In the News

CMS Finalizes ‘Fast-Track’ for Patient Appeals of MA Plan Home Health Denials

McKnight’s Home care / By Adam Healy
The Centers for Medicare & Medicaid Services finalized a rule Thursday that aims to expedite the process by which beneficiaries could appeal home health claims denied by Medicare Advantage plans.
Traditional Medicare utilizes a Quality Improvement Organization (QIO) to review fast-tracked appeals, whereas MA plans do not. Rather, the MA plan itself is responsible for reviewing appeals for denied services. In its new rule, CMS will require QIOs to also review MA appeals, which should make fast-track appeals more accessible to MA enrollees.

“CMS is revising regulations to require the QIO, instead of the Medicare Advantage plan, to review untimely fast-track appeals of a Medicare Advantage plan’s decision to terminate services in a skilled nursing facility, comprehensive outpatient rehabilitation facility or by a home health agency,” CMS stated. 
The rule would also “fully eliminate the provision requiring forfeiture of an enrollee’s right to appeal a termination of services from these providers when they leave the facility,” it said. These changes will more closely align MA regulations with traditional Medicare, expanding MA enrollees’ ability to take advantage of the fast-track appeals process, according to CMS.
The final rule will also update standards set for Supplemental Benefits for the Chronically Ill (SSBCI). New regulations hold that MA plans must be able to demonstrate that these benefits “meet the legal threshold of having a reasonable expectation of improving the health or overall function of chronically ill enrollees,” CMS said. To prove that the benefits meet all requirements, MA plans must compile databases of research to back up their claims that SSBCI can meet beneficiaries’ heath needs.
Finally, CMS’ rule updated MA marketing policies to protect customers from misleading advertising. Plans must now include disclaimers in all marketing materials that mention SSCBI to ensure enrollees are aware of the benefits they can access, encourage greater utilization of these benefits and “ensure MA plans are better stewards of the rebate dollars directed towards these benefits,” CMS said in the rule.


New Study Calls Home Health Star Ratings into Question

McKnight’s Home Care / By Adam Healy
A comparison of agency-reported functional measures and claims-based hospitalization measures raises doubts about the value of star ratings as a means of evaluating home health agency (HHA) quality.
The study, published Wednesday in JAMA Network Open, analyzed differences between claims-based and agency-reported outcomes for nearly 23 million patient episodes before and after the introduction of the star ratings system to compare changes over time. The researchers found that observed improvement in agency-reported functional measures had corresponding increases in hospitalization rates and less timely initiation of care. The data included claims-based hospitalization measures (both during the patient spell and 30 days after HHA discharge). Agency-reported functional measures included improvement in ambulation, bathing and bed transferring.
“The observed functional improvement was dampened by corresponding increases in more objective measures, such as hospitalizations and declines in timely initiation of care,” study authors Amanda C. Chen, Christina Xiang Fu, PhD, and David C. Grabowski, PhD, wrote. “This raises concern about how HHA-reported outcomes should be interpreted and used to assess quality.”
These discrepancies are not a surprise to home care providers. The Centers for Medicare & Medicaid Services uses Outcome and Assessment Information Set (OASIS) survey responses, an agency-reported measure, and medical claims data, to determine agencies’ star ratings. The OASIS portion is not objective, affirmed Mary Carr, vice president for home health regulatory policy at the National Association for Home Care & Hospice.
“The disparity in OASIS-based measures [versus] claims-based measures is not surprising,” she said in a statement to McKnight’s Home Care Daily Pulse. “Responses to the OASIS items for the functional measures can be very subjective and influenced by the accuracy of the assessor when completing the item.”
“And, as the author(s) noted, data does not capture more recent changes for HHAs, such as the Patient-Driven Groupings Model or nationwide expansion of the Home Health Value-Based Purchasing Model, which might contribute to changes in HHA behavior and performance,” she added. 
The study also found that the introduction of the star ratings was associated with sustained increases in the hospitalization rate and functional improvement measures for patients with Alzheimer’s disease, those who are dual-eligible, and those who are Black and Hispanic. 
A widening gap between self-reported and objective measures
CMS launched the 5-star rating system on Care Compare to provide summary information using the number of stars to denote quality. The system began with a quality of patient care star rating in July 2015 and added a patient satisfaction star rating in January 2016.
Since the introduction of quality of patient care star ratings, the differences between agencies’ self-reported measures of patient improvement and more objective measures has only widened, study co-author Amanda Chen told McKnight’s Home Care Daily Pulse.
“In the pre-period before the star ratings were introduced, we kind of see some of these trends,” she said. “But it’s really magnified after the star ratings were introduced.”
Agencies might be incentivized to inflate functional improvement scores on OASIS surveys to achieve higher scores, according to the researchers. 
“Once these star ratings were introduced, I think there was an incentive for home health agencies to prioritize perhaps, achieving high performance on some measures that allow them to have a higher star rating,” Chen said. “Particularly, we see these in terms of self-reported measures by the agencies. So again, it’s these OASIS-based measures. And so I think it’s a little bit easier to move the needle on measures that you’re reporting yourself as a home health agency versus something that is collected — what we’re calling a little bit more of these objective measures — like hospitalization rates.”
She added that these issues are not unique to home care. Other healthcare sectors that use self-reporting to inform quality measures, such as nursing homes, have also seen subjectivity influence results…
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Change Healthcare Attack Sheds Light on Industry's Weak Points

Axios / By Tina Reed

The expansive impact of the Change Healthcare cyberattack was a wake-up call for a health care system that's now racing to safeguard itself against another industry-rattling hack.
Why it matters: There's recently been increased focused on defending individual health care organizations against bad actors as the vulnerable sector increasingly finds itself under attack

  • But the Change Healthcare hack that disrupted payments to providers for weeks revealed the industry's heavy reliance on just a few technology companies to keep day-to-day operations running.

