/ en Fri, 25 Apr 2025 19:28:12 -0500 Tue, 11 Mar 25 12:52:15 -0500 /testimony/2025-03-11-aha-statement-house-ways-and-means-subcommittee-health-hearing-march-11-2025 <div class="container"><div class="row"><div class="col-md-8"><h2>Statement<br>of the<br>şÚÁĎŐýÄÜÁż Association<br>for the<br>Committee on Ways and Means<br>Subcommittee on Health<br>of the<br>U.S. House of Representatives<br>“After the Hospital: Ensuring Access to Quality Post-Acute Care”<br>March 11, 2025</h2><p>On behalf of our nearly 5,000 member hospitals and health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and our 2,425 post-acute care members, the şÚÁĎŐýÄÜÁż Association (AHA) appreciates the opportunity to submit this statement for the record to the Ways and Means Subcommittee on Health on the value of post-acute care and how Congress can better support patients’ access to these critical services.</p><h2>General Policy & Regulatory Challenges</h2><p>Post-acute care is provided to patients who have been discharged from an acute-care hospital but still require services such as close medical supervision, nursing care, therapies and other support. Long-term care hospitals (LTCHs) act as a pressure relief valve for high-acuity patients needing extended hospital stays, thereby easing the burden on intensive care units (ICUs). Inpatient rehabilitation facilities (IRFs) assist patients recovering from life-changing illnesses like brain injuries, spinal cord injuries and amputations. Skilled nursing facilities (SNFs) offer rehabilitation therapy services aimed at strengthening patients and making them more independent before they return home. Home health agencies (HHs) enable seniors to remain independent by providing medical or non-medical care in their homes. Each of these facilities plays a crucial role across the continuum of care.</p><p>While each specific post-acute sector faces unique challenges, there are several policy and regulatory issues that are universal.</p><h3>Medicare Advantage</h3><p>Medicare Advantage (MA) plans are an increasingly popular choice for older Americans, and measures must be taken to ensure that patients who require post-acute care services are able to access them in a timely manner. Perhaps the biggest challenge facing post-acute care providers and their patients is the ongoing restrictions that MA plans place on access to care. The issue has been well documented by providers as well as by Department of Health and Human Services Office of Inspector General and congressional investigations.<a href="#fn1"><sup>1</sup></a><sup>,</sup><a href="#fn2"><sup>2</sup></a> The prior authorization process used by MA plans places significant administrative burden on both acute-care hospitals and post-acute care providers. Perhaps more importantly, it is directly harmful to Medicare beneficiaries — at best delaying their care and at worst outright denying medically necessary treatment.</p><p>MA plans’ practices have directly contributed to the growing discharge delay problems plaguing acute-care hospitals. While all beneficiaries have faced these delays, the increase in length of stay for MA beneficiaries seeking post-acute care has increased twice as much compared to Traditional Medicare beneficiaries. Specifically, the average length of stay (ALOS) prior to discharge to post-acute care settings has grown by 11.3% for MA patients between 2019 and 2024. However, for patients in Traditional Medicare, the ALOS has grown by only 5.2%, according to industry benchmark data from Strata Decision Technology, LLC.</p><p>Despite steps taken by the Centers for Medicare & Medicaid Services (CMS) in recent years, providers have seen little to no meaningful change in MA plan behavior and no increased access for beneficiaries. Additionally, post-acute care providers still face challenges with MA plans listing them within their networks. CMS should conduct regular audits to ensure that MA plans include robust post-acute care options with sufficient bed spaces and resources to provide the in-network care that patients need. As MA enrollment continues to grow, it is imperative that Congress continue to rein in these harmful practices to ensure that beneficiaries are not denied the care to which they are entitled.</p><h3>Ongoing Workforce Challenges</h3><p>The U.S. health care system is facing unprecedented workforce shortages, with the Bureau of Labor Statics estimating there will be 193,100 openings for nurses in each of the next 10 years.<a href="#fn3"><sup>3</sup></a> For physicians, there could be a shortage of between 37,800 and 124,000 physicians by 2034 for both primary and specialty care.<a href="#fn4"><sup>4</sup></a> Since mid-2020, post-acute care providers have seen a significant number of patient care technicians, registered nurses, and respiratory therapists, among other vital professionals, shifting employment to other organizations. Some post-acute care providers in rural areas have experienced significant challenges in filling open positions, sometimes going months without receiving an application for open registered nurses, licensed practical nurses, certified nursing assistants or key leadership roles. Staffing challenges jeopardize the ability of seniors to access the care they need and deserve.</p><p>To ensure residents and families have access to high-quality care close to home, meaningful, long-term solutions and investments in workforce development must replace stop-gap measures, reimbursement cuts and punitive regulations. The AHA encourages Congress to pass the Conrad State 30 and Physician Access Reauthorization Act (S.709/H.R.1585) and the Healthcare Workforce Resilience Act, as well as support visa recapture initiatives and continue support for the Health Resources and Services Administration’s (HRSA) health professions and nursing workforce development programs.</p><h2>Sector Specific Comments</h2><h3>Long-Term Care Hospitals</h3><p>LTCHs play a unique role for Medicare and other beneficiaries by caring for the most severely ill patients who require extended hospitalization. LTCHs offer an intensive, hospital-level of care that may not be available in other post-acute care settings. LTCH patients are typically very medically complex, with multiple organ failures, and stay in LTCHs on average for at least 25 days. Many LTCH patients depend on ventilators due to respiratory failure or similar ailments, which require highly specialized care and extended stays. In addition, LTCHs are critical partners for acute-care hospitals, alleviating capacity for overburdened ICUs and other parts of the care continuum that would otherwise be further strained without access to LTCHs for these patients.</p><p>In 2016, Congress put in place a dual-rate payment system under the LTCH prospective payment system (PPS) for Traditional Medicare beneficiaries.<a href="#fn5"><sup>5</sup></a> This fundamental change in the payment system and other coinciding market factors dramatically reshaped the landscape of both LTCHs and the beneficiaries they serve. Since implementation of the dual-rate payment system, the volume of standard LTCH cases has fallen by approximately 70% from its peak under the legacy payment system and the number of LTCH providers also has decreased by 20%. At the same time, the average acuity of LTCH patients has risen by 20% or more in that same period, and these patients are increasingly consolidated into a limited number of Diagnosis-Related Groups (DRGs).<a href="#fn6"><sup>6</sup></a> In addition, approximately one-third of all Medicare LTCH discharges nationally are paid the inpatient PPS-equivalent rate. However, these reimbursements fall well short of the cost of care. AHA’s analysis shows that as of fiscal year 2020 reimbursement for these cases totaled only 46% of the cost of care.<a href="#fn7"><sup>7</sup></a> Finally, the growth of MA has further shrunk the patient population for LTCHs as MA plans routinely inappropriately deny access to LTCHs.</p><p>The smaller, sicker patient population and dwindling reimbursement has created many challenges for LTCHs, as evidenced by the closure of so many of these facilities. The remaining patient pool is notably more acute and costly to treat, resulting in cases increasingly qualifying for high-cost outlier (HCO) payments to compensate for lack of precision in the DRGs as so many cases are consolidated into a limited number of DRGs. In 2016, the fixed-loss amount (FLA) for HCO cases, which is the amount of financial loss an LTCH must incur before qualifying for an HCO payment, was $16,423. Since that time, the FLA has risen by more than 300% to $77,048. This unsustainable figure puts LTCHs in the untenable position of having to lose tens of thousands of dollars in order to care for some of the sickest patients. Unfortunately, CMS has been unable to deviate from its current methodology to provide relief from this policy due to a congressional mandate to cap total outlier payments at 8% of total payments.<a href="#fn8"><sup>8</sup></a></p><p>The AHA appreciates this Subcommittee’s awareness of the need to provide relief to the LTCH sector and supports efforts to provide additional flexibility and funding for HCO cases, and additional flexibility to provide care for different types of patients through the standard payment system.</p><h3>Inpatient Rehabilitation Facilities</h3><p>IRF patients are typically admitted directly from an acute-care hospital following a serious accident or illness such as stroke, brain injury, amputation or others that have resulted in serious functional deficits and medical complications. IRFs provide hospital-level care, which means they are closely supervised by a physician who also oversees patients’ overall rehabilitation. The intensive course of rehabilitation provided in IRFs must include a minimum of 15 hours per week of intensive therapy services involving multiple therapy disciplines, as well as around-the-clock specialized nursing care. This level of care is critical for debilitated patients who are stable enough to be discharged from the acute-care hospital to begin intensive rehabilitation but are at risk for medical complications without continued close medical management.</p><p>The AHA continues to hear from IRFs regarding their concerns with CMS’ IRF Review Choice Demonstration (RCD). CMS initially created the IRF RCD to “assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud.” However, the agency never provided credible evidence to support its belief that there may be high rates of fraud in the IRF field — it only cited its improper payment rate for IRFs, which, as it knows, is not the same as fraud. Since being operationalized by the Biden administration in 2023, CMS has not subsequently provided any evidence that the IRF RCD has revealed or assisted in uncovering any fraud. Specifically, the demonstration currently subjects 100% of IRF claims to review in both Alabama and Pennsylvania. Yet, according to CMS’ <a href="https://www.cms.gov/files/document/irf-rcd-stats-fy-2024.pdf" target="_blank" title="CMS: Review Choice Demonstration for Inpatient Rehabilitation Facility Services (IRF RCD) Quarterly Updates. Fiscal Year 2024 (Oct 2023 – Sept 2024).">most recent data</a> collected during fiscal year 2024, approximately 90% of all claims reviewed have been approved. Of those, more than 95% were approved on the initial submission. Despite this high affirmation rate and lack of evidence of any fraud, CMS says it still plans to continue its expansion of the demonstration to more than half of all states and territories, subjecting hundreds of thousands of IRF claims annually to the burdensome manual medical review process. It has become clear that this demonstration is burdensome, diverts valuable clinical resources, and is not achieving its stated objective of uncovering or preventing fraud in the Medicare program.</p><p>Therefore, the continued need for the IRF RCD remains highly dubious, and the AHA continues to encourage CMS and Congress to end this program.</p><h3>Skilled Nursing Facilities</h3><p>SNFs play another critical role for many hospitalized patients who need continued care after discharge. However, hospitals have faced increasing difficulty discharging patients to post-acute care settings, including SNFs. This challenge has largely been due to staffing shortages and the associated reduced capacity of SNFs and other providers. These shortfalls then place additional burden back on hospitals, including the need for hospitals to board patients until a discharge location can be found. Therefore, it is vital for the entire continuum of care, including for acute-care hospitals, that SNFs are properly resourced.</p><p>The AHA and its members are committed to safe staffing to ensure high-quality, patient-centered care in all health care settings, including long-term care (LTC) facilities. Yet, the process of safely staffing any health care facility is about much more than achieving an arbitrary number set by regulation. It requires clinical judgment and flexibility to account for patient needs, facility characteristics, and the expertise and experience of the care team. The Biden administration’s one-size-fits-all minimum staffing rule for LTC facilities creates more problems than it solves and could jeopardize access to all types of care across the continuum, especially in rural and underserved communities that may not have the workforce levels to support these requirements.</p><p>The AHA supports the Protecting America’s Seniors Access to Care Act (H.R. 1683) to prohibit the Department of Health and Human Services from implementing the provisions of the minimum staffing rule. We have recommended to CMS specific alternative strategies that take more patient- and workforce-centered approaches to ensuring LTC facilities have a strong foundation of policies and processes to continually assess, reassess and adjust their staffing levels. These strategies constitute starting points for further standards development, which we would encourage CMS to engage in with the assistance of patients and the entire health care continuum. Not only would these proposed alternatives support more timely and effective action by LTC facilities to address staffing challenges, but they also would be more consistent with modern clinical practice. Thus, repealing the Biden-era mandate would both protect patient access to care and allow for the development of more effective and clinically appropriate strategies to improve LTC patient outcomes.</p><h3>Home Health Agencies</h3><p>Approximately one in five hospitalized Medicare beneficiaries are discharged to HH.<a href="#fn9"><sup>9</sup></a> These services alleviate pressure on hospitals, other post-acute care sites and caregivers, who would otherwise be responsible for these patients. HH agencies also can prevent rehospitalization by safely providing needed interventions at home thus avoiding potential complications and accidents.