Providers Side with MedPAC on Changes to Home Health Referral Rules

Hospital discharge planners should have more leeway in how they educate and inform patients about post-acute care options, perhaps making star ratings a more important part of the conversation, home health providers believe. But it’s a change that would need to be handled carefully to prevent favoritism or abuse in how referrals are made, they caution.

The issue of referral patterns has been of concern recently because the star ratings on Home Health Compare aren’t steering patients toward the highest quality providers in their neighborhoods. To help fix that, the Centers for Medicare & Medicaid Services (CMS) should consider giving discharge planners more authority and flexibility in terms of guiding patients out of hospitals and toward top home health agencies, the Medicare Payment Advisory Commission (MedPAC) recommended in its latest report to Congress.

Currently, Medicare’s discharge planning policies emphasize patient choice and discourage hospital staff from limiting that choice in any away.

“I would support [the MedPAC recommendation], provided that it’s actually based in quality performance,” Susan Sender—senior vice president and chief clinical officer of Baton Rouge, Louisiana-based Amedisys, Inc. (Nasdaq: AMED)—told Home Health Care News. “As long as there is some structure or criteria around how they do that so it’s not just, ‘Oh, the last person who was in and gave me donuts, that’s who I’m going to say my patient should use.’”

Amedisys is one of the largest home health care providers in the country, providing care to more than 369,000 patients each year when also factoring in its hospice and personal care offerings.

Smaller providers—including Advanta Home Health Care in Northbrook, Illinois—have expressed similar concerns as well.

“I think it’s definitely a good idea to give discharge planners more leeway,” Advanta Administrator Nataly Koshev told HHCN. “But, at times, discharge planners may have their own agenda, their own friends and acquaintances, people who they may have known in the past who now work for home health agencies. The star ratings and patient outcomes might not be their top consideration.”

Advanta is a standalone agency that provides skilled home health services to about 150 patients.

The impact of star ratings

The star rating system for home health is meant to be a tool that consumers use in helping them choose a high-quality provider. But the system isn’t working that way.

More than 94% of beneficiaries who use home health agency services after a discharge have at least one provider within a 15-mile radius with a higher quality score than the provider from which they receive services, a MedPAC review of referral patterns revealed. About 70% of beneficiaries have five or more home health agencies in their area known to provide better quality care.

Additionally, on average, the best performing agencies on Home Health Compare have only increased their market share by less than 1% since the system rolled out in 2015, according to MedPAC.

Amedisys is one home health provider that routinely touts its company-wide star ratings. Amedisys agencies, on average, have 4.38 stars, well above the national mark. More than 90% of Amedisys agencies are rated as 4 stars or higher, while 72 total agencies have 5 stars. It’s a point of pride for the company, Sender said, and Amedisys is actively working on an internal recognition program for those high-performing agencies.

“I’m very, very proud of our star ratings,” she said.

That holds true even if the ratings haven’t directly led to more patients.

“At the individual consumer perspective, no, I don’t believe [star ratings] have [affected market share],” Sender said. “I don’t think that the rank-and-file consumer is aware of what they should be looking for.”

Advanta, itself a 5-star home health provider, has also not seen jumps in its patient census, despite continued success on Home Health Compare, Koshev said. Occasionally, though, the agency does receive some “random” inquiries from people who first heard about Advanta through the CMS website.

“There are some changes that we’re seeing in terms of getting those phone calls, people saying that the star ratings are why they contacted us,” she said. “But not as much as we would hope for.”

Mayo Clinic: discharge planning today

At Mayo Clinic, a licensed social worker coordinates all discharge planning services for hospitalized patients based upon a thorough assessment and input from hospital staff and patients. As a rule, the social worker purposefully avoids interfering with a patient’s ability to choose a home health provider, however.

“The personal preference of the social worker is never to interfere in the choice of a patient and the family member,” Anita Milburn, a Mayo Clinic social worker and a member of its discharge committee, told HHCN.

Making decisions regarding transition planning is, by nature, difficult, Lisa Carter, Mayo Clinic nurse administrator, told HHCN. Several factors weigh into that decision making, complicated by the fact patients are often in a vulnerable position as they recover from unexpected illness or injury.

“Due to the current CMS regulations, staff are unable to guide patients, thus patients often rely on past experience and information provided by an informal network of family and friends, which may not always be the most optimal option for them,” Carter said. “Some patients are more informed in this space and rely on ratings, such as Medicare’s Home Health Compare website or the [star ratings] to help guide their choices.”

Giving planners more power 

MedPAC is proposing three different approaches to discharge planning: a “flexibility approach,” a “prescriptive approach” and a “hybrid approach” that combines elements from each.

Under a flexible approach, hospitals would be largely responsible for defining the criteria that they use to identify high-quality home health providers for their patients. The hospital itself would be responsible for selecting quality measures, collecting data from providers and setting up performance levels that they have to meet to be recommended by the hospital. The expanded flexibility would help to reflect the best local home health options, according to MedPAC, but it would also place greater burden on hospitals to maintain standards and on CMS to monitor them. A flexible approach may also be confusing for patients, as different hospitals could have different definitions of high quality care.

It may also be more susceptible to fraud, waste and abuse, according to MedPAC.

“I think that’s the downside,” Koshev said. “But I think that it would be a good idea if discharge planners could give patients ‘hints,’ maybe point them to the star ratings to help them choose when they’re making decisions.”

In a potential prescriptive approach, in contrast, CMS would basically determine who the “high quality” post-acute providers are via its own standards, then hospitals would use that information to better guide patients. Having unified standards and definitions concocted by CMS would create clarity, but it would also come with rigidity, and the number of designated providers would vary from community to community.

If those two approaches don’t make sense, policymakers could instead combine the best parts of each to mitigate their disadvantages. For example, Medicare could leave quality measure open for hospitals to develop, but require that post-acute providers meet certain performance levels on certain points, such as coming in the top third on a given metric to be recommended to patients.

“Medicare policy currently places a premium on protecting beneficiary choice of [post-acute care] provider, but it does not encourage beneficiaries to use higher quality [providers],” MedPAC wrote in its report to Congress, issued June 18. “Any new policy should seek to easy or simplify the burden on beneficiaries, many of whom already report that discharge planning can be a difficult and confusing period.”

Written by Robert Holly

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Robert Holly
When Robert's not covering the latest in home health care news, you can likely find him rooting for the White Sox or roaming his neighborhood streets playing Pokemon Go. Before joining HHCN, Robert covered everything from big agribusiness to the hottest tech startups. 

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