By the Numbers: Breaking Down Home Health LUPA Patterns

Table of Content

• LUPAs persist
• Health
• Clinician Estimated Hourly Burden for All HHAs for OASIS-E DAH Assessments = 2,953 Hours
• Transfer of Care
• CMS Proposes Calendar Year 2022 Home Health …
• II. Home Health Prospective Payment System
• Clinician Estimated Hourly Burden for All HHAs (11, for OASIS-E SOC Assessments = 7,937,363 Hours
• How Can LUPA Be Avoided in Home Health?

This final rule sets forth routine updates to the Medicare home health payment rates for calendar year in accordance with existing statutory and regulatory requirements. This rule finalizes the reassignment of certain diagnosis codes under the PDGM case-mix groups, and establishes a permanent mitigation policy to smooth the impact of year-to-year changes in home health payments related to changes in the home health wage index. This rule also finalizes recalibration of the PDGM case-mix weights and updates the low utilization payment adjustment thresholds, functional impairment levels, comorbidity adjustment subgroups for CY 2023, and the fixed-dollar loss ratio used for outlier payments. Additionally, this rule discusses comments received on the future collection of data regarding the use of telecommunications technology during a 30-day home health period of care on home health claims.

We requested commenters' views on which of these adjustments, if any, would be most effective for the expanded HHVBP Model. Additionally in the CY 2022 HH PPS proposed rule , we solicited comments on the challenges unique to value-based purchasing frameworks in terms of health equity and ways in which we could incorporate health equity goals into the expanded HHVBP Model. In the CY 2022 HH PPS final rule , we summarized and responded to these comments received. The FDL ratio and the loss-sharing ratio are selected so that the estimated total outlier payments do not exceed the 2.5 percent aggregate level (as required by section 1895 of the Act). Historically, we have used a value of 0.80 for the loss-sharing ratio, which, we believe preserves incentives for agencies to attempt to provide care efficiently for outlier cases.

LUPAs persist

We also recognize the impact inflation and the COVID-19 PHE has had on healthcare providers, however, we note that in its March 2022 Report to the Congress, MedPAC states that Medicare margins increased under the PDGM, from 15.4 percent in 2019 to 20.2 percent in 2020. Additionally, they projected margins for home health agencies in 2022 will be roughly 17.0 percent. Furthermore, MedPAC stated in their report that the Commission found positive access, quality, and financial indicators for the sector, with average margins of 20.2 percent for freestanding HHAs in 2020, even though the cost per 30-day period increased by 3.1 percent in this year. We believe that these margins, despite economic challenges, demonstrate that the payment rate, along with the market basket update, are more than adequate to support business operations. Finally, while we appreciate the commenters' suggestion regarding targeted claim review for specific home health agencies, we do not believe targeted program integrity efforts would mitigate behavioral changes resulting from a case-mix system. We previously addressed this suggestion in the CY 2016 HH PPS and CY 2019 HH PPS final rules .

All HHAs certified to participate in the Medicare program prior to January 1, 2022, will be required to participate and will be eligible to receive an annual Total Performance Score based on their CY 2023 performance. In the CY 2017 HH PPS final rule , we stated that we did not plan to re-estimate the average minutes per visit by discipline every year. Additionally, the per unit rates used to estimate an episode's cost were updated by the home health update percentage each year, meaning we would start with the national per visit amounts for the same calendar year when calculating the cost-per-unit used to determine the cost of an episode of care .

Health

Based upon this feedback, we conclude that the privacy issues raised initially are no longer a concern. On February 28, 2013, OMB issued Bulletin No. 13-01, announcing revisions to the delineations of MSAs, Micropolitan Statistical Areas, and CBSAs, and guidance on uses of the delineation of these areas. In the CY 2015 HH PPS final rule , we adopted OMB's area delineations using a 1-year transition. Complex nursing with a visit threshold of two saw the highest LUPA rate, on average, of 22.5% Meanwhile the wound clinical grouping with a LUPA threshold of two saw the lowest LUPA rate of 4.9%.

