Almost Family Proposes A Different Groupings Payment Model

The home health care industry was celebrating a recent decision by the Centers for Medicare & Medicaid Services (CMS) not to include a controversial payment model in its final prospective payment system (PPS) 2018 update—but there could be another idea on the table for a new payment model.

At least one major home health care provider has offered an alternative model to the home health groupings model (HHGM), which would have made significant changes to the payment system in 2019. HHGM was not included in the 2018 final payment rule after more than 1,300 comments from industry stakeholders were posted to the proposal on the Federal Register.

Within its comments, Louisville-based Almost Family (Nasdaq: AFAM) proposed a new groupings model to CMS—and the industry may want to take a look at what the provider has put forth, as CMS has said it is still interested in pursuing a payment overhaul and will be looking for stakeholder input.


A new model

Almost Family echoed several other industry groups in its concern that CMS actually underestimated how much HHGM would cut reimbursements. HHGM, as it was proposed, would have switched the current 60-day episode of care to a 30-day payment period and grouped patients in categories based on diagnosis, as well as re-incentivized therapy rates. The changes could have resulted in an estimated $950 million in cuts to the industry in 2019 alone.

While CMS stated HHGM would cut payment rates to providers by 4%, Almost Family’s analysis found the actual rate was more than 14%, according to the comments. The analysis is on par with what other industry groups have found. And AFAM pointed out that rate cuts in home health translate directly to lower service levels to patients.


“From the moment the rule came out, we looked it and thought there was likely a better way,” Denis Fleming, vice president of government relations at Almost Family, told HHCN when the comments were made public at the end of September. “We saw an unacceptable impact on our patients that was completely counterintuitive to what we try to do, counter to the mission of home care, and to seniors.”

Almost Family was not alone in disparaging the HHGM proposal in public comments, but it was alone in offering an alternative case mix model of its own, which was prepared by company President Steve Guenthner and his analytics team under the supervision of Chairman and CEO Bill Yarmuth.

The model “focuses on patient ‘goals,” such as staying out of the hospital and enabling patients to care for themselves. It also utilizes OASIS data, rather than retrospective measures.

The proposal notes that home health care patients are nearly as sick as those in skilled nursing facilities (SNFs) and much sicker than those in the general Medicare population. It argues that cutting the 60-day episode day of care to 30 days should come with a higher reimbursement payment to eliminate reductions at the individual patient level, the proposal reads.

Almost Family’s model, which it calls a Risk-Based Grouper Model (RBGM), groups patients based on their risks, with respect to their goals, in seven elements. Risks of adverse events are considered, as is probability of improvements.

The Almost Family model also leans toward value-based purchasing initiatives, according to the company.

“We developed a weighted average risk and probability of improvement score, and developed a model we think would develop nicely with where the House and Senate seem to want to go—and that is performance-based models,” Fleming said. “[It’s a] model that measures performance against a risk adjustment benchmark.”

Most importantly, the model proposes to make changes in a budget-neutral fashion—something the HHGM proposal did not accomplish—and encourages a 2020 target implementation date.

Find Almost Family’s public comments here.

Industry voices

Along with other home health care companies, industry associations and other stakeholders, Almost Family had the opportunity to meet with CMS and present their proposal and data.

Bill Dombi, president of the National Association for Home Care & Hospice (NAHC), has also considered the Almost Family proposal and sees it as a positive step for the industry to work with regulators on a new model.

“This is how the home care community can help come up with a better payment model,” Dombi told media during NAHC’s annual conference and expo in Long Beach, California, in October. “We are constructively working to have a better model out there, and it may be an Almost Family model, it may be a value-based purchasing (VBP) approach, it may be tweaking HHGM here and there. But most importantly… the message is we’re going to roll up our sleeves and accomplish something with [CMS]. We won’t do Washington speak—where [saying] we want to delay translates to we want to kill this thing and bury it 27 feet under the ground.”

Within the public comments on the Federal Register and in interviews with HHCN, industry stakeholders, including Dombi and Joy Cameron, vice president of policy and innovation at ElevatingHome, have expressed the desire to be a part of the rule making when coming up with a new payment system.

One of the ongoing concerns that was brought up prior to HHGM’s exclusion from the 2018 final rule is the influence of the Medicare Payment Advisory Commission (MedPAC), which is an independent advisory that recommends payment rates to Congress, and has continually suggested reducing payments for the home health industry over the last several years.

“A new Almost Family model, a VBP model, a Bill Dombi model—all will affect behavior, and we want to make sure there’s no backdoor way,” Dombi said in October. “The No.1 thing we’ve been watching for—and definitely have concerns with HHGM—is MedPAC getting its way, which is to redefine the home health care benefit as a short-term, post-acute care model, with all the emphasis on patients coming from the hospital rather than the community. It gets deeper than payment rates; it gets into redefining the model.”

Lawmakers in particular have become essential allies for the industry, with Congress members stepping in with letters to CMS Administrator Seema Verma multiple times to ask the agency to work with home health providers and groups, and change HHGM.

While the ultimate shape of payment reform remains a question, one thing is certain: As regulators and lawmakers continue to push out alternative models and focus on in-home care, home health care providers are pushing to get seats at the table.

Written by Amy Baxter

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