The Centers for Medicare and Medicaid Services (CMS) has announced plans to expand a Medicare home health program model that discriminates against people with longer term and chronic impairments whose conditions are not improving. It significantly limits access to home health care for beneficiaries who need it most, and directly conflicts with the Jimmo v. Sebeliussettlement.
The Home Health Value-Based Purchasing Model (HHVBP) was implemented in 2016 in nine states. According to CMS’ January 8, 2021 press release, the purpose of the model was “to test whether providing payment incentives for better quality care with greater efficiency would improve the quality and delivery of home health care services to Medicare beneficiaries.” CMS recently concluded the model was successful, with a 4.6% improvement in agencies’ quality scores and certified program expansion to be accomplished through future rule-making.
One major flaw of HHVBP is that it does not provide any meaningful measurement criteria for people who qualify for home health care under the law, but who have an illness or injury that will not improve, or will not improve relatively quickly. As a result, the HHVBP design penalizes agencies that serve people with longer term and chronic conditions, by taking payments back from agencies serving people who do not meet the improvement criteria.
Under HHVBP, Medicare payments to home health agencies are adjusted based on a home health agency’s (HHA) total performance score (TPS) on specified quality measures compared to other HHAs in a state. The maximum payment adjustment, upward or downward, is 7% for 2021. The quality measures in the HHVBP are based primarily on improvement in a patient’s condition, and quality measures in the model are absent for conditions not likely to improve (or to improve quickly). Thus, agencies are monetarily discouraged under HHVBP from serving many patients with longer-term conditions who qualify for Medicare-covered care.
As CMS developed HHVBP, “maintenance or stabilization measures” were considered to allow for inclusion of beneficiaries who were not improving and were, therefore, deliberately excluded. Discussion of this exclusion is reflected in the final Medicare home health rule for 2019 and has not been addressed by CMS since that time:
Comment: Many commentators suggested that stabilization measures should be recognized in HHVBP as opposed to just focusing on improvement measures, given that stabilization is sometimes a more realistic goal than improvement for certain patients.
CMS Response: We previously discussed our analyses of existing measures relating to stabilization in the CY 2016 HH PPS final rule. Specifically, we stated that while we considered using some of the stabilization measures for the model…we have not identified any such measures that we believe would allow for meaningful comparison of HHA performance. Although we appreciate commenter’s concerns that some beneficiaries may have limited opportunity to improve and that stabilization may be a more realistic goal for such patients, based on these analyses, we do not believe these measures are appropriate for inclusion in the Model at this time.
Since HHVBP was first proposed, the Center for Medicare Advocacy has continuously urged CMS to develop appropriate quality measures for all patients who qualify for Medicare-covered home health care. The quality measurement void for serving people with chronic conditions has not been addressed. Simply put, if a person cannot be measured in some way that is of value to the home health agency – to show improvement – that person will face barriers to home care because of potential penalties and sacrificed rewards. The lack of measures that properly relate to quality care to maintain an individual’s condition or slow decline creates a discriminatory practice against patients who medically and legally qualify for care.
The HHVBP model should not continue, let alone expand, until quality care for all patients is included in the measurements and policies are developed that provide fair access to care for all qualifying beneficiaries.
January 14, 2021 – K. Holt
 Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington.
 https://www.govinfo.gov/content/pkg/FR-2017-11-07/pdf/2017-23935.pdf, pages 56527-56547.