LHC Group Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, Sept. 9 -- Keith G. Myers, CEO of the LHC Group Inc., Lafayette, Louisiana, has issued a public comment on the Centers for Medicare and Medicaid Services proposed rule entitled "Medicare and Medicaid Programs: CY 2021 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements; and Home Infusion Therapy Services Requirements". The comment was written on Aug. 24, 2020, and posted on Sept. 4, 2020:

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LHC Group, Inc. ("LHC") submits these comments on the Medicare CY 2021 Home Health PPS Proposed Rule published at 85 Federal Register 39408 on June 30, 2020 (the "Proposed Rule"). Like the Centers for Medicare and Medicaid Services ("CMS"), LHC is committed to ensuring that health care services are provided in the least restrictive, most cost-effective, and most appropriate environment possible. Accordingly, we appreciate this opportunity to respond to CMS' requests for comments on the Proposed Rule.

LHC is a provider of post-acute health care services in 35 states and the District of Columbia with a significant presence in rural areas in the western, southern and central regions of the United States. We provide post-acute care services, including skilled home health, hospice, home and community-based, and long-term acute care hospital services. Our home health services include skilled nursing, in-home rehabilitation, chronic disease management, chronic care coordination, medication management and the provision of care through emerging technologies such as telehealth monitoring. LHC also provides primary care services through our Advanced Care Home Call services by nurse practitioners. These services are provided by a skilled staff of over 32,000 nurses, physicians, therapists, social workers and aides in over 816 locations.

Since 1998, LHC has partnered with hospitals and health systems in post-acute home health care delivery. Today, we are involved with home health and hospice operations with hospitals in over 350 locations across the country. LHC has also been an active participant in several CMS sponsored initiatives to reform the healthcare delivery system. As a result of these experiences we have repeatedly demonstrated our ability to successfully shift patients needing post-acute care away from skilled nursing facilities and other institutional settings into home-based care. During the COVID-19 Public Health Emergency, LHC has successfully implemented focused programs in collaboration with our hospital partners to accommodate discharges of COVID-19 patients to the home instead of skilled nursing facilities. We plan to build on this experience to expand our capabilities to shift patients to home from institutional care during and following the Public Health Emergency.

We found that, during the onset of the pandemic, there was great difficulty for hospital discharge planners to effectively place clinically appropriate patients in skilled nursing facilities for post-acute care. Moreover, patients and their families, as the pandemic spread, became anxiety filled about receiving their post-acute care in skilled nursing facilities (SNF). LHC worked with health systems to review patients with discharge planners, and where appropriate, take patients into the newly developed SNF Diversion Program. We found that many patients that would have otherwise (pre-pandemic) been discharged to a SNF, were now testing the capabilities and appropriateness of discharge to home health. We also found that, the PDGM rates for these, so-called SNF Diversion patients were adequate to cover (in general) the increased costs associated with these more complex patients. These patients required a greater number of in-home clinical visits, more interdisciplinary team meetings, more tele health touches with the patients, and in some cases, tele-monitoring.

We also found that there are still many patients that could be brought home with home health, if there were additional services available, such as transportation, personal care, meals, and a few DME items. Even if there is the availability of some or all of these services to patients (some are covered by the Medicare program), the timing and coordination is critical to be effective in the case of a post-acute discharge.

Three critical learnings from this experience, that is still building today, are 1. Many patients that have gone to, and still are going, to a SNF for post-acute care, and are clinically appropriately cared for in their home with home health; 2. The rates developed for PDGM does an adequate job of accounting for the increased level of acuity of these patients and should not present a barrier for caring for these patients at home; and 3. Many more patients would be able to come home with home health if there were supplemental benefits available to the patients and their caregiver(s).