</p><p>Over the last few years, the AHA has seen a strain on HH operations — along with other post-acute care providers — due to financial challenges, creating ripple effects throughout the continuum of care. Hospitals have seen the length of stay for patients being discharged to HH increase as they face increasing difficulty finding placements for these patients.<a href="#fn10"><sup>10</sup></a> This has been due in large part to the reductions in reimbursement to HH providers put in place by CMS since its implementation of the new Medicare fee-for-service payment system in 2020. CMS determined it must permanently cut HH payments from between 4% to 8% annually in order to meet statutory budget neutrality requirements. In addition, CMS has indicated that it intends to recoup billions more in temporary reductions in the coming years. These payment reductions, paired with staffing shortages, and other administrative burdens and costs will continue to have serious implications for access to services for Medicare beneficiaries. The AHA is thankful for the Committee’s ongoing support of home health agencies.</p><h2>Conclusion</h2><p>Thank you for your leadership on these important issues and for the opportunity to provide comments. We look forward to continuing to work with you to address these important topics on behalf of our patients and communities.</p><hr><ol><li id="fn1">HHS, Office of Inspector General (OIG); Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care (April 2022) (<a href="https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf" target="_blank">https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf</a>).</li><li id="fn2"><a href="https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf" target="_blank">https://www.hsgac.senate.gov/wp-content/uploads/2024.10.17-PSI-Majority-Staff-Report-on-Medicare-Advantage.pdf</a>.</li><li id="fn3">3<a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-6" target="_blank">https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-6</a>.</li><li id="fn4">4<a href="https://www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-physician-shortage" target="_blank">https://www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-physician-shortage</a>.</li><li id="fn5">Bipartisan Budget Act Of 2013 (P.L. 113–67).</li><li id="fn6"><a href="/white-papers/2023-12-29-white-paper-medicares-ltch-outlier-policy-needs-reforms-protect-extremely-ill-beneficiaries" target="_blank">/white-papers/2023-12-29-white-paper-medicares-ltch-outlier-policy-needs-reforms-protect-extremely-ill-beneficiaries</a>.</li><li id="fn7"><a href="/system/files/media/file/2019/06/aha-cms-long-term-care-proposed-rule-fy2020-6-21-2019_0.pdf" target="_blank">/system/files/media/file/2019/06/aha-cms-long-term-care-proposed-rule-fy2020-6-21-2019_0.pdf</a>.</li><li id="fn8">Section 15009(b) of the 21ST Century Cures Act added section 1886(m)(7) to the Act.</li><li id="fn9">MedPAC; July 2024 Data Book; Section 8, Pg. 107 (<a href="https://www.medpac.gov/wp-content/uploads/2024/07/July2024_MedPAC_DataBook_Sec8_SEC.pdf" target="_blank">https://www.medpac.gov/wp-content/uploads/2024/07/July2024_MedPAC_DataBook_Sec8_SEC.pdf</a>).</li><li id="fn10"><a href="/lettercomment/2024-08-26-aha-comments-calendar-year-2025-home-health-prospective-payment-system-proposed-rule" target="_blank">/lettercomment/2024-08-26-aha-comments-calendar-year-2025-home-health-prospective-payment-system-proposed-rule</a>.</li></ol></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2025/03/AHA-Statement-to-House-Ways-and-Means-Subcommittee-on-Health-for-Hearing-March-11-2025.pdf" target="_blank" title="Click here to download the AHA Statement to House Ways and Means Subcommittee on Health for Hearing March 11, 2025 PDF.">Download the Testimony PDF</a></div><a href="/system/files/media/file/2025/03/AHA-Statement-to-House-Ways-and-Means-Subcommittee-on-Health-for-Hearing-March-11-2025.pdf"><img src="/sites/default/files/inline-images/Page-1-AHA-Statement-to-House-Ways-and-Means-Subcommittee-on-Health-for-Hearing-March-11-2025.png" data-entity-uuid="ef5df51a-efdf-417b-bd24-197ee16b5607" data-entity-type="file" alt="AHA Statement to House Ways and Means Subcommittee on Health for Hearing March 11, 2025 page 1." width="695" height="900"></a></div></div></div> Tue, 11 Mar 2025 12:52:15 -0500 Home Health PPS <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) Nov. 1 issued its calendar year (CY) 2025 <a href="https://www.federalregister.gov/documents/2024/11/07/2024-25441/medicare-program-calendar-year-cy-2025-home-health-prospective-payment-system-hh-pps-rate-update-hh">final rule</a> for the home health (HH) prospective payment system (PPS). New policies will generally be effective Jan. 1, 2024</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>The final rule will:</p><ul><li>Increase net HH payments by an estimated 0.5%, or $85 million, after all policy changes, compared to CY 2024. This increase results from a net 2.7% market basket update, a 1.8% downward behavioral adjustment and a 0.4% reduction to outlier payments.</li><li>Adopt new core-based statistical areas (CBSAs) for wage indexes.</li><li>Require HH agencies (HHAs) to report four new patient assessment items in the HH agency Outcome and Assessment Information Set (OASIS) under the social determinants of health category beginning with CY 2027.</li><li>Add a new standard within the Medicare Conditions of Participation (CoP) that will require HHAs to develop, implement and maintain a “patient acceptance to service” policy that is consistently applied to each prospective patient referred for HH care.</li><li>Adopt requirements for long-term care (LTC) facilities to report certain data related to respiratory elements as part of their infection control programs.</li></ul></div></div><h2>AHA TAKE</h2><p>AHA is pleased that CMS provided some relief from its proposed behavioral adjustments. As AHA advocated, HHAs are important partners for hospitals, allowing for safe and timely discharges to the home for many patients. However, we continue to disagree with CMS’ plan to apply additional adjustments in future years; as such, we will continue to urge the agency to reconsider its approach to these payment reductions to ensure access for patients needing continued care.</p><p>View the detailed Regulatory Advisory below.</p></div><div class="col-md-4"><a href="/system/files/media/file/2024/11/home-health-prospective-payment-system-final-rule-for-cy-2025-advisory-11-21-2024.pdf" target="_blank" title="Regulatory Advisory PDF"><img src="/sites/default/files/inline-images/cover-%20home-health-prospective-payment-system-final-rule-for-cy-2025-advisory-11-21-2024.pdf_.png" data-entity-uuid="7172cfab-d20f-4b8e-b99a-d5b9fcd4e86c" data-entity-type="file" alt="Advisory Cover Image" width="679" height="878"></a></div></div></div> Thu, 21 Nov 2024 14:42:32 -0600 Home Health PPS <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) Nov. 1 issued its calendar year (CY) 2025 <a href="https://www.federalregister.gov/public-inspection/2024-25441/medicare-program-calendar-year-2025-home-health-prospective-payment-system-rate-update-quality" target="_blank">final rule for the home health (HH) prospective payment system (PPS)</a>. This Special Bulletin reviews highlights from this rule. The changes from this rule go into effect Jan. 1, 2025.</p><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title">Key Highlights</h3></div><div class="panel-body"><p>CMS’ final rule will:</p><ul><li>Increase net HH payments by an estimated $85 million (0.5%) in CY 2025, relative to CY 2024, based upon:<ul><li>A 3.2% market basket increase, reduced by a 0.5% productivity adjustment.</li><li>A 1.8% behavioral adjustment reduction designed to achieve budget neutrality under the transition to the Patient-driven Groupings Model (PDGM).</li><li>An adjustment to the fixed-dollar loss ratio for outlier payments which will result in an estimated 0.4% decrease in payments.</li></ul></li><li>Adopt new core-based statistical areas (CBSAs) for wage indexes.</li><li>Require HH agencies (HHAs) to report four new patient assessment items in the HH agency Outcome and Assessment Information Set (OASIS) under the social determinants of health category beginning with CY 2027.</li><li>Add a new standard within the Medicare Conditions of Participation (CoP) that will require HH agencies to develop, implement and maintain a patient acceptance to service policy that is consistently applied to each prospective patient referred for home health care.</li><li>Adopt requirements for long-term care (LTC) facilities to report certain data related to respiratory elements as part of their infection control programs.</li></ul></div></div><h2>AHA Take</h2><p>AHA is pleased that CMS provided some relief from its proposed behavioral adjustments. As AHA advocated, HH agencies are important partners for hospitals, allowing for safe and timely discharges to the home for many patients. However, we continue to disagree with CMS’ plan to continue applying additional adjustments in future years; as such, we will continue to urge the agency to reconsider its approach to these payment reductions to ensure access for patients in need of continued care.</p><p>Highlights from the rule follow.</p><h2>HH PPS Payment Changes</h2><h3>Overall CY 2025 Payment Update</h3><p>Under the final rule, HH PPS payments will increase by a net 0.5%, or $85 million, in CY 2025 compared to CY 2024. This includes a 3.2% market-basket increase, reduced by a 0.5% productivity cut, as required by statute. CMS also finalizes a 1.8% permanent decrease in payments to help achieve budget-neutral implementation of the PDGM. As discussed further below, this is a more limited reduction than was originally proposed. Lastly, CMS also finalizes a change to the fixed-loss dollar ratio for outlier payments that will result in a 0.4% decrease in total payments.</p><h3>Budget Neutral Implementation of PDGM</h3><p>The Bipartisan Budget Act of 2018 required CMS to implement the PDGM in a budget-neutral manner, as calculated through annual assessments of the differences between assumed and actual behavior changes, beginning in 2020 and ending in 2026. CMS is required to make temporary and permanent increases or decreases as needed.</p><p>The initial implementation of this new case-mix classification system for the HH PPS on Jan. 1, 2020, included a substantial behavioral offset of 4.36 percentage points. In the CY 2023 rulemaking, CMS said it would implement an additional 7.85 percentage point permanent reduction to the base payment rate over two years to ensure that aggregate expenditures under PDGM would equal what they would have been under the old payment system. Then, in the CY 2024 rulemaking, CMS said it determined a total remaining cut of 5.78 percentage points was necessary to ensure budget neutrality through CY 2022. In the CY 2024 final rule, the agency determined it would implement this permanent adjustment to the base payment over two years (CY 2024-2025).</p><p>This year, CMS proposed to apply an additional reduction of 4.1% to achieve budget neutrality through CY 2023, which would reduce payments overall by 3.6%. However, CMS finalizes a reduction of only 2%, or about half of the proposed reduction, which will reduce total payments by 1.8%. CMS states it finalized a lower amount for this year due to concerns from stakeholders like AHA regarding threats to access to care, but that it will implement the remainder of the reduction in future years.</p><p>The statute also requires CMS to implement one or more temporary adjustments to retrospectively offset increases or decreases already completed in individual years. However, the agency has the discretion to implement these adjustments in a time and manner it deems appropriate; it has not yet proposed to implement these additional offsets. However, this final rule says that as of CY 2023 claims, it will need to recoup approximately $4.5 billion through temporary adjustments.</p><h3>Updated 30-day Episode Rates</h3><p>After applying the net market basket increase and behavioral adjustment, as well as budget neutrality factors for updated case-mix weights, wage indexes and labor-related share, CMS finalizes a standardized 30-day payment amount of $2,057.35. This is an approximately 0.9% increase from the CY 2024 amount. This standardized amount is multiplied by case-mix weight and other factors to determine final payment for claims. The chart below from the final rule provides a breakdown of these changes. Providers who fail to submit quality data will receive a two-percentage-point reduction in this payment factor.</p><p><img src="/sites/default/files/inline-images/Table-21-CY-2025-National-Standardized-30-Day-Period-Payment-Amount.jpg" data-entity-uuid="4d76e974-6b4d-4993-a2f9-5f04f0511c00" data-entity-type="file" alt="Table 21: CY 2025 National, Standardized 30-Day Period Payment Amount" width="936" height="234"></p><h3>Case-mix Weights</h3><p>PDGM categorizes patients into one of 432 payment units, known as HH resource groups (HHRGs), using patient assessment data collected with the OASIS tool and other data. CMS annually recalibrates the HH case-mix weights based on the most recent, complete year of claims and patient assessment data. To recalibrate the final CY 2025 weights, CMS used CY 2023 data for 30-day episodes under PDGM. This is the same methodology used by CMS for CY 2024. The final CY 2025 case-mix weights are provided in Table 12 in the final rule and are available for download from <a href="https://www.cms.gov/medicare/payment/prospective-payment-systems/home-health/home-health-prospective-payment-system/cms-1803-f" target="_blank">CMS’ HH PPS webpage</a>.</p><h3>High-cost Outliers</h3><p>HH PPS outlier payments are applied to 30-day episodes with estimated costs that exceed the outlier threshold, which is the sum of the payment amount and a wage-adjusted fixed-dollar loss (FDL) amount. The FDL amount is calculated by multiplying the FDL ratio by the payment amount for that claim. The payment made to providers for qualifying outlier claims is a percentage (or the loss-sharing ratio) of the costs that surpass the threshold. For the HH PPS, the statute requires that the FDL amount and the loss-sharing ratio be set to target total outlier payments at 2.5% of aggregate payments. CMS did not propose any change to the existing 0.80 (80%) loss-sharing ratio. However, it finalized a higher FDL ratio, increasing it to 0.35 from 0.27, which it says will decrease outlier payments by approximately $70 million (or 0.4% of total payments).