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By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON - Members of the Medicare Payment Advisory Commission (MedPAC; Washington) raised a series of concerns about the Health Care Financing Administration’s (HCFA; Baltimore) proposed regulation for the home health prospective payment system (PPS) at the commission’s public meeting here on Nov. 18. Among the concerns raised by various MedPAC commissioners were the 60-day episode, outliers, and several other components of the proposed system.
Perhaps most significantly, the commission decided to study whether there are any administrative or legislative issues that would be raised by a transition that used costs as the base to transition from as opposed to the interim payment system. That decision was based on anticipated difficulties with the agency’s proposal to transition without any phase-in. While MedPAC has no formal impact on changes to the proposed regulation, its views typically carry significant weight with HCFA.
"Right now, as it’s proposed, what we’re talking about is no transition from the interim payment system," said MedPAC Chair Wilensky. "I personally would rather have a transition from the IPS than no transition."
Several other concerns were also raised. MedPAC Vice Chairman Gary Newhouse noted that HCFA says it will institute medical review if there is a spike in the number of visits. "But it’s not clear to me that we have such well-defined criteria for review that we can say the fifth visit was or was not necessary in the same sense that we could say an extra day in the hospital was or was not necessary," he argued.
Newhouse said he is also concerned about incentives to stint at the high end. "Again, HCFA says they are going to monitor quality and outcomes, but I just don’t think our ability to monitor quality and outcomes is really good enough to rely on making this no marginal revenue for another service," he said.
Wilensky said she was concerned with the 60-day episode proposed by HCFA. "The concern I had," she said, "is that that is such a big unit in what seems to be a pretty amorphous type of service distinction, unlike for example hospital admissions or discharge for very specific DRGs where you have a much more defined activity that is being done.
"I am uncomfortable in the aggregated grouping of something like a 60-day episode," Wilensky added. She said it is unclear whether it can be defined what is reasonable in that episode and whether or not something substantially smaller might be more appropriate.
Commissioner Carol Newhouse, who represents the home health industry before MedPAC, countered that it will provide home care providers a different way of looking at patient care. She argued that the 60-day episode matches both current practice, which requires recertification after 62 days, and the OASIS system, which is supposed to be completed every 60 days.
In addition, Raphael pointed out that the largest proportion of patients are in home care for 30 days or less. "The you have another very substantial consumer of resource group that’s at the tail end, that stays probably for two or more episodes," she added. "I don’t yet understand how this system deals with those two key groups which are very disparate in their needs.
"This is very important because I’m trying to move away from incentives which are tied to how many visits and how many hours," she argued. "I’m looking for some movement to a system that will in fact reward and encourage efficiency and will in some way discriminate among those people who enter based on what their real acuity and need level is."
Raphael also expressed concerns about how the new system will be monitored and administered. She noted that under the PPS demonstration there was 100% medical review at the outset but that it was dropped to 25% because the fiscal intermediaries could not sustain that level. "But even 25% medical review is quite a high level of medical review to sustain in this system," she argued. "I think we need to pay more attention to what this really would require on the part of most fiscal intermediaries and HCFA to monitor and make sure there are not poor incentives driving behavior here."
Newhouse also asserted that under the PPS the physician is "much more centrally involved" in the decision about whether to have one or more home health visits. "It seems to me one of the consequences of this will be to potentially increase the burden on physician certification, which I’m not sure physicians are prepared to cope with," he argued.
Commissioner Judith Lave noted that for outliers, there are a significant number of cases with five or fewer visits. "What’s not clear to me is why those cases would not define a case-mix group," she asserted. "The definition of the group seems to be a little strange." She argued that if the expected number of visits was four, that should define the group as opposed to an outlier status.
Lave also raised a concern with regard to the services that are bundled into the cost of care that are supposed to be paid for under the case-mix system. "Basically, the system is not making the same kind of change with respect to what home health agencies are responsible for as the skilled nursing facility PPS did with respect to what SNFs were responsible for."
Commissioner Peter Kemper raised concerns regarding the quality of services provided under PPS. He argued it might be necessary to build in a refinement that he said was not just a re-basing but an assessment of the system at a defined point even though HCFA opted not to phase-in the PPS. "I think it is very important to have one and as part of that to collect the data that you would need to refine it," he said. "I don’t know what the bright line is, but it’s something we need to look at."
Commissioner Long questioned the use of a calendar period of time as the basic unit for episodic events within that period of time that do not in any way relate to what is typically considered a continuous event. "I think we have the potential of creating some sort of extraordinary burden on the physician who is constructing the plan," he said. "I can see them evolving perhaps to specifying exactly the frequency and number of visits and the services within each one."