Tell Medicare what you think about its proposed 2024 policies and pay cuts for Home Health Agencies

The Centers for Medicare and Medicaid Services (CMS) published the CY 2024 Home Health PPS proposed rule in the Federal Register on July 10, 2023. The proposal will affect occupational therapy practitioners who work for home health agencies, as it includes payment updates, changes to quality measures in the Home Health (HH) Quality Reporting Program (QRP) and HH Value-Based Purchasing Program (HHVBP), as well as a new lymphedema benefit under Part B.

Payment rate cuts loom

Unfortunately, the proposal includes an estimated 2.2% payment cut or a $375 million aggregate decrease in Medicare payments to home health agencies. The proposed payment decrease is primarily due to a behavior assumption adjustment that CMS believes is necessary to adjust for provider reaction to the Patient Driven Groupings Model (PDGM) and make the implementation of PDGM budget neutral as required by Congress. PDGM was effective January 1, 2020, and intended to better align payments with patient care needs by using patient characteristics such as diagnoses and functional impairment level to determine payment rather than the number of services or therapy visits. Congress required CMS to make assumptions about agency behavior changes due to PDGM and make temporary and permanent payment adjustments to offset expenditure changes. CMS focused on differences in clinical group coding, comorbidity coding, and low utilization payment adjustments (LUPAs). According to CMS calculations, Medicare paid more under PDGM than it would have under the old payment system; therefore, CMS proposed a permanent adjustment of -5.653% in CY 2024 to address the differences in the aggregate expenditures under PDGM. Other proposed payment updates would offset that decrease, resulting in an approximately 2.2% decrease in overall payments to home health agencies.

Another concern is that CMS must determine how to reconcile retrospective overpayments due to agency behavior changes in CYs 2020, 2021, and 2022, estimated at $3.4 billion – CMS did not address this in the CY 2024 proposed rule.

CMS also proposes changes to the HH QRP and the HHVBP, among many other policy revisions. For the HH QRP, CMS proposals include:

• Adopt and publicly report the Discharge Function Score measure;
• Remove the Application of Functional Assessment/Care Plan measure;
• Remove 2 OASIS items: M0110 – Episode Timing and M2200 Therapy Needs; and
• Begin public reporting of the Transfer of Health Information to the Provider—PAC Measure and the Transfer of Health Information to the Patient—PAC Measure (TOH measures).

In addition, CMS identified measurement gaps in the HH QRP and seeks input and feedback in the domains of cognitive function, behavioral and mental health, resident experience and resident satisfaction, and chronic conditions and pain management. These are key areas for occupational therapy, and with the help of member experts, AOTA will address the importance of measuring quality and the role of OT for each of these areas in comments to the proposed rule.

For the HHVBP, CMS proposals include:

• Replace the 2 Self-Care and Mobility measures with the Discharge Function Score measure;
• Replace the OASIS-based Discharge to Community measure with the claims-based Discharge to Community-Post Acute Care Measure for Home Health Agencies; and
• Replace the claims-based Acute Care Hospitalization During the First 60 Days of Home Health Use and the Emergency Department Use without Hospitalization During the First 60 Days of Home Health measures with the claims-based Potentially Preventable Hospitalization measure.

New lymphedema benefit

Finally, CMS proposes establishing a new Medicare Part B benefit for lymphedema compression items and defining a standard or custom-fitted gradient compression garment. The new benefit would cover custom garments and compression supplies under certain conditions, allowing two daytime and one nighttime garment per year. CMS proposed Healthcare Common Procedure Coding System (HCPCS) codes and payment methodology options for custom garments. AOTA supports this new benefit, and staff is developing detailed comments in response to this proposal.

Response to the proposed HH rule

AOTA is greatly concerned about the impact of the proposed payment cut on the utilization of OT services and patient access to medically necessary OT services. Since the adoption of PDGM, AOTA has heard from numerous OTs and OTAs about PDGM's negative impact on their ability to treat HH patients who need their services. These reports include:

• Agencies are applying pressure to reduce the number of OT visits to clients.
• Agencies are using predictive analytic tools that use algorithms to determine how many therapy visits (if any) should be provided based on diagnosis.
• Agencies are instructing staff to delay OT to later in the HH episode, or patients are told they can wait to get therapy after discharge when they are outpatient.
• Physician orders for OT are ignored, revised, or deleted.
• Nursing and Physical Therapy are determining when and if OT services are needed.
• Agencies are shifting OT visits to PT or nursing colleagues.
• OTs are having to do more, with less support.
• Therapists' clinical judgment is overridden or ignored.

We believe additional payment cuts could further decrease therapy utilization. AOTA continues to communicate these concerns to CMS and encourages practitioners to share their experiences, and the impact on patient care with CMS. We are developing written comments to CMS expressing our concerns with the proposed rule and input on OT's role in quality measures and other policy proposals, and we will keep urging CMS to adopt safeguards to protect patient access to medically necessary OT services. Agencies must rely on the therapist's clinical judgment to determine the type and amount of therapy services an individual patient needs. To that end, AOTA opposes the removal of item M2200 Therapy Needs from the OASIS because we believe it is an important item to help track the need for therapy, and removing the item could contribute to a further decrease in the provision of therapy services.

Comments on the HH PPS proposed rule are due August 29, 2023. CMS typically releases the final HH PPS rule in early November – watch for AOTA updates.

Act Now: What You Can Do to Protect OT Services in HH

Join your colleagues in submitting comments to CMS online by August 29. Go to the Federal Register and enter your comments in the Comment field. We encourage you to share your concerns and specific examples, if applicable, of how PDGM has affected your ability to see HH patients needing your services. If the concerns listed above resonate with you, let CMS know.

If you are uncomfortable submitting comments to CMS directly, email us at regulatory@aota.org by August 24 to share your input so we can include your perspective in AOTA's comment letter. Remember – there is power in numbers! The more OT practitioners who express concerns about the proposed rule's impact, the more likely CMS will recognize the potential threat to patient access to OT services and seek safeguards to ensure appropriate utilization of OT services.