</p><h3>Area Wage Index</h3><p>CMS uses wage indices to adjust HH payments regionally to account for a variation in labor costs. To do this, CMS utilizes CBSAs established by the Office of Management and Budget (OMB). Each county or county equivalent is assigned to a CBSA. Further, each CBSA is assigned a wage index. CBSAs are also designated as either urban or rural. In July 2023, OMB issued a <a href="https://www.whitehouse.gov/wp-content/uploads/2023/07/OMB-Bulletin-23-01.pdf" target="_blank">bulletin that updated the CBSAs</a>, and CMS finalized the adoption of these updates. CMS states that a total of 54 counties that were previously assigned to rural CBSAs are now assigned to urban CBSAs. In addition, 53 counties that were previously in urban CBSAs are now in rural CBSAs. Finally, CMS says other counties have been assigned to different CBSAs, and new CBSAs have been created and/or renamed.</p><p>CMS currently has a policy of applying a 5% year-to-year cap on any reductions in an individual HH provider’s wage index. In addition to continuing this policy, CMS has also finalized a temporary 5% cap on any reductions at the county level. This means that for counties assigned to a new CBSA, that county’s wage index will be assigned a figure that is no less than 95% of the amount from the prior year. The list of counties impacted by this transition policy is found in Table 19 of the final rule.</p><h2>HH Quality Reporting Program</h2><p>CMS will require HH agencies to report four new patient assessment items in the HHA OASIS under the social determinants of health category beginning with the CY 2027 HH Quality Reporting Program (QRP), with admissions beginning on Jan. 1, 2027. The items are currently collected in the Accountable Health Communities Health-Related Social Needs Screening Tool and include:</p><ul><li>Living situation: addresses housing stability.</li><li>Food: addresses the frequency of worry that food would run out.</li><li>Food: addresses food running out without the ability to buy more.</li><li>Utilities: addresses utilities being shut off in the home.</li></ul><p>In addition, CMS modifies the patient assessment item on transportation to simplify the response options and revise the look-back period.</p><h3>All-payer Data Collection</h3><p>In the CY 2023 HH PPS final rule, CMS announced that it would end the temporary suspension of OASIS data collection on non-Medicare/Medicaid HHA patients, meaning that HHAs would be required to submit all-payer OASIS data for purposes of the HH QRP beginning with the CY 2027 program year. In this rule, CMS finalizes processes to operationalize this requirement. As previously finalized, CMS will conduct a voluntary phase-in period for HHAs to begin all-payer data collection with start-of-care (SOC) patient assessments conducted beginning Jan. 1, 2025, followed by mandatory data collection with SOC assessments conducted beginning July 1, 2025.</p><h2>HHA CoP Update</h2><p>CMS adds a new standard within the Medicare CoP that requires HHAs to develop, implement and maintain an acceptance of service policy consistently applied to each prospective patient referred for home health care. The policy must be reviewed annually and address minimum criteria for the HHA’s capacity, caseload and case mix, and current staffing. HHAs must make public information about their services (as well as any limitations, such as lack of specialty services). CMS makes these updates in light of “the challenges of finding the right HHA and resultant potential delays in the timely initiation of home health care,” as well as the agency’s concern that “HHAs are at higher risk of overextending their available resources when accepting new patients.”</p><h2>Long-Term Care Requirements for Acute Respiratory Illness Reporting</h2><p>CMS finalizes its proposal to adopt requirements for LTC facilities to report certain data related to respiratory elements as part of their infection control programs. During the public health emergency (PHE) for COVID-19, LTC facilities were required to electronically report information related to confirmed or suspected COVID-19 cases to the National Healthcare Safety Network (NHSN) operated by the Centers for Disease Control and Prevention. Due to the ongoing threats presented by the broader respiratory virus season, CMS will require ongoing respiratory illness reporting. Specifically, beginning Jan. 1, 2025, LTC facilities must electronically report information about COVID-19, influenza and respiratory syncytial virus in a standardized format every week through NHSN. Facilities will be required to report their census and resident vaccination status, confirmed cases of certain respiratory illnesses, and hospitalized residents with confirmed cases of certain respiratory illnesses. The agency notes that the secretary will have the discretion to revise the reporting frequency based on changing needs for data collection.</p><p>In addition, CMS will allow the secretary to require facilities to report this and additional data up to daily without additional notice and comment rulemaking during a declared national, state or local PHE for respiratory infectious disease. However, the agency did not finalize its proposal to allow increased reporting “in the event of a likely PHE.”</p><h2>Further Questions</h2><p>Please contact Jonathan Gold, AHA’s senior associate director of payment policy, at <a href="mailto:jgold@aha.org?subject=RE: Special Bulletin: CMS Releases CY 2025 Home Health PPS Final Rule Payment">jgold@aha.org</a> with any questions related to payment, and Caitlin Gillooley, AHA’s director of policy, at <a href="mailto:cgillooley@aha.org?subject=RE: Special Bulletin: CMS Releases CY 2025 Home Health PPS Final Rule Quality">cgillooley@aha.org</a>, regarding any quality-related questions.</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/11/Special-Bulletin-CMS-Releases-CY-2025-Home-Health-PPS-Final-Rule.pdfm" target="_blank" title="Click here to download the Special Bulletin: CMS Releases CY 2025 Home Health PPS Final Rule PDF."><img src="/sites/default/files/inline-images/Page-1-Special-Bulletin-CMS-Releases-CY-2025-Home-Health-PPS-Final-Rule.png" data-entity-uuid="bc02594e-e38e-478f-9eb9-b53bd7e0c7f2" data-entity-type="file" alt="Special Bulletin: CMS Releases CY 2025 Home Health PPS Final Rule page 1." width="696" height="900"></a></p></div></div></div> Mon, 04 Nov 2024 15:20:48 -0600 Home Health PPS /news/headline/2024-11-01-cms-releases-cy-2025-home-health-pps-final-rule-partially-delays-behavioral-adjustments <p>The Centers for Medicare & Medicaid Services today issued its calendar year 2025 final rule for the <a href="https://www.federalregister.gov/public-inspection/2024-25441/medicare-program-calendar-year-2025-home-health-prospective-payment-system-rate-update-quality">home health prospective payment system</a>. Overall, this rule will increase HH payments by $85 million, or 0.5% compared to CY 2024. This update is the result of a 3.2% market basket update, offset by a 0.5% productivity reduction. In addition, CMS says payments will be reduced by 0.4% overall due to changes to fixed-dollar loss ratio for outlier payments. Further, CMS is applying a behavioral adjustment of -1.8% as required as part of implementation of the new Patient Driven Groupings Model. This reduction is half of the -3.6% CMS originally proposed due to concerns raised by AHA and other stakeholders about the impact further reductions will have on access to care. However, the agency states that it will apply the remainder of this permanent adjustment in future years. <br><br>For the Home Health Quality Reporting Program, CMS finalized its proposal to adopt four new standardized patient assessment data elements related to social determinants of health beginning with the CY 2027 program. In addition, the agency finalized a new Condition of Participation that sets standards for patient acceptance-to-service policies for HH agencies, as well as a new data reporting standard on respiratory illnesses for long-term care facilities beginning Jan. 1, 2025.</p> Fri, 01 Nov 2024 15:15:40 -0500 Home Health PPS /news/headline/2024-09-06-aha-comments-cms-home-health-pps-proposed-rule-cy-2025 <p>The AHA Aug. 26 commented on the Centers for Medicare & Medicaid Services' home health prospective payment system proposed rule for calendar year 2025, expressing <a href="/lettercomment/2024-08-26-aha-comments-calendar-year-2025-home-health-prospective-payment-system-proposed-rule">concerns</a> about ongoing access challenges for beneficiaries needing home health care and the potential for the proposed rule to cause additional disruption. AHA urged CMS to reconsider its proposals and ensure home health agencies receive payment updates reflecting their financial standing to provide high-quality care. Additionally, AHA noted concerns about the proposed rule for long-term care facility Medicare conditions of participation requiring ongoing respiratory virus data reporting. <br> </p> Fri, 06 Sep 2024 13:18:24 -0500 Home Health PPS /news/headline/2024-06-26-cms-releases-cy-2025-home-health-pps-proposed-rule-continues-budget-neutrality-adjustments <p>The Centers for Medicare & Medicaid Services June 26 issued its calendar year 2025 proposed rule for the <a href="https://public-inspection.federalregister.gov/2024-14254.pdf" target="_blank">home health prospective payment system</a>, which would reduce net home health payments by an estimated $280 million, or -1.7%, in calendar year 2025 relative to the current year. This update includes a 3.0% market basket update, reduced by a 0.5% productivity adjustment. However, CMS is also proposing to reduce the base payment rate by 4.1% due to the implementation of the Patient-driven Groupings Model, which reduce total payments by 3.6%. The AHA has raised serious concerns about such adjustments, which come on top of multiple years of similar downward adjustments. CMS also is proposing to adjust the fixed-dollar loss amount for high-cost outliers, which it estimates will reduce payments by an additional 0.6%, or $100 million.<br><br>CMS also proposes to update the HHA Conditions of Participation to add a new standard that would require HHAs to develop, consistently apply, and maintain a policy for accepting patients to service. While CMS does not propose to adopt or remove any quality measures from the HH Quality Reporting Program, the agency proposes to adopt and modify certain patient assessment items related to health-related social needs; HHAs would be required to collect and report specific data elements related to living situation, food and utilities beginning with the CY 2027 HH QRP. The agency would also remove an element found to be redundant. As finalized in previous rulemaking, CMS will end the suspension of all-payer data collection also beginning with CY 2027 and proposes practices for this requirement. <br>Finally, CMS proposes to revise the infection prevention and control requirements for long-term care facilities to extend reporting to the Centers for Disease Control and Prevention of a subset of the current COVID-19 data elements and also require reporting for data related to influenza and RSV to begin Jan. 1, 2025.<br><br>CMS will accept comments on the proposed rule through Aug. 26. AHA members will receive a Special Bulletin with additional details on the rule in the coming days.</p> Wed, 26 Jun 2024 16:12:28 -0500 Home Health PPS <div class="container"> <div class="row"> <div class="col-md-8"> <p>The Centers for Medicare & Medicaid Services (CMS) on Nov. 1 issued its calendar year (CY) 2024 final rule for the home health (HH) prospective payment system (PPS). New policies will generally be effective Jan. 1, 2024.</p> <div class="panel module-typeC"> <div class="panel-heading"> <h2>Key Highlights</h2> <p>The rule will:</p> <ul> <li>Increase HH payments by an estimated $140 million (0.8%) in CY 2024, relative to CY 2023, based upon: <ul> <li>a 3.3% market basket increase, reduced by a 0.3 percentage point productivity adjustment</li> <li> a 2.6 percentage point behavioral adjustment that CMS says is necessary to achieve budget neutrality under the Patient-driven Groupings Model (PDGM); and</li> <li>an adjustment to the fixed-dollar loss ratio for outlier payments that will result in an estimated 0.4 percentage point increase in payments.</li> </ul> </li> <li>Rebase the HH market basket using updated claims and cost data.</li> <li>Adopt two new measures to the Quality Reporting Program</li> <li>Replace five measures in the Value-based Purchasing program with three new measures and change the weights of the individual measures in scoring.</li> </ul> </div> </div> <h2><br> AHA TAKE</h2> <p>The AHA is troubled by the continued application of harmful behavioral offsets over the past several years. The reduction included in this rule, which negates most of the 2024 market basket update, is in addition to the more than 8% in permanent negative adjustments the agency has applied since 2020. While we appreciate that the agency will now phase in the behavioral offset over two years, these cuts will nevertheless further exacerbate the severe access challenges facing patients in need of home health care. However, the impact will not be limited to just those patients. The inability to move patients in a timely manner into home health care constrains hospitals’ ability to care for other patients, creating backlogs for patients in need of a wide range of higher acuity care.</p> <h2>CY 2024 PAYMENT UPDATES</h2> <p>The final rule’s estimated impact is an increase of 0.8% or $140 million in HH payments after all policy changes, compared to CY 2023. This includes a market basket update of 3.3%, reduced by a statutorily required negative 0.3% productivity factor. The behavioral cut of 2.89% (described in more detail below) is expected to reduce payments by 2.6% since it is only applied to the 30-day payment rate and not to low-utilization case payments. In addition, CMS estimates that there will be an 0.4% increase in overall payments because of the effects of an updated fixed-dollar loss ratio for outlier payments.</p> <p>CMS also provides an estimate of impact by type of HH agency. Freestanding HH agencies are estimated to see a 0.8% increase, but facility-based HH agencies are estimated to see a 1.1% increase, relative to CY 2023. In addition, HH agencies located in rural areas are estimated to receive a 0.4% increase, while those in urban areas are estimated to realize a 0.9% increase. CMS states that this difference between rural and urban facilities is largely attributable to changes in wage indices (which are available for download from CMS <a href="https://www.cms.gov/medicare/medicare-fee-service-payment/homehealthpps/home-health-prospective-payment-system/cms-1780-f" target="_blank">here</a>).