MA Past, Present, and Possible Future: Nothing Good to Report

CMS

by Tim Rowan | Jul 26, 2024 | CMS, Editorial, Medicare Advantage, Regulatory

by Tim Rowan, Editor Emeritus

Past

For at least the last five years, every Home Health conference this reporter has attended has featured at least one keynote speaker or expert panelist complaining about sparse and shrinking payments from Medicare Advantage plans. As thousands of seasonal TV ads convince more and more Medicare beneficiaries to enroll in what insurance company executive-turned-whistleblower Wendell Potter called “neither Medicare nor an advantage,” the calls from Home Health executives to turn away MA members, following the lead of many hospitals, have grown louder and more frequent.

Originally designed to extend the lifespan of the Medicare Trust Fund by bringing managed care practices to the federal healthcare program for seniors and disabled, Medicare Advantage has failed to do so. As long ago as 2021, an exposé by Fred Schulte in Kaiser Family Foundation Health News found that MA costs to taxpayers began to explode in 2018 and today equal 119 percent of what traditional Medicare should cost. We looked at more recent studies and found similar reports.

From the Experts

Referencing a study by Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, Schulte said, “his analysis of newly released Medicare Advantage billing data estimates that Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients. A third of that overpayment occurred in 2018 and 2019.”

Since Kronick’s 2021 report, more beneficiaries have opted in to Medicare Advantage. So far, just over half have switched from straight Medicare, with or without a supplement, and that number may reach 100 percent if those who profit most from the option have their way.

Present

In recent months, we have investigated and reported on the insurance industry’s practice of exaggerating MA member health conditions and denying care that traditional Medicare would have covered, collecting from both ends of the CMS trough. We have also mentioned several federal and state lawsuits piling up against insurance companies for both of those practices. One of our sources, The Center for Economic and Policy Research, said this in the Executive Summary of its detailed, September 2023 study:

Profiting at the Expense of Seniors: The Financialization of Home Health Care

“The nonpartisan Medicare Payment Advisory Commission (MedPAC) estimates that upcoding by MA plans that make enrollees appear to be sicker than they are costs CMS 106 percent of what traditional Medicare costs; adding in the quality bonus payments brings it to 108 percent. MA plans also enroll healthier Medicare beneficiaries, increasing their operating surplus by another 11 percent, making the payments to MA plans 19 percent higher than the payments to traditional Medicare.

CMS’s announced goal for traditional Medicare beneficiaries is to move all of them to Accountable Care Organizations, which use the valued-based payment model, or other similar care arrangements, by 2030. CMS’s leading model to accomplish this shift is ACO REACH — a gentler, kinder version of the Trump administration’s backdoor enrollment of traditional Medicare beneficiaries in a capitated payment model.”

The Center for Economic Policy Research

Future

Depending on results in the unpredictable world of politics later this year, CMS may or may not see its shift to value-based ACO models come to fruition. Kaiser News‘ Schulte examined the Heritage Foundation’s “Project 2025,” the conservative think tank’s blueprint for any possible future Republican administration, and found an entire section on the Department of Health and Human Services.

Within its “Mandate for Leadership,” the authors identify Medicare and Medicaid as “the principal drivers of our $31 trillion national debt.” While admitting that Medicare and Medicaid “help many,” the authors assert that the programs “operate as runaway entitlements that stifle medical innovation, encourage fraud, and impede cost containment, in addition to which their fiscal future is in peril.”

Rebuttal

Commenting on the Heritage Foundation’s claim, researcher Sonali Kolhatkar, writing for “OtherWords.org,” counters that this opinion is often used to justify ending social programs, but actual CMS data indicates that per person Medicare spending has plateaued for more than a decade and represents one of the greatest reductions to the federal debt. Even with 10,000 to 11,000 Boomers reaching Medicare eligibility every day, total per beneficiary expenditures have stopped climbing, hovering around $12,000 per year since 2010. Before reaching that 2010 plateau, per beneficiary spending had steadily risen from $2,000 at the program’s 1965 inception.

Medicare Advantage for All

Project 2025 proposes making Medicare Advantage the default enrollment option rather than a choice beneficiaries can opt into. With 100 percent of seniors on MA plans, already historic insurance profits will skyrocket further. But will Medicare beneficiaries benefit as well?

