Home Health Industry Gains Ground After Final Rule — But PDGM Behavioral Adjustment Battle Isn’t Over

The Centers for Medicare & Medicaid Services (CMS) released the 2020 home health final payment rule on Oct. 31, reaffirming many aspects of next year’s payment overhaul while also updating certain quality reporting metrics and solidifying changes to policymakers’ maintenance therapy proposal.

The National Association for Home Care & Hospice (NAHC) and Axxess were among the initial group of home health stakeholders to weigh in on CMS’s rule, particularly its somewhat surprising move to lower the proposed 8.01% behavioral adjustment baked into the Patient-Driven Groupings Model (PDGM). Amedisys Inc. (Nasdaq: AMED), Bayada Home Health Care and LeadingAge more recently shared their thoughts.

For the most part, the group unanimously viewed CMS’s decision to lower PDGM’s behavioral adjustment to 4.36% as a win for the industry. At the same time, however, they called for more to be done.


“Overall, this is a positive move for the home health industry and preferred over the proposed 8.01% payment reduction,” Anthony D’Alonzo, director of clinical strategy and innovation for Moorestown, New Jersey-based Bayada, told Home Health Care News in an email. “[But] this is still a significant payment reduction and continues to be based on assumptions, rather than observed behavioral changes. We will continue to work with our national associations to advocate for congressional action to further limit the potential impact of future behavioral assumptions.”

Similarly, Baton Rouge, Louisiana-based Amedisys said in a company statement that it was “pleased to learn” CMS chose not to finalize the entirety of its proposed behavior adjustment.

“This is welcome and warranted relief to patients and the home health industry,” the company noted. “If the behavioral assumption reduction of [8.01%] had been fully implemented in the first year of PDGM, patient access would have been significantly impacted, as it was projected that as much as a third of the home health industry, especially in rural areas, would have been at risk.”


Meanwhile, LeadingAge also touted CMS’s change of heart as a win.

Nonetheless, the Washington, D.C.-based advocacy organization still urged its members to voice support for S. 433 and H.R. 2573, legislation that seeks to remove PDGM’s behavioral adjustment entirely for 2020 and force CMS to only make adjustments in the future based on hard data. 

“The bills have been gaining cosponsors, which is a positive sign,” LeadingAge said in a statement. “But your voice is critical to have [calendar year] 2020 rates reflect the true PDGM design — not behavior assumptions.”

In addition to the behavioral adjustment, Bayada and LeadingAge also provided feedback on CMS’s plans to phase out Requests for Anticipated Payment (RAPs) starting in 2020, eliminating them completely by 2021.

Broadly, CMS is opting to terminate RAPs as a way to combat potential fraud and abuse of the home health benefit. In place of RAPS, the agency is implementing a new Notice of Admission (NOA) requirement.

Although the NOA still comes with a potential penalty as proposed, CMS simplified the requirement in response to industry concern. 

“Bayada is prepared to adapt to the RAP changes, and we are supportive of the simplification of the NOA process, slated for implementation in 2022,” D’Alonzo said. “This was an area of emphasis in our formal response to the proposed rule, so it is encouraging that CMS adjusted based on feedback.”

Apart from PDGM details and RAPs, CMS’s final rule last week also tweaked home health quality measures.

Specifically, LeadingAge pointed out, the final rule adds “Transfer of Health Information to Providers of Post-Acute Care” and “Transfer of Health Information to Patient of Post-Acute Care” measures.

Both are designed to improve patient safety by ensuring patients’ medication information is shared throughout the discharge process, according to the nonprofit organization.

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