LHC takes pride in the fact that our home health clinicians are particularly adept at effectively managing beneficiaries with multiple chronic conditions who suffer suboptimal outcomes and are responsible for a majority of Medicare spending. We are also proud that CMS has recognized the quality and value of this benefit to patients, and the value it creates through savings for the Medicare program. The Medicare home health benefit is particularly important to the vulnerable population of homebound seniors who tend to be older, sicker with more chronic conditions, and poorer than all other Medicare beneficiaries./1

LHC is a member of the National Association for Home Care and Hospice ("NAHC"), the Partnership for Quality Home Healthcare (the "Partnership"), and the Alliance for Home Health Quality and Innovation (the "Alliance") and we are actively involved in the preparation of the extensive comments to the Proposed Rule submitted by each of these organizations on behalf of the home health community. In particular we wish to point to the detailed analysis of the initiation of the PDGM payment system during the first four months of 2020 contained in the Partnership's comment letter which is supported by the detailed technical report prepared by Dobson DaVanzo and Associates. We support those comprehensive comments, and offer our additional comments on selected issues in the Proposed Rule in the remainder of this letter.

Behavioral Assumptions and Adjustments

In the CY 2020 Final Rule CMS finalized behavior adjustments of 4.36%, a substantial reduction from the proposed 8.01% adjustment. We thank CMS for considering the home health provider community's comments and reducing the behavior adjustment accordingly.

For the CY 2021 rule, LHC joins with others in the home health provider community, NAHC and the Partnership to call on CMS to reverse its 4.36% behavior adjustments to the home health payments system. The technical report prepared by Dobson DaVanzo for the Partnership (and attached to the Partnership's comment letter), clearly establishes that the assumed coding and LUPA behaviors did not occur during the first four months of 2020. Thus, home health reimbursements have been reduced despite no actual change in behaviors as was assumed by CMS. This is true even for the months of January and February 2020 prior to the full impact of the COVID-19 Public Health Emergency. Based on this work, it is perfectly clear that the LUPA adjustment is no longer warranted. We believe there is a serious lack of budget neutrality between aggregate CY 2020 and CY 2019 home health payments.

To achieve and maintain budget neutrality CMS should fully reverse the 4.36% behavior adjustments imposed for the remainder of CY 2020 and all of CY 2021. If necessary CMS could impose a future budget neutrality adjustment based on actual observations.

Alternatively, at a minimum CMS should reverse that portion of the 4.36% behavior adjustment attributable to LUPAs for CY 2020 and CY 2021.

Proposed CY 2021 PDGM LUPA Thresholds

Like most other home health providers, LHC experienced extraordinary increases in LUPAs during the Public Health Emergency related to COVID-19. Rather than repeat the analysis here, we refer CMS to the Partnership's comments supported by a detailed analysis prepared by Dobson DaVanzo and Associates which quantifies a substantial national increase in LUPAs affecting about a quarter of 30 day payment periods during the months of February, March and April, 2020. The frequency of LUPAs far exceed the frequency assumed by CMS in the CY 2020 Final Rule.

We believe that CMS should adjust its LUPA policy for CY 2021 to reduce the LUPA threshold for all case-mix groups to two visits and reassess the impact during CY 2021.

CMS should reverse that portion of the 4.36% behavior adjustment attributable to LUPAs for CY 2020 and CY 2021.

Homebound Status

LHC appreciates the additional flexibilities provided by CMS related to the definition of homebound status during the public health emergency, related to medical contraindication for a patient to leave the home during the COVID-19 pandemic. Likewise we encourage CMS to continue to explore means by which the homebound status can be waived during the time of the public health emergency and outside of the emergency as a patient preferred and cost effective means for patients to recover at home as opposed to post-acute institutional care. We also suggest that CMS include a description of such flexibility with regard to homebound status in its subregulatory guidance to minimize any delays in its application in the event of a similar public health emergency in the future.

Home Health Prospective Payment System

CMS does not propose any changes to the PDGM case mix system and we thank CMS for refraining from further complicating the home health payment system at this time. We also support CMS' decision not to recalibrate case-mix weights for CY 2021, and to maintain the CY 2020 weights.

However, LHC Group would like to comment on future rulemakings for the PDGM payment model. In the hospital outpatient and ambulatory surgical center Notice of Proposed Rulemaking for CY 2021, CMS proposes the discontinuation of the inpatient only procedure list and proposes to add several new procedures to the ASC procedure list, including total hip arthroplasty. (85 Federal Register 48772, August 12, 2020). Last year we commented expressing concern that the impact of institutional versus community admission sources might dampen the ability of home health agencies to accept patients referred following surgical procedures performed in ambulatory surgery centers, or as hospital outpatient or short-stay procedures. Many of these alternative surgical facilities are now performing total joint replacements on an outpatient basis and this practice will be almost certainly be expanding to Medicare beneficiaries. We propose that CMS classify patients undergoing outpatient surgical procedures as institutional admissions in future PDGM refinements.

