A growing body of evidence suggests that Medicare reimbursement policies may compromise access to care for certain groups of beneficiaries due to insufficient payment to providers for their complex needs. In collaboration with VNAA, and with support from Community Health Accreditation Program (CHAP) and the Visiting Nurse Services of New York (VNSNY), the Center for Home Care Policy and Research conducted a study to investigate potential deficiencies in the Medicare Home Health PPS. The purpose of this research was to identify whether characteristics of vulnerable patients (e.g. clinical complexity, low socioeconomic status) are associated with inadequate Medicare reimbursement. The primary goal of this research is to ensure that vulnerable patient populations retain access to the services that they need through sufficient payment to home healthcare providers.
To address this research objective, VNSNY collected the OASIS, claims records, and patient files for more than 96,000 Medicare episodes provