Five Stars in Home Health – Not Enough for the Long Haul
Most home health agency leaders aspire for 5-star ratings at their agencies. Of course, in the short run, they are a very good thing – a great beginning However, these ratings are not nearly enough as we move forward over the long haul, especially during the next two to three years. New alternate payment methods and models are being introduced that require nothing more than the re-engineering of all of home health agencies’ business structures and functions. We have an example to follow, though: This restructuring will happen in the same way it did when during the acute care reforms that affected hospitals two decades ago, Michael McGowan, president of Opera Care, and former state CMR regional OASIS coordinator, said.
McGowan points out that hospitals once engaged in a high-volume, large capacity model, but home health providers who are currently engaged in a high-volume, large census, low-value care model will soon be replaced with a high-acuity, outcomes-driven rapid cycle care model, mimicking the restructuring of the hospitals that we’ve previously seen. When the hospital reform initially began, it was a fill-the-beds type of environment, but suddenly, almost overnight, the model became an empty-the-beds, get-the-patients out, get them out the door and move them into the home model — that practice continues currently almost without fail almost 20 years later.
As is likely obvious, McGowan said during a recent Netsmart/DeVero webinar, “5 Star Ratings Not Good Enough for the Long Haul,” CMS payment reforms will change the clinical behaviors of physicians, nurses and hospital paraprofessionals, and change the entire focus of hospital administrators and CFOs. The primary change, the easiest one to see, is how the payment methodology and the payment structure is changing the model of care from procedure/recovery/discharge to procedure/discharge/recovery.
“We see this and the evidence of this as our patients are being discharged home to us far sicker than we ever saw them before,” McGowan said. “The beds were filled on average 13 or 14 days under the procedure/recovery/discharge model and now we look under the procedure/discharge/recovery model and beds are filled for a matter of hours – often 24 to 36 hours.”
CMS has watched these developments, examined innovations that were born of it, and they considered this a success in meeting its agenda. CMS is convinced and thinks it understands that it has proof that placing quality over cost and quantity actually does produce better outcomes and reduce costs of care, he said.
Medicare certified oversight is data driven
Medicare Home Health is the only Medicare certified provider of home healthcare that sends one person by themselves into a home with no support or accountability to determine the acuity, case mix, outcomes development, and revenue integrity; develops a care plan and design a care cycle program; and they do this without any support whatsoever. “This is how we’ve been operating the last 20 years; CMS sees it, they see our data, they read our documentation, they have a fair idea of what we do and they are now saying they are no longer going to embrace this,” he said.
The care delivered in the acute care venue is data driven in every respect. The data is developed by a team during the assessment process, utilization and services review to be delivered and are strictly governed by a utilization review team, which is a centralized group, that authorizes best practice, cookie cutter-type care that is then carried out by the clinical team, adjusted and molded to the unique and individual aspects of the patient’s disease in direct relation to the severity of the illness and injury of the patient. Home health agencies wishing to continue doing business with CMS will soon learn to follow this lead and mimic the hospitals in their reporting and data collection or they will lose market share as the competitors learn these skills and surpass the quality metrics of those who cannot or will not embrace these new payment models.
This is a noteworthy change because home health has always been about the visits instead of what takes place during the visits and what happens between the visits during the episode and over the course of the episode. CMS’ intent is to create a payment model where the visit performed in home health is done so with an acuity comparable to the same type of visit performed in a skilled nursing facility, in-patient rehab or long-term care hospitals. This, in many manners, will prove to be a significant challenge to providers who embraced a volume-, instead of a value-based business.
As we move toward Home Health Grouper Model (HHGM), and the 30-day episode being implemented in 2019, it is estimated that there will be considerably more Low Utilization Payment Adjustment (LUPA) episodes than we see today and far fewer late episodes that we see in the Prospective Payment System (PPS) model. This is CMS’ goal – enhanced outcomes, reduced costs.
“As I talk to providers about HHGM, a lot of them say we’ll just double down on the re-certification to keep their cash flow,” McGowan told webinar attendees. “This doubling down is going to consolidate the data and as the patterns of data start to become reveled, this presents problems that will be exponentially faster for an auditor to audit.”