As we noted last year, LHC has experienced an increase in home health admissions following total joint replacement from ambulatory or outpatient settings. Previously, the majority of this increase has been for patients covered by private or employer sponsored health insurance. However, CMS recently expanded opportunities for total joint replacement in both hospital outpatient and ambulatory surgery center settings. For instance, CMS removed the total knee arthroplasty from Medicare's Inpatient-Only List effective January 2018. This change allowed total knee procedures to be performed in hospitals in an outpatient setting. In the CY 2020 Hospital Outpatient PPS and Ambulatory Surgery Center final rule, CMS added total knee arthroplasty to the ASC covered procedures list. In that same rule, CMS also removed total hip arthroplasty from the Medicare's Inpatient-Only List, making the procedure eligible for Medicare reimbursement in the hospital outpatient setting. (84 Federal Register 61142, November 12, 2019) Because of these changes we foresee an increase in home health referrals of beneficiaries undergoing total joint replacement from these outpatient settings which would be classified as "community" admissions as PDGM is currently structured. Clearly, beneficiaries undergoing total joint replacement in an outpatient or ambulatory setting share more characteristics with institutional admissions than community admissions. Resource use in these patients is necessarily higher than the average community admission due to the need for additional skilled visits and supplies during the immediate post-operative period. The same could be said of patients admitted from a hospital Emergency Department or from an observation stay. Such patients should be considered institutional admissions for the purposes of PDGM.

CMS should review its classification of institutional admissions and include beneficiaries having hospital outpatient and ASC total joint replacement procedures as institutional admissions. Further, CMS should also consider classifying beneficiaries admitted from hospital Emergency Department and observation stays as institutional to better reflect the resource use for these patients.

Proposed Home Health Wage Index Changes

LHC Group, others in the home health provider community, NAHC, and the Medicare Payment Advisory Commission have annually, and consistently, commented opposing CMS' use of the hospital wage index to establish the home health wage index. Last year LHC submitted extensive comments in response to comment solicitation regarding geographic adjustment, and CMS acknowledged receipt of our comments and stated they would consider them in future rulemakings. LHC greatly appreciates CMS' willingness to consider our comments on geographic adjustment of home health payments in future rulemakings. We believe our extensive comments that included several alternatives to modify the home health wage index to make it more accurate and equitable, including, abandoning the applied pre-floor, pre-classified hospital wage index, adjusting the wage index based on population density, applying the hospital wage indices to home health agencies, and using an 80% Floor as is done for hospice wages as more appropriate measures. We believe these alternatives will make the necessary changes to the wage index for home health to improve accuracy and equity, particularly in CMS' application of payments overall and specifically in rural areas. We stand ready to work with CMS in this process and offer our expertise and resources to assist CMS in assessing, developing and implementing improvements to the wage index.

LHC provides approximately 37% of its home health services to beneficiaries residing in rural areas, and is sensitive to issues affecting rural providers. Once again, LHC wants to stress that rural areas are disproportionately affected by artificially reduced rural hospital wage indices.

Rural areas are also generally less densely populated than urban or suburban areas. In areas with lower population densities, travel costs are increased because of the time and mileage involved in traveling from patient to patient to provide services. Conversely, in densely populated areas, these costs are significantly reduced because of the relative proximity of beneficiaries to the home health agency. The current method of adjusting labor costs using the hospital wage index does not accurately account for increased travel costs and lost productivity in serving rural areas.

Until CMS develops a home health specific wage index, LHC supports CMS' proposal to continue to use OMB's new area delineations in the CY 2020 Home Health wage index as the improved specificity should give some relief to the generally onerous blanket rural wage index in most states.

CMS should consider establishing a floor for home health wage indices, as it did for hospice in 1983, to establish equity in geographic adjustment among provider types. LHC would welcome the opportunity to work with CMS to develop a more equitable geographic adjustment system.