</p> <p><strong>Updated 30-day Episode Rates</strong>. Utilizing the updated 2021-based market basket, applying the net 3.0% market basket increase, 2.89% behavioral adjustment as well as budget neutrality factors for updated case-mix weights, wage indices, and the labor-related share (all discussed further below), CMS finalized an updated standardized 30-day payment amount of $2,038.13. This is the standardized amount that is multiplied by case-mix weight and other factors to determine final payment for claims. The chart below from the final rule provides a breakdown of these changes. Providers who fail to submit quality data will receive a two-percentage point reduction in this payment factor.</p> <p><img alt="Table B24" data-entity-type="file" data-entity-uuid="f0db57c1-be79-4806-9ad9-5b542b97a3a0" height="233" src="/sites/default/files/inline-images/table-b24.jpg" width="785"></p> <p><strong>Low Utilization Payment Adjustment (LUPA) Rates</strong>. Under PDGM, claims that do not meet a certain threshold of total visits are paid under the LUPA methodology, which is a per-visit rate. The LUPA methodology sets a visit threshold for each payment group at the 10th percentile of visits or two visits, whichever is higher. If the LUPA threshold is met, the case is paid the full 30-day period payment; if not, the LUPA per-visit rates apply. The final rule updated the LUPA thresholds using CY 2022 HH claims. The final thresholds for the 2024 PDGM payment groups are listed in Table B12 of the final rule.</p> <p>CMS also updates the per-visit payment amount for LUPA cases for each type of visit using the payment update factors listed in the chart below from the final rule. Providers that do not submit required quality data will have the LUPA payments amounts reduced by two percentage points.</p> <p><img alt="Table B22" data-entity-type="file" data-entity-uuid="a4849175-1919-4c4b-9728-d83c96cd1cc2" height="412" src="/sites/default/files/inline-images/table-b22.jpg" width="803"></p> <p><strong>Case-mix Weights</strong>. PDGM categorizes patients into one of 432 payment units, known as HH resource groups (HHRGs), using patient assessment data collected with the Outcome and Assessment Information Set (OASIS) tool and other data. CMS annually recalibrates the HH case-mix weights based on the most recent, complete year of claims and patient assessment data. To recalibrate the CY 2024 weights, CMS used CY 2022 data for 30-day episodes under PDGM. This is the same methodology used by CMS for CY 2023. The final 2024 case-mix weights are provided in Table B12 in the final rule and are also available for download from <a href="https://www.cms.gov/medicare/medicare-fee-service-payment/homehealthpps/home-health-prospective-payment-system/cms-1780-f" target="_blank">CMS’ HH PPS webpage</a>.</p> <p><strong>Functional Impairment Levels</strong>. Under PDGM, the functional impairment-related case- mix adjustment is determined by responses to certain OASIS items associated with activities of daily living and risk of hospitalization. A HH period of care receives points based on responses from these functional OASIS items. The sum of all these points is used to group HH periods into low-, medium- and high-functional impairment levels, designed so that about one-third of HH periods fall within each level. For 2024, CMS used 2022 claims data to update the functional points and functional impairment levels by clinical group and used the same methodology previously finalized to update the functional impairment levels for CY 2023. The updated OASIS functional points and the functional impairment thresholds by clinical group for CY 2024 are listed in final rule’s Tables B7 and B8, respectively.</p> <p><strong>Comorbidity Groups</strong>. Thirty-day episodes of care receive a comorbidity adjustment based on the presence of certain secondary diagnoses. These diagnoses are based on a HH list of clinically and statistically significant secondary diagnoses subgroups with similar resource use. A “low-comorbidity adjustment” will be applied if one secondary diagnosis is present that is associated with higher resource use and a “high-comorbidity” adjustment will be applied if two or more qualifying secondary diagnoses are present. For 2024, CMS continued using the same methodology it had used previously, in combination with 2022 data. This resulted in 22 low-comorbidity adjustment subgroups and 101 high-comorbidity adjustment subgroups. These subgroups are listed in tables B9 and B10 of the final rule.</p> <p><strong>High-cost Outliers</strong>. HH PPS outlier payments are applied to 30-day episodes with estimated costs that exceed the outlier threshold, which is the sum of the payment amount and a wage-adjusted fixed-dollar loss (FDL) amount. The FDL amount is calculated by multiplying an FDL ratio by the payment amount for that claim. The payment made to providers for qualifying outlier claims is a percentage (referred to as the loss-sharing ratio) of the costs that surpass the threshold. For the HH PPS, statute requires that the FDL amount and the loss-sharing ratio be set to target total outlier payments at 2.5% of aggregate payments. For CY 2024, CMS did not propose any change to the existing 0.80 (80%) loss-sharing ratio. However, it did finalize a lower FDL ratio, from 0.35 to 0.27, which is says will increase outlier payments by approximately 0.4%, or $70 million, relative to CY 2023.</p> <p><strong>Area Wage Index</strong>. CMS will continue to use the pre-floor, pre-reclassified inpatient PPS wage index to adjust the labor portion of HH PPS rates for CY 2024. The finalized 2024 wage indices are available on CMS’ <a href="https://www.cms.gov/medicare/medicare-fee-service-payment/homehealthpps/home-health-prospective-payment-system/cms-1780-f" target="_blank">website</a>. CMS also will continue to apply a permanent cap on any decrease to a geographic area’s wage index from its wage index in the prior year, regardless of the circumstances causing the decline. Under this policy, any final wage index cannot be less than 95% of the prior year’s wage index. The wage index changes will continue to be implemented in a budget-neutral fashion, with a factor applied to the standardized payment amounts to account for year-to-year changes, as shown in the calculation of the standardized payment amounts above.</p> <p><strong>Payment for Disposable Negative Pressure Wound Therapy</strong>. In the 2023 Consolidated Appropriations Act (CAA), Congress required CMS to modify the payment mechanics for provision of disposable negative pressure wound therapy (DNPWT) for HH beneficiaries. Currently, separate payment is made in addition to the HH PPS payment for provision of DNPWT for HH beneficiaries. The current additional amount paid is an amount equal to what would be paid under the Medicare outpatient prospective payment system (OPPS), which includes payment for both the device and professional services rendered. The CAA requires that, beginning in 2024, the separate payment amount be determined according to the supply price used for these devices in the CY 2022 Medicare physician fee schedule, updated by the percent increase in the Consumer Price Index for All Urban Consumers (CPI–U) for the 12-month period ending in June 2023, minus the productivity adjustment. Beginning in 2025 and each subsequent year, this amount will be updated according to the CPI-U. This supply price will be the entirety of the additional payment made, and any professional services rendered as part of providing the DNPWT will be considered part of the episode payment provided under the HH PPS. The payment amount for CY 2024 will be $270.09.</p> <p><strong>Home Intravenous Immune Globulin (IVIG) Benefit</strong>. The CAA also established coverage for items and services related to administration of IVIG in a patient’s home beginning Jan. 1, 2024, expanding the existing IVIG benefit category. Currently, Medicare pays for the in-home administration of IVIG through a demonstration program, which ends on Dec. 31, 2023. In this rule, CMS implements the permanent provisions of the benefit by adopting regulations related to:</p> <ul> <li><u>Scope of the benefit</u>: CMS builds upon the existing regulations and sub-regulatory guidance to maintain one set of coverage standards across the entire IVIG benefit. Thus, the items and services covered under the existing IVIG demonstration will be covered under the payment being added to the benefit category.</li> <li><u>Bundled payment</u>: CMS establishes a bundled payment to cover the items and services necessary to administer the drug intravenously in the home, including the infusion set and tubing and nursing services lasting on average three to five hours.</li> <li><u>Payment rate</u>: The bundled payment is based on the LUPA amount for skilled nursing based on an average four-hour infusion, paid on a per-visit basis. As the final HH payment update for CY 2024 is 3.0 percent, the payment rate for home IVIG items and services for CY 2024 will be a 3% increase over the LUPA rate used in the home IVIG Demonstration, resulting in a payment rate of $420.48.</li> <li><u>Billing procedures</u>: CMS will use the existing Q-code (Q2052) under the IVIG demonstration with a new descriptor, along with a J-code for the IVIG product. These claims will be processed through durable medical equipment Medicare administrative contractors (MACs).</li> </ul> <h2>BEHAVIORAL ADJUSTMENTS RELATED TO PDGM IMPLEMENTATION IN CY 2020</h2> <p>In 2018, Congress mandated that CMS implement the PDGM, which transitioned the HH PPS from a 60-day payment episode payment to a 30-day payment episode on Jan. 1, 2020. The PDGM case-mix system bases payments on the clinical characteristics of a patient, abandoning the prior methodology relying on therapy volume to determine payment. The clinical characteristics used to determine payment amount include admission source and timing, principal diagnosis, functional impairment level, and comorbidities. Under the PDGM, each 30-day episode is assigned to one of 432 payment units known as HHRGs.</p> <p>CMS was required to set the initial PDGM 30-day episode payment amount at budget-neutral levels. In order to accomplish budget neutrality, CMS made several assumptions regarding providers’ expected behavioral changes following the implementation of PDGM. First, CMS assumed that HH agencies would alter their coding of primary diagnoses and coding of secondary diagnoses on which payments are based. In addition, CMS assumed that the number of LUPA cases would decrease. After estimating the impact of these assumed behavioral changes, CMS finalized a behavioral offset of 4.36% to the 30-day payment rate in the CY 2020 final rule.</p> <p>However, Congress required that CMS maintain budget neutrality through CY 2026 relative to the former payment system. The agency says it must apply two types of adjustments going forward to maintain budget neutrality. The first is permanent adjustments to the 30-day payment rate to ensure that future spending neither increases nor decreases relative to what otherwise would have been paid. The second is temporary adjustments to recoup or repay past over or underspending.</p> <p>CMS did not apply additional PDGM budget neutrality adjustments in the CY 2021 or CY 2022 final rules. However, in the CY 2023 final rule, CMS determined that 30-day payments in CYs 2020 and 2021 were approximately 7.85% higher than would have been the case under the legacy payment model. Therefore, it would need to reduce the standard 30-day payment rate by that amount to achieve prospective budget neutrality. In addition, it determined that overpayments for those two years totaled approximately $2.1 billion, and that it would need to apply a temporary adjustment to the 30-day payment amount to recoup the overpayments. However, for CY 2023, CMS only applied half of the permanent adjustment (-3.925%) and did not apply any of the temporary adjustments to recoup overpayments. The agency said it would revisit applying the additional adjustments in future rulemakings.</p> <p>This year, CMS proposed to apply the remainder of the permanent adjustments for CYs 2020-21, as well as an additional permanent percentage for overpayments in CY 2022. The agency has yet to address any retrospective, temporary adjustments. The tables below summarize CMS’ findings regarding overpayments for CYs 2020-22.</p> <p><img alt="CMS calculation" data-entity-type="file" data-entity-uuid="b9a66642-df93-4ab6-8c6b-b3528d62d0f1" src="/sites/default/files/inline-images/cms-calculation-1.jpg" width="725" height="357"></p> <p><img alt="CMS calculation 2" data-entity-type="file" data-entity-uuid="fcd87b0f-a4d1-4b52-ae74-e398259685d1" src="/sites/default/files/inline-images/cms-calculation-2.jpg" width="735" height="442"></p> <p>Per the above tables, CMS determined that, in total, it must apply a cut of 9.48%. Taking into account the cuts it has already applied, it stated that a further, negative adjustment of 5.78% is necessary to ensure budget neutrality through CY 2022 (updated from negative 5.65% in the proposed rule due to updated data). However, in response to concerns from providers in the final rule, CMS decided to implement only half of this amount, or negative 2.89%, for CY 2024 and will implement the remainder in the future. As mentioned above, the behavioral cut of 2.89% is expected to reduce payments by 2.6% since it is only applied to the 30-day payment rate and not to low utilization case payments. CMS noted that this decision to phase in the cut will result in higher aggregate permanent adjustments needing to be made in the future to account for this accommodation. In addition, and as previously noted, CMS still has not proposed how it will implement its temporary recoupments totaling an aggregate $3.4 billion to date in the future.</p> <p><strong>While AHA appreciates the limited temporary relief offered by CMS in the final rule, we remain troubled by the aggregate effects of these behavioral impacts. We are deeply troubled by the dwindling access to care for patients in need of post-acute care and the effects this has on the entire continuum of care, including patient access to acute-care services.</strong></p> <h2>REBASING OF HH MARKET BASKET</h2> <p>Approximately every four years CMS rebases the HH market basket to help ensure it accurately reflects the mix of goods and services provided by HH agencies. This year, CMS proposed to rebase the market basket using CY 2021 cost report data. The last rebasing was in CY 2019 utilizing CY 2016 claims data.