Home Health Value-Based Purchasing Model Likely Headed to the Scrap Yard

The Home Health Value-Based Purchasing Model (HHVBPM) is likely headed for the scrap yard in the not-too-distant future.

Implemented in 2016, HHVBPM was generally designed to pay home health providers in nine states based on outcomes and the value of services delivered. While many thought HHVBPM was fated for expansion, the initiative appears to be losing steam and destined for expiration.

On a basic level, a lack of interest in expanding HHVBPM is simply because of changing administrations, though there are certainly more nuanced reasons as well, according to National Association for Home Care & Hospice (NAHC) President William A. Dombi.

“If I can talk about why we haven’t seen it expand, … HHVBPM started under the Obama administration. We are now in the Trump administration and a new set of leadership at the Center for Medicare and Medicaid Innovation (CMMI),” Dombi said earlier this week during NAHC’s annual conference and expo in Seattle.

Success uncertain

Under HHVBPM, home health providers in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska and Tennessee are exposed to both upside and downside risk.

Effectively, that means an individual agency’s Medicare payment goes up or down based on its performance on specific measures, including clinical quality of care plus communication and care coordination. Efficiency and cost reduction, as well as patient safety and satisfaction, also factor into payment calculations.

In terms of a timeline, HHVBPM kicked off in 2018 based on quality measures from 2016, with the payment adjustment set at a 3% maximum rewards or penalties cap.

By 2019, that cap rose to 5%. It’s set to progressively rise to 6% in 2020, 7% in 2021 and 8% in 2022 moving forward.

The most recent update to HHVBPM came in July, when the Centers for Medicare & Medicaid Services (CMS) proposed new reporting requirements for year five of the model — its final year.

Specifically, CMS proposed publicly reporting Total Performance Scores (TPS) and TPS Percentile Ranking for each home health agency in the nine states that qualified for a payment adjustment, believing it would lead to an improvement in overall quality performance, as well as allow beneficiaries to make informed decisions about their care plans.

Originally, there had been a lot of optimism surrounding HHVBPM, with industry experts believing that the model could play a key role in ongoing efforts aimed at lowering national health care costs.

In its first four years, HHVBPM scores have not just impacted the nine participating states, but the star rating scores across the U.S., according to Melinda Gaboury, CEO of Healthcare Provider Solutions Inc.

Still, relatively flat metrics across a few important categories — including hospital readmission rates — have made it difficult to gauge the success of HHVBPM.

CMS has been able to recoup money from agencies, but when it comes to improving the overall quality of patient care, conclusive results remain to be seen, according to Gaboury.

“We’ve learned that no matter how they change the percentages, at least at this point, this hasn’t changed the improvement value of the patient satisfaction or the patient HHCAHPS. This hasn’t changed or improved acute care hospitalizations across the board or emergency room visits,” Gaboury told Home Health Care News. “They changed the improvement scores for year four so dramatically that agencies that were able to show high value-based purchasing scores have been curtailed.”

Indeed, it is hard to determine whether HHVBPM has had a positive impact on home health.

A July 2018 report on year one from CMS, for example, found that HHVBPM showed no evidence of impact on patient experience measures and mixed results in terms of cutting costs.

“Overall, we observed mixed findings regarding changes in measures of Medicare spending and utilization among Medicare Fee-for-Service (FFS) beneficiaries who received home health services,” CMMI officials wrote in the report. “We observed no statistically significant change in unplanned hospitalizations, while the average Medicare payment per unplanned hospitalization decreased relative to the comparison group.”

Additionally, as structured, HHVBPM meant that home health agencies that were already high achievers in terms of outcomes and working toward a higher star rating were not on an even playing field with agencies that had lower scores in the baseline year.

“Agencies that weren’t great performers could get extremely high improvement scores and surpass agencies … that had already been doing so well, Gaboury said. “Because those agencies that had been doing well didn’t have anywhere to go.”

Looking ahead

HHVBPM may be getting pushed to the back burner because of the Patient-Driven Groupings Model (PDGM) and other issues, but that doesn’t mean the model won’t be important in 2020.

Heading into the fifth year of HHVBPM, providers need to understand the significance of an 8% swing.

“Looking at [HHVBPM] as, ‘It’s the last year and we’ve got other things to worry about such as PDGM,’ is not a very wise position to take because of the fact that you have 8% at risk,” Gaboury said.

Meanwhile, Dombi pointed out that as the HHVBPM heads closer to an 8% payment adjustment in 2022, providers have become less interested in the expansion of the demo. Additionally, there has been nothing from CMS that indicates a continuation of the program, he said.

“There is no energy it seems at [CMMI] for expanding the program,” Dombi said.

That’s not likely to change either. Experts believe that the slow shift to a potential unified payment model for all of post-acute care providers will keep the expansion of HHVBPM as an afterthought.

“The efforts to develop a post-acute care payment model or a post-acute care value-based purchasing program that bundles everyone together into the same model, that’s where the energy has gone since HHVBPM started,” Dombi said.

But whether home health providers can expect to see a unified post-acute care payment model is still up in the air, according to Gaboury.

“We don’t expect that anytime in the near future,” she said.