Assure Case-Mix Performance while Preparing for Healthcare Reforms
Case-Mix Rebasing
The 2014 PPS Final Rule outlines the rebasing of Home Health rates as mandated by the Patient Protection and Affordable Care Act of 2010 (PPACA). The Rebasing, in the form of rate adjustments phased in over four years, makes its impact in many areas of the PPS Home Health landscape. Specific changes, in payment or policy, affect the homecare model in the traditional manner for 2014, including adjustments to the market basket and episode rates, wage index, LUPA and per visit amounts. Though payment rate reductions are limited to 3.5% annually through 2017, intrinsic changes to the PPS model found in the Final Rule will affect Providers through adjustments to the case-mix weight. In addition, as part of their response to the PPACA mandate, CMS will reduce HHRG weights, resetting the average case-mix weight to 1.0. The current average case mix-weight of 1.35, according to CMS, is a result of gradual case-creep, and excessive for a Home Health PPS model originally based on an average 1.0 case-mix level. As a result of the 1.35 average case-mix, homecare payment rates are higher than the costs of patient treatment. The CMS alteration of the acuity-to-case-mix ratio, which for the purposes of this article we will refer to as “Case-Mix Rebasing”, will affect all Home Health Providers as they formulate the care episodes of 2014.
Intending to adjust the average case-mix weight to 1.0, CMS will reduce HHRG payment rates by 25.7% in an across-the-board fashion in January 2014. The net result will be a markedly lower case-mix identity for the typical Home Health episode claim. As defined by CMS, the case-mix represents the patient’s condition and care needs, and delineates the level of payment for a homecare episode. These elements, which identify clinical profile and produce case-mix ratings on an individual patient basis, are found in the OASIS admission tool performed at the Start of Care (SOC) visit. Issues surrounding the OASIS have been well catalogued since introduction of the assessment as part of the Interim Payment System in 1999. The evolution of OASIS educational training, scrubbing software, and OASIS certification status, all testify to the importance of performance with this admission assessment.
The Admission OASIS
The general attitude towards the cumbersome and involved OASIS document often serves to promote a less than optimal level of performance at the point of admission. Front-line clinicians, whether nursing or rehab based, may fail to consider the importance of OASIS findings in identifying much of the tonality of the entire clinical episode. Generally separated from the specifics of billing activities, SOC clinicians rarely are knowledgeable of the case-mix derived from the OASIS document they completed. Burdened by the stresses of community care delivery, homecare clinical staff traditionally focuses on the service aspect of the program, basing care delivery on traditional views of what they feel should occur in the episode. After the OASIS is completed by the SOC clinician, it usually is coded and reviewed for qualification by Quality Assurance (QA) personnel. Clinical staff then turns their attention towards the routine visit phase of the care aspect of the program.
A level of disconnection occurs between the clinical staff collecting OASIS data during the SOC visit, and the agency-based personnel coding and performing QA functions. This situation exists across the homecare industry, regardless of Provider size, profit or non-profit, hospital-based or free-standing status. As a result, few involved in the admission management process are conscious of the multi-faceted role the OASIS plays in a Medicare Part A Home Health episode. Primarily, the OASIS illustrates the clinical profile of the patient by its objective, multi-disciplinary assessment. This patient profile relates directly to the clinical course of treatment, defining the Plan of Care that drives the episode. But in addition, the OASIS also serves as the “payslip” for the Provider by its establishment of the case-mix identity of the patient program. When we seek OASIS accuracy to custom-fit our programming, creating efficient care plans, we also assure that we are being paid accurately for the care we are providing. As we face an era of reform efforts and significant change in our care design, accurate reimbursement would seem a basic requirement for future survival.
Inaccurate OASIS answers can vary in any direction; either “underscoring” by creating a clinical profile that minimizes the patient’s actual acuity, or “overscoring” to create an exaggerated profile that leads to higher reimbursement for the episode. HHSM analyzes SOC documents for Providers from all parts of the country as part of our Utilization Review services; this experience reveals a more typical scenario where OASIS content is incorrect in general and fails to adequately outline the patient in question. Despite the outstanding efforts of the educational services addressing the SOC document, inaccuracy is quite common in the average OASIS produced today. Only now, in the face of the Case-Mix Rebasing outlined by the 2014 Final Rule does the value of OASIS accuracy become apparent for Providers seeking success as the Home Health Benefit evolves.
Admissions across the Care Continuum
SOC clinicians are rarely vetted for OASIS accuracy on a per patient basis, and as a result, case-mix levels are dependent on the front-line clinician’s performance at admission. This approach differs from protocols many other Medicare Providers enact to assure their programming achieves the desired level of qualified care. Acute hospitals employ Utilization Review (UR) personnel to validate both admissions and in-episode DRG control; Sub-acute Providers received the Minimal Data Set (MDS) as a facet of their PPS model, allowing for UR control of their nursing and rehab programming. This level of clinical care management is relatively absent from the homecare PPS era. Progressive Home Health Providers, particularly those focused on survival under a changing Medicare Benefit, will respond to Case-Mix Rebasing by installing UR-managed clinical protocols into their daily care production practices. By doing so they will assure the development of contemporary patient programs fitted efficiently to care needs, marked by appropriate levels of PPS-based reimbursement.