</p> <p><strong>Updated Weights and Price Proxies</strong>. CMS used almost entirely the same methodology to create the 2021-based market basket as it did to create the CY 2016-based market basket. As part of this methodology, CMS uses cost report data to calculate weights for eight cost categories, listed in the table below. Of note, the CY 2016-based market basket did not include Medical Supplies as a major cost category. However, CMS will now derive these data from cost reports and make it its own cost category going forward. The table below, reproduced from the final rule, provides CMS’ reweighting of the cost categories using the updated data.</p> <p><img alt="table B13" data-entity-type="file" data-entity-uuid="44a1511e-cc41-4bad-abec-73e43a61eb1b" height="241" src="/sites/default/files/inline-images/table-b-13.jpg" width="630"></p> <p>CMS states that the decrease in the Wages and Salaries and Benefits cost category weights is primarily attributable to direct patient care contract labor costs decreasing from 2016 to 2021. The rule also notes that this trend is consistent across provider types, as well across most occupational categories and specialties.</p> <p>After setting weights for each category, CMS then applies price proxies it assigns to track the changes of each cost category for annual payment updates. CMS generally used the same proxies for each category that it used for the current market basket. One exception is Medical Supplies, where CMS will use a different, but similar, price proxy. CMS estimates that the new market basket will result in updates that are very similar to the current market basket and provides a retrospective and prospective analysis between the two, as shown in the table below, reproduced from the final rule.</p> <p><img alt="Table B22" data-entity-type="file" data-entity-uuid="8da0cf0a-d73c-4fa3-ac1b-97d512d0e670" height="316" src="/sites/default/files/inline-images/table-b22_0.jpg" width="617"></p> <p><strong>Impact on the Labor-related Share</strong>. The labor-related share is the portion of the payment rate that is attributable to labor and labor-related cost; this percentage of the payment is multiplied by a wage index to determine final payment for a claim. The labor-related share is derived from the weight assigned to labor-related factors in the HH market basket. Due to the aforementioned changes, CMS is reducing the labor-related share from 76.1% to 74.9%. As previously mentioned, this decrease is primarily due to cost reports indicating lower direct patient care contract labor costs, and CMS says it is a trend that has been consistent over the last 10 years. Finally, CMS applies a budget neutrality factor to ensure overall aggregate payments are not impacted by a change in the labor-related share, as shown earlier in the calculation of payment rates for CY 2024.</p> <h2>HH QUALITY REPORTING PROGRAM (QRP)</h2> <p>As mandated by the Social Security Act, HH agencies receiving Medicare payments have been required to collect and submit patient assessment data using the OASIS since 1999 and to participate in the HH QRP since 2007. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act required that, starting in CY 2020, providers report standardized patient assessment data elements (SPADEs) as part of the HH QRP. Failure to comply with these requirements results in a two-percentage point reduction to the HHA’s annual market-basket update. In this rule, CMS finalizes its proposals to adopt two new quality measures for the HH QRP; remove one measure and two items from the OASIS; and begin publicly displaying performance data on four quality measures.</p> <p><img alt="Table 1" data-entity-type="file" data-entity-uuid="d6f8d7cf-eb55-4e13-95c6-d64b33045468" src="/sites/default/files/inline-images/table-1.jpg" width="566" height="653"></p> <p><strong>Adoption of Discharge Function Score Measure</strong>. Beginning with the CY 2025 HH QRP, CMS will adopt this assessment-based outcome measure that estimates the percentage of HH patients who meet or exceed an expected discharge score during the reporting period.</p> <p>The observed discharge function score is calculated by summing individual function item values from the OASIS at discharge. The expected discharge function score is calculated by risk-adjusting the observed score to control for patient characteristics including age, admission function score and clinical conditions – in other words, based on the patient’s characteristics and where they started in terms of function, and how much improvement would be expected after their HH episode.</p> <p>The measure uses a statistical imputation approach to account for “missing” OASIS elements when codes demonstrate that an “activity was not attempted.” In the event that an OASIS item is coded as “not attempted,” the imputation approach inserts variables based on the values of other, non-missing items that are similar to the missing item; that is, the calculation makes assumptions about what the patient would have scored on that item if it had been attempted based on their performance on other, similar activities that were attempted. CMS argues that this approach “increases precision and accuracy and reduces the bias in estimates of missing item values.”</p> <p>CMS plans to begin publicly displaying data for this measure on Care Compare beginning in CY 2025 using data collected between April 1, 2023 and March 31, 2024. Displayed performance will be based on four quarters of data, updated quarterly.</p> <p>The measure is not endorsed by a consensus-based entity; CMS states that it intends to submit it for endorsement as soon as is feasible. CMS also adopted this measure for the skilled nursing facility (SNF), inpatient rehabilitation facility (IRF) and long-term care hospital (LTCH) QRPs.</p> <p><strong>Removal of Overlapping Discharge Function Measure</strong>. CMS will remove the <em>Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function</em> from the HH QRP, beginning in CY 2025, as the agency believes the newly adopted Discharge Function Score measure better measures functional outcomes.</p> <p>In addition to its overlap with the new measure, CMS states that performance on this measure among HH agencies is so high and unvarying that meaningful distinctions in improvements in performance can no longer be made (i.e., the measure is “topped out”). Indeed, average performance rates have reached nearly 100% over the past three years. Accordingly, CMS also will remove two corresponding items from the OASIS, and HH agencies will no longer be required to report M0110 (Episode Timing) and M2220 (Therapy Needs Items) beginning Jan. 1, 2025.</p> <p><strong>Adoption of Percent of Patients/Residents who are Up to Date with COVID-19 Vaccination Measure</strong>. Beginning with the CY 2025 HH QRP, CMS will adopt this assessment-based process measure that reports the raw rate of stays in which HH patients are up to date on their COVID-19 vaccinations per the CDC’s latest guidance. The agency reasons that the measure will, when publicly reported, provide useful information for patients and their caregivers when choosing a facility, and “would be an indirect measure of HH agency action” since the HH agency will have the opportunity to administer the vaccine to patients during their episode, coordinate a follow-up visit for the patient to obtain the vaccine at their physician’s office or local pharmacy, or educate the patient about the importance of staying up to date with vaccinations.</p> <p>The measure is calculated as the total number of HH episodes in the denominator in which the new OASIS item, “Patient’s COVID-19 vaccination is up to date” is coded as “1. Yes, patient is up to date.” Collection of data does not require additional documentation or proof of vaccination. There are no exclusions (including for medical comorbidities, sincerely held religious beliefs, or patients who were offered a vaccination onsite but refused).</p> <p>CMS plans to begin publicly displaying data for this measure, beginning with the January 2026 refresh of Care Compare, using data collected from April 1, 2024 through June 30, 2024. The measure is not risk-adjusted. It has not completed testing for reliability and has not been submitted for endorsement by a consensus-based entity.</p> <p><strong>Public Reporting</strong>. Beginning with the October 2025 Care Compare refresh, CMS will publicly display data for the previously adopted Transfer of Health Information to the Patient and Transfer of Health Information to the Provider measures. These measures were adopted in the CY 2020 HH PPS final rule, but the compliance date for collection and reporting of the measures was delayed until Oct. 1, 2022, due to the COVID-19 public health emergency.</p> <p>CMS will publicly display four rolling quarters of data for these two assessment-based measures. The initial display will be based on data from discharges from April 1, 2023 through March 31, 2024. A HH agency’s performance will not be publicly displayed if it has fewer than 20 eligible cases in any four consecutive rolling quarters for the measure.</p> <p><strong>Codification of Data Completion Threshold.</strong> In previous rulemaking, CMS finalized proposals to gradually increase the percentage of OASIS assessments that each HH agency must submit to meet pay-for-reporting requirements from 70% to 90%; HH agencies have been required to submit at least 90% of collected OASIS assessments since the CY 2019 HH QRP. In this rule, CMS finalizes its proposal to codify the 90% threshold, which applies to required quality measure data and standardized patient assessment data collected via the OASIS. If an HH agency does not meet the threshold, it will receive a two-percentage point reduction to its annual payment update for a given CY (as previously codified).</p> <h2>HH VALUE-BASED PURCHASING PROGRAM</h2> <p>The HH VBP model was adopted as a demonstration in the CY 2016 HH PPS final rule. In the CY 2022 HH PPS final rule, CMS finalized the expansion of the model nationwide, beginning Jan. 1, 2022, with one “pre-implementation” year; read about the expansion in AHA’s <a href="/advisory/2021-11-22-home-health-pps-final-cy-2022-rule" target="_blank">Regulatory Advisory</a> on that rule. The program officially began on Jan. 1, 2023. In this rule, CMS finalizes its proposals to remove five measures from the HH VBP program and add three.</p> <p><strong>Codification of Measure Removal Factors</strong>. CMS will codify the measure removal factors for the HH VBP program effective CY 2024. In the CY 2022 HH PPS final rule, CMS adopted eight measure removal factors that the agency considers when determining whether to remove measures from the expanded HH VBP Model’s applicable measure set; these are the same measure removal factors used in all other Medicare QRPs.</p> <h3>Measure Set Updates</h3> <p><u>Replacement of OASIS-based Discharge to Community (DTC) Measure with Claims-based Version.</u> The DTC measure assesses discharges to the home or community with no unplanned admission to an acute-care hospital or LTCH or death in the 31 days following discharge. The claims-based version of the measure was added to the HH QRP in 2017 and is identical to the OASIS-based version except that the claims-based version is informed by two years of claims data, rather than one year of OASIS assessment data. The DTC measure is also used in other post-acute care QRPs. CMS will remove the OASIS-based measure, which has not been publicly reported since 2016, and adopt the claims-based measure beginning CY 2025.</p> <p><u>Replacement of OASIS-based Function Measures with New Discharge Function Score Measure</u>. CMS adopted for the original model two measures, beginning CY 2019: Total Normalized Composite Change in Self-Care (TNC Self-Care) and Total Normalized Composite Change in Mobility (TNC Mobility). These measures assessed performance on three mobility OASIS items and six additional activities of daily living.</p> <p>In this rule, CMS finalizes its proposal to adopt the Discharge Function score measure for the HH QRP (see description above) as well as other post-acute care QRPs. The measure relies upon existing assessment items, and thus the agency believes providers have had sufficient time to ensure successful reporting of the data elements that inform the measure even though it has not yet been implemented. CMS reasons that using the Discharge Function score measure rather than the TNC measures currently used in the program will improve alignment across post-acute programs and be more efficient (one measure, rather than two). CMS will remove the two TNC measures and begin use of the Discharge Score measure beginning CY 2025.</p> <p><strong>Replacement of Hospital Use with Potentially Preventable Hospitalizations</strong>. CMS currently uses two measures to assess HH patient use of hospital services during their HH episode: Acute Care Hospitalization During the First 60 Days of Home Health (ACH) and Emergency Department Use Without Hospitalization During the First 60 Days of Home Health (ED Use). In the CY 2022 HH PPS final rule, CMS replaced the ACH and ED Use measures in the HH QRP with the Potentially Preventable Hospitalizations</p> (PPH); the PPH measure calculates a risk-adjusted rate of hospitalizations or observation stays for certain diagnoses that could have been prevented with proper management and care according to the Agency for Healthcare Research and Quality’s Prevention Quality Indicator Ambulatory Care Sensitive Conditions. In the same rule, CMS requested feedback on whether the agency should make the same change for the HH VBP and received generally supportive comments. Thus, CMS will remove the ACH and ED Use measures and adopt the PPH measure, beginning CY 2025. <p><strong>Weighting Changes.</strong> CMS finalized the distribution of weights to measures and measure categories (OASIS-based measures, claims-based measures, and HHCAHPS survey-based measures) used in the HH VBP in the CY 2022 HH PPS final rule. For HH agencies in the larger-volume cohort, OASIS-based measures contribute 35% of the score, claims-based measures contribute 30%, and HHCAHPS survey-based measures contribute 30%. For HH agencies in the smaller-volume cohort, OASIS-based measures and claims-based measures contribute 50% of the score each (this approach assumes agencies would have HHCAHPS surveys volume too low to reliably calculate scores).</p> <p>Because the agency is finalizing the changes to the measure set as proposed, there will be a different number of measures and thus the weights of individual measures must be redistributed to maintain the weights of the categories. The table below shows the changes to measure weights based on the final measure set adjustments.