ÐÇ¿ÕÈë¿Ú

Medically complex patients at risk under revamped methodology, commenters warn.

In a proposed change to its outlier reimbursement, Medicare tries to focus financial resources on at-risk medically complex patients. But the policy may end up doing just the opposite in some cases, critics say.

Reminder: The Centers for Medicare & Medicaid Services wants to switch from the current per-visit-based outlier payment calculation methodology to a per-unit based calculation based on selfreported 15-minute visit units, according to the Home Health Prospective Payment System proposed rule for 2017 (see related story, p. 296).

In conjunction with the switch to per-unit counting, CMS also wants to put an eight-hour cap per day or 28-hour cap per week limit on the visit units counted toward outlier reimbursement. “We are not limiting the amount of care that can be provided on any given day,” CMS took pains to point out in the rule. “We are only limiting the time per day that can be credited towards the estimated cost of an episode when determining if an episode should receive outlier payments and calculating the amount of the outlier payment.”

Impact: Analysis of 2015 claims indicates that “only 1,600 episodes or so, out of 5.4 million episodes, would be impacted due to the proposed 8 hour cap,” CMS highlighted.

But multiple commenters are worried about what the cap might mean for the very patients this policy change is supposed to help.

“CMS should take care that the development of caps not hinder the ability to treat complex patients who are sicker and frailer than the average patient,” said the American Academy of Home Care Medicine in its comment letter. “Such patients represent the sickest Medicare beneficiaries.”

Risk: “Applying these caps should not produce the unintended consequence of dis-incenting agencies to take on the sickest patients who are likely to be outlier patients,” the Academy chastised. That “would have the perverse effect of increasing rather than decreasing Medicare program cost by driving such patients into institutional care.”

“Capping the hours of care at 28 per week is 1) inconsistent with the language in the Program Manual specifying less than eight hours per day OR less than six days per week, and 2) creates an undue burden on providers by requiring additional paperwork in order to provide adequate care to outlier patients,” Interim HealthCare said in its comments.

Trend: “Since the implementation of OASIS, there tends to be an overall higher number of critically complex patients being treated in the home health setting,” noted the American Physical Therapy Association in its letter. This trend will continue, since “the shift to a bundled payment system as well as the shift to move care out of institutionalized setting[s] ... will lead to an influx of patients with more severe conditions being treated by HHAs. We ask that CMS consider this when crafting the final rule, so that HHAs are not penalized for the natural occurrence of sicker patients being treated.”

The caps “may create a disincentive to serve certain patient groups who require more care, specifically the type of patients that benefit from the services provided by home health agencies,” urged the California Association for Health Care Services At Home in its letter. “We recommend eliminating the eight hour per day cap.”