The home health PPS final rule makes the patient-driven groupings model a reality.
For calendar year (CY) 2020, the home health (HH) prospective payment system (PPS) will be increased by 1.5 percent, resulting in an estimated extra $250 million paid to home health agencies (HHAs). In the advance release of the final rule, scheduled to publish in the Federal Register November 8, 2019, CMS also finalized home health value-based payment (HHVBP) model policy to publicly report performance data for payment year (PY) 5 of the model. The rule also implements the patient-driven groupings model (PDGM) case-mix adjustment methodology, which uses a 30-day unit of payment.
PDGM. The PDGM shifts the formation of case-mix groups to focus more on patient characteristics, such as admission source, diagnoses, and functional impairment. CMS believes that the methodology better reflects clinicians’ treatment of differing patient needs. The new case-mix adjustment is expected to result in some provider behavior changes, which is accounted for in the 1.5 percent payment rate update to achieve budget neutrality. The rate change takes into account updated wage index data and updates to the fixed-dollar loss ratio. In addition, there is a 0.2 percent aggregate decrease in HHA payments (totaling about $40 million) due to changes in rural add-on percentages. The payment adjustments will result in a 30-day payment amount of $1,864.03 for HHAs reporting the required quality data.
Quality reporting. HHAs that fail to submit data for the adopted HH quality reporting program (QRP) measures are subject to a 2 percent reduction in their market basket increase. CMS has adopted two new QRP measures for HHAs that govern the transfer of information to both the relevant provider and to the patient following acute care. In further efforts to promote care coordination and interoperability, CMS finalized several standardized patient assessment data elements (SPADE) to be added to the Outcome and Assessment Information Set (OASIS). These SPADEs assess cognitive function, mental status, medical conditions, impairments, and social aspects.
Home infusion therapy. CMS has finalized transitional policies to prepare providers and suppliers for the CY 2021 home infusion therapy benefit. For CY 2020, home infusion drugs are grouped into three categories and paid under the physician fee schedule (PFS). The payment amounts will be adjusted for geographic costs. The first home infusion therapy visit will receive a higher payment amount.
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