Karen Vance, OTR Managing Consultant BKD, LLP
kvance@bkd.com
Tuesday, February 17, 2015 | 2 – 3 p.m. Central time
2015 Home Health Medicare Payment &
Regulatory Updates – Part 2
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Objectives
• Articulate rationale for therapy reassessments
• Define 2015 regulatory changes for therapy reassessment timing
• Describe changes needed in home health agency operations for monitoring reassessments
• Elucidate potential changes beyond 2015 & impact on therapy utilization
• Explain changes in therapy practice needed for home health success
3 // experience access 3
RATIONALE FOR REASSESSMENT
Rationale for Therapy Reassessment Requirement
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Rationale for Therapy Reassessment Requirement
• “Effective January 1, 2011, therapy reassessments must beperformed on or ``close to'' the 13th and 19th therapy visits and at least once every 30 days (75 FR 70372). A qualified therapist, … must functionally reassess the patient using a method which would include objective measurement.” • “We anticipated that policy regarding therapy coverage and
therapy reassessments would address payment
vulnerabilities that have led to high use and sometimes overuse of therapy services. We also discussed our expectation that this policy change would ensure more qualified therapist involvement for beneficiaries receiving high amounts of therapy.” (CMS-1611-F)
Episode % – 14 & 20 Therapy Visits
Table 35 Calendar year Episodes with at least 1 covered therapy visit Episodes with at least 14 covered therapy visits Episodes with at least 20 covered therapy visits2010
54.1
17.2
6.0
2011
54.2
16.0
5.4
2012
55.2
15.6
5.2
2013
56.3
16.3
5.3
7Visit % Provided by Therapy Assistants
Table 36Calendar year % PT visits provided by a PTA % OT visits provided by an OTA
2011
23.8
14.4
2012
28.5
15.4
2013
29.2
15.4
RATIONALE FOR REASSESSMENT
2015 Rule
Federal Register Volume 79, Number 215
(November 6, 2014)• “We note that in our CY 2012 HH PPS final rule (76 FR 68526), we recalibrated and reduced the HH PPS case-mix weights for episodes reaching 14 and 20 therapy visits, thereby diminishing the payment incentive for episodes at those therapy thresholds.
• Recent analysis of claims data from CY 2010 through CY 2013 does not show significant change in the percentage of cases reaching the 14 therapy visit and 20 therapy visit thresholds between CY 2010 and CY 2011.
• Moreover, payment increases at the 14 therapy visit and 20 therapy visit thresholds have been somewhat mitigated since the recalibration of the case-mix weights in CY 2012.”
Federal Register Volume 79, Number 215
(November 6, 2014) • Effective for episodes beginning on or after January 1, 2015• At least every 30 days a qualified therapist (instead of an assistant) must provide the needed therapy service and functionally reassess the patient.
• Where more than one discipline of therapy is being provided, a qualified therapist from each of the
disciplines must provide the needed therapy service and functionally reassess the patient at least every 30 days.
(Emphasis added)
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RATIONALE FOR REASSESSMENT
Monitoring Reassessment Visits
• “The reassessment will not have to be done on exactly the 30th day. For example, the reassessment could be done on the 21st day or the 28th day as clinically appropriate and deemed necessary by the therapist.”
• Reassessment clock is not measured by episode but by patient's full course of treatment, starting with therapist's first assessment/visit & continuing until patient is discharged from home health
• Each therapy discipline has its own separate clock, beginning with first therapy service (of that discipline) & clock resets with each therapist's visit/assessment/measurement/ documentation (of that discipline)
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Federal Register Volume 79, Number 215
(November 6, 2014)• Therapy reassessments are to be performed
o Using a method that would include objective
measurement
o In accordance with accepted professional standards of
clinical practice
o Which enables comparison of successive measurements
to determine effectiveness of therapy goals
Therapy Reassessment Documentation
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• Does not require a full
blown evaluation to
the extent of initial
evaluation
• Does require an
‘intervention review’,
demonstrating
effectiveness of
intervention
• Does not have to be
on a particular form
• Does have to be
recognizable as a
reassessment
• Clarification added to documentation later must be
a “legal late entry”
Therapy Reassessment Elements
• Functional
o Goals & interventions must satisfy, “so what?” assuring
appropriateness to patient
• Objective
o Terms or measures used to mean same thing, by any
therapist, any time they are used
• Measurable
Objective Measures
• OASIS functional items or other commercially
available therapy outcomes instruments OR
• Tests & measurements validated in professional
literature OR
• Accepted standards of clinical practice appropriate
for condition/function being measured
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Standards of Clinical Practice
• Include guidelines or frameworks that guide clinical
reasoning through assessment, goal setting, plans of
care & discharge planning
• Include ethical standards
• Include guidelines for supervision
• Require practice within regulatory & payment policy
of employment setting
• Assure practice & measures are appropriate for
Objective vs. Standardized Measures
• If a tool is standardized but not for home health, it is
not appropriate to be used as a standardized tool
• If a standardized tool is adapted to fit home health,
then it is no longer standardized
• There may be accepted standards of clinical practice