  • That essentially creates what The Atlantic's Juliette Kayyem recently described as a "single point of failure" — and experts warn Change Healthcare likely isn't the only one.

What they're saying: "Change is the canary in the coal mine," said Nate Lesser, chief information security officer at Children's National Hospital.

  • "We need to find out where the others are or we're just going to collapse."

Between the lines: Experts who spoke with Axios say there are a number of companies that offer critical infrastructure to pockets of the health care industry, creating major vulnerabilities in the event of an attack.

  • Companies often create that kind of market share through mergers of smaller companies that later get acquired by bigger companies.

  • "There are some of these pieces of software that have just been consolidated over and over and over, and it turns out like 50,000 pharmacies, usually within hospitals, use the same piece of software," said Kyle Hanslovan, CEO of cybersecurity firm Huntress.

  • The way some of those products have been stitched together along the way, potentially pairing old and new technologies, could also introduce weaknesses that are difficult to completely engineer away, he said.

The Change Healthcare hack also showed how contracting practices within the industry even exposed health care providers who didn't have direct relationships with the company and initially didn't expect to be affected.

  • That was the case for Children's National, which discovered that some insurers it worked with have exclusive relationships with Change Healthcare and wouldn't allow for claims to be submitted through any other vendor.

  • These sort of opaque agreements can make it hard for providers to know exactly where their data is being shared, said Shawntea Gordon, a member of the Medical Group Management Association's government affairs council.

  • "It made it very difficult for people to just say 'OK, let me bounce everything through somewhere else,'" Gordon said.

Some experts said the federal government quickly needs to do a sector wide accounting to understand where health care's biggest systemic cyber risks are and address them — before hackers beat them to it.

  • The Change Healthcare attack "caught us all by surprise and shouldn't have," Lesser said.

  • He pointed to actions the government took in the aftermath of the 2007-08 financial crisis to designate some banks as "systemically important," making them subject to tougher oversight and standards because their failure would jeopardize the entire banking system. 

  • If nothing else, the industry needs to take its own inventory to understand where catastrophic failure would be most damaging so health systems and smaller providers can better evaluate their risks and create appropriate backup plans, Hanslovan said…

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The New Frontier of Healthcare: Bringing Hospital Care Home

Health Data Management / By Fred Bazzoli

Like many “new” trends in healthcare, the hospital at home movement is not new. The foundational research goes back nearly 30 years, to work by Bruce Leff, MD, of Johns Hopkins to flesh out the concept of providing acute-level care to patients in their own homes.

It seems to harken back to the notion of doctors carrying black bags into patients’ homes to do house calls, but multiple advances in technologies and trends in healthcare have thrust hospital at home programs to the forefront.

When those pressures converge, change happens. And providing hospital services in the home is gaining new attention.

Provider realities

From the hospital side, several factors are forcing providers to get creative. Census levels are high nationwide, often near full capacity and beyond. Staff rolls are shrinking as growing numbers of clinicians quit because of burnout or unmitigated stress. There’s not enough money to build new brick-and-mortar facilities. And then, lordy, there was the pandemic – many organizations had a crash course in virtual care, forced by restrictions on in-person encounters, full COVID caseloads and nearly instantaneous changes in reimbursement policy that enabled virtual care.

And patients – well, they weren’t big fans of being in the hospital before. The pandemic opened their eyes to the possibility of virtual care, and nascent hospital-at-home programs revealed alternatives to traditional delivery of acute care services.

As one chronic care patient told Leff in his early formulation of a hospital at home strategy, “You run a great hospital, doc, but it’s a lousy hotel.” Factor in the risks of hospital-acquired infections, falls as unsteady patients exit unaccompanied from hospital beds, loneliness and disorientation in a strange clinical environment, harried hands-on caregivers managing multiple patients and … well, it’s clear that an alternative would be welcome.

And inpatient facilities are in no position to fix these ills. Capacity is strained at many hospitals, says Colleen Hole, vice president of clinical integration and chief nurse executive for Atrium Health Medical Group. “Our hospitals are running at 110 percent to 120 percent occupancy in this market,” she says. “And Charlotte is a growing market, and we really can’t afford nor spend the time to keep building brick-and-mortar beds to manage the growth. Money and time are precious, and it doesn’t make sense to keep building beds. But we can deliver hospital-level care in the home and with the same – or in some cases, better – outcomes.”…

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