The 2011 PPS Proposed Rule, released for public comment in July, defines sweeping refinements of the Home Health benefit that will change how all qualified services will be delivered. Through modifications designed to address many well- documented areas of concern regarding contemporary service delivery and coverage, CMS seeks to achieve many of their reform goals. Funding reductions, case-mix updates, additional reporting and re-evaluation requirements, and increased therapy changes will affect all aspects of how we do what we do. Traditional industry protocols will be challenged, care outcomes definitions will be re-interpreted, and the progressive provider and clinician will be prompted to examine care delivery habits and beliefs established over the last decade.

            What are the motivations behind CMS plans, how did we arrive at this point, and what are the elements in our industry that must be addressed by Home Health participants to survive in the future? What challenges lie ahead regarding the role of therapy not only in care terms, but also in the fiscal profile of the agency? How will the presence of recently introduced auditors, each with a unique focus on program integrity, affect providers’ stability and practices as they re-wire care for the proposed changes? We will examine these and other questions in our series on the 2011 PPS Proposed Rule, and propose essential strategies that will allow us to continue our care mission while meeting these new reforms. Additionally, as we progress through this series on these latest changes to the benefit, new information will be acquired as a result of the release of the final, post-public comment 2011 PPS Rule.

            The last quarter century in Home Health has been defined by the steady stream of changes as to how CMS and MedPac view, and implement, the homecare benefit. The move from fee-for-service to the PPS model (initiated in 1999) was marked by a 30% reduction in the number of certified providers in America as agencies were required to adopt the acuity-based model that had achieved success in both acute hospital and SNF care programming. At that time, providers had been delivering extended clinical programs that had evolved as CMS utilized Home Health to address the length of stay and cost concerns surrounding expensive inpatient treatment. Agencies and clinicians who left the industry at that time were, for whatever reason, unwilling to alter care to address the focus on acuity that PPS mandated.

            The subsequent PPS era included models that either rewarded therapy delivery volumes (High Therapy Threshold) or visit-specific therapy programs based on individualized patient care concerns (2008 New Rule). The lack of an effective audit mechanism, initially described by CMS when PPS was introduced, left providers and clinicians alike to define what qualified care requirements were to be found in their programs. As a result, the growth realized by the Home Health industry under the PPS model was beyond any expectations. In addition, significant fraud and abuse concerns became evident that further inflated both the number of participating providers as well as the cost of the benefit.

            Over the last decade, industry costs have risen to nearly $18 Billion/year; achieving un-sustainable levels that prompted some of the changes seen in the 2011 PPS Proposed Rule. While fraud and abuse based practices, and the need to eliminate their costs from the Home Health landscape, are recognized and supported by nearly all providers, waste and efficiency currently present in all agencies and their care programs, are also targeted by the Proposed Rule. All corners of our industry will be challenged by the specificity of the refinements, and the resultant financial realities will require a wholesale re-evaluation of the value of any and all direct costs providers incur. Clinical delivery patterns of all types of care will be reviewed, as well as office and management approaches being streamlined; in fact, all aspects of direct and indirect costs will be affected.

            Future articles will address a number of important topics that must be considered when preparing your care to adapt to the proposed changes. Any reluctance to integrate the required changes could jeopardize your ability to deliver Home Health services in the near future. Areas to be discussed include:

 

      - Elements of the 2011 Proposed Rule

      - Fiscal Changes for Home Health

      - Identified Therapy Requirements and How to Address

        Changes

      - Nursing Questions and Concerns

      - Summary of Roadmap for Future Success

 

           Deliberate and focused study of the changes will be necessary; many of the reforms provide significant challenges not only to how we deliver care, but also to the underlying philosophies that form our programming pathways. By diving headfirst into the process of care refinement as identified by the Proposed Rule, we can maximize not only patient outcomes, but professional goals as well.