Proposed CY 2021 Home Health Payment Rate Updates

LHC supports CMS' proposal to increase home health payments 2.7% for CY 2021. We also recommend that CMS should carefully consider not reducing this adjustment as was recently done for a similar adjustment to hospice rates. Home health providers have incurred significant additional costs in addressing the issues brought forward by the COVID-19 pandemic, not the least of which was unplanned additional expenses for personal protective equipment. As detailed by the National Association for Home Health and Hospice in its comment letter, these costs are approximately 5% of the thirty day payment amount.

No-pay RAP and Five Day Notice of Admission

LHC recognizes that CMS finalized the no-pay RAP and Notice of Admission (NOA) in the CY 2020 Final Rule. We also recognize that CMS greatly relaxed the requirements for filing of the RAP and NOA to help expedite submissions. However, we remain concerned that the timeframe for submission remains as 5 calendar days. As you are aware, home health providers have had to deal with significant operational difficulties during the ongoing Public Health Emergency related to COVID-19, including difficulty contacting treating physicians. In addition, based on our experience with inconsistent treatment of exception requests by the MACs for hospice NOEs, we suggest that CMS should extend the timeframe for submission of no-pay RAPs in CY 2021 to five business days. This will help the provider community better transition from the current RAP system, to the no-pay RAP system and ultimately to the NOA process.

For FY21 and to transition to the NOA, we recommend CMS allow for a 5-business day timeframe for the submission of all no-pay RAPs.

Rural Add-On Payments for CYs 2020 through 2022

LHC provides approximately a third of its home health services to beneficiaries residing in rural areas. We recognize that CMS is statutorily required to continue the phase out of the rural safeguard and cannot make any administrative changes to the scheduled phase out.

However, we also note that the rural safeguard may no longer be necessary if CMS implements wage index floor or an improved wage index adjustment that takes into account the higher costs of providing services in rural areas as discussed above and in our comment from last year's rule.

LHC does not object to the methodology used by CMS in implementing Section 50208 of the Bipartisan Budget Act of 2018. However, we request that CMS join with the home health community in asking Congress to modify and reauthorize the three percent (3%) rural safeguard for all rural counties to ensure access to home health services by Medicare beneficiaries residing in rural areas. In the alternative, we recommend that CMS exercise its discretion and adopt a wage index floor of 0.8 for the home health wage index.

The Use of Technology Under the Medicare Home Health Benefit

LHC appreciates CMS' willingness in the IFC to add additional flexibilities to home health agencies permitting them to utilize telecommunications systems to provide services that are not substituted for in-person visits, and for visits that are not related to payment or eligibility.

We also appreciate CMS' permitting providers to claim costs of telecommunications systems on the Medicare cost report which will assist in reimbursement in the future. LHC and most of our peers found that permitting telehealth face to face encounters originating from the patients' homes was a very helpful waiver during the PHE, and suggest CMS consider making that permanent which would facilitate access to care for homebound beneficiaries.

Since the expanded permitted uses of technology and telecommunications are not separately reimbursed or used for eligibility purposes, we suggest that CMS should explicitly clarify that audio-only services are also permitted as specified in the plan of care. Audio only visits have been permitted during the PHE, but it is not clear that audio only telecommunications equipment can be included as costs under Sec. 409.46(e).

Conclusion

LHC appreciates the opportunity to comment on CMS' proposals for the CY 2021 Home Health Prospective Payment System. We hope that you will carefully consider the comments provided by us, as well as the extensive comments to be submitted by the National Association for Home Care and Hospice, the Alliance for Home Health Quality and Innovation, and the Partnership for Quality Home Healthcare. LHC would welcome the opportunity to continue to work with CMS to develop improvements and refinements to the PDGM model and the home health wage index in order to ensure beneficiaries' maintain access to home care services

Thank you for your careful consideration of these concerns and issues. Please contact Mr. Richard MacMillan of LHC Group at 337-233-1307 or by email at: [email protected] if you have any questions regarding our comments.

Sincerely,

LHC Group, Inc.

BY: Keith G. Myers, CEO

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Footnote:

1/ Home Health Chartbook 2019: Prepared for the Alliance for Home Health Quality and Innovation Avalere Health | An Inovalon Company, October 2019, accessed on August 3, 2020 at: http://ahhqi.org/images/uploads/AHHQI_2019_Home_Health_Chartbook_Final_Updated_10.3.2019.pdf

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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0077-0002

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