</p> <p><img alt="current measure weights" data-entity-type="file" data-entity-uuid="af375aeb-0f57-4edb-bc51-063de0f7449b" height="372" src="/sites/default/files/inline-images/current-measure-weights-1.jpg" width="621"></p> <p><img alt="current measure weights 2" data-entity-type="file" data-entity-uuid="26620075-def3-4657-ae80-3a2eb6f8a46e" height="144" src="/sites/default/files/inline-images/current-measure-weights-2.jpg" width="623"></p> <p><strong>Model Baseline Year Change</strong>. In the CY 2022 HH PPS final rule, CMS adopted CY 2019 as the baseline year for the expanded HH VBP mode – that is, performance in CY 2023 (the program’s first year) would be compared to performance in CY 2019 to determine payment adjustments in CY 2025. However, in the CY 2023 HH PPS final rule, CMS changed the baseline year to CY 2022, meaning that performance in CY 2023 will be compared to performance in CY 2022.</p> <p>In this rule, CMS finalizes its proposal to update the baseline year to CY 2023 beginning with the CY 2025 performance year to account for the various changes in the measure set; this means that performance in CY 2025 will be compared to performance in CY 2023 to determine payment adjustments in CY 2027. The only exception to this is for the DTC measure, which is based on two years of data; for this measure, the baseline will be CY 2022-2023, and the performance year would be CY 2024-2025.</p> <p>CMS will provide HH agencies with the final achievement thresholds and benchmarks in their July 2024 Interim Performance Report.</p> <p><strong>Changes to Appeals Process</strong>. As finalized in previous rulemaking, HH agencies may submit recalculation requests as well as reconsideration requests if they disagree with the results of a recalculation request for their Annual Performance Report (APR). Currently, CMS makes the final APR available no later than 30 days before the payment adjustment takes effect.</p> <p>In this rule, CMS finalizes its proposal to amend the policy to specify that a HH agency may request Administrator review of a reconsideration decision within seven days from CMS’ notification of the outcome of the request. Then, a CMS official will issue a written decision that is final and binding seven calendar days after the official’s decision, unless the Administrator renders a final determination reversing or modifying the reconsideration decision. CMS makes these changes to align the reconsideration review process with those used by other CMS appeals entities, and to ensure that HH agencies are aware that administrative review is available.</p> <h2>FURTHER QUESTIONS</h2> <p>For questions about payment provisions, contact Jonathan Gold, AHA’s senior associate director of payment policy, at <a href="mailto:jgold@aha.org">jgold@aha.org</a>; for quality-related questions, contact Caitlin Gillooley, AHA’s director of policy, at <a href="mailto:cgillooley@aha.org">cgillooley@aha.org</a>.</p> </div> <div class="col-md-4"> <p><br> <a href="/system/files/media/file/2023/11/home-health-prospective-payment-system-final-rule-for-cy-2024-advisory-11-16-23.pdf" target="_blank" title="Click here to download the Leapfrog Updates Hospital Safety Grade Methodology PDF."><img alt="Cover Home Health Prospective Payment System Final Rule for CY 2024 Regulatory Advisory" data-entity-type="file" data-entity-uuid src="/sites/default/files/2023-11/cover-home-health-prospective-payment-system-final-rule-for-cy-2024-advisory-11-16-23.png"></a></p> </div> </div> </div> Thu, 16 Nov 2023 14:11:05 -0600 Home Health PPS /2023-11-16-home-health-prospective-payment-system-final-rule-cy-2024 <div class="container"> <div class="row"> <div class="col-md-8"> <p>The Centers for Medicare & Medicaid Services (CMS) on Nov. 1 issued its calendar year (CY) 2024 final rule for the home health (HH) prospective payment system (PPS). New policies will generally be effective Jan. 1, 2024.</p> <div class="panel module-typeC"> <div class="panel-heading"> <h2>Key Highlights</h2> <p>The rule will:</p> <ul> <li>• Increase HH payments by an estimated $140 million (0.8%) in CY 2024, relative to CY 2023, based upon: • a 3.3% market basket increase, reduced by a 0.3 percentage point productivity adjustment; • a 2.6 percentage point behavioral adjustment that CMS says is necessary to achieve budget neutrality under the Patient-driven Groupings Model (PDGM); and • an adjustment to the fixed-dollar loss ratio for outlier payments that will result in an estimated 0.4 percentage point increase in payments. • Rebase the HH market basket using updated claims and cost data. • Adopt two new measures to the Quality Reporting Program. • Replace five measures in the Value-based Purchasing program with three new measures and change the weights of the individual measures in scoring.</li> </ul> </div> </div> TEXT</div> <div class="col-md-4"> <p><a href="/system/files/media/file/2023/11/cms-and-onc-propose-provider-disincentives-for-health-care-information-blocking-advisory-11-13-23.pdf" target="_blank" title="Click here to download the CMS and ONC Propose Provider Disincentives for Health Care Information Blocking PDF."><img alt="Regulatory Advisory Cover: CMS and ONC Propose Provider Disincentives for Health Care Information Blocking ." data-entity-type="file" data-entity-uuid src="/sites/default/files/2023-11/cover-cms-and-onc-propose-provider-disincentives-for-health-care-information-blocking-advisory-11-13-23.png"></a></p> </div> </div> </div> Thu, 16 Nov 2023 11:52:24 -0600 Home Health PPS /news/headline/2023-08-29-aha-comments-cy-2024-home-health-proposed-rule-expresses-concern-over-net-negative-update <p>AHA <a href="/lettercomment/2023-08-28-aha-comment-letter-cms-home-health-prospective-payment-system-proposed-rule-cy-2024">responded</a> to the Centers for Medicare & Medicaid Services’ calendar year 2024 proposed rule for the home health prospective payment system by voicing its extreme concern with the overall net negative update. “We urge the agency to adequately resource HH providers as they are a critical part of the care continuum,” AHA wrote. “We are particularly concerned about the substantial size of the agency’s proposed budget neutrality adjustment, a cut of 5.653%, and again call on CMS to withdraw it.” AHA pressed CMS to instead revise its methodology to account for changes more accurately in the payment system and care delivery due to the implementation of the Patient-driven Grouping Model.</p> Tue, 29 Aug 2023 15:03:00 -0500 Home Health PPS /lettercomment/2023-08-28-aha-comment-letter-cms-home-health-prospective-payment-system-proposed-rule-cy-2024 <p>August 28, 2023</p> <p>The Honorable Chiquita Brooks-LaSure<br /> Administrator<br /> Centers for Medicare & Medicaid Services<br /> Hubert H. Humphrey Building<br /> 200 Independence Avenue, S.W.<br /> Room 445-G<br /> Washington, DC 20201</p> <p><em>Submitted electronically.</em></p> <p><em><strong>Re: Medicare Program; Calendar Year (CY) 2024 Home Health (HH) Prospective Payment System Rate Update; HH Quality Reporting Program Requirements; HH Value-Based Purchasing Expanded Model Requirements; Home Intravenous Immune Globulin Items and Services; Hospice Informal Dispute Resolution and Special Focus Program Requirements, Certain Requirements for Durable Medical Equipment Prosthetics and Orthotics Supplies; and Provider and Supplier Enrollment Requirements; 88 Fed. Reg. 43,654 (July 10, 2023)</strong></em></p> <p>Dear Administrator Brooks-LaSure:</p> <p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, including approximately 1,000 hospital-based home health (HH) agencies, and our clinician partners — more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the şÚÁĎŐýÄÜÁż Association (AHA) appreciates the opportunity to comment on the calendar year (CY) 2024 HH prospective payment system (PPS) proposed rule.</p> <p>Our comments focus on CMS’ proposed budget neutrality adjustment related to the Patient-Driven Groupings Model (PDGM) under the HH PPS as well as its proposed market basket update. The AHA is extremely concerned that these policies, if finalized, would result in an overall net negative update to the HH PPS. We urge the agency to adequately resource HH providers as they are a critical part of the care continuum. We are particularly concerned about the substantial size of the agency’s proposed budget neutrality adjustment, a cut of 5.653%, and again call on CMS to withdraw it. Instead, we urge the agency to revise its methodology to more accurately account for changes in care delivery and payment dynamics due to the implementation of the PDGM. We also have concerns about the inadequacy of the proposed market basket update given the financial pressures facing HH agencies, including critical staffing shortages and rising supply costs. In addition, final data from CYs 2021 and 2022 indicate that the market basket forecasts underpaid HH agencies by a combined 5.1% for these years. This, combined with the difficult inflationary environment and the large budget neutrality adjustment proposed in this rule, risks putting HH agencies in serious financial peril. As such, we urge CMS to utilize its authority to provide a market basket adjustment to account for these extraordinary circumstances.</p> <h2>HH PPS PAYMENT PROPOSALS</h2> <h3>PDGM Behavioral Offset</h3> <p>AHA reiterates its staunch opposition to CMS’ proposal to continue to apply a PDGM budget neutrality adjustment based on a defective methodology. The agency specifically proposes to cut the standardized 30-day period payment rate by 5.653% in CY 2024. As described below, using this flawed methodology would erroneously lower overall payment levels to HH providers relative to the prior payment system. In addition, these proposed reductions have the potential to exacerbate capacity issues throughout the entire continuum of care, including for acute-care hospitals. <strong>Therefore, the AHA again calls on CMS to revise its methodology to more accurately account for changes in care delivery and payment due to the PDGM transition</strong>.</p> <p>In compliance with the Balanced Budget Act (BBA) of 2018, CMS implemented the PDGM case-mix system together with a 30-day payment episode on Jan. 1, 2020. This law called for a budget neutral implementation that centered on the new 30-day episode of care. The adjustment includes two types of behavioral offsets:</p> <ul> <li>Temporary adjustments to recoup or repay past over or underspending; and</li> <li>Permanent adjustments to ensure that <em>future</em> spending neither increases nor decreases relative to what otherwise would have been paid.</li> </ul> <p>The BBA did not specify a particular methodology for determining budget neutrality. Indeed, CMS’ budget neutrality adjustment for CY 2020 was set prospectively at -4.36% based on several assumptions regarding expected provider behavioral changes. Specifically, CMS assumed that HH agencies would alter their coding of primary and secondary diagnoses, both of which are key drivers of the PDGM payment setting process. In addition, CMS assumed that the number of low-volume cases, known as low-utilization payment adjustment (LUPA) cases, would decrease.</p> <p>By law, the budget neutrality adjustment process will continue to occur each year through 2026, although the agency deferred action until CY 2023 in response to the COVID-19 pandemic. For CY 2023, CMS finalized a -7.85% permanent adjustment for purported overpayments in CYs 2020-21, to be applied over two years (CYs 2023 and CY 2024). Thus, in this CY 2024 rule, the agency is proposing to apply the second half of this reduction, a cut of 3.925%. However, it is also proposing an additional permanent adjustment to account for estimated CY 2022 overspending. In total, it proposes a cut of 5.653% for CY 2024. Finally, CMS says that while it has not yet proposed any temporary adjustments, it currently estimates it will need to recoup a total of approximately $3.4 billion in future years, which, for context, would be approximately a 20% reduction if applied in a single payment year at current net payment levels.</p> <p><u>CMS’ Methodology Remains Flawed. </u><strong>The AHA reiterates its concerns that CMS overlooked numerous factors when calculating its PDGM-related budget neutrality adjustments</strong>. As discussed in our <a href="/lettercomment/2022-08-16-aha-comment-letter-cms-home-health-pps-proposed-rule-cy-2023" target="_blank">comment letters</a> for CYs 2022 and 2023, the three behavioral assumptions that CMS made when calculating its initial adjustment of -4.36% did not match actual behavior by the field in CY 2020.</p> <p>In addition, as AHA also has raised in its preceding year’s comment letters, CMS’ methodology for determining budget neutrality does not account for the drop in average per-episode therapy services under PDGM. This shift in care delivery means that CMS cannot simply reprice claims as it has done to date; instead, it must account for these additional dynamics to reach an accurate budget neutrality figure. Indeed, PDGM shifted incentives away from therapy visits resulting in a different unit of care with a new clinical and cost profile, which is incomparable to the pre-PDGM unit of care. Accounting for such shifts in care delivery when calculating budget neutrality is precisely what CMS did for the transition to the new PDPM under the SNF PPS. When determining a behavioral adjustment under that system, CMS determined that a drop in therapy utilization meant that comparison of data between the two payment systems would lead to a significant underestimation of what payments would have been under the prior system, thus leading to an inappropriately higher budget neutrality adjustment.<sup>1</sup> However, for its PDGM calculations, CMS has refused to factor in changes in therapy delivery, which dropped by 29.7% in CY 2020, relative to CY 2019.</p> <p>In addition, the PDGM framework — with 432 payment units, a 30-day episode of care and multiple case-mix levers — is significantly different, and therefore impossible to crosswalk to the prior payment system — with 153 payment groups, a 60-day episode of care and one dominant case-mix factor (therapy volume). Given these multiple, major differences, and consistent with CMS’ position noted above on the SNF PPS parity adjustment, PDGM-era claims from CY 2020 and 2021 cannot simply be recalculated using the prior payment system’s parameters to estimate what payments would have been under the prior model. Combining this significant shortcoming with a global pandemic that temporarily but fundamentally reshaped hospital and post-acute practices makes the repricing comparison done by CMS even more unsound.</p> <p>We refer CMS to AHA’s comments in response to the CYs 2022 and 2023 HH PPS proposed rules for the entirety of our methodological objections to CMS’ budget neutrality approach. In addition, AHA reiterates its strong support for the analysis commissioned by the Partnership for Quality Home Healthcare, which has raised substantial concerns with the accuracy of the PDGM budget neutrality cuts. <strong>For these reasons, AHA continues to urge CMS to withdraw its proposed budget neutrality cuts and revise its methodology to more accurately account for changes in care delivery and payment dynamics due to the transition to PDGM</strong>.