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Home Health Industry Pushes Back on CMS Budget-Neutrality Methodology for PDGM

Home Health Care News

Since the release of the U.S. Centers for Medicare & Medicaid Services’ (CMS) proposed payment rule, home health stakeholders have been sitting in their respective “war rooms” trying to navigate the proposal.

As providers geared up for the unveiling of the proposal, many knew that CMS’ analysis of whether the Patient-Driven Groupings Model (PDGM) led to higher, lower or equal spending compared to the old payment model would be a major factor, according to William A. Dombi, the president of the National Association for Home Care & Hospice (NAHC).

Many are pushing back against CMS’ methodology for assessing budget neutrality, with organizations such as NAHC expressing their concerns even prior to the release of the proposed rule.

“When we found out on Friday that CMS chose to use the same methodology which had been roundly condemned by anybody who had evaluated it, we had to conclude the CMS had effectively declared war against home health,” Dombi said. “I don’t mean that in an emotional sense, but in a practical sense, where the outcome of this proposal could be extraordinarily — not just disruptive — but devastating to the home health care community.”

He made these comments during NAHC’s latest webinar on Thursday.

Overall, the proposed rule comes with a decrease to payment rates by 4.2%, or $810 million less compared to 2022 rates.

“CMS only gets to that [$810 million] by adding in the inflation update, so the inflation update for 2023 is a meager 2.9%,” Dombi said.

The proposed rule also includes a 7.69% PDGM budget-neutrality adjustment.

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House Lawmakers Call Out ‘Bad Actors’ Within Medicare Advantage

Home Health Care News / By Joyce Famakinwa
 
House lawmakers are pushing for more oversight of Medicare Advantage (MA) plans in light of concerns over higher spending, improper claim denials and access to treatment.
 
A number of lawmakers on the House Energy and Commerce Committee’s oversight subcommittee examined the issue during a hearing that centered around the MA program on Tuesday.
 
“I am deeply concerned with recent reports that seniors in private sector Medicare Advantage plans are facing unwarranted barriers to accessing timely, medically necessary care,” Energy and Commerce Chairman Frank Pallone, Jr. (D-N.J.) said during the hearing. “Several studies have raised concerns that insurance companies are denying beneficiaries’ access to treatment and imposing burdensome requirements that delay care. Improper claim denials and increased use of prior authorizations are preventing beneficiaries from receiving the care they need.”
 
Pallone noted that while many Medicare Advantage plans seemed to be acting responsibly, “bad actors” were endangering the health of seniors and increasing costs for taxpayers.
 
Though several officials from federal agencies testified, including the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG), the Medicare Payment Advisory Commission (MedPAC) and the Government Accountability Office. The U.S. Centers for Medicare & Medicaid Services (CMS) was not represented at the hearing.
 
“It’s a shame CMS did not agree to testify at this hearing to speak to the work the agency is doing to improve this program,” Rep. Morgan Griffith (R-Va.), a ranking member of the subcommittee, said.
 
Additionally, no MA plans spoke at the hearing.
 
During the hearing, Erin Bliss, the assistant HHS inspector general, pointed to OIG findings that plans were using chart reviews or in-home health risk assessments to diagnose patients. Oftentimes, there would be no follow-up.
 
In total, these diagnoses resulted in an estimated $2.6 billion in risk-adjustment payments for 2017.
 
Bliss also expressed that plans sometimes delayed or denied beneficiaries’ access to medical care, despite the requested care being medically necessary and meeting Medicare coverage rules.
 
“In other words, these Medicare Advantage beneficiaries were denied access to needed services that likely would have been approved if the beneficiary had been enrolled in original Medicare,” she said. “These denials likely prevented or delayed needed care for beneficiaries.”

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Biden-Harris Administration Takes Action to Expand Access to Emergency Care Services in Rural Communities

CMS proposes new rule that creates a pathway for rural hospitals and critical access hospitals to increase access to emergency and outpatient care

Today, as part of the Biden-Harris Administration’s ongoing effort to strengthen rural health, the Centers for Medicare & Medicaid Services (CMS) is releasing a new proposed rule protecting access to emergency care and additional outpatient services for people in rural communities. CMS is establishing the Conditions of Participation (CoPs) for Rural Emergency Hospitals (REHs). The proposed rule will allow small rural hospitals to seek this new health care provider designation and provide continued access to emergency services, observation care, and additional medical and outpatient services. In accordance with the statutory legislation, REHs will be eligible to receive payment for services provided on or after January 1, 2023. This is a significant step in building on the Administration’s efforts to reduce health care disparities and maintain access to services in rural communities.