All Home Health Providers will feel the results of Case-Mix Rebasing in their care claims, as the 25% HHRG reduction goes into effect. In addition, this re-establishment of the definition of clinical acuity as it relates to payment will have long-ranging ramifications on homecare programming. The level of reduction involved creates an additional challenge for the Provider; assuring performance in this area becomes paramount for solvency of any particular patient episode. This author feels that Case-Mix Rebasing set to begin January 1st, more than any other element contained within the 2014 Final Rule, will define the care changes felt by Home Health Providers as they continue to develop the inaccurate episodes of the next twelve months. Furthermore, as the new care models re-wire clinical delivery along episodic lines, losses of program volumes (from the silo effect of the care continuum) will be seen. Both ACOs and Single Payment Bundling will decrease the utilization levels currently seen in Post-Acute care, and Home Health will be no exception. This increases the importance of capturing acuity (and Case-Mix) accurately during the SOC OASIS visit. Efficient assessments prompt efficient care programs, which allow for decreases in standard care costs without compromising clinical outcomes. As you read this, Bundled Payment for Care Improvement (BPCI) pilot programs are reinventing acute care along episodic lines, employing the DRG identity to define the level and quality of the Post-Acute phase of the care episode. PPACA mandates ALL hospital discharges will be Bundled by January 1st, 2018; Home Health Providers intending to continue on the care path of tomorrow should focus on improved OASIS accuracy for the effect on patient acuity today.
Utilization Review for Home Health
So Home Health Providers seeking to minimize the effects of Case-Mix Rebasing by assuring OASIS accuracy will find themselves on the path of Utilization Review, joining many other facility-based Medicare Providers in the development of efficient care episodes through UR control. Consistent UR management of evidence-based, best practice care production philosophies assures PPS compliant programs with better fiscal returns that those produced and managed today primarily by front-line clinical staff. By assuring an accurate admission profile, the Home Health Provider can seamlessly produce and deliver a care program that works for everyone; CMS, the MD, the patient, the caregiver, the agency, and the clinician. Similar UR protocols helped acute care hospitals respond to the introduction of DRG control over 30 years ago, and they continue to manage inpatient utilization today. Assisting in helping physicians and clinicians produce and deliver efficient care, these UR departments and their protocols define quality care on a daily basis, and their role in our lives are often taken for granted. Their efforts have helped your loved ones come home from the hospital earlier than expected, or leave a SNF sooner than projected to complete the care episode in the home.
Home Health Providers can employ Utilization Review to assure that accurate OASIS assessment captures appropriate payment for their care; minimizing the effects of Case-Mix Rebasing in the process. Establishment of an assertive UR process changes the entire tonality of the clinical program. The SOC clinicians’ role changes to one of assessment and data collection; they only need to capture correct admission information, and UR will assist in the development of the Plan of Care. And, in a manner similar to IRF or SNF control, UR programming can assure consistent care for rehab disciplines on the case. These UR care production elements are not only the appropriate response for Home Health Providers confronting Case-Mix Rebasing; they are the identical UR clinical management practices employed by Part A Providers across the care continuum. In addition, the UR-managed Home Health approach can energize clinical programs and staff in a manner rarely seen today. Nursing and rehab clinicians can assume roles in which they are historically comfortable; assessing and delivering quality care managed by outside personnel. Patients and physicians receive care programs consistent with healthcare experiences outside of the homecare world. Factor in patient compliance and caregiver participation, and the homecare episode takes on an entirely new tonality.
HHSM routinely sees inaccurate SOC data that causes hundreds of dollars of underpayment on a per case basis; a UR-based admission eliminates these concerns. Vetting OASIS data is the cornerstone of UR-managed care; assuring inter-reliability and accuracy essential for the patient program. Connecting proportional rehab services to address the Functional elements of the OASIS case-mix findings is the next step, including safety-based intensities to reduce readmissions for falls or other occurrences. Managing these care aspects on an in-episode basis improves clinical results due to the focus on the specifics of functional decline, and decreases the effect of the traditional certification period approach. In addition, all aspects of the UR protocol prepares the Provider for the Healthcare Reform care models as utilization is subdivided by the episodic rewiring of the acute experience.
So the challenge lies ahead for Home Health Providers responding to Case-Mix Rebasing and other elements of the 2014 PPS Final Rule; agencies and clinicians must evolve their care processes to match advancing industry requirements and care models. HHSM clients who install UR in their daily clinical production protocols find they gain control of the Home Health model, delivering new levels of clinical and financial outcomes. Patient care and clinical scores improve as their programming focuses on contemporary Home Health coverage for homebound community clients. And Providers find themselves on the road to success in the future healthcare landscape; delivering efficient care programs poised for the care demands of tomorrow.
Contact HHSM for more information on UR-managed care programs.
Arnie Cisneros, P.T., President of Home Health Strategic Management, is the most progressive speaker in homecare today. He provides coaching and consulting services to providers on a national basis (see www.homehealthstrategicmanagement.com) regarding S.U.R.C.H. and other clinical management protocols for quality outcomes.