CMA Alert – HH Issue Brief; SNF Reimbursement Rules – Goodbye, Therapy; Comments on Medicaid Work Requirements

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  1. Home Health Issue Brief – Statistical Trends and Published Articles with Studies and Research from 2002-2017
  2. Final Rules for New Medicare Reimbursement System for Skilled Nursing Facilities: Goodbye Therapy
  3. The Center for Medicare Advocacy Submits Comments Opposing Kentucky’s Medicaid Work Requirements

Home Health Issue Brief – Statistical Trends and Published Articles with Studies and Research from 2002-2017

This is the ninth in a ten-part CMA Issue Brief Series examining the growing crisis in access to Medicare home health coverage and necessary care – and outlining the Center for Medicare Advocacy’s work to address these issues. We invite you to follow this Issue Brief Series and submit Medicare home health stories to the Center at http://www.medicareadvocacy.org/submit-your-home-health-access-story/.

CMA Issue Brief Series: Medicare Home Health Care Crisis


  1. Overview – The Crisis in Medicare Home Health Coverage and Access to Care
  2. Medicare Home Health Coverage, Legally Defined
  3. Medicare Coverage for Home Care Is Based On a Need For Skilled Care – Improvement Is Not Required
  4. Misleading and Inaccurate CMS Medicare Home Health Publications
  5. The Home Care Crisis: An Elder Justice Issue
  6. Beneficiary Protections Expanded in Revised Home Health Conditions of Participation
  7. Barriers to Home Care Created by CMS Payment, Quality Measurement, and Fraud Investigation Systems
  8. Proposed CMS Rules and Systems Will Worsen the Home Care Crisis
  9. Statistical Trends and Published Articles with Studies and Research from 2002-2017
  10. Strategic Plans to Address and Resolve the Medicare Home Care Crisis

Statistical Trends and Published Articles with Studies and Research from 2002-2017

The Center for Medicare Advocacy reviewed key articles, published between 2002 and 2017, that cite data and research and provide theories and conclusions about the evolution and current status of the Medicare home health benefit. This Issue Brief quotes or paraphrases these articles by topic and provides citations to articles referenced. The Brief concludes with a Center for Medicare Advocacy discussion of the impact this information has on Medicare beneficiary access to home health care.

Read the full Issue Brief at: http://www.medicareadvocacy.org/statistical-trends-and-published-articles-with-studies-and-research-from-2002-2017/

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Final Rules for New Medicare Reimbursement System for Skilled Nursing Facilities: Goodbye Therapy

Effective October 1, 2019, CMS will replace the prospective payment system for skilled nursing facilities, Resource Utilization Group (RUG-IV), with a new prospective payment system called the Patient-Driven Payment Model (PDPM).[1] In all significant respects, the final rules are unchanged from proposed rules published in May.[2]

The new system, which is budget-neutral, bases payment on resident characteristics, rather than on services provided. CMS cites its own research showing that, under RUGs, SNFs classify residents into the highest (and most highly-paying) RUG categories.[3] In Fiscal Year 2017, for example, more than 60% of Medicare-covered SNF stays were billed for one of three Ultra-High Rehabilitation categories (out of 66 RUG-IV categories).[4]  CMS cites additional studies by the HHS Inspector General and by the Medicare Payment Advisory Commission that similarly criticize the RUG system for encouraging excessive therapy and not paying adequately for non-therapy ancillaries (NTA) (chiefly drugs).[5]

Unfortunately, as CMS expressly confirms, PDPM changes the financial incentives for SNFs so dramatically that SNFs will actually receive higher reimbursement when they do not provide residents with any therapy at all.[6]

CMS notes in the preamble to the final rules that more than 99% of therapy is now provided on an individual basis and that individual therapy “should be considered the primary therapy mode and standard of care in therapy services provided to SNF residents.”[7] Nevertheless, PDPM allows up to 25% of therapy services to be provided in group or concurrent settings, rather than individually.[8] Providing group or concurrent therapy is considerably less costly for facilities because it allows a single therapist to work with multiple residents at the same time. CMS confirms that a SNF exceeding the 25% limit on group and concurrent therapy will receive only “a non-fatal warning edit,” – a “reminder” that it is out of compliance[9] – but “no penalty.”[10]