In regard to Medicare auditors, their contractors are tied directly to data-driven patterns. Those home health agencies that are improperly recertifying patients and utilization that is outside usual and customary in direct correlation to the acuity imported and transmitted by OASIS will find that their data is quickly compressed and that the audits will be happening in four to six months instead 12 to 18 months.
We are where we are today with the evolution of payment models because of too many visits, too few costs and not enough outcomes.
At present: The future of HHGM
At present, there is very little continuity between hospital acuity and post-acute care in the home health segment. The new home health value-based purchasing (HH VBP) and HHGM are designed to ensure that payments for services made are correlated or similar to the acuity levels in the setting in the entire Medicaid certified continuum. In essence, if a therapy visit reimbursed in the in-patient rehab for $150 it would be expected that the patient and the money spent to perform that visit would have relatively the same acuity as a patient in the home health agency. HHAs have routinely failed to meet this threshold and this is one of the primary drivers behind removing therapy bonuses in the HHGM payment models.
Couple this with an assess-and-treat mentality, and care planning that is done off of an objective or subjective care assessment that does not parallel the acuity of hospitals – where high levels of acuity and low levels of maintain exists – creates a disparity. These subjective assessments that result in three to four visits per episode focused on low tech or nonskilled items or interventions really provide little benefit to the payer or the patient in general. CMS describes this as waste.
The obsolete 1week9 re-cert patterns is rapidly being diminished because of HHVBP, but are highly prevalent in more than 50 percent of agencies. They don’t produce outcomes, therefore, they don’t produce bonuses. When looking at home care, this type of care is often utilized when the patient would be more suited for ambulatory services. CMS describes that as abuse. At times when service utilization in episodes where ambulatory care is indicated is then coupled with very high levels of therapy utilization is described by CMS as upcoding, which it describes as fraud.
A substantial number of agencies have embraced a model called “what can I find that Medicare will pay for.” This has fostered the assess-and-treat mentality – a fishing expedition – and results in care planning that keeps the patient dependent on the services of the clinical staff and the agency rather than fostering independence and self-management of the disease process.
These components created the volume vs. value model. In the volume model clinicians and patients are seemingly incentivized to fail as a dependency on the agency in lieu of independence and self-management. Under HHVBP and HHGM, home health agencies are not being told that they cannot provide maintenance care or chronic care maintenance, instead, CMS has evaluated what is going on in the maintenance and chronic care models and simply has chosen not to financially reward this model. Thus, if a primary care model embraced by the agency does not transmit OASIS-based outcomes to CMS the home health agency will soon find that its business model is irrelevant to those who pay the claims and those who refer patients to it.
Hospitals are under great pressure to refer patients to agencies with above average star ratings. How long will it be before physicians are pressured to refer to home health agencies with a star rating of 3.5 stars or more or before CMS pressures healthcare leaders to say, “We can’t have you refer patients to organizations that don’t produce quality”?
Markers for success
The current markers for success include:
Average daily census
Length of stay, greater to or equal to 120 days
Therapy utilization drives case mix – drive reimbursement of the agency
Recertification wherever possible: fall, medication change, etc.
According to McGowan, if these continue to be the markers of success, home health agencies need to reinvent themselves to be more like the following: How many wraps and finals they are submitting on a weekly basis to drive outcomes; how many of these can be submitted that can be attributed to the agency in a positive manner? Additionally, length of stays in excess of 58 days demonstrates a higher than average cost of care and an elevated beneficiary disbursement. This alone makes this agency a very poor candidate for a hospital or ACO partnership.
Length of stay in excess of 58 days starts to be the primary cause of beneficiary disbursement surveys and length of stay review by CMS contractors. To manage discharge, agencies must manage their census in the same manner that hospitals do by using their OASIS metrics during the start of care, resumption and recertification time points exactly the same ways hospitals use their diagnosis related groups (DGR) data during the admission, interim time points and when the condition is noted. Hospitals that use their DGR data in this manner experience significantly more predictable financial stability. Home health providers who show that they have not done this will be on shaky ground, but those who learn this skill and embrace a cyclical rhythm model of admission and discharge, growing their unduplicated census instead of their average daily census, are going to have rewards very similar to the early days of PPS.