</p> <p><u>Budget Neutrality Adjustments Jeopardize Access to Care and Disrupt the Care Continuum.</u> CY 2023’s budget neutrality adjustment accelerated the strain on a HH field that already had been facing a two-pronged challenge of a critical labor-shortage and a particularly sharp inflationary environment. The imposition of additional cuts could seriously imperil Medicare beneficiaries’ access to HH services and contribute to additional limits in hospitals’ capacity to care for patients.</p> <p>The most recent analysis from Kaufman Hall in its National Hospital Flash Report indicates that from 2020 to present, overall expenses have risen by 22% for hospitals.<sup>2</sup> Although HH agencies have a different mix of goods and services, many of the key components of their expense profiles are the same, such as heavy reliance on nurses, nurse aides, therapists and other clinicians, as well as medical supplies. Indeed, much of the increase in expenses for health care providers have been driven by labor costs, including contract labor costs, which have risen 258% since 2019.<sup>3</sup> As CMS knows, there has been a nationwide shortage of both clinical and non-clinical workers, including those needed to staff HH agencies. With reductions to payment rates, HH agencies struggle to retain and train staff to provide high-quality care for Medicare beneficiaries. Further, the Department of Health and Human Services (HHS) has found that health care workforce shortages will persist well into the future, meaning that CMS’ plan to continue to apply erroneous budget neutrality adjustments will continue to accelerate serious threats to the HH field’s ability to properly recruit and staff for their patients’ needs.<sup>4</sup></p> <p>In addition to labor costs, medical supply costs per patient have risen 18.5% from 2019 through 2022. Drugs make up a large portion of this increase, with an HHS study finding that many commonly used drugs have had their price increase by more than 30% in recent years.<sup>5</sup></p> <p>The threat to access to care is not hypothetical. Indeed, recent data highlight the ongoing reduction in access to HH services. Specifically, a 2023 report from Careport demonstrates that as the COVID-19 pandemic continued, patients were increasingly rejected from HH agencies as providers struggled to meet staffing demands.<sup>6</sup> <strong>Notably, the rejection rate rose to 76% at the beginning of CY 2023, the highest levels ever recorded, which coincided with the imposition of the first post-implementation PDGM budget neutrality cuts. To emphasize, this means that three-fourths of all requests for HH agency care, most coming from hospitals for hospitalized patients, are rejected. This is very concerning and deserves examination.</strong></p> <p>In addition to overall disruptions in access to services, the data also indicate there is a disproportionate impact on historically marginalized communities. CareJourney’s analysis of Medicare fee-for-service claims data, shown below, found that these groups had a significantly lower conversion rate than white beneficiaries when referred for HH services following discharge from an acute-care hospital. The same holds true for Medicare-Medicaid dual eligibles when compared to non-dual eligible beneficiaries. This indicates that access challenges by the combination of factors discussed herein is having an inordinate impact on these communities, something that CMS should seek to address.</p> <p><img 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" /><em><strong>Source:</strong> CMS Virtual Research Data Center<br /> <strong>Data:</strong> 2022 inpatient claim files filtered for STAC claims. Discharge data based on Q1-Q3 2022 data.<br /> <strong>ADI:</strong> Area Deprivation Index (ADI) - from the University of Wisconsin Neighborhood Atlas Area Deprivation Index (ADI). It allows for the rankings of neighborhoods by socioeconomic disadvantage in a region of interest (https://www.neighborhoodatlas.medicine.wisc.edu/)</em></p> <p>Further, CMS’ own data bears out how the recent economic conditions have strained access to HH services. As presented in Table B1 of the proposed rule, both the total 30-day periods of HH care and unique beneficiaries utilizing HH care was lower in CY 2022 than in CY 2020. In addition, the total visits per period of care was lower in CY 2022 than CY 2020 in every discipline other than social work, which remained flat. These figures are undoubtedly related to the difficult financial circumstances facing providers.</p> <p>If addition to the growing impasse for HH services, CMS should be further troubled by the repercussions access restrictions have on acute-care hospitals. The same Careport analysis found that the average length of stay for patients discharged to HH has risen by 11% from 2019 to 2022. This is consistent with recent AHA findings of a 12.9% increase.<sup>7</sup> As HH agencies lose capacity, acute-care hospitals proportionately lose their ability to discharge their patients. This, in turn, forces the acute-care hospitals to board patients who are ready for discharge, driving up costs and minimizing capacity to admit new patients. <strong>Indeed, CMS should consider adequately resourcing HH providers as a valuable tool that can be used to maximize acute-care hospital capacity and ensure the entire care continuum runs as smoothly as possible for Medicare beneficiaries.</strong></p> <h3>Proposed CY 2024 HH Market Basket Update</h3> <p>The proposed market basket update of 2.7% (3% reduced by 0.3% productivity adjustment) for CY 2024 is inadequate to ensure Medicare beneficiaries have continued access to HH services. First, the update fails to account for missed forecasts from recent years. In addition, the proposed update continues to underappreciate the inflationary environment for health care providers.<strong> For these reasons AHA recommends CMS utilize its authority to revise the market basket upwards to meet its mission of ensuring access to HH services for traditional Medicare beneficiaries and to account for what the agency missed in the CY 2021 and CY 2022 market basket forecast. </strong>This is especially important if CMS proceeds with its plans to apply its budget neutrality adjustments as proposed.</p> <p>In recent years, data indicate that the agency’s recent HH market basket updates were significantly lower than actual market basket growth. Specifically, CMS finalized updates of 2.3% and 3.1% in CYs 2021 and 2022, respectively; however, actual growth for these years were 4.2% and 6.2% respectively.<sup>8</sup> This resulted in a substantial cumulative shortfall of 5.1%. Indeed, an analysis by Dobson DaVanzo & Associates, commissioned by the Partnership for Quality Home Healthcare, found that from 2021 through 2030, these forecast errors will result in nearly $11 billion in underpayments to HH agencies under the HH PPS — an astounding figure.</p> <p>While final figures will not be available for several years, it is likely that the trend of under forecasting market basket cost growth has continued for CY 2023 and 2024. This is because, as AHA explained in last year’s <a href="/lettercomment/2022-08-16-aha-comment-letter-cms-home-health-pps-proposed-rule-cy-2023" target="_blank">comment letter</a>, in atypical economic environments, the market basket approach used by CMS is much less adept at properly forecasting. And the atypical economic conditions are continuing. Specifically, as explained in the section above, health care costs, and especially labor and medical supplies, have seen historic increases which are slow to ameliorate.</p> <p>The missed forecasts and inadequate proposed updates by themselves would be problematic and create serious strain on HH agencies’ ability to meet the needs of their communities. However, when combined with the budget neutrality cuts proposed by CMS, they are simply unsustainable. As CMS knows, a 2.7% update, reduced by a 5.653% budget neutrality adjustment would result in net update of -2.4% overall. Given the past forecast errors of 5.1%, the more than 8% in budget neutrality cuts already applied, and the difficult economic environment, a -2.4% update for CY 2024 could grievously disrupt access to HH services for Medicare beneficiaries.</p> <p><strong>Due to the consistent under-forecasting of the HH market basket, the unusual economic circumstances and the reductions in payment due to PDGM implementation, AHA appeals to CMS to deviate from its typical methodology and apply a more robust update to the HH market basket for CY 2024.</strong> This one-time adjustment would ensure that access to HH services is preserved for Medicare beneficiaries. Further, and of special importance to AHA, it will help ensure hospitals are not limited in their capacity to care for their communities and safely discharge patients in need of HH care.</p> <p><u>Productivity Adjustment.</u> CMS proposes to apply a productivity cut of -0.3% to the HH PPS market basket update. Specifically, under the Affordable Care Act, the HH payment update is reduced annually by a productivity factor, which is equal to the 10-year moving average of changes in the annual economy-wide, private nonfarm business total factor productivity (TFP). This measure was intended to ensure payments more accurately reflect the true cost of providing patient care. The use of the TFP is meant to capture gains from new technologies, economies of scale, business acumen, managerial skills and changes in production. However, as CMS knows, services provided through the HH benefit are hands-on, labor-intensive services and do not lend themselves to the productivity gains realized in other sectors. CMS itself has acknowledged that health care providers, due to the nature of their service, lack the ability to add efficiencies in the way other sectors do.<sup>9</sup></p> <p>Given all the various circumstances putting financial pressures on HH agencies, AHA would again like to express its concern about the application the productivity adjustment to HH agencies. AHA respectfully asks CMS to use its authority to account for the lack of parity in this adjustment when considering its overall payment adjustment to HH providers.</p> <h2>QUALITY REPORTING-RELATED PROPOSALS</h2> <h3>HH Quality Reporting Program</h3> <p>In this rule, CMS proposes to adopt two new quality measures for the HH Quality Reporting Program (HH QRP); remove one measure and two items from the Outcome and Assessment Information Set (OASIS); and begin publicly displaying performance data on four quality measures.</p> <p><u>Discharge Function Score Measure and Removal of Overlapping Discharge Function Measures</u>. CMS proposes to adopt this assessment-based outcome measure that estimates the percentage of HH patients who meet or exceed an expected discharge score during the reporting period beginning with the CY 2025 HH QRP; in the FY 2024 final rules for their respective payment systems, the agency has finalized adoption of the same measure in the Inpatient Rehabilitation Facility (IRF), Skilled Nursing Facility (SNF) and Long-term Care Hospital (LTCH) QRPs. While this cross-setting discharge function score measure appears to fulfill requirements of the IMPACT Act better than the current, setting-specific self-care and mobility discharge score measures used in the various post-acute care quality reporting programs (which CMS proposes to remove in this same rule), we continue to doubt the cross-setting applicability of this measure considering the different patient populations served by the various post-acute care settings. <strong>We urge CMS to wait until this measure has undergone endorsement review by a consensus-based entity (CBE) and demonstrates that it gleans useful information for patients and providers before adopting it for use in the HH QRP.</strong></p> <p>Additionally, the measure uses information from Section GG items that appear on all four of the patient assessment instruments across the various post-acute care settings. While patients are assessed using the same or similar items, the capabilities and goals of patients differ widely by setting. The measure developer notes that the measure is risk adjusted and calculated individually by setting; then, the calculation for measure performance “rolls up” information from several items to calculate an overarching score. Risk adjustment takes many variables into account, and denominators vary by setting (for example, the denominator for the measure when calculated in the LTCH QRP includes all patients regardless of payer, while for the SNF QRP the denominator consists of patients/residents under Medicare fee-for-service).</p> <p>While we appreciate the work the developer has done to attempt to consider the myriad of differences in patient populations across the various settings — including demographics, case mix, severity of illness, length of stay and comorbidities — at some point these variables alter the underlying calculation of the cross-setting measure and result in four different measures. In other words, discharge function is calculated in a way that is not truly standardized, as the IMPACT Act intended. It is at this point we ask whether it is necessary to force a measure that is “cross setting” in name only into CMS quality programs. Perhaps it is if testing of the measure demonstrates that this measure produces statistically meaningful information that can be used to inform improvements in care processes, but until we have that information from the endorsement review process by a CBE, the AHA has serious doubts about the utility of this measure.</p> <p>In addition, the measure uses a statistical imputation approach to account for “missing” assessment elements when codes on the assessments note that the “activity was not attempted” (ANA). If an assessor codes an item as “not attempted,” the imputation approach inserts variables based on the values of other activities that were completed; in other words, the calculation makes assumptions about what the patient would have scored on that item if it had been attempted based on their performance on other, similar activities that were. CMS argues that this approach “increases precision and accuracy and reduces the bias in estimates of missing item values.” While we understand that scores would be influenced more heavily by individual assessment items if there are fewer included in the calculation, CMS errors in labeling items coded ANA as “missing.” When an activity is not attempted, it is likely because it would be clinical inappropriate or dangerous for a patient to attempt it; for example, it would be ill-advised (and painful) for a patient with a healing wound on one side to roll left to right. In such a case, making assumptions about the patient’s function based on other activities would, in fact, not improve the precision of the score.