Rural communities represent a fifth of the U.S. population, and the Department of Health and Human Services (HHS) is committed to improving health outcomes and promoting health equity in rural America. Since 2010, 138 rural hospitals have closed — with a record-breaking 19 hospitals closing in 2020 alone. These closures occur disproportionately within communities with a higher proportion of people of color and communities with higher poverty rates. Rural communities experience shorter life expectancy, higher mortality, and have fewer local health care providers, leading to worse health outcomes than in other communities. Rural hospital closures deprive people living in rural areas of crucial services, including access to emergency care.

“The availability of the new Rural Emergency Hospital provider type will maintain access to essential health care services and help to reduce disparities in rural communities,” said CMS Administrator Chiquita Brooks-LaSure. “CMS is committed to advancing health equity, driving high-quality person-centered care, and promoting the sustainability of our programs. Today’s action to strengthen rural health furthers our goal of ensuring everyone served by our programs the has access to quality, affordable health care.”

To address these concerns, CMS is implementing a new Medicare provider designation called REHs, which will provide an opportunity for small rural hospitals and CAHs to right-size their service footprint and avoid potential closure so they can continue to provide essential services for their communities. The REH provider type was established by the Consolidated Appropriations Act of 2021 to address the growing concern over closures of rural hospitals. . .

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For more information on the Rural Emergency Hospital and Critical Access Hospital Conditions of Participation, visit: https://www.federalregister.gov/public-inspection/current

To read the Fact Sheet on the Rural Emergency Hospital and Critical Access Hospital Conditions of Participation, visit: https://www.cms.gov/newsroom/fact-sheets/conditions-participation-rural-emergency-hospitals-and-critical-access-hospital-cop-updates-cms-3419.

To read the Fact Sheet on HHS actions to strengthen rural health, click here

 

FDA Advisers Recommend Updating COVID Booster Shots for Fall

Associated Press / By Lauran Neergaard and Matthew Perrone

At least some U.S. adults may get updated COVID-19 shots this fall, as government advisers voted Tuesday that it's time to tweak booster doses to better match the most recent virus variants.

Advisers to the Food and Drug Administration wrestled with how to modify doses now when there's no way to know how the rapidly mutating virus will evolve by fall — especially since people who get today's recommended boosters remain strongly protected against COVID-19's worst outcomes.

Ultimately the FDA panel voted 19-2 that COVID-19 boosters should contain some version of the super-contagious omicron variant, to be ready for an anticipated fall booster campaign.

"We are going to be behind the eight-ball if we wait longer," said one adviser, Dr. Mark Sawyer of the University of California, San Diego.

The FDA will have to decide the exact recipe, but expect a combination shot that adds protection against either omicron or some of its newer relatives to the original vaccine

"None of us has a crystal ball" to know the next threatening variant, said FDA vaccine chief Dr. Peter Marks. But "we may at least bring the immune system closer to being able to respond to what's circulating" now rather than far older virus strains.

It's not clear who would be offered a tweaked booster — they might be urged only for older adults or those at high risk from the virus. But the FDA is expected to decide on the recipe change within days and then Pfizer and Moderna will have to seek authorization for the appropriately updated doses, time for health authorities to settle on a fall strategy.

Current COVID-19 vaccines have saved millions of lives globally. With a booster dose, those used in the U.S. retain strong protection against hospitalization and death but their ability to block infection dropped markedly when omicron appeared. And the omicron mutant that caused the winter surge has been replaced by its genetically distinct relatives. The two newest omicron cousins, called BA.4 and BA.5, together now make up half of U.S. cases, according to the Centers for Disease Control and Prevention.

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2023 Home Health Rule: 4.2% Reduction With Warnings of More to Come

APTA

After holding off on any big changes to home health payment in 2022, CMS plans to take some major steps in 2023 to address what it describes as the gaps between "assumed behavior changes and actual behavior changes" resulting from the Patient-Driven Groupings Model payment system implemented in 2020. Translation: The PDGM has cost significantly more than CMS hoped, so to reach its goal of budget neutrality compared with the previous system, the agency has proposed changes that would reduce payment by 4.2%, or about $810 million compared with 2022 amounts.

The bulk of the cuts is directed at the 30-day payment rate, but even if those reductions are put into place in 2023, CMS believes more changes will need to be made in the future to recoup the payment differences that have already occurred under the PDGM — an estimated $2 billion gap so far. To that end, the proposed rule also seeks public comment on how to best make up the difference.

APTA is preparing comments on the rule to submit by the Aug. 16, 2022, deadline. APTA members may submit their own comments directly to CMS here.

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