Again, maintenance care will still be covered – as long as it’s done in accordance to CMS guidelines — but it may become cost prohibitive as maintenance care is far less expensive than complete restoration.
MedPAC HH Future
Medicare Payment Advisory Commission (MedPAC) payment models are designed to ensure that payment for service approximate the same level of acuity across the entire Medicare certified continuum. Agencies that have traditionally depended on the six-, 14- and 20-visit therapies utilization bonuses (which seems to be more than 50 percent of the agencies) state they cannot live without these bonuses. It’s time to learn how to finance operations without these extra payments.
“This is easily done; it’s not impossible, it does require a change in mindset and how you think, and the component that will lead to your success is real-time service utilization review and live quality assurance activities that are performed during the OASIS assessment while the nurse is in the home. These types of processes parallel hospital practices,” McGowan said.
He offers the following advice: Live, interactive quality assessment during the patient assessment will maximize your reimbursement, ensure your revenue integrity and establish your ability to perform a meaningful service utilization review.
Why HHGM is viable in the eyes of CMS
CMS examined clinical visits over a period of 60 days. More than 50 percent of the second 30 days had the least amount of visits – almost all of the visits are during the first 30 days.
Moving into the future, if home health agencies don’t have an acute care provider or an ACO as a referral source they are likely already feeling the financial pain. These organizations control the flow of patients into an agency.
Regarding OASIS assessments: Agencies that are wildly success are able to perform an OASIS assessment within four to eight hours of referral. All OASIS assessments and quality assurance will be done in concert with the nurse being in the home in real time. Once done, the care plan is initiated during the start of the care visit with goals expected to be reached by the next visit. No longer is a completion and return of an OASIS assessment in eight to 12 hours sufficient. This is simply not going to be adequate if you’re waiting 24 to 36 hours on your OASIS as doing so means you’re probably losing between $300 t0 $500 in efficiency and revenue.
“We’re going to be transitioning into rapid cycle unduplicated census that leads to turnover and outcomes,” McGowan said. “Agencies that realize that carrying a large volume, long-term census will realize that this is sinking them financially.”
Practical steps to being a success during industry change
CMS expects patients and caregivers to comply with the care plans being implemented. Thus, patients should have to ability to assume responsibility for self-care. Patients who refuse to comply with best practices actually do damage an agency’s star ratings, and they damage the agency’s outcomes. This is what the hospitals are focusing on and this why the hospitals are taking a strong stance and saying to patients that they must comply with treatment plans because the hospital is financially penalized otherwise
Those patients that are fully unable to comply are a different story and they need special accommodations or additional services. Documenting goals of the patients, and which are not able to comply with the care plan is essential.
Agencies also must take accountability for how the OASIS assessment is performed in the home. If agencies can’t ensure that a walking OASIS assessment is done, they’re not getting the acuity they need. Getting this acuity in a standardized and efficient manner will increase productivity. This is something directly related to the cost of care, the next performance metric to conquer.
The agency with a future is going to centralize all clinical programming, McGowan said, with no outliers in the agency’s nursing staff doing things on their own or in their own way. Centralized clinical programming must become a foundational culture for the organization to success. Once clinical programming is centralized and is coupled with utilization reviews, the agency will have a completely different feel and look to the agency.
There so much more …
There’s so much more than maintaining a high star rating; so much more now that payment reforms are on their way, and the measure of quality care is changing. Confusion seems rampant, according to the feedback received by McGowan and DeVero following its webinar, “5 Star Ratings Not Good Enough for the Long Haul,” but answer also are plenty, and available.
For example, McGowan’s presentation provides a great deal more information than can be covered here, with additional valuable insight about HHGM, HHVBP and how home health agencies can ensure their success in the changing marketplace. Listen for free, here: Five Stars in Home Health Webinar Recording.