Proposed rule would revise Medicare certification requirements for home health agencies.
Organizations that provide home health care services to the elderly and disabled may soon need to meet new requirements in order to receive Medicare or Medicaid reimbursement. The Centers for Medicare and Medicaid Services (CMS) recently proposed a rule that would significantly revise the criteria under which home health agencies (HHAs) qualify for federal funds.
The proposed rule – which is part of a larger quality-improvement effort by CMS – would revise and consolidate existing requirements. In addition, the proposed rule would evaluate HHA performance under four new quality control categories: (i) patient rights; (ii) care planning, coordination of services, and quality of care; (iii) quality assessment and performance improvement; and (iv) infection prevention and control.
According to CMS, requiring providers to concentrate on these four categories will help ensure that home health services are safe, effective, and focused on meeting patient needs. For example, a proposed standard requiring assessment of each patient’s level of risk for re-hospitalization would encourage HHAs to evaluate patients more thoroughly.
CMS’s proposed rule aims to fundamentally shift how it regulates HHAs. Historically, CMS has focused on identifying HHAs that deliver substandard care or violate federal regulations. This “problem-focused approach,” CMS argues, has created an environment where resources are spent “dealing with marginal providers, rather than on stimulating broad-based improvements in the quality of care delivered to all patients.”
The proposed rule would take a different approach. Rather than requiring all HHAs to meet uniform administrative requirements that may “lack adequate consensus or evidence that they are predictive of achieving clinically relevant outcomes for patients,” CMS would instead give HHAs more responsibility for setting goals and addressing quality concerns.
The first new category of quality standards would toughen HHA obligations regarding patients’ rights. Rather than simply requiring HHAs to notify patients of their rights in writing, the new rule would require HHAs to provide both written and verbal notices in “the primary or preferred language of the patient or representative, and in a manner that the individual[s] can understand.” HHAs would also need to provide patients with the contact information for the administrator responsible for responding to complaints.
CMS acknowledges that general requirements regarding patient rights can be complicated because not all patients are able to make decisions about their care. For that reason, the agency is seeking comment on how to balance patient choice with ensuring safety.
The second proposed category of standards, “care planning, coordination of service, and quality of care,” is aimed at ensuring that each patient has a care plan specific to his or her needs and that each plan involves interdisciplinary collaboration between different providers. Every care plan would be required to define measurable outcomes, and a physician would review each plan periodically to ensure patient progress is being made.
Emphasis on measurable outcomes is also evident in CMS’s addition of the “quality assessment and performance improvement” category. Requirements in this area focus on quality control at the agency level and are intended to provide HHAs with tools for conducting organizational quality assessment and developing improvement strategies.
Under the proposed rule, each HHA would develop a quality control plan specifically tailored to its own operations and the needs of its patients. This differs from CMS’s current process-oriented approach, in which all HHAs are subject to a uniform set of standards. According to CMS, the change in approach is needed because HHAs vary in the populations they serve and the services they offer and, in some cases, metrics that deliver meaningful information about one HHA may communicate very little about another.
Rather than imposing uniform standards, the proposed rule would require each HHA, under the supervision of its governing body, to develop its own “effective, ongoing, agency-wide, data-driven [quality assessment] program.”
The final proposed addition to HHA requirements pertains to infection prevention and control. These measures are intended to enhance and expand existing policies and practices where science and medicine have made significant strides. This change reflects CMS’s expectation that HHAs will follow modern “best practices” to avoid the spread of infection.
If adopted, the proposed revisions have the potential to impact more than five million Medicare and Medicaid beneficiaries currently receiving home health care services and approximately 12,500 certified HHAs. As a recent report by the Institute of Medicine suggests, those numbers could grow because demand for home health care will likely continue to rise as more people live into their seventies, eighties, and beyond.
CMS contends that patients can regain independence more quickly when they receive in-home care rather than when they receive treatment at a hospital or nursing facility. Home health services tend to be cheaper, too, according to CMS. However, some researchers and the Medicare Payment Advisory Commission (MedPAC) have questioned the cost-effectiveness of the current system. MedPAC claims that Medicare’s current payment system creates incentives for HHAs to increase the number and duration of patient events requiring home health care.
CMS is accepting comments on the proposed rule until December 8, 2014. The agency specifically requested comments on how the proposed rule could be used to reduce health disparities in vulnerable populations, including those that have historically faced greater obstacles to health care based on their racial or ethnic group, socioeconomic status, religion, gender, sexual orientation, disability status, or geographic location.