Lawmakers taking on PDGM



Proposed legislation would base home health payment on evidence, not assumptions

EDITOR'S NOTE: This article is reprinted from the April issue of The Absolute Agency, a free monthly best practices and home care guide from Home Health Solutions. To sign up for our free e-newsletters, click here. A pair of home health-related bills now making their way through Congress could take some of the sting out of Medicare's new payment model -- and make it possible to provide home care to more patients.

Home care providers are watching closely to see whether two separate bills garner enough support on Capitol Hill to make it out of the U.S. Senate Finance Committee.

A bill with bi-partisan sponsorship aims to remove the home health industry's biggest objection to the new payment model known as Patient-Driven Groupings Model (PDGM) by prohibiting a reimbursement structure based on expected behavior from agencies. The bill would require the Centers for Medicare and Medicaid Services (CMS) to base all payment on hard evidence rather than assumptions about how home care agencies will behave.

The same bill proposes to allow certain homebound status waivers, making it possible for more people to qualify for home care.

A second bill also making its way through Congress would allow nurse practitioners and other non-physician practitioners to certify patients for home care, a move expected to increase the availability of home care in rural areas which may lack primary physicians.

Advocacy efforts

"These two bills are important to home care," said J'non Griffin, owner and president of Home Health Solutions LLC. "We're seeing a united effort from agencies to really get behind them and make certain elected officials understand their value."

Home care advocacy groups such as the National Association for Home Care and Hospice are lobbying hard for passage of these bills and many home care associations are asking home health professionals to contact their representatives in support. What's in S_433? The Home Health Payment Innovation Act, or S_433, would:

1. Ensure budget neutrality. The bill calls for budget neutrality in any payment changes so that future spending would remain consistent with current spending projections. 2. Require data-based payment methodology. One of the primary objections to PDGM from the home health industry has been that it bases reimbursement rates on behavior CMS expects from agencies. The model projects behavior such as upcoding and adding visits to avoid Low Utilization Payment Adjustments (LUPAs).


"S_433 would require payment adjustments to align with patient characteristics, data and evidence rather than expectations," J'non said.

3. Allow eligibility waivers. The bill would allow waivers to homebound eligibility requirements to be issued to beneficiaries in the Medicare Advantage plan or innovative Medicare payment models such as Accountable Care Organizations.

What's in S_296? The Home Health Care Planning Improvement Act, S_296, would authorize non-physician practitioners such as nurse practitioners or physician assistants to certify a patient's eligibility for home health services.

"This would be of real benefit in rural communities lacking physicians," J'non said. "In many cases, a nurse practitioner or a physician's assistant is already serving as the primary care provider role in these communities."

CMS already allows nurse practitioners and physician assistants to conduct the required face-to-face encounter as long as certain requirements are met. This bill would allow them to certify homebound eligibility as well.

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