How The Sausage Gets Made: Inside CMS’ Home Health Payment Rulemaking Process
Home Health Care News | By Joyce Famakinwa
Every year, industry stakeholders anticipate the U.S. Centers for Medicare & Medicaid Services’ (CMS) release of the home health proposed payment rule and the final rule.
The final rule’s provisions and updates determine what the Medicare home health landscape will look like for the foreseeable future, but sometimes providers aren’t well-versed on the ins and outs of the rule-making process.
On an annual basis, there are several steps that CMS routinely goes through to put together the home health proposed payment rule.
It begins with the annual inflation update, otherwise known as the market basket index.
“That process to get to the proposed rule has two main elements to it,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told Home Health Care News. “One of them is to look at what the formula is for determining the annual inflation update, and that examines a variety of cost elements and the weight given to those cost elements.”
Periodically, there’s a rebasing of the market basket index, and a revision to the weights given to each element, according to Dombi.
“That would entail examining what the inputs are, and then what the sources of those inputs might be,” he said. “CMS uses a combination of numbers from the cost report and Bureau of Labor Statistics data.”
This first step is for CMS to determine whether it will stick with its most recent formula or make adjustments.
Data is then sent to an outside firm that CMS uses to forecast what the inflation rate was estimated to be for the particular year. This year CMS likely used data from the third or fourth quarter of 2022, Dombi noted.
“The forecasting methodology is employed to say, ‘Okay, if this is what the trends look like, this is what the inflation in cost will be during 2024,” he said. “It really is a prediction of inflation costs.”
Budget neutrality adjustment — which has received industry pushback after the switch to the Patient-Driven Groupings Model — is also a big factor when it comes to the proposed rule and the proceeding final rule.
Achieving budget neutrality is a fairly complex process, health care policy expert Lisa Grabert told HHCN.
“CMS has rules that they have to follow [regarding] budget neutrality, and they’re given some flexibility in how they can achieve that,” she said.
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2024 Home Health Proposed Rule Points to Consider
- The CY 2024 Home Health Proposed Rule, CMS is proposing to apply an additional -5.653% permanent cut to Medicare’s HHA rates, which already reflect a -3.925% reduction put in place for CY 2023. This amounts to a -9.356% cut that would apply in perpetuity. In 2024 alone, the -5.653% cut would remove $870 million from the home health benefit. CMS is also proposing that an additional $3.44 billion in cuts be levied under the “temporary adjustment” authority at some point in the near future.
- Medicare’s home health benefit in Parts A and B totaled approximately $16.1 billion in annual spending in 2022. In aggregate, this constitutes an almost 10% cut over two years. The unpredictable nature of these cuts from year to year is a moving target, making it impossible for businesses to plan as they need to for appropriate budgeting.
- The squeeze on home health is already beginning to affect patient access. In the last few years, 200,000 fewer patients pursued home health, despite 10,000 individuals aging in Medicare daily. Data analytics from CareJourney (using 2022 claims data) shows that while around 20% of patients are discharged with a directive to pursue medically necessary home health care, only 63% actually are able to get it in place within 7 days. These declines in access to care will, over time, have a material effect on not only patient and caregiver quality of life, but on the health outcomes of patients and the finances of the Medicare program. Home health is proven to reduce emergency department rates, lower readmission rates, and lower mortality rates. It is a site of care we should be creating more incentive to bring patients to; not less.
Complete your Action Alert asking Congress to Stop the Cuts. It takes 30 seconds! Here's the link: Stop Home Health Cuts (p2a.co) |
Medicare to Pay for At-Home Dementia Care Coordination
MedScape | By Alicia Ault
Under a new Medicare pilot program that will begin in 2024, the federal government will pay clinicians to coordinate at-home dementia support services, including respite care for family members.
A Department of Health & Human Services (HHS) initiative, part of the aim of the Guiding an Improved Dementia Experience (GUIDE) program is to help Medicare beneficiaries with dementia stay in the community for as long as possible. It is estimated that there are 6.7 million Americans living with Alzheimer's disease or some other form of dementia, said HHS.
The program is voluntary and will be open to Medicare-enrolled clinicians and other providers who can assemble an interdisciplinary care team and meet the program's participation criteria.
"Our new GUIDE Model has the potential to improve the quality of life for people with dementia and alleviate the significant strain on our families," said HHS Secretary Xavier Becerra, in a statement.
"Not only is dementia care management a proven way to improve the quality of care and quality of life for those living with Alzheimer's and other dementia, but now we know that it would also save the federal government billions of dollars," Robert Egge, Alzheimer's Association chief public policy officer and Alzheimer's Impact Movement (AIM) executive director, said in a statement.
Egge cited a recent analysis commissioned by AIM that found that dementia care management would save the federal government nearly $21 billion over 10 years.
