MedPAC readies home care recommendations for Congress
By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON The Medicare Payment Advisory Commission’s (MedPAC; Washington) March Report to Congress will likely recommend several significant changes in the Medicare home health benefit. These changes could include co-pays on home care visits, requirements for independent case managers, and changes that narrow the scope of available home care services and could have a major impact on the industry if adopted by Congress.
As part of the Balanced Budget Act of 1997, Congress merged the Physician Payment Review Commission with the Prospective Payment Assessment Commission to create MedPAC. The permanent advisory panel, which is headed by former Health Care Financing Admin istration (Baltimore) Administrator Gail Wilensky, submits recommendations to Congress each year on proposed changes in the Medicare program.
At its Jan. 15 meeting, MedPAC discussed five draft recommendations: 1) Establish clear coverage and eligibility guidelines in law; 2) Medicare bills should describe services provided during visits; 3) Require independent assessment of need for individuals receiving extended care; 4) Implement beneficiary cost sharing for home health services; and 5) Collect common data elements across post-acute care settings.
All of the draft recommendations discussed at the Jan. 15 meeting were already on the table when MedPAC met in December. In fact, many of them have been on the table for years.
"Many of these proposals, and the discussion around them, have remained substantively unchanged over recent years," National Association for Home Care (NAHC; Washington) President Val Halamandaris wrote Wilensky following the commission’s December meeting. "IPS, physician certification requirements, multiple audits, increased denials, and other concurrent administrative requirements have forced home care providers to carefully consider which patients they can lawfully accept, significantly reduce lengths of stay and visits per patient, and look for other ways to provide care as efficiently as possible," Halamandaris asserted.
At least some commission members acknowledged these changes. "The world has changed because instead of having a payment system whereby people who provided home health services were paid for each visit, there are now limits," said commission member Judith Lave. "In fact, the agency can bump up against its limits, and its payment rates would go down. So that’s where the incentives for these long stays that we were concerned about, in fact, have decreased."
MedPAC’s home health specialist Louisa Buatti told the commission, however, that setting payment rates that create incentives for providers to furnish clinically appropriate high quality care is difficult. "It’s important for payment systems to employ other mechanisms to support the payment rates," said Buatti.
"Current home health eligibility coverage guidelines are "broad and difficult to enforce," she said. "An individual may qualify for the home health benefit if he or she is confined to the home and in need of skilled care as certified by a physician, and once eligible to receive the home healthcare, a beneficiary may receive an unlimited number of services."
Buatti noted that the Secretary of Health and Human Services (HHS; Washington) is required by the BBA to submit a report to Congress on the homebound requirement and to develop normative standards for home health claims denials. "These are important first steps in defining the home health benefit," said Buatti, but she added that, "it is likely that any guidelines will be difficult to enforce without a legislative authority."
Wilensky said she would support this recommendation. "It does seem that a different statutory language, however the Congress wants to write it, would be helpful unless they feel that the existing language, in fact, is to their liking."
The most contentious recommendation addressed by the commission was the proposed requirement for case managers. "Although physicians are technically required to certify medical necessity for home care, decisions about that care are made by the provider subject to Medicare rules," Buatti told the commission. "An independent assessment of need, made in consultation with the physician, could help to ensure that appropriate levels and types of services are provided, consistent with the needs of the patient."
Several commission members questioned how a case manager requirement would be implemented once a prospective payment system (PPS) is in place, particularly if it is a per-episode system. "How does this interface with that system?" asked commission member Peter Kemper. "I think we should be looking ahead." The commission discussed the possibility of a demonstration project in this area to assess its long-term viability. This could be accomplished "on a limited basis in a couple of states," Wilensky suggested.
Commission member William McBain agreed that if payment is ever based on a per-case basis or a DRG model, no outside assessment would be needed. "Presumably you wouldn’t need to have some outside assessment," said McBain. "If it fit at all, it would probably fit in the context of some sort of outlier assessment."
Wilenski remarked that a "reasonable cut-off" for imposing the case manager requirement would be 60 visits. "Having an individual with expertise in this area provide an assessment after 50 or 60 visits would be helpful," said Wilensky, especially for "a small number of [patients] where all the money is spent as frequently happens."
The commission also was divided over the recommendation of a co-pay for home health visits. "The patients who have services from home health agencies are usually older. They’re sicker, and they’re poor," said commission member Anne Jackson. "A co-pay, even if it’s a small one, would impose a burden on these individuals."
But commission member Alice Rosenblatt countered that "general insurance principles" argue in favor of "some cost-sharing." Again, much of the debate hinged on the indeterminate form that PPS will assume. For example, Lave said she would favor a $5 co-pay under the current system or a system that paid a per-diem prospective payment, but that under an episode-based system, she would favor no co-pay.
The home care industry is working aggressively to have a home care representative appointed to the commission. Those appointments will be made by the General Accounting Office (GAO; Washington) this spring. The commission will not meet again prior to the release of its March Report.
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