</p> <p>We also question whether it is precise and accurate to generically apply an “expected” discharge score based on statistical regressions to unique patient populations, and whether the comparison of observed to “expected” function could wholly be attributed to the facility’s quality of care. The calculation approach for the “expected” discharge score is opaque, which makes it difficult for providers to know what they are working towards. In reality, providers strive to help each individual achieve his or her own specific goals related to function, independence and overall health. These goals are not based on statistical regressions.</p> <p>The AHA understands the purpose of this measure and agrees that the discharge function measure currently in use in the HH QRP (Application of Percent of Long-term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function) does not meaningfully evaluate comparative performance across post-acute care settings. However, without further testing and review of the proposed Discharge Score measure by a CBE, we are not certain that this measure brings value to the QRP and thus cannot support it for adoption.</p> <p><strong>Percent of Patients/Residents who are Up to Date with COVID-19 Vaccination Measure.</strong> Beginning with the CY 2025 HH QRP, CMS proposes to adopt this assessment-based process measure that reports the percentage of stays in which HH patients are up to date with their COVID-19 vaccinations per the CDC’s latest guidance. The agency reasons that the measure would, when publicly reported, provide useful information for patients and their caregivers when choosing a facility, and “would be an indirect measure of HH agency action” since the agency would, according to CMS, have the opportunity to administer the vaccine to patients during their episode, coordinate a follow-up visit for the patient to obtain the vaccine at their physician’s office or local pharmacy, or educate the patient about the importance of staying up to date with vaccinations. CMS finalized the adoption of this measure for the SNF, LTCH and IRF QRPs in their respective FY 2024 proposed payment system final rules.</p> <p>The AHA strongly supports the vaccination of health care providers and communities for COVID-19 and acknowledges the importance of up to date vaccinations. However, this measure has not been tested for validity and reliability and thus we cannot support it without knowing that it is, at minimum, feasible to report and likely to produce statistically meaningful information. Furthermore, we are not clear that the conceptual construction of the measure is the best way to encourage vaccination, especially in post-acute settings where care is delivered in episodic rather than longitudinal fashion. When reviewed by the National Quality Forum (NQF)’s Measure Applications Partnership (MAP) during the 2022-2023 review cycle, the Post-acute/Long-term Care Workgroup voted “Do Not Support” for this measure, meaning that a multi-stakeholder panel of experts representing providers, patients and payers do not support this measure for inclusion in the HH QRP as well.</p> <p>Vaccination status among patients is subject to many patient-level factors outside of the control of providers. For post-acute facilities and providers, it may be infeasible or inappropriate to offer vaccination for patients due to length of episode, ability to manage side effects and medical contraindications, or other logistical challenges to gathering information from a patient who may have received care from multiple proximal providers. Even without these challenges, however, patients/residents may choose to forgo vaccination despite a provider’s best efforts. It is possible that a post-acute care provider could have a robust effort to encourage vaccination among their patients/residents, but still have a relatively low rate of vaccination. As the Health Equity subcommittee of the NQF MAP noted in its review of this measure, cultural norms often play a large role in vaccine confidence. While post-acute providers will always seek to counsel vaccination in a culturally sensitive way, they also want to honor the choice of their patients once they have offered their clinical advice.</p> <p>We reiterate that we understand the importance of vaccination in protecting patients from the most serious outcomes of COVID-19. However, it is unclear whether the use of this measure will produce those results or if it is feasible for post-acute care facilities to collect and report the information necessary. The measure consists of a single yes or no item on the OASIS without any requirements for documentation or validation of vaccination status; while we acknowledge that additional documentation would be unduly burdensome for providers to collect, without it the measure is a mere checkmark in a box with no evidence that it leads to improved quality of care (since, as stated above, the measure has not been fully tested). For these reasons, <strong>we do not support the adoption of this measure in the HH QRP</strong>. CMS also may want to consider whether alternative measure constructions focused on the actions providers take in encouraging vaccination might be better suited to achieving the goal of higher vaccination rates.</p> <h3>HH Value-based Purchasing (VBP) Program</h3> <p><u>Replacement of OASIS-based Discharge to Community (DTC) Measure with Claims-based Version.</u> CMS proposes to replace the measure that is currently used in the HH VBP program with a measure identical except for its data source (claims rather than OASIS assessments) and period (two years rather than one). The AHA does not oppose this proposal, as the OASIS-based measure has not been publicly reported since 2016 and thus does not appear to provide value to patients and providers. In addition, the claims-based measure is informed by two years of data, which is likely to improve the reliability of performance calculations.</p> <p><u>Replacement of OASIS-based Function Measures with New Discharge Function Score</u><strong>.</strong> As we note above in our comments on CMS’ proposal to adopt this measure for the HH QRP, we have serious doubts about the utility of this measure if it were to undergo the evaluation by a CBE. We understand that CMS has already finalized the measure for adoption into the other post-acute care quality reporting programs and is thus likely to adopt it for the HH QRP as well; however, <strong>we strongly urge the agency to hold off on adopting this measure into a pay-for-performance program until we have better information about whether the measure gleans information as intended.</strong></p> <p><u>Replacement of Hospital Use Measures with Potentially Preventable Hospitalizations Measure</u>. CMS currently uses two measures to assess HH patient use of hospital services during their HH episode: Acute Care Hospitalization During the First 60 Days of Home Health (ACH) and Emergency Department Use Without Hospitalization During the First 60 Days of Home Health (ED Use). In the CY 2022 HH PPS final rule, CMS replaced the ACH and ED Use measures in the HH QRP with the Potentially Preventable Hospitalizations (PPH), The PPH measure calculates a risk-adjusted rate of hospitalizations or observation stays for certain diagnoses that could have been prevented with proper management and care according to the Agency for Healthcare Research and Quality’s Prevention Quality Indicator Ambulatory Care Sensitive Conditions. CMS would remove the ACH and ED Use measures and adopt the PPH measure beginning CY 2025.</p> <p>We agree that the all-cause hospital utilization measures proposed for replacement may not provide accurate assessments of provider performance or actionable information. HH providers may be unable to prevent ED visits due to factors outside of their control, including geographic factors like a lack of alternative (and lower intensity) sites of care or patient-level factors like a lack of family or community support. In addition, it is difficult to determine appropriate attribution for hospitalization between different providers and settings, especially because the current all-cause hospitalization measure does not require the reason for admission to be related to the reason the patient is receiving home health care. By removing these two measures in favor of one that is more likely to reflect whether HH agencies are providing proper management and care as well as clear discharge instructions and referrals, CMS can better assess quality of care for the purposes of the HH VBP program. <strong>Thus, we support removal of the ED Use and Hospitalization During the First 60 Days of Home Health measures.</strong></p> <p>However, when CMS proposed this replacement in the CY 2022 HH PPS rule, we voiced two concerns that we continue to urge CMS to consider regarding the PPH measure. First, the PPH measure uses the Agency for Healthcare Research & Quality’s Prevention Quality Indicators and Ambulatory Care Sensitive Conditions to inform the definition for hospitalizations that can be potentially prevented. These frameworks are not specific to post-acute care or to hospitalization, and HH care generally is not included in the definition of ambulatory care. While CMS shares its analyses that applied the conceptual definition of potentially preventable hospitalization to claims data, we encourage the agency to continue to monitor performance and hone this definition with the help of stakeholders and quality improvement experts.</p> <p>Second, we recommend that CMS incorporate social determinants of health (SDOH) into its risk adjustment methodology. As proposed, the PPH measure is risk-adjusted for demographics including age, sex, enrollment status and activities of daily living scores, but not other SDOH that have a demonstrated impact on hospitalization. Several reports, including from the National Academies of Medicine, have shown that there are a number of plausible mechanisms by which sociodemographic information can be incorporated meaningfully into quality measurement. We urge CMS to incorporate social risk factors into the risk adjustment for the PPH measure and submit the measure for review by a CBE before its adoption.</p> <p>We appreciate your consideration of these issues. Please contact me if you have questions or feel free to have a member of your team contact Jonathan Gold, AHA’s senior associate director for policy, at (202) 626-2368 or <a href="mailto:mailto:jgold@aha.org">jgold@aha.org</a>.</p> <p>Sincerely,</p> <p>/s/</p> <p>Ashley Thompson Senior Vice President,<br /> Public Policy Analysis and Development</p> <p>__________</p> <p class="MsoFootnoteText"><small><span><span><span class="MsoFootnoteReference"><span><span class="MsoFootnoteReference"><span><span>1</span></span></span></span></span><span> CY 2023 SNF PPS Proposed Rule, 87 FR 22720; </span></span></span></small><span><span><a href="https://www.federalregister.gov/d/2022-07906/p-193"><span><span>https://www.federalregister.gov/d/2022-07906/p-193</span></span></a><span>.</span></span></span><br /> <small><span><span><span>2 Kaufman Hall, <i>National Hospital Flash Report</i> (July 2023) </span><a href="https://www.kaufmanhall.com/sites/default/files/2023-07/KH-NHFR_2023-07.pdf"><span><span>https://www.kaufmanhall.com/sites/default/files/2023-07/KH</span></span></a>-<a href="https://www.kaufmanhall.com/sites/default/files/2023-07/KH-NHFR_2023-07.pdf"><span><span>NHFR_2023-07.pdf</span></span></a><span>.</span><span><span><span> </span></span></span><br /> <span>3 Syntellis and AHA, Hospital Vitals: Financial and Operational Trends. </span></span></span></small><span><span><a href="https://www.syntellis.com/sites/default/files/2023-03/AHA%20Q2_Feb%202023.pdf"><span><span>https://www.syntellis.com/sites/default/files/2023-03/AHA%20Q2_Feb%202023.pdf</span></span></a><span>. </span></span></span><small><span><span><span> </span><br /> <span class="MsoFootnoteReference"><span><span class="MsoFootnoteReference"><span><span>4</span></span></span></span></span><span> ASPE Office of Health Policy, Impact of the COVID-19 Pandemic on the Hospital and Outpatient Clinician Workforce, HP-2022-13 at 1 (May 3, 2022).</span><br /> <span class="MsoFootnoteReference"><span><span class="MsoFootnoteReference"><span><span>5</span></span></span></span></span><span> Arielle Bosworth, et al., Assistant Secretary for Planning and Evaluation, Price Increases for Prescription Drugs, 2016-2022, HP-2022-27 at 1 (Sep. 30, 2022).</span><br /> <span class="MsoFootnoteReference"><span><span class="MsoFootnoteReference"><span><span>6</span></span></span></span></span></span></span><span><span> The evolution of care: An annual care delivery report. 2023 CarePort.</span></span><br /> <span><span><span class="MsoFootnoteReference"><span><span class="MsoFootnoteReference"><span><span>7</span></span></span></span></span><span> şÚÁĎŐýÄÜÁż Association. Issue Brief: Patients and Providers Faced with Increasing Delays in Timely Discharges (December, 2022) </span></span></span></small><span><span><a href="/issue-brief/2022-12-05-patients-and-providers-faced-increasing-delays-timely-discharges"><span><span>/issue-brief/2022-12-05-patients-and-providers-faced-increasing-delays-timely-discharges</span></span></a><span>.</span></span></span><small><span><span><span> </span><br /> <span class="MsoFootnoteReference"><span><span class="MsoFootnoteReference"><span><span>8</span></span></span></span></span></span></span></small><span><span> <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicareprogramratesstats/marketbasketdata"><span><span>https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicareprogramratesstats/marketbasketdata</span></span></a><span>.</span></span></span><br /> <small><span><span><span class="MsoFootnoteReference"><span><span class="MsoFootnoteReference"><span><span>9</span></span></span></span></span><span> Centers for Medicare and Medicaid Services. (February 2016). Hospital Multifactor Productivity: An Updated Presentation of Two Methodologies. </span></span></span></small><span><span><a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/ProductivityMemo2016.pdf"><span><span>https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/ProductivityMemo2016.pd</span></span></a></span></span><small><span><span><a href="https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/ProductivityMemo2016.pdf"><span><span>f</span></span></a>   </span></span></small></p> <p class="MsoFootnoteText"> </p> <p class="MsoFootnoteText"> </p> Mon, 28 Aug 2023 15:08:24 -0500 Home Health PPS