Fact Sheets


Details for: SUMMARY OF PROPOSED HH PPS REFINEMENTS COMPARED TO CURRENT HH PPS PAYMENT SYSTEM



For Immediate Release: Friday, April 27, 2007
Contact: CMS Media Relations
202-690-6145


SUMMARY OF PROPOSED HH PPS REFINEMENTS COMPARED TO CURRENT HH PPS PAYMENT SYSTEM
(GLOSSARY OF ACRONYMS CAN BE FOUND AT BOTTOM OF PAGE)

 

Existing HH PPS

Proposed Rule

Home health disciplines included in the National 60-Day Episode rate:

  • Skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, and medical social services

Home health disciplines included in the National 60-Day Episode rate:

  • Unchanged

For eligible beneficiaries under a home health plan of care:

  • National 60-day episode prospective payment for covered home health services, adjusted for case mix and wage index 
  • LUPA, SCIC, PEP, and outlier

            adjustments allowed

For eligible beneficiaries under a home health plan of care:

  • Unchanged

 

  • LUPA, PEP, and outlier adjustments allowed; SCIC adjustment eliminated

Average case-mix weights per episode:

  • Per design of a case-mix adjusted system, case-mix weights were designed to average 1.0.
  • Using the most recent available data from 2003, a total increase in the average case-mix of 23.3% (from 1.0 to 1.233) has occurred since the implementation of the HH PPS.

Average case-mix weights per episode:

  • Trend toward coding that increased average case-mix weights

 

  • Of the total 23.3% change in the average case-mix, 8.7% of increase is believed to be due to coding behavior (i.e., a nominal change) rather than a real change in the underlying condition of home health patients

 

National 60 Day Episode rate =

$2,339.00 for CY 2007

  • Includes home health market basket increase (3.3% for CY 2007)
  • No adjustment for aggregate changes in case mix that are not related to home health patient’s actual clinical condition case-mix changes

 

  • Adjusted for case-mix and wage-index

National 60 Day Episode rate = 

Episodes beginning in CY 2007 and ending in CY 2008 =$2,355.96 Episodes beginning and ending in CY 2008 = $2,300.60 for hospitals that report quality data

 

For HHAs that do not report quality data:

Episodes beginning in CY 2007 and ending in CY 2008 = $2,310.17

For HHAs that do not report quality data:

Episodes beginning in CY 2008 and ending in CY 2008 = $2,255.88

 

  • Includes home health market basket increase (2.9% for CY 2008) for hospitals that report quality data. Two Percent Reduction for hospitals that do not report quality data (0.09%)
  • Adjusted for aggregate changes in case mix that are not related to home health patient’s actual clinical condition (-2.75% per year for 3 years)

 

  • Unchanged

Home health market basket:

  • Labor portion = 76.775%
  • Non-labor portion = 23.225%

Home health market basket:

  • Labor portion = 77.082%
  • Non-labor portion = 22.918%

Case-mix regression model:

  • Single therapy threshold at 10 therapy visits
  • No accounting for timing of episodes

 

 

 

 

 

 

  • Single equation model for weight calculation, with single therapy threshold

 

 

 

 

 

 

 

  • Model r-squared = 0.34
  • Increase in payment (approximately double) for delivering at least 10 therapy visits in a 60-day episode
  • 80 case-mix groups

Case-mix regression model:

  • Therapy thresholds at 6, 14, and 20 visits

 

  • Accounts for early episodes (the first or second episode in a sequence of adjacent episodes) and later episodes (3rd or subsequent episodes in a sequence of adjacent episodes), regardless of whether the same home health agency provided care for the entire series of episodes.
  • Four-equation model for weight calculation:          

      1) < 14 therapy visits occurring in

          early episode;

            2) ≥ 14 therapy visits occurring in

                early episode;

      3) < 14 therapy visits occurring in

          later episode;

      4) ≥ 14 therapy visits occurring in

          later episode

  • Model r-squared = 0.44
  • Gradual increase in payment between first and third therapy thresholds

 

  • 153 case-mix groups

Case-mix model variables:

  • M0175 & M0610 included
  • M0470, M0520, & M0800 not included
  • Scores not given for infected surgical wounds, abscesses, chronic ulcers, and gangrene
  • No gastrointestinal, pulmonary, cardiac, cancer, blood disorders, or affective and other psychoses  diagnosis groups included
  • Points not given for secondary diagnoses
  • Points not given for combinations of conditions in the same episode

Case-mix model variables:

  • Excluded M0175 & M0610
  • M0470, M0520, & M0800 are added

 

  • Included scores for infected surgical wounds, abscesses, chronic ulcers, and gangrene
  • Added gastrointestinal, pulmonary, cardiac, cancer, blood disorders, and affective and other psychoses diagnosis groups
  • Points assigned for some secondary diagnoses
  • Points assigned for some combinations of conditions in the same episode

Wage Index:

  • Routine update based on most recently available pre-floor/pre-reclassified hospital wage index

Wage Index:

  • Unchanged

Non-routine supplies (NRS):

  • Included in national episode rate as a fixed amount of $49.62, updated annually as part of the national episode rate.

 

 

 

  • Case-mix adjusted as part of the national 60-day episode rate

 

 

 

  • Updated annually, as part of the national episode rate, by the home health market basket factor

Non-routine supplies (NRS):

  • Based on a NRS conversion factor of $52.30. (The original $49.62 from the July 3, 2000 final rule, updated to 2008, adjusted to account for the outlier target of 5%, and adjusted for the nominal change in case-mix).

 

  • Case-mix adjusted separately based on 5 NRS severity groups.  The case-mix weights associated with these 5 NRS severity groups are to be recalibrated annually.
  • Unchanged

 

LUPA Adjustment:

  • Calculated if episode has 4 or fewer visits
  • No additional payment for LUPA episodes that occur as the first or only episode during a period of home health benefit use

 

LUPA Adjustment :

  • Unchanged

 

  • Additional $92.63 for LUPA episodes that occur as the only episode or the first episode during a period of home health benefit use (sequence of adjacent episodes); to be updated annually by the home health market basket

PEP adjustment calculation:

  • Allowed for partial episodes

PEP adjustment calculation:

  • Unchanged

Outlier adjustment:

  • Fixed dollar loss ratio = 0.67
  • Loss-sharing ratio = 0.80
  • Outlier expenditure target = 5% of total home health PPS payments

Outlier adjustment:

  • Unchanged (Fixed dollar loss ratio =  0.67)
  • Unchanged
  • Unchanged

Quality Data Reporting:

  • Report data on 10 measures of quality
  • HHAs that do not submit quality data subject to 2% reduction in home health market basket percentage increase

Quality Data Reporting:

  • Report data on 12 measures of quality
  • Unchanged

Average case-mix under the current case-mix system, based on 10% sample of 2003 data:

  • Proprietary agencies: 1.2601
  • Voluntary non-profit agencies: 1.1404
  • Rural agencies: 1.1583
  • Urban agencies: 1.2032

Average case-mix under the proposed case-mix system, based on a 10% sample of 2003 data:

  • Proprietary agencies: 1.2227
  • Voluntary non-profit agencies:  1.1716
  • Rural agencies: 1.1417
  • Urban agencies: 1.2074

 

Glossary of Terms

 

(LUPA) Low utilization payment adjustment

(SCIC) Significant changes in condition

(PEP) Partial episode payment

 

 

 

 


Page Last Modified: 5/14/07 12:00 PM
Help with File Formats and Plug-Ins

Submit Feedback