"People living with dementia and their caregivers too often struggle to manage their health care and connect with key supports that can allow them to remain in their homes and communities," said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure, in the HHS statement.
"Fragmented care contributes to the mental and physical health strain of caring for someone with dementia, as well as the substantial financial burden," she said, adding that Black, Hispanic, Asian American, Native Hawaiian, and Pacific Islander populations have been especially disadvantaged.
The GUIDE Model will provide new resources and greater access to specialty care to those communities, said Brooks-LaSure.
Care teams that seek to participate in the GUIDE model must have a care navigator who has received required training in dementia, assessment, and care planning.
The teams also must have a clinician with dementia proficiency as recognized by experience caring for adults with cognitive impairment; experience caring for patients aged 65 years old or older; or specialty designation in neurology, psychiatry, geriatrics, geriatric psychiatry, behavioral neurology, or geriatric neurology.
Medicare beneficiaries will be eligible if they are not residing in a nursing home; are not enrolled in hospice; and have a confirmed dementia diagnosis.
Beneficiaries who receive care from GUIDE participants will be placed in one of five "tiers," based on a combination of disease stage and caregiver status. Beneficiary needs, and care intensity and payment, increase by tier.
GUIDE teams will receive a monthly, per-beneficiary amount for providing care management and coordination and caregiver education and support services. They can also bill for respite services — up to an annual cap — for Medicare beneficiaries who have an unpaid caregiver.
Clinicians seeking to participate in GUIDE can apply beginning in the fall. The program will run for 8 years beginning July 1, 2024.
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Industry Voices—Let's Treat Loneliness Like Other Public Health Crises
Fierce Healthcare | By Kyu Rhee, Tom Insel, Dan Russell, Dena Bravata, Boaz Gaon
A silent and grossly underserved epidemic of loneliness is affecting 60% of all Americans including 75% of young adults and 40% of older adults—influencing and complicating mental health disorders, physical health disorders, adherence to treatment and increasing hospitalizations.
The U.S. Surgeon General, in a recently published and widely discussed “Advisory on our Epidemic of Loneliness and Isolation”, has stated that “we must prioritize building social connection the same way we have prioritized other critical public health issues such as tobacco, obesity, and substance use disorders.”
Numerous experts have called attention to our loneliness epidemic, describing its negative health impact as similar to “smoking 15 cigarettes a day”. It is time for a systematic approach to address the loneliness epidemic that is crippling US healthcare as well as the quality and health of human relationships in America.
A crucial and pressing step toward achieving this goal is universal screening for loneliness.
What is loneliness?
Social isolation is the objective lack of interaction with others (as happens when people live alone). Loneliness is similar but refers to the subjective feeling of being alone or the gap between one’s expectations of the quantity or quality of relationships and what is actually experienced.
In other words, loneliness is a “subjective feeling that the human connections we need in our life exceed the human connections we have." These feelings, as well as comorbid stress, anxiety and depression, have intensified even as the rates of COVID-19 detections have receded.
The “Big Resignation” did not start with COVID-19 and has not slowed down since nor has the adoption of social networks and media that over the past two decades have changed how humans connect and engage with each other.
When the Pew Research Center began tracking social media adoption in 2005, just 5% of American adults used at least one of these platforms. By 2011 that share had risen to half of all Americans, and in 2021 72% of Americans reported using some type of social media. Ad-driven social media sites have made it infinitely easier to create new “human” connections — but research has shown that adults with high social media use seem to feel more socially isolated than their counterparts with lower social media use.
We are all connected it seems—and yet, we are more disconnected than ever.
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How Much Pain Is in the Mind? This Doctor Thinks the Answer Is, Most
Medscape Staff
More than three decades ago, John E. Sarno, MD, published Healing Back Pain, a popular book that garnered something of a cult following. Looking at his own practice, Sarno, a rehabilitation medicine specialist in New York City, saw that most of his patients with chronic pain did not have evidence of acute injury or degenerative disk disease. Their persistent pain appeared to be independent of any structural damage to the spine. Sarno attributed the pain to what he called tension myoneural syndrome (TMS), or the body’s reaction to suppressed stress and emotional turmoil. Resolving that psychological conflict, Sarno believed, would lead to an improvement in pain.
Sarno’s theory has met skepticism from the mainstream community, but glowing testimonies from patients who say they benefitted from his strategies fill the internet. Sarno wrote several books on his ideas before his death in 2017. But he published only one peer-reviewed study, a 2003 review in the Archives of Physical Medicine and Rehabilitation co-authored by Ira Rashbaum, MD.
Medscape Medical News spoke recently with Rashbaum, a physiatrist and chief of tension myoneural syndrome at NYU Langone Health, New York City, about TMS and how he manages patients with chronic pain.
This interview has been edited for length and clarity
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