Effective October 1, 2019, CMS adds new items to the PPS Discharge Assessment to identify minutes for each therapy discipline and the mode of therapy (that is, whether the therapy is individual, group, or concurrent), in recognition of concerns by commenters on the proposed rules and CMS itself that PDPM may lead to a considerable decline in therapy services.[11] The new items will allow CMS to monitor the total number of minutes a resident receives therapy as well as the mode of therapy.[12]

The Center for Medicare Advocacy is especially concerned about maintenance therapy under the Jimmo v. Sebelius Settlement.[13] In a single dismissive response to some commenters’ requests for clarification on how PDPM would accommodate Jimmo, CMS says that no special tracking of maintenance services is needed.[14]

PDPM is extremely complex. Each resident’s payment depends on the summation of five case-mix adjusted components (physical therapy, occupational therapy, speech language pathology, nursing, and nontherapy ancillaries),[15] each with its own case-mix groups; application of a variable per day adjustment schedule, which reduces the daily payment for three of the case-mix categories on a sliding scale;[16] and addition of these sums to the non-case-mix adjusted component.[17]

Under the guise of reducing burdensome paperwork, PDPM uses the five-day resident assessment for determining the Medicare rate for the resident’s entire Part A stay, eliminating the RUG requirement for additional assessments on days 14, 30, 60, and 90.[18] The Center for Medicare Advocacy sees this change as promoting gaming by facilities. The rules allow a SNF to reclassify a resident after the five-day assessment under an optional Interim Payment Assessment (IPA), but, in one of the few changes in the final rules, CMS did not include criteria for triggering an IPA.[19]

The final rules include two tables describing the impact of PDPM’s changes on residents[20] and on facilities[21] and summarizing some of the most significant changes in payments under PDPM. According to CMS, rates will be higher under PDPM for residents “who have high NTA costs, receive extensive services, are dually enrolled in Medicare and Medicaid, use IV medication, have ESRD, diabetes, or a wound infection, receive amputation/prosthesis care, and/or have longer prior inpatient stays.”[22] Facilities will receive higher reimbursement if they have “high proportions of non-rehabilitation residents” and if they “are small facilities, non-profit facilities, government-owned facilities, and hospital-based and swing-bed facilities.”[23]

Conclusion

The new SNF payment system does not bode well for nursing home residents who need therapy, especially for individuals who need one-on-one therapy for longer periods of time.  Advocates should remain alert to help people in need of this care and contact the Center if access to necessary therapy is denied.

August 23, 2018 – T. Edelman


[1] 83 Fed. Reg. 39162, 39183-39265 (Aug. 8, 2018).
[2] 83 Fed. Reg. 21018, 21034-21080 (May 8, 2018).  See CMA, “CMS Tries Again: Another New Skilled Nursing Facility Medicare Reimbursement System Proposed – If Implemented, Would Gut Therapy” (CMA Alert, May 17, 2018), http://www.medicareadvocacy.org/cms-tries-again-another-new-skilled-nursing-facility-medicare-reimbursement-system-proposed-if-implemented-would-gut-therapy/
[3] 83 Fed. Reg. 39162, 39183-39184 (Aug. 8, 2018).
[4] 83 Fed. Reg. 39162, 39194 (Aug. 8, 2018).
[5] 83 Fed. Reg. 39162, 39184-39185 (Aug. 8, 2018).
[6] See Table 37, PDPM Impact Analysis, Resident-Level, at 83 Fed. Reg. 39162, 39257-39259 (Aug. 8, 2018).
[7] 83 Fed. Reg. 39162, 29238 (Aug. 8, 2018).
[8] 83 Fed. Reg. 39162, 39237-39243 (Aug. 8, 2018).
[9] 83 Fed. Reg. 39162, 39239 (Aug. 8, 2018).
[10] 83 Fed. Reg. 39162, 39250 (Aug. 8, 2018).
[11] 83 Fed. Reg. 39162, 39235-39236 (Aug. 8, 2018).
[12] 83 Fed. Reg. 39162, 39237 (Aug. 8, 2018).
[13] See http://www.medicareadvocacy.org/?s=Jimmo&op.x=0&op.y=0
[14] 83 Fed. Reg. 39162, 39187 (Aug. 8, 2018).
[15] 83 Fed. Reg. 39162, 39225 (Aug. 8, 2018).
[16] 83 Fed. Reg. 39162, 39225, 39226-39229 (Aug. 8, 2018).
[17] 83 Fed. Reg. 39162, 39225 (Aug. 8, 2018).
[18] 83 Fed. Reg. 39162, 39229
[19] 83 Fed. Reg. 39162, 39233 (Aug. 8, 2018).
[20] 83 Fed. Reg. 39162, 39257-39259 (Table 37) (Aug. 8, 2018).
[21] 83 Fed. Reg. 39162, 39260-39261 (Table 38) (Aug. 8, 2018).
[22] 83 Fed. Reg. 39162, 39257 (Aug. 8, 2018).
[23] 83 Fed. Reg. 39162, 39259 (Aug. 8, 2018).

