMS is changing
the submission window to 15 calendar days rather than 30 calendar days in order for
recalculations of the July quarterly reports to be completed prior to the posting of the August
annual reports. Reconsideration requests will be available only for the annual report and must
be submitted within 15 calendar days of release as well.
CMS will also provide HHAs with the final TPS and payment adjustment percentage no later
than 30 calendar days in advance of payment determination, rather than 60 days. A list of
instructions on how to submit an appeal is available on Federal Register pages 76748-76749.
CMS is also considering public reporting for the HHVBP Model beginning no earlier than
CY2019 to allow analysis of at least eight quarters of performance data for the model and the
opportunity to compare how those results align with other publicly reported quality data.
A report on the development/design of a VBP program for home health providers (as
mandated by the PPACA) is available on the CMS Web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HomeHealthPPS/downloads/stage-2-NPRM.PDF.
UPDATES TO THE HOME HEALTH QUALITY REPORTING PROGRAM Federal Register pages 76752-76787
CMS collects quality data from HHAs on process, outcomes, and patient experience of care.
HHAs that do not successfully participate in the Home Health Quality Reporting Program
(HH QRP) are subject to a 2.0 percentage point reduction to the market basket update for the
applicable year.
All of the process and most outcomes measures required under the HH QRP are derived from
the OASIS assessment instrument. Medicare Conditions of Participation (CoPs) require all
home health providers that participate in Medicare and Medicaid to collect and report OASIS
data to CMS. In addition, home health providers must collect patient experience of care data
using the HHCAHPS survey; CMS also calculates two HH QRP outcomes measures based on
home health claims data that do not require additional reporting.
CMS is finalizing that, similar to the hospital IQR, when they initially adopt a measure for the
HH QRP for a payment determination, that measure will be automatically retained for all
subsequent payment determinations unless it is proposed to be removed or replaced.
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In the CY2015 final rule, CMS established a new pay-for-reporting performance standard to
be phased-in over three years for the submission of OASIS quality data. HHAs must meet a
minimum reporting threshold, titled Quality Assessment Only (QAO), for OASIS data in
order to avoid a two percent market basket reduction. In the CY2016 final rule, CMS
implemented an increase in the minimum reporting threshold over the next three years:
QAO = (# 𝐨𝐟 𝐐𝐮𝐚𝐥𝐢𝐭𝐲 𝐀𝐬𝐬𝐞𝐬𝐬𝐦𝐞𝐧𝐭𝐬 𝐑𝐞𝐩𝐨𝐫𝐭𝐞𝐝
# 𝐨𝐟 𝐐𝐮𝐚𝐥𝐢𝐭𝐲 𝐀𝐬𝐬𝐞𝐬𝐬𝐦𝐞𝐧𝐭𝐬 𝐑𝐞𝐩𝐨𝐫𝐭𝐞𝐝 + # 𝐨𝐟 𝐍𝐨𝐧𝐐𝐮𝐚𝐥𝐢𝐭𝐲 𝐀𝐬𝐬𝐞𝐬𝐬𝐦𝐞𝐧𝐭𝐬 𝐑𝐞𝐩𝐨𝐫𝐭𝐞𝐝) *100
Performance Period QAO Minimum Reporting
Threshold
July 1, 2015 – June 30, 2016 70 percent
July 1, 2016 – June 30, 2017 80 percent
July 1, 2017 – June 30, 2018 90 percent
CMS is adopting three measures to meet the Resource Use and Other Measures domain in
CY2018:
Total Estimated Medicare Spending Per Beneficiary – Post Acute Care Home Health
Quality Reporting Program (MSPB-PAC HH QRP);
Discharge to Community – Post Acute Care (PAC) HH QRP; and
Potentially Preventable 30-Day Post-Discharge Readmission Measure for PAC HH
QRP.
Additionally, CMS is adopting one measure to meet the Medication Reconciliation domain in
CY2018:
Drug Regimen Review Conducted with Follow-Up for Identified Issues – PAC HH
QRP.
CMS is removing 28 measures from the Home Health Quality Initiative (HHQI) that were
either topped out and/or determined to be of limited clinical and quality improvement value.
Separately, there are six process measures that CMS is removing from the HH QRP beginning
with the CY2018 payment determination because they are also topped out:
Pain Assessment Conducted;
Pain Interventions Implemented during All Episodes of Care;
Pressure Ulcer Risk Assessment Conducted;
Pressure Ulcer Prevention in Plan of Care;
Pressure Ulcer Prevention Implemented during All Episodes of Care; and
Heart Failure Symptoms Addressed during All Episodes of Care.
Furthermore, CMS is considering eight quality measures for future years:
Transfer of Health Information and Care Preferences When an Individual Transitions;
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Application of NQF #0674 – Percent of Residents Experiencing One or More Falls
with Major Injury (Long Stay);
Application of NQF #2631 – Percent of Long-Term Care Hospital (LTCH) Patients
with an Admission and Discharge Functional Assessment and a Care Plan that
Addresses Function;
Application of NQF #2633 – Change in Self-Care Score for Medical Rehabilitation
Patients;
Application of NQF #2634 – Change in Mobility Score for Medical Rehabilitation
Patients;
Application of NQF #2635 – Discharge Self-Care Score for Medical Rehabilitation
Patients;
Application of NQF # 2636 – Discharge Mobility Score for Medical Rehabilitation
Patients; and
Application of NQF #0680 – Percent of Residents or Patients Who Were Assessed and
Appropriately Given the Seasonal Influenza Vaccine (Short Stay).
HOME HEALTH CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND
SYSTEMS SURVEY Federal Register pages 76787-76789
In the CY2016 HHPPS final rule, CMS stated that the home health quality measures reporting
requirements include the HHCAHPS survey for the CY2017 and CY2018 Annual Payment
Update (APU) periods. CMS will continue to maintain these requirements as stated in the
CY2016 final rule. CMS requires monthly HHCAHPS data collection and reporting all four
quarters of each year. CMS requires that all HHAs with fewer than 60 HHCAHPS-eligible
unduplicated or unique patients in the previous year collection period are exempt from the
HHCAHPS data collection and submission requirements. Also, if an HHA receives Medicare
certification after the collection period, CMS automatically exempts them from the survey.
Collection periods are shown below.
APU Period Collection Period
CY2017 April 2015 – March 2016
CY2018 April 2016 – March 2017
CY2019 April 2017 – March 2018
CY2020 April 2018 – March 2019
All the requirements for the HHCAHPS survey and which home health patients are ineligible
for the HHCAHPS survey are detailed at http://homehealthcahps.org.
