Home Health Payment Reform The Home Health Groupings Model (HHGM) August 23rd, 2016
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1 Home Health Payment Reform The Home Health Groupings Model (HHGM) August 23rd, 2016
2 Agenda Motivation for Home Health Groupings Model (HHGM) Setup of HHGM 30 day periods Timing Referral source Clinical grouping Functional and cognitive level Comorbidity adjustment Estimating Case-Mix Weights for the HHGM Abt Associates pg 2
3 Motivation Section 3131(d) Report to Congress Examined costs associated with beneficiaries who were: low-income, lived in underserved areas, had high severity of illness Report found current payment system produced lower margins for those needing parenteral nutrition with traumatic wounds or ulcers who required substantial assistance in bathing admitted to home health following an acute or post-acute stay who have a high Hierarchical Condition Category score who had certain poorly controlled clinical conditions who were dual eligible Abt Associates pg 3
4 Motivation MedPAC Annual Reports (2011, 2015) The Medicare Home Health Benefit is illdefined Home health payment should not be based on the number of therapy visits Current system incentivizes more therapy visits and fewer non-therapy visits Home health payment should be determined by patient characteristics Abt Associates pg 4
5 Motivation Payment Reform Principles Improve payment accuracy for home health services Promote fair compensation to HHAs Increase the quality of care for beneficiaries Initial Work Assessing utilization of current payment system Considered alternative approaches to construct case-mix weights (CY2016 Rule) Diagnosis on Top Predicted Therapy Home Health Groupings Model Abt Associates pg 5
6 Setup of HHGM Each home health episode is categorized into different subgroups within each of the five categories below: Timing (early or late; episode is placed into 1 of 2 groups) Referral source (community or institutional source; episode is placed into 1 of 2 groups) Clinical grouping (musculoskeletal rehab, neuro/stroke rehab, wounds, MMTA, behavioral, or complex nursing care; episode is placed into 1 of 6 groups) Functional/cognitive level (low or high; low, medium, or high; episode is placed into 1 of 2 groups (MS Rehab and Behavioral Health) or 1 of 3 groups for the other clinical groups) Comorbidity adjustment (no or yes; based on secondary diagnoses; episode is placed into 1 of 2 groups) In total, HHGM produces 2*2*(2*2+4*3)*2 = 128 different payment groups Abt Associates pg 6
7 Abt Associates pg 7
8 30 Day Periods HHGM uses a 30 day period not a 60 day episode like in the current payment system Episodes have more visits on average during the first 30 days compared to the last 30 days Dividing a single 60 day episodes into two periods allows payments to be more accurately apportioned No impact to OASIS - an assessment would apply to two consecutive 30 day periods Abt Associates pg 8
9 Average Visits per 15 Days During a 60 Day Episode (Only First Episodes in a Sequence of Episodes that Last a Full 60 Days) 30 Day Episodes Days 1-15 Days Days Days SN PT OT SLP Aide MSS Abt Associates pg 9
10 Timing Under the HHGM, the first 30-day period in a sequence of periods is classified as early All subsequent periods in the sequence (second or later) are classified as late periods Large drop in episode cost from first episode to second episodes in the current payment system Large drop in episode cost from the first 30 days to second 30 days within an episode Abt Associates pg 10
11 Timing- Percentage of Periods by Early versus Late 68.8% 31.2% Early Late Abt Associates pg 11
12 Referral Source Referral source based on a 14 day lookback before the episode begins Community or institutional Episode cost is higher for episodes coming from an institutional setting compared to a community setting Abt Associates pg 12
13 Percentage of Periods by Referral Source 64.6% 35.4% Institutional Community Abt Associates pg 13
14 Clinical Group Episodes grouped into one of six groups based on OASIS primary diagnosis Clinical group is useful in case-mix adjustment and provides clarity on the primary purpose of the episode Clinical Group Musculoskeletal Rehabilitation Neuro/Stroke Rehabilitation Main Reason for HH Encounter is to Provide: Therapy (PT/OT/SLP) for a musculoskeletal condition Therapy (PT/OT/SLP) for a neurological condition or stroke Wounds - Post-Op Wound Aftercare and Skin/Non-Surgical Wound Care Assessment, treatment & evaluation of a surgical wound; nonsurgical wounds, ulcers burns and other lesions Medication Management, Teaching and Assessment (MMTA) Behavioral Health Care Complex Nursing Care (Based on answers to OASIS item M1030, M1410, and M1630) Assessment, evaluation, teaching, and medication management for a variety of medical and surgical conditions not classified in another group Assessment, treatment & evaluation of psychiatric and substance abuse conditions Assessment, treatment & evaluation of complex medical & surgical Abt Associates pg 14 conditions with nursing interventions including IV therapy, total parenteral nutrition, enteral nutrition, ventilator, and ostomies
15 Percentage of Periods by Clinical Group 7.7% 11.0% 2.9% Behavioral Health MMTA 2.6% 11.0% 64.9% Complex Nursing Care Musculoskeletal Rehabilitation Neuro Rehabilitation Wound Abt Associates pg 15
16 Functional and Cognitive Level Under the HHGM, episodes are categorized into levels based on the relationship between functional and cognitive status and episode cost MS Rehab and Behavioral Health episodes are categorized into one of two levels (low and high) Roughly half of episodes are grouped into each level Episodes in other clinical groups are categorized into one of three levels (low, medium, and high) Roughly a third of episodes are grouped into each level A selection of OASIS items are used to create these levels The levels are created similarly to how the functional levels are created currently Abt Associates pg 16
17 Comorbidity Adjustment Under the HHGM, the primary diagnosis is used to construct the clinical group Secondary diagnoses contain information that can case-mix adjust payments even after controlling for other aspects of the HHGM We have explored two approaches so far Identifying commonly occurring comorbidities present in episodes with above average episode cost Identifying whether comorbidities are MCCs or CCs Abt Associates pg 17
18 Estimating Case-Mix Weights for the HHGM s 128 Payment Groups Regression estimates the relationship between episode cost and the broad categories on the HHGM process diagram The model is used to predict episode cost for each episode used to estimate model Case-mix weights equal predicted episode cost divided by average episode cost Abt Associates pg 18
19 Strengths of the HHGM Similar to the current payment system in design and setup But uses different variables to case-mix adjust payments Addresses criticisms of the current payment system Easier to identify the reason for the home health episode Abt Associates pg 19
20 Next Steps HHGM is still being developed finalizing our approach for comorbidities A technical report describing the HHGM will be released later this year Please contact Abt Associates (HomeHealth@abtassoc.com) for questions or comments on today s presentation Abt Associates pg 20
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