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The Center for Medicare Advocacy Submits Comments Opposing Kentucky’s Medicaid Work Requirements

In conjunction with other advocacy organizations, the Center for Medicare Advocacy submitted comments during the re-opened comment period for the Kentucky HEALTH Medicaid Section 1115 waiver demonstration application. The Center strongly believes that Kentucky HEALTH should be rejected as it will lead to substantial coverage losses. Kentucky’s proposal will take health coverage away from individuals who cannot document that they meet rigid work requirements, including those who are working or eligible for an exemption but fail to meet the paperwork requirements.

The threat of losing insurance is not a proper way to promote work among Medicaid beneficiaries. Nationally, 60 percent of non-SSI adults are already employed and working; however, most beneficiaries who work full-time still have “annual incomes . . . low enough to qualify for Medicaid.”[1] As the data indicate, these beneficiaries are employed in vital industries where they earn low wages. Many of these beneficiaries work in our nation’s hospitals, home health care services, and nursing facilities.[2]

Even Kentucky estimates that 15 percent of adult beneficiaries—97,000—will lose coverage due to these proposed requirements. [3] States with similar proposals likewise estimate a significant drop in coverage. However, studies on the impact of the Affordable Care Act’s Medicaid expansion suggest that work requirements may actually have a negative effect on a beneficiary’s ability to find or maintain employment. For instance, one study finds that 52.1 percent of beneficiaries in Ohio believe that “attaining coverage made it easier to secure and maintain employment.” Creating unnecessary barriers to health care may result in more beneficiaries losing employment opportunities, instead of gaining them.  

Medicaid expansion is proving to be a critical lifeline, allowing beneficiaries to fill important positions that might otherwise go unfilled due to low wages and the lack of health coverage. Perhaps this lifeline is why “national, multi-state, and single state studies show that states expanding Medicaid under the ACA have realized budget savings, revenue gains, and overall economic growth.”[4] Building barriers to health care coverage not only hurts Medicaid beneficiaries but also the labor market. The Center respectfully urges HHS not to approve Medicaid waivers that place unnecessary burdens on beneficiaries, the Medicaid program, and the economy.

 


[1] Rachel Garfield and Robin Rudowitz, Understanding the Intersection of Medicaid and Work, Kaiser Family Foundation (Dec. 7, 2017), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/.
[2] Id.
[3] Hannah Katch et al., Taking Medicaid Coverage Away From People Not Meeting Work Requirements Will Reduce Low-Income Families’ Access to Care and Worsen Health Outcomes, Center on Budget and Policy Priorities (Aug. 13, 2018), https://www.cbpp.org/research/health/taking-medicaid-coverage-away-from-people-not-meeting-work-requirements-will-reduce.
[4] Larisa Antonisse et al., The Effects of Medicaid Expansion under the ACA: Updated Findings from a Literature Review, Kaiser Family Foundation (Mar. 28, 2018), https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/.

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