Due to the continuation of the COVID-19 PHE through CY 2021 and its effects on the quality measures in the expanded HHVBP Model used to determine payment adjustments for eligible HHAs (as described in section IV.B.2.b. of this final rule), we believe an HHA's baseline year that would be CY 2021 should be adjusted to CY 2022. This policy aligns with similar proposals in the Hospital VBP and SNF VBP Programs to account for the continued effects of the COVID-19 PHE on measures in 2021. Commenters broadly applauded CMS for seeking to address health equity in home health. Many noted that health equity is critical to address in home health and requires attention from CMS and providers.

Clinician Estimated Hourly Burden for All HHAs for OASIS-E DAH Assessments = 2,953 Hours

We note that for HHAs with sufficient data on each of the 12 applicable measures, performance on the two claims-based measures makes up 35 percent of the total performance score used to determine payment adjustments under the Model. While average national performance on these measures in CY 2021 was similar to average national performance in CY 2020, CY 2022 is the first year where the vast majority of beneficiaries are vaccinated; as of January 27, 2022, 95 percent of Americans ages 65 years or older had received at least one dose of vaccine and 88.3 percent were fully vaccinated. In addition, there were viable treatments available and healthcare providers had nearly 2 years of experience managing COVID-19 patients. Use of CY 2022 data for the HHA baseline year for all measures under the expanded Model would also allow all HHAs certified by Medicare prior to CY 2022 to have the same baseline period, based on the most recent available data, beginning with the CY 2023 performance year.

In the beginning of morning astronomical twilight and at the end of astronomical twilight in the evening, sky illumination is very faint, and might be undetectable. Hotel partners displayed with an inspection label have installed enhanced protective measures in their establishments to mitigate the spread of COVID-19. There are no 30-day PDGM claims which started in CY 2019 and ended in CY 2020, and therefore this exclusion would not apply to the CY 2020 dataset. The HHA baseline year is the first full calendar year of services beginning after the date of Medicare certification. Collection or public reporting of a measure leads to negative unintended consequences other than patient harm.

Transfer of Care

For a given level of outlier payments, there is a trade-off between the values selected for the FDL ratio and the loss-sharing ratio. A high FDL ratio reduces the number of periods that can receive outlier payments, but makes it possible to select a higher loss-sharing ratio, and therefore, increase outlier payments for qualifying outlier periods. Alternatively, a lower FDL ratio means that more periods can qualify for outlier payments, but outlier payments per period must be lower. We invited comments on the proposed updates to the low comorbidity adjustment subgroups and the high comorbidity adjustment interactions for CY 2023.

Consultants and medical officers) and current ICD-10-CM coding guidelines to determine if the ICD-10-CM diagnosis codes under review for reassignment are significantly similar or different to the existing clinical group and/or comorbidity subgroup assignment. As we stated in the CY 2018 HH PPS proposed rule , the intent of the clinical groups is to reflect the reported principal diagnosis, clinical relevance, and coding guidelines and conventions. Therefore, for the purposes of assignment of ICD-10-CM diagnosis codes into the PDGM clinical groups we would not conduct additional statistical analysis as such decisions are clinically based and the clinical groups are part of the overall case-mix weights.

CMS data systems conform to all applicable federal laws, regulations and standards on information security and data privacy. The systems limit data access to authorized users and monitor such users to help protect against unauthorized data access or disclosures. CMS anticipates updating the current provider data reporting system in iQIES to address the addition of private payer patients. For a detailed discussion of the considerations we historically use for measure selection for the HH QRP quality, resource use, and other measures, we refer readers to the CY 2016 HH PPS final rule . In the CY 2019 HH PPS final rule with comment period we finalized the factors we consider for removing previously adopted HH QRP measures. Therefore, for CY 2022 we decided to continue our practice of using the most recent, complete home health claims data available; that is, we used CY 2020 claims data for the CY 2022 payment rate updates.

Within-agency correlation between Medicare/Medicaid and private pay patient outcomes was low, indicating that outcomes based on Medicare/Medicaid patient data cannot be generalized to serve as a proxy for private pay patients. The following is a summary of the public comments received on the CY 2023 annual payment update and our responses. Of diagnosis codes J98.2 and J98.3 to respiratory 4 when listed as a secondary diagnosis.

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