Downsides to the CMS Home Health Value-Based Purchasing Model Expansion Plan

For the most part, home health operators are saying “bring it on” to the Home Health Value-Based Purchasing (HHVBP) Model expansion plan from the U.S. Centers for Medicare & Medicaid Services (CMS).

There are plenty of very real concerns buried under that enthusiasm, however.

Dr. Bob Parker is the chief clinical and compliance officer at Intrepid USA, a Dallas-based home health, hospice and personal care services provider with a presence in 17 states, including three of the nine HHVBP demonstration states. Among his concerns, Parker is worried that, as currently structured, the national rollout of HHVBP starting in 2022 could negatively impact patient care.

“This model doesn’t really take into account the polar opposites of folks that we have to take care of in home health care,” he told Home Health Care News. “There’s the very sick, then those who are fairly well health wise. They have some intermittent [issues], but then they’re going to get back to baseline.”

Specifically, Parker was referring to the fact HHVBP was built upon a two-pronged foundation of both achievement and improvement. In other words, home health providers perform better in value-based purchasing when the condition of their patients improve.

“But improvement may not happen, which is something we may have already known coming in,” Parker said. “Instead of ‘improvement,’ the conversation that we have to keep pushing for is, ‘How do we get quality care? And how do we provide quality care to those folks who we know aren’t going to progress?’”

The potentially shortsighted approach to improvement is just one of many HHVBP red flags.

Others, for example, have expressed concerns with the way CMS is comparing home health agencies on a national level, instead of the state-level approach used in the demo since its implementation in 2016.

Additionally, some home health operators believe it’s unfair to use 2019 as the new standard baseline year for all home health agencies, regardless of whether they were already participating in HHVBP.

“If this expansion happens and we have to have a new baseline year of 2019, all the work we’ve done in the pilot is going to seemingly put us at a disadvantage,” Molly McDonald, the program manager of quality and regulatory compliance at the Washington-based EvergreenHealth Home Care, told HHCN.

The right incentives

Under the HHVBP expansion plan that CMS unveiled in June, home health providers would compete on a variety of performance measures for a maximum upward or downward payment adjustment of 5%.

To calculate that adjustment, CMS would use an intricate method that looks very similar to the HHVBP demonstration. Home health agencies would receive “points” for both achievement and improvement, with the higher of the two used to determine an overall “total performance score” that’s then plugged into a complex algorithm.

Effectively, “achievement” is how well a home health agency fares compared to national benchmarks, while “improvement” refers to the progress a provider has made over its past performance.

For home health organizations known for taking care of the sickest of the sick, the HHVBP methodology can sometimes feel like they’re competing in a national relay race while carrying a bag of cement.

Intrepid’s Parker isn’t the only home health leader with this concern.

“If my patient mix is skewed toward chronic illness and Medicare-Medicaid dual eligibles, perhaps with the way that improvement scores are calculated, I’m going to be in trouble,” Tim Ashe, chief clinical officer at the international software and professional services company WellSky, told HHCN. “That might create a counter-incentive to providing care to those vulnerable patients — the chronically ill.”

Ashe spent much of 2015 working with home health agencies in demo states preparing for HHVBP. He has been following the value-based care initiative ever since.

There aren’t concrete numbers to verify whether providers serving chronically ill populations were at an HHVBP disadvantage, but that has remained a common point of conversation, Ashe said.

“I don’t know if we saw that play out, as I don’t have data that suggested it did during the pilot,” he said. “But certainly, there have been conversations about how to make [HHVBP] more equitable.”

Dan Savitt, CEO of the Visiting Nurse Service of New York (VNSNY), echoed those sentiments during a recent HHCN+ TALKS appearance.

“The [HHVBP] model needs to recognize that some home health agencies simply care for much sicker and more complex populations than others,” Savitt said. “That should be a factor in the risk adjustment models, so agencies can compare fairly and ensure that incentives are aligned to care for patients with complex health and social determinant needs.”

To improve the HHVBP framework, Parker said CMS should take into account patients’ clinical conditions to a greater extent. Additionally, he added, CMS should look at ways to grade home health agencies on their ability to efficiently and appropriately move patients along the care continuum.

“This has to be done in collaboration with the hospital systems, physician-practice groups and other stakeholders, but how are we making sure that we’re incentivizing agencies to be more adept at moving the patient along the continuum?” Parker said. “How do we move these patients along, so they’re really getting the right care at the right time?”

An unfair approach

Beyond the questions surrounding improvement and aligning incentives, some believe there are other unfair elements of the HHVBP expansion plan.

Unlike the demo, the national HHVBP proposal would take place on a national scale, meaning home health agencies serving Tallapoosa, Georgia, would be compared against peers in New York City and Chicago. There are very different health challenges from one region to another, so a one-size-fits-all approach may be overly simplistic.

“We are a very rural-oriented enterprise,” Parker said. “We are in those types of markets that are underserved. The health risks are high. There are very diverse populations.”

Chris Attaya, vice president of product strategy at Strategic Healthcare Programs (SHP), painted a picture of the complications with the national approach during the National Association for Home Care & Hospice (NAHC) Financial Management Conference.

In the HHVBP demo, Attaya explained, home health agencies in Florida scoring at the 75th had a TPS of 44 during one performance year. During that same period, agencies in Maryland had a TPS of 45.8 — at just the 25th percentile.

“We’ll have to see how that all kind of washes out,” he said. “But we are going to be compared nationally. It will not be within the state.”

Switching back to a state-level approach may not be an option, considering other value-based care efforts from CMS, Attaya pointed out.

“One of the things that CMS will do, however, is they’ll look to their other value-based purchasing programs,” he said at the NAHC event. “Hospitals, skilled nursing facilities — those are all national. There’s a precedent, in some respects, in terms of that approach.”

If the CMS HHVBP plan is finalized as is, home health agencies will also be broken up into two groups. Slightly less than 7,100 agencies will fall within a “large” cohort, with 485 agencies falling within a “small” cohort.

Some argue that breakdown is likewise unfair, especially considering that the home health industry itself is made up of hundreds of mom-and-pop-type agencies.

“You could be just a mid-size home health agency, but you might be competing with one of the mega agencies,” DeAnn Briscoe, senior director of clinical education at home health coding and consulting firm MAC Legacy, told HHCN. “That might be one thing that’s not considered very fair. You’ve got these mega agencies that have full-time quality staff and all these background people who can help educate. They simply have more resources.”

Starting over

McDonald’s organization, EvergreenHealth Home Care, is a health system-based home health and hospice provider — one of the largest in the Pacific Northwest.

When EvergreenHealth Home Care learned the HHVBP demo was coming, it invested heavily around quality and clinician education. That investment paid off, with EvergreenHealth improving its star ratings and becoming one of the most successful HHVBP participants in Washington.

“We were part of the pilot states, so we started in the first performance year, back when it started in 2016,” McDonald said. “We’ve been doing it since then.”

Under the demo, EvergreenHealth Home Care is partly “judged” upon the baseline year of 2015 — before it had made any of its investments around quality. But as part of its nationwide expansion plan, CMS is looking to make 2019 the new starting point for most home health agencies.

Certain exceptions would be made for newly certified home health agencies.

“That’s a huge concern for us and likely others in the pilot states,” McDonald said. “There has been a lot of work that we’ve done in those [demo] years to kind of get us to this point.”