Certain HHVBP Measures Remain Disconnected From On-The-Ground Home Health Care Delivery

The Home Health Value-Based Purchasing (HHVBP) Model is one of the Center for Medicare and Medicaid Innovation’s (CMMI) only cost-saving successes, which is why it was expanded nationwide on Jan. 1, 2023.

Just six of 49 CMMI payment demonstrations have produced savings, with HHVBP standing out in a major way. HHVBP is expected to save hundreds of millions of Medicare dollars on a yearly basis moving forward.

The HHVBP demonstration alone saved the Centers for Medicare & Medicaid Services (CMS) $1.38 billion. Some home health providers believe those savings – as well as future savings in the expanded model – should be shared with them.

That doesn’t seem to be in the cards. But quality home health agencies do stand to benefit, at least to a certain extent. Those performing above the 50th percentile under the model get positive payment adjustments up to 5%. Those performing below that threshold see a negative payment adjustment, however, of up to 5%. The first performance year was 2023.

All the while, CMS continues to change the HHVBP model, implementing tweaks yearly that raise provider eyebrows.

“The one [change] that’s scary is the OASIS-based discharge function score; it’s a brand new measure,” Healing Hands Healthcare CEO Summer Napier told me in November. “You’re looking at what you expect that patient’s discharge function to be when you submit that score. But a lot of what happens from the time a patient comes on service until they’re discharged is out of our control, right? One of the things that we get held accountable a lot for in home health is everything else that the care team does that’s outside of home health.”

Other parties have their eyes on the model – and CMS’ changes to it – as well.

Recently, a technical expert panel (TEP) dove into HHVBP, and provided subsequent thoughts on its measures’ strengths and weaknesses. The panel’s latest findings and meeting summaries were released in December.

Some of those findings were refreshingly new, while others backed up home health provider gripes.

We dive into those findings in this week’s exclusive, members-only HHCN+ Update.

Reviewing HHVBP adjustments

The TEP is made up of health care experts with diverse backgrounds that catapulted them to “expert” status. There were professors, researchers, front-line workers and business owners on the panel. Many of them had direct experience in home health care.

The panel’s goal was to provide input and advice to CMS on the measures it was considering putting forth in the expanded HHVBP model, viewing things from a provider perspective – and health equity perspective – as well.

The TEP will continue to meet in the future to discuss refinements to the HHVBP model, and it will meet in person once per year and virtually four times per year moving forward.

There were many suggestions from the TEP that seemed worthwhile to share with home health stakeholders, beginning with those tied to health equity.

When the model was expanded, nonprofit home health agencies were immediately concerned. Specifically, they were concerned that they would ultimately be penalized for taking care of sicker, more complex patients. Providing care in underserved and socioeconomically challenged areas could mean less patient improvement during an episode of care, resulting in negative payment adjustments for those agencies.

The TEP warned CMS about the possibility of agencies prioritizing certain patients under the HHVBP model to achieve better scores.

One suggestion was to consider a Health Equity Adjustment (HEA) similar to the one being implemented for skilled nursing facilities in 2027. Under that adjustment, providers could receive “bonus points” added to the total performance score (TPS) depending on their “performance level and share of dually eligible beneficiaries.”

But there was concern from the TEP that would actually exacerbate disparities in the home health setting.

Ultimately, the TEP urged CMS to focus on certain factors with health equity in HHVBP in mind: “The TEP reiterated that caregiver availability, payer source, and history of missed visits are key drivers of patient success in home health and encouraged CMS to consider developing measures related to these factors.”

CMS already adjusted the measures that matter most for HHVBP in the CY 2024 final home health payment rule.

One HHVBP measure CMS plans to introduce – “improvement in dyspnea” – got a reaction from the TEP. Panelists expressed concern that this would be an area difficult for home health agencies to improve on, while also cautioning that improvement could lead to bad motivators.

“The concerns expressed by the TEP about the Improvement in Dyspnea measure did not lead them to support dropping the measure from the expanded HHVBP Model,” the TEP summary read. “Rather, several TEP members stated that they felt the measure of the weight of the measure should be decreased (with a corresponding increase in the weight of the claims and HHCAHPS survey-based measures). They suggested that CMS continue to monitor HHA performance on this measure to ensure that the benchmarks and achievement thresholds are consistent with clinical expectations about how well HHAs can perform on this measure.”

The TEP noted that an “improvement in the management of oral medications” is difficult, too, because it would not apply to all home health patients. Several panelists also recommended reducing the weight of that measure.

The panelists also suggested that HHCAHPS survey-based measures reword questions to ensure that respondents understood they were rating their experience with the home health agency they interacted with.

In terms of the discharge function score touched on above by Napier, panelists were generally supportive of the measure. They did provide caveats, however.

“Several TEP members agreed that it is good that the measure is not focused on improvement, which reduces concern about upcoding,” the TEP summary read. “One TEP member noted that it is important to recognize that not all patients have the same potential to improve, which means that, for some patients, slowing decline or stabilizing is a positive outcome.”

Several panelists also were concerned that the discharge function measure does not include all the activities of daily living elements, such as bathing and dressing, which have been a major focus for home health agencies in the past.

Positive overview

Providers often find that regulators are out of touch with the ins and outs of home health care delivery. Simple adjustments to scoring in HHVBP can both be nonsensical and extremely damaging to a home health business’ bottom line.

While industry stakeholders may believe that their concerns fall on deaf ears at CMS from time to time, it should be reassuring that there are examinations, like the above, being sent directly to the agency.