that may be appropriate for home health, but not
objective & not measurable
• Define measures you are currently using to make
them objective & measurable
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Therapy Reassessment = Intervention Review
• Re-evaluate plan
• Modify plan
Clinical Reasoning OVER Rules
• Be careful to not be so concerned about measuring progress that is standardized or measurable that you find yourself documenting progress not salient to patient’s goals
• Be careful about following “rules of thumb” & prescribed documentation that you don’t catch what is important about patient’s performance
• Consider variables of performance that can be measured incrementally
• Level of assistance & increments of strength or ROM do not always describe a patient’s function
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Documentation Standards
“The service of a physical therapist, speech-language
pathologist or occupational therapist is a skilled
therapy service if inherent complexity of the service is
such that it can be performed safely and/or effectively
only by or under the general supervision of a skilled
therapist. To be covered, the skilled services must also
be reasonable and necessary to the treatment of a
patient's illness or injury or to the restoration or
maintenance of function affected by the patient's
illness or injury.“
(Emphasis added)RATIONALE FOR REASSESSMENT
Beyond 2015
Volume- to Value-Based Health Care
• Quality data, from patient’s perspective, is often not
meaningful & is incomplete, with little information available to compare expected functional outcomes among providers • But main culprit for current system’s ills is fee-for-service
payment system, which rewards volume over value & does nothing to promote coordination of care among providers • First step in correcting system is a transition from
Medicare Payment Advisory Commission (MedPac)
“The Secretary should revise the home health
case-mix system to rely on patient
characteristics to set payment for therapy and
nontherapy services and should no longer use
the number of therapy visits as a payment
factor.”
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Value-Based Health Care
Healthcare Financial Management Association (HFMA). (2011). Value in health care: current state and future directions. Retrieved from www.hfma.org
Volume-Based Practices
• 13
th& 19
ththerapy reassessments
• Documentation justifying visits to payor
• Documenting progress & need
• Using same visit frequency & duration
• Defending volume of services to justify associated
payment
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Value-Based Practices
• Selecting services based on contribution that service
will make toward desirable & sustainable outcomes
• Justification, not to the payor, but to the agency, that
services are worth providing
• Value-based practices require different skills &
knowledge (competencies) than volume-based
practices
RATIONALE FOR REASSESSMENT
Therapy Skill Set
Most Common Primary Home Health Diagnosis,
Medicare Beneficiaries
(2010)Diagnosis ICD-9-CM Code
% total served with this HH 1o diagnosis Diabetes 250 10.3 Essential hypertension 401 9.3 Heart failure 428 7.4 Chronic ulcer of skin 707 4.3 Osteoarthrosis related dx 715 3.7 Cardiac dysrhythmias 427 2.6 Total 37.6
Management of Chronic Conditions
• “As much as 90% of the management of a chronic
condition must be performed, not by health care providers, but by the person who has the condition.”
California Healthcare Foundation, 2008
• “Patients with chronic conditions self-manage their illness. This fact is inescapable. Each day, patients decide what they are going to eat, whether they will exercise, and to what extent they will consume prescribed medication.”
Bodenhemer, Lorig, Holman & Grumbach, 2002
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Don’t Confuse . . .
Knowledge
Behavior
Verbalize Understanding
Implementation
Outcomes
• What will result of therapy intervention be?
• Will it be sustainable?
o Capable of being sustained
o Resources needed to sustain
• Will it matter?
• A shift in metrics from possible to practical
o Are resources required to achieve result worth the result
achieved?
o Are resources required to sustain result reasonable?
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Management of Chronic Conditions
• Medications (obtain, administer as directed, refill) • Self monitoring (BP, glucose, skin)
• Other treatments (oxygen, nebulizer, insulin) • Physical activity (exercise, pacing)
• Diet (carbs/glycemic index, sodium, potassium) • Attend & participate in health care encounters
Outcome Indicators
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Outcomes Measures State Nat’l How often patients got better at walking or moving around. 63% 63% How often patients got better at getting in and out of bed. 61% 58% How often patients got better at bathing. 72% 68% How often patients had less pain when moving around 66% 68% How often patients breathing improved. 70% 65% How often patients’ wounds improved or healed after an operation. 90% 89% How often patients got better at taking their drugs correctly by mouth. 53% 52%
How often patients receiving home health care needed any urgent, unplanned
care in the hospital emergency room – without being admitted to the hospital 14% 12% How often home health patients had to be admitted to the hospital 14% 16%
Satisfying All Stakeholders
• Effective o Good outcomes • Productive o Cost efficient • Compliant o Good documenting • Effective o Reduce hospitalization • Efficient o Reduced costs • Compliant o With
Agency Payor/Regulators Patient/ Support System • Effective o Feel better o Manage condition o Stay at home
Questions?
Thank You!
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CPE Credit
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