The Center for Economic and Policy Research cites multiple lawsuits that have proven eight of the ten largest MA plans routinely add chronic conditions – some non-existent – to patient assessments at enrollment…or later. We reported recently that UnitedHealth Group, operator of the largest MA plan, recently began sending nurses into homes to search for additional health conditions that would raise company payments from the trust fund. The report we quoted included evidence that these home visit upcodes do not lead to any treatments. The Center added that MA’s “heavily restricted networks damage one’s choice of provider along with introducing dangerous delays and denials of necessary care.”

As we have mentioned before, Medicare Advantage is neither Medicare nor an Advantage.

Medicaid also Attacked

Project 2025 also proposes restrictions on Medicaid eligibility by imposing work requirements. The blueprint sees the program for low-income Americans as a “cumbersome, complicated, and unaffordable burden on nearly every state.” Their plan includes bringing private insurance companies in to “manage” care.

A June, 2024 report by the Center on Budget and Policy Priorities concluded that the ACA’s expansion of Medicaid helped millions of Americans who would otherwise be uninsured, and that its enabling and encouragement of preventive care actually saved money in state budgets. Last month’s report asserted “the people who gained coverage have grown healthier and more financially secure, while long-standing racial inequities in health outcomes, coverage, and access to care have shrunk.”

Project 2025 authors make no mention of a KFF News report from April 2023 that said most Medicaid-eligible people are already working. Nor does it take into account a Government Accountability Office report to Congress October 2020 and again in 2023 that determined that hourly wages in many large companies are low enough to keep even full-time workers eligible for Medicaid and SNAP. Walmart and McDonalds, to name two, land in the top five in almost every state for having Medicaid-eligible workers.

EVEN THE WALL STREET JOURNAL IS CRITICAL

Under the front page Headline “Medicare paid $50 billion to insurers for untreated ills,” a detailed WSJ investigation highlighted a number of findings, including:

“The questionable diagnoses included some for potentially deadly illnesses, such as AIDS, for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea.”
“Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said.”
“Medicare Advantage has cost the government an extra $591 billion over the past 18 years, compared with what Medicare would have cost without the help of the private plans, according to a March report of the Medicare Payment Advisory Commission, or MedPAC, a nonpartisan agency that advises Congress. Adjusted for inflation, that amounts to $4,300 per U.S. tax filer.”
“The Journal reviewed the Medicare data under an agreement with the federal government. The data doesn’t include patients’ names, but covers details of doctor visits, hospital stays, prescriptions and other care.”

Now it is in the Hands of Voters

Home Health, Hospice, and Home Care owners, management, and workers will be voting in November. Consideration of what four years under a Project 2025-friendly administration will mean to businesses dependent on Medicare and Medicare will weigh heavily on their minds as they enter their polling booths.

# # #

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

BREAKING NEWS: Warren, Cassidy React to Supreme Court Ruling

CMS

by Kristin Rowan | Jul 26, 2024 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

The Background

Senators Warren and Cassidy react to the landmark decision by the Supreme Court in Loper Bright Enterprises v. Raimondo. That decision effectively overturned the Chevron Doctrine, which gave deference to federal agency decisions in interpreting ambiguous statutes. Eliminating the Chevron Deference puts more responsibility on federal agencies to show reason behind their interpretations. Likewise, it requires Congress to be less ambiguous in its wording of statutes. This decision would impact CMS’s ability to create their own definitions of terms when calculating reimbursement rates, implementing rules.

Senator Elizabeth Warren Reacts

Senator Elizabeth Warren (D-MA)

Less than one month after the U.S. Supreme Court decided the case that overturned Chevron Deference, Senator Elizabeth Warren (D-MA) introduced a bill in the Senate that would override the Supreme Court’s decision and establish Chevron Deference as law.

“Giant corporations are using far-right, unelected judges to hijack our government and undermine the will of Congress,” Warren said. According to Warren, the pending legislation, “The Stop Corporate Capture Act”, will stop corporate interest groups from using their own interpretations of statutes over the judgment of Congress or expert agencies.

Senator Cory Booker (D-NJ) called the Supreme Court decision “an egregious power grab from the US Supreme Court.”

Warren asserts that the overturning of Chevron Deference would put more power in the hands of industry-backed lobbyists who already have more negotiating power than the general public. This assertion is contrary to the majority opinion from Chief Justice John Roberts, who wrote, “Courts must exercise their independent judgment in deciding whether an agency has acted within its statutory authority.”

Increasing Congressional Authority

In addition to making Chevron Deference law, the Stop Corporate Capture Act would also:

Modernize and Reform the Regulatory Process

- Streamline the White House’s review period for regulations, creating a 120-day time limit for review.
- Authorize agencies to reinstate rules that are rescinded by Congress through the Congressional Review Act.
- Reform agencies’ cost-benefit analysis to emphasize public benefits of a rule, including non-quantifiable benefits like promoting human dignity, securing child safety, and preventing discrimination.

Empower and Expand Public Participation in Rulemaking

- Create an Office of the Public Advocate to help members of the public participate more effectively in regulatory proceedings.
- Strengthen agency procedures for notifying the public about pending rulemakings.
- Provide the public with greater authority to hold agencies accountable for unreasonable delays in completing rules.
- Require agencies to respond to citizen petitions for rulemaking that contain 100,000 or more signatures.

Increase Transparency and Protect Independent Expertise in Rulemaking

- Require all rulemaking participants to disclose industry-funded research or other related conflicts of interest.
- Require any submitted scientific or other technical research that raises a specified corporate conflict of interest be made available for independent public review.
- Bring transparency to the White House regulatory review process by requiring disclosure of changes to draft rules during that process and the source of those changes.
- Require agency officials to provide justification when the regulatory review process ends with a rule being withdrawn.
- Establish financial penalties for corporate special interests that knowingly submit false information during the rulemaking process.

Senator Bill Cassidy Responds

At the same time that Warren introduced her bill overriding Loper v. Raimondo, Senator Bill Cassidy (R-LA) introduced the “Upholding Standards of Accountability (USA) Act of 2024.” Cassidy’s bill takes the removal of the Chevron Deference further than simply overturning the previous ruling. According to the description, the USA Act imposes additional accountability in agency rulemaking.

Senator Cassidy is the ranking member of the Senate Health, Education, Labor, and Pensions (HELP) Committee. He stated, “For decades, the executive branch has exploited Chevron deference to increase its power beyond what Congress intended, all while skirting congressional oversight. Now, with Chevron deference overturned, Congress must work to rein in the executive branch and hold it accountable to the people and their elected representatives.”

Senator Bill Cassidy (R-LA)

Decreasing Agency Authority

The direct impact of the Supreme Court decision is that federal agencies do not get preferential treatment when interpreting a statute. Cassidy’s bill requires the head of any federal agency signing a major rule to testify before the committee of jurisdiction within 30 days of the rule’s publication.

Additionally, the bill would:

- Require each person nominated to a Senate-confirmed position to testify before the committee of jurisdiction prior to Senate confirmation;
- Improve cost-benefit analyses by requiring federal agencies to conduct retrospective reviews of such analyses for major rulemakings within five years of each rule’s effective date;
- Clarify that federal agencies are permitted to communicate with Congress at all times regarding proposed rules; and
- Require timely, substantive responses to congressional oversight from federal agencies.

Cassidy Challenges Existing Rules

Immediately after the Loper v Raimondo decision, Sen. Cassidy sent a letter to the U.S. Secretary of Education Miguel Cardona asserting that the Education Department has established rules outside of the authority given to it by Congress. He specifically alluded to the new Title IX rule. Cassidy asked Cardona, “How will the department change its current practice to enforce the laws as Congress writes them, and not to improperly legislate via agency action?”

Given Cassidy’s position in the Senate HELP Committee and his previous statements on medical debt, the multitude of bills he introduced on transparency, accountability, and decreasing authority, this is likely not Cassidy’s last attempt to challenge agency rules.

Likely Outcomes

Senator Warren's Bill

There are ten co-sponsors of Warren’s bill and a long list of endorsing organizations. Despite that, experts say the bill has only a slim chance of passing in an election year in the Senate, where Democrats currently have a narrow majority control. The bill is even less likely to pass in the Republican controlled House of Representatives.

Senator Cassidy's Bill

Similar to Warren’s bill, Cassidy’s bill has a low likelihood of passing. The Democrat majority in the Senate may dismiss the bill before it ever reaches the house. In 2023, the 118th Congress passed only 34 bills, the lowest number in decades. With only a few months remaining for the Congress, and the focus turning to a new Democratic nominee, passing this, or any other, bill seems improbable.

Final Thoughts

Regardless of your political affiliation, the overturning of the Chevron Deference is good news for home health, hospice, and palliative care. This ruling puts more pressure on CMS to justify its reasoning for certain decisions it has made. Senator Warren’s bill threatens the advantage given to the home health industry related to NAHC’s senate and house bills and pending lawsuits. Senator Cassidy’s bill ensures federal agency oversight and requires CMS to rationalize their decisions and prove budget-neutrality.

We will continue following these and other Chevron Deference related stories.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Payer or Competitor?

Admin

by Tim Rowan | Jul 19, 2024 | Admin, Editorial, Medicare Advantage

by Tim Rowan, Editor Emeritus

UnitedHealth Making Home Health Visits

Payer or Competitor…that is the question. According to a report in the Wall Street Journal, and questioned by the insurance industry’s lobbying arm, AHIP, UnitedHealth Group has increased its revenue from the Medicare Trust Fund by $50 billion by “finding” additional health issues during home visits to its MA customers.

In a July 16 investor call, CEO Andrew Witty said UnitedHealth clinicians made more than 2.5 million home health visits to UnitedHealthcare MA members in 2023. Following these visits to more than 500,000 seniors, UnitedHealth upgraded over 300,000 of them to higher payment levels by uncovering health conditions the individual seniors did not know they had.

The WSJ investigation found that between 2018 and 2021, insurers received $50 billion for diagnoses they added to members’ charts. Many of these diagnoses were “questionable,” according to that investigation.

Questionable Visits

Though a UnitedHealth spokesperson called the analysis “inaccurate and biased,” former UnitedHealth employees told the Journal home visits are often used to add diagnoses. Clinicians say they use software during visits that offer suggestions as to what illnesses a patient might have.

CEO Witty maintained in the investor call that the practice is good for seniors. “UnitedHealth clinicians discovered more than 3 million gaps in care through home visits in 2023,” he reported, “and 75% of patients receive follow-up care in a clinic within 90 days of a home visit.”

He added that the United home visit program “helps patients live healthier lives and saves taxpayers money,” concluding. “…Medicare Advantage makes programs and results like this possible.”

The Journal concluded with the finding that few of these upgraded seniors are ever seen by a physician for their newly discovered health conditions.

# # #

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Poor Joe is Out of A Job

CMS

by Tim Rowan | Jun 27, 2024 | CMS, Medicare Advantage

by Tim Rowan, Editor Emeritus

We have been keeping an eye on the Medicare Advantage business as the number of beneficiaries who switch exceeds fifty percent. In past reports, we have described the federal lawsuits that accuse MA insurance companies of illicitly padding revenues while illegally denying treatments that straight Medicare would have covered. (See MedPAC Exposes More Medicare Advantage Crimes – 3/20/24)

Until now, we haven’t gone into detail about those independent brokers with the continuous TV commercials every November. It turns out, they may be even more dishonest than the insurance companies themselves.

Poor Joe

Perhaps the most famous of these brokers is the one that put Broadway Joe Namath in our living rooms a hundred times a day. The company started life as Health Insurance Innovations, owned by Chicago-based private equity firm Madison Dearborn Partners. After accusations of fraud, the company folded and re-emerged as Benefytt. When the same accusations returned, the owners shut that company down and came back as Blue Lantern Health.

According to Healthcare Uncovered, the firm filed for a state-level bankruptcy equivalent in Delaware last April, called “assignment for the benefit of creditors.” Blue Lantern’s website is down, as are MedicareCoverageHelpline.com and HealthInsurance.com, their signature assets. Nobody answers the 800 number Namath hocked for years.

A History of Fraud

The bankruptcy litigation revealed a database of 7 million seniors who had been bombarded by 17 million phone calls. The bankruptcy was apparently precipitated by the Federal Trade Commission, which forced Benefytt to pay $100 million to the people it had scammed by selling sham Obamacare plans, with checks distributed to victims in March. The Securities and Exchange Commission forced Health Insurance Innovations and the company’s co-founder Gavin Southwell to pay a $12 million settlement. Another close associate of the company, Steven Dorfman, was convicted of wire fraud in February.

Deceptive Practices

Tolerance for the firm’s deceptive advertising scheme ended with changes to the Medicare Advantage rule in 2023 that took effect in 2024. Blue Lantern stated after the fines were imposed that the new rule was critical to the company’s downfall,

Previously, former HHS Security Alex Azar characterized the Namath ads as “real savings, real options” in Medicare Advantage, ignoring the studies showing that the MA program costs the Trust Fund not less but $140 billion more than original Medicare.

Healthcare Uncovered concluded with this observation, “Further rules imposed since then by the Biden administration are putting even more pressure on Medicare Advantage lead generators, also called ‘third-party marketing organizations.’ (TPMOs) Beginning October 1 of this year, CMS will require that TPMOs get express consent from individuals before selling contact information to other marketers and brokers — a key loophole that enabled the growth of Blue Lantern and its predecessors.”

Don’t worry about Joe Namath’s retirement income though.
He has already landed a gig hawking hearing aids.

# # #

The Wrong Way to Use AI in Healthcare

Admin

by Tim Rowan | May 16, 2024 | Admin, Artificial Intelligence, CMS, Medicare Advantage, Regulatory

by Tim Rowan, Editor Emeritus

Lawsuits are beginning to pile up against insurance companies participating in the Medicare Advantage program. The complaint? The wrong way to use AI in healthcare is with faulty algorithms to approve or deny claims. While AI can be extremely helpful in streamlining administrative tasks — comparing physician notes with Home Health assessments and nursing notes or reading hospital discharge documents — it seems not to be any good at deciding whether to approve or deny care.

The Wrong Way to Use AI in Healthcare Example 1

The Minnesota case, November, 2023, UnitedHealth Group:

- An elderly couple’s doctor deemed extended care medically necessary
- UnitedHealth’s MA arm denied that care
- Following their deaths, the couple’s family sued UnitedHealth, alleging:
  - Straight Medicare would have approved the extended care
  - United uses an AI model developed by NaviHealth called nH Predict to make coverage decisions
  - UnitedHealth Group acquired NaviHealth in 2020 and assigned it to its Optum division
  - nH Predict is known to be so inaccurate, 90% of its denials are overturned when appealed to the ALJ level
  - UnitedHealth Group announced in October, 2023 that its division that deploys nH Predict will longer use the NaviHealth brand name but will refer to that Optum division as “Home & Community Care.”

The family’s complaint stated, “The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because [UnitedHealth’s] AI model ‘disagrees’ with their real live doctors’ determinations.”

The Wrong Way to Use AI in Healthcare Example 2

The Class-Action case, December 2023, Humana:

- A lawsuit was filed on December 12, 2023 in the U.S, District Court for the Western District of Kentucky
- It was filed by the same Los Angeles law firm that filed the Minnesota case the previous month, Clarkson
- The suit notes that Louisville-based Humana also uses nH Predict from NaviHealth
- The plaintiffs claim, “Humana knows that the nH Predict AI Model predictions are highly inaccurate and are not based on patients’ medical needs but continues to use this system to deny patients’ coverage.”
- The suit says Medicare Advantage patients who are hospitalized for three days usually are eligible to spend as many as 100 days getting follow-up care in a nursing home, but that Humana customers are rarely allowed to stay as long as 14 days.
- A Humana representative said Humana their own employed physicians see AI recommendations but make final coverage decisions.

What Makes This Possible

According to experts we speak with, there are many ways to use data analytics. The insurance companies named in the lawsuits use predictive decision making. This way of analyzing data compares a patient to millions of others and deduces what treatment plan might be suitable for one patient, based on what was effective for most previous patients. Opponents of this method have called it “data supported guessing.”

A superior analysis method experts are coming to understand is prescriptive decision making. This is taking all of the available historical and current data surrounding a patient and making a clinical decision specifically designed to that patient’s age, gender, co-morbidities, doctor recommendations, and treatment records.

Until recently, predictive analysis was the preferred method because of its resource efficiency. Examining the data of every individual patient used to be prohibitively labor-intensive, requiring hours of reading hospital records, physician notes, and claims. Today, however, AI tools are able to do that work in seconds, making prescriptive analytics and customized plans of care possible.

Fix May Be in the Works

In a February 6, 2024 memo to all Medicare Advantage Organizations and Medicare-Medicaid Plans, CMS explained the difference between predictive and prescriptive analytics. The memo said these plans may not make coverage determinations based on aggregated data but must look at each individual:

“For Medicare basic benefits, MA organizations must make medical necessity determinations in accordance with all medical necessity determination requirements, outlined at § 422.101(c)1 ; based on the circumstances of each specific individual, including the patient’s medical history, physician recommendations, and clinical notes; and in line with all fully established Traditional Medicare coverage criteria.”

In response to a request for clarification, the CMS memo laid out its rule in specific language: Wrong AI in Healthcare Prescriptive Analytics

An algorithm or software tool can be used to assist MA plans in making coverage determinations, but it is the responsibility of the MA organization to ensure that the algorithm or artificial intelligence complies with all applicable rules for how coverage determinations by MA organizations are made. For example, compliance is required with all of the rules at § 422.101(c) for making a determination of medical necessity, including that the MA organization base the decision on the individual patient’s circumstances, so an algorithm that determines coverage based on a larger data set instead of the individual patient’s medical history, the physician’s recommendations, or clinical notes would not be compliant with § 422.101(c).
(emphasis added)

“Therefore, the algorithm or software tool should only be used to ensure fidelity with the posted internal coverage criteria which has been made public under § 422.101(b)(6)(ii).”

In further responses to questions in the same memo, CMS made it clear MA plans must make the same coverage decision original Medicare would make. The only allowable exception is that plans may use their own criteria when Medicare Parts A and B coverage criteria “are not fully established.”

Knowledge of this CMS directive may give Home Health agencies one more arrow in their quiver when going to battle with powerful, profit-oriented insurance companies over harmful, illogical AI algorithm decisions.

For information on the right way to use AI in healthcare, see our complimentary article in this week’s issue.

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

HOPE is on the Way: Part 3

CMS

by Rowan Report | Apr 26, 2024 | CMS, Medicare Advantage, Regulatory

By Beth Noyce, RN, BSJMC, BCHH-C, COQS
CHAP-certified home health & hospice consultant

This is part 3 of the 3 in the series, outlining the discussions and implications in adopting new outcome and process measures for Hospice care. The final segment addresses future process and outcome measures that the board discussed, but did not yet implement. Read Part 1 on Outcome Measures and Part 2 on Process Measures.

The TEP discussed potential future process and outcome measure concepts that Abt Associates presented to the panel as well.

The process measures included:

Education for Medication Management
Wound Management Addressed in Plan of Care
Transfer of Health Information to Subsequent Provider
Transfer of Health Information to Patient/Family Caregiver

Hope-based outcome measures were:

Patient Preferences Followed throughout Hospice Stay
Hospitalization of Persons with Do-Not-Hospitalize Order

Developing education for medication management as a process measure was a popular concept, and the top priority of the recommended measures with the TEP as they “broadly agreed that CMS should develop this measure,” the report says, citing “a significant need for training in medication management for patients and their caregivers.” They recommended that the measure weigh more heavily when care is provided in a home setting than in a facility setting because hospices are unable to control facility training and hiring practices. One panelist commented that including the phrase “during today’s visit” in the measure is important.

Whether CMS should further develop the process measure addressing wound management in the plan of care was less straight-forward, as panelists provided varied feedback. They generally agreed that this measure is important, as having a record of wound management addressed in the plan of care can hold the staff accountable for treating the wounds. But some members recommended measuring wound management with outcome measures rather than process measures. One panelist cited potential problems from patients’ deterioration over time and another noted that the time frame of this measure is important, and encouraged recording the process of getting care in place once a wound is identified. The panel agreed CMS should carefully define the measure’s specifications.

Because standard practice for most agencies is, when a patient is discharged live, to transfer health information to the subsequent provider and to the patient and family or caregiver, TEP members expressed that the two measures were likely to “top out,” meaning they would almost always be marked “Yes,” making them of no value in differentiating between hospice providers. The group generally discouraged developing these process measures.

The group strongly rejected any merit in developing two outcome measures concerning Patient Preferences Followed Throughout Hospice Stay and Hospitalization of Persons with Do-Not-

Hospitalize Order. The report says “Multiple TEP members described situations in which patients who had preferred not to be hospitalized changed their minds when a crisis occurred. Patients’ preferences and unexpected crises are usually out of the hospice’s control. Although it is still important for hospices to ask patients about their preferences as part of patient-centered care, the TEP did not believe these two items would be practical measures of a hospice’s care quality.”

Dr. McNally expects that Abt. Associates will apply the HQEP TEP’s suggestions to the HOPE tool.

“Oh yeah, they did it,” he says. “Abt would come to a specific meeting with information, data, suggestions, and specific information about how these things would be measured. We’d give feedback. Then they’d come back to the next meeting having incorporated our suggestions,” he explains. “All of us felt very much heard and responded to. It didn’t feel in the least bit perfunctory.”

Whatever specific measures are eventually included in the HOPE tool, Lund Person sees value in its implementation. “Hospice providers have had a woeful lack of outcome measures for hospice patients, which has made the evaluation of quality hospice care based only on process measures and the family’s evaluation of hospice care in the CAHPS® Hospice Survey, she explains. “Implementing HOPE will begin to identify outcome measures that can be compared between providers.”

Lund Person warns of potential challenges as well. “The selection of risk adjustment and stratification must be carefully done to minimize bias and maximize effectiveness of measures,” she says. “In addition, hospice providers have been awaiting the release of the HOPE tool with significant anxiety about content and administrative burden.”

Dr. McNally is confident the HOPE tool will be a healthy change for hospices.

“A lot of my role as a medical director and hospice physician is supporting our nurses,” he says. “They do 95% of the work. I really would like to see this not be burdensome for our hospice nurses. I’m looking forward to seeing what the [HOPE tool] beta testing translates to in our own hospice world.” He added “What I would hope to see is that the tool feels user-friendly to the hospice team, the people who have to use it, and that it also provides useful information to patients and families.”

NAHC’s Wehri says that standardizing processes through the HOPE tool is the key foundational element for the hospice industry. “High quality care is driven by reducing variance through standardized processes, Wehri writes. “Also, CMS will have a better idea of how the type of population a hospice serves impacts some of the clinical care.” This small glimpse into hospice variances that CMS does not currently have could be very helpful in future policy and payment decisions, according to Wehri. “What CMS finds in terms of differences between hospices and their care for patients may be a bit of a surprise to CMS,” she says. “I hope they are pleasantly surprised with the overall quality of care that is revealed.”

# # #

Beth Noyce provides education, consulting, mentoring, compliance assessments and auditing services to home health and hospice agencies and their clinicians in several states. She also now provides patient and family guidance concerning hospice and home health services. Beth loves teaching and helping others succeed. She also makes available recordings of much of her education for her clients’ convenience.

CMS News

CMS

by Rowan Report | Oct 11, 2023 | CMS, Medicare Advantage, Regulatory

NOW AVAILABLE IN iQIES – Preview Reports and Star Rating Preview Reports for the January 2024 Refresh

CMS just published updated measure for Home Health Outcome Information Set (Oasis) and all HH QRP claims-based measures. These updated measures are no based on the standard number of quarter.

For additional information, please see the HH Quality Reporting Training webpage and the Home Health Data Submission Deadlines webpage.

©2023 by Rowan Consulting Associates, Inc., Colorado Springs, CO. This article originally appeared in Home Care Technology: The Rowan Report. Click here to subscribe. It may be freely reproduced provided this copyright statement remains intact. editor@homecaretechreport.com

CMS News: New Rule Cracks Down on Medicare Advantage Upcoding

CMS

by Tim Rowan | Feb 1, 2023 | CMS, Medicare Advantage, Regulatory

by Tim Rowan, Editor

CMS Rule to Protect Medicare

The U.S. Department of Health and Human Services, through the Centers for Medicare & Medicaid Services, finalized the policies for the Medicare Advantage “Risk Adjustment Data Validation” program, which is CMS’s primary audit and oversight tool of MA program payments.

Under this program, CMS identifies improper risk adjustment payments made to Medicare Advantage Organizations in instances where medical diagnoses submitted for payment were not supported in the beneficiary’s medical record. The commonsense policies finalized in the RADV final rule (CMS-4185-F) will help CMS ensure that people with Medicare are able to access the benefits and services they need, including in Medicare Advantage, while responsibly protecting the fiscal sustainability of Medicare and aligning CMS’s oversight of both Traditional Medicare and MA programs.

In Other Words, Fraud

As required by law, CMS’s payments to MAOs are adjusted based on the health status of enrollees, as determined through medical diagnoses reported by MAOs. Studies and audits done separately by CMS and the HHS Office of Inspector General have shown that Medicare Advantage enrollees’ medical records do not always support the diagnoses reported by MAOs, which leads to billions of dollars in overpayments to plans and increased costs to the Medicare program as well as taxpayers.

No Overpayments Collected Since 2007

“Protecting Medicare is one of my highest responsibilities as Secretary, and this commonsense rule is a critical accountability measure that strengthens the Medicare Advantage program. CMS has a responsibility to recover overpayments across all of its programs, and improper payments made to Medicare Advantage plans are no exception. For years, federal watchdogs and outside experts have identified the Medicare Advantage program as one of the top management and performance challenges facing HHS, and today we are taking long overdue steps to conduct audits and recoup funds. These steps will make Medicare and the Medicare Advantage program stronger.”

Xavier Becerra

Secretary, Department of Health and Human Services

“CMS is committed to protecting people with Medicare and being a responsible steward of taxpayer dollars,” said CMS Administrator Chiquita Brooks-LaSure. “By establishing our approach to RADV audits through this regulation, we are protecting access to Medicare both now and for future generations. We have considered significant stakeholder feedback and developed a balanced approach to ensure appropriate oversight of the Medicare Advantage program that aligns with our oversight of Traditional Medicare.”

The RADV final rule reflects CMS’s consideration of extensive public comments and robust stakeholder engagement after the release of the 2018 Notice of Proposed Rulemaking. The finalized policies will also allow CMS to continue to focus its audits on those MAOs identified as being at the highest risk for improper payments. The RADV final rule can be accessed at the Federal Register.

Pre-Implementation Performance Report

The January 2023 Pre-Implementation Performance Report is now available to download from the Internet Quality Improvement Evaluation System (iQIES).

Instructions on how to access the PIPR are available below and on the Expanded HHVBP Model webpage under “Model Reports.”

Background

To support home health agencies during this first performance year, CMS issued PIPRs in November 2022 and January 2023 to all active HHAs. The PIPR provides HHAs with data on their quality measure performance used in the expanded HHVBP Model, in comparison to HHAs nationally within peer cohorts, in advance of the first Interim Performance Reports (IPRs) in July 2023. The PIPRs do not contain calendar year (CY) 2023 data. The January 2023 PIPR includes a new tab containing preliminary achievement thresholds and benchmarks by volume-based cohort.

Need Help Understanding Your PIPR?

To assist HHAs in understanding the purpose, content, and use of the PIPRs, the HHVBP Technical Assistance Team created an on-demand video and downloadable resource, “Introduction to the Pre-Implementation Performance Report,” available on the Expanded HHVBP Model webpage. The video is also available on the Expanded HHVBP Model YouTube channel.

Additionally, the December 2022 edition of the “Expanded HHVBP Model Frequently Asked Questions” includes questions regarding the PIPR. If you do not see an answer to your specific question, please email the HHVBP Model Help Desk at HHVBPquestions@lewin.com.

If you experience an issue with accessing resources on the Expanded HHVBP Model webpage, first try refreshing the webpage. If that does not work, please try closing and reopening the browser. If you continue to experience issues, please try clearing the cache/cookies—links to instructions are below.

Locating the PIPR in iQIES

Log into iQIES at iqies.cms.gov.
Select the My Reports option from the Reports
From the My Reports page, select the HHA Provider Preview Reports
Select the HHVBP file to view the desired report. To quickly locate the most recently published report, select the down arrow adjacent to the Created Date label at the top of the table. This will order the reports in the folder from newest to oldest.
Select the file name link and the contents of the file will display.

Help Desk Information

Should you experience difficulty locating the HHVBP file or with downloading, please contact the iQIES Help desk staff by email at iQIES@cms.hhs.gov or by phone at (800) 339-9313.

For questions about the content of the expanded HHVBP Model reports, please contact the HHVBP Help Desk staff by email at HHVBPquestions@lewin.com.

*Please include your name, agency name, and the CCN when contacting the help desks.

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©2023 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

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