All About the Home Health Groupings Model HHGM Proposed by CMS

 In Home Health, Industry News, News, Regulatory

CMS Surprises the Industry with Publication of the Home Health Groupings Model (HHGM)

The home health industry was surprised earlier this year when CMS published the Home Health Groupings Model (HHGM) as part of the Home Health Proposed Rule for cy2018. Although not scheduled for implementation until 2019, the publication of the new model came as a big surprise for the industry.

The proposed rule would change the home health prospective payment system (HH PPS) case-mix adjustment methodology, including a change in the unit of payment from 60-day episodes of care to 30-day periods of care that would be implemented Jan. 1, 2019, were it to be finalized and become binding. The rule includes proposals for the Home Health Value-Based Purchasing Model and the Home Health Quality Reporting Program.

In overview, CMS’ proposed HHGM rule would update payment rates and the wage index and proposes a redesign of the payment system in 2019, which for many, is the most important, even stressful, component worth watching. The proposed rule is one of several that are designed to reflect a broader strategy that CMS says it is pursuing to relieve regulatory burdens for providers; support the patient-doctor relationship in healthcare; and promote transparency, flexibility and innovation in the delivery of care.

CMS, along with the Medicare Payment Advisory Commission (MedPAC), has long described the need for a new payment model that shifts from paying for volume to paying for value by eliminating therapy visits as a factor in payment determinations. CMS also wants to ensure that more complicated clinical cases are sufficiently compensated for their higher acuity. Accordingly, CMS will now use primary diagnosis to identify six clinical groupings for patient assignment.

The OASIS items used in the calculation of the functional score will include two new items: M1800 (Grooming), and M1033 (Risk for Hospitalization), in addition to the six that are used today. The referral source — looking back 14 days from the start of care — will identify whether community or institution will be used in the model. Early and late will be determined by new 30-day billing periods with only the first 30-day period being defined as early. Finally, co-morbidities will be added as another factor determining the patient’s clinical group assignment.

There are several other details provided in the rule that the industry has been quick to consume, including:

  • Dropping therapy from the case mix altogether;
  • Adjusting rates based on source of admission within the last 14 days – institutions versus community;
  • Adjusting rates by placing patients into six clinical groups: musculoskeletal rehabilitation; neuro/stroke rehab; wounds; medication management; teaching and assessment; behavioral health; or complex nursing intervention; and
  • Adjusting rates by placing patients into two or three functional groups, depending on clinical group.

“We’re redesigning the payment system to be more responsive to patients’ needs and to improve outcomes. The new payment system aims to encourage innovation and collaboration and to incentivize home health providers to meet or exceed industry quality standards,” said CMS administrator Seema Verma in a statement released to support the proposed changes.

To read more, we recommend checking out our three-part series on the Netsmart CareThreads blog. You can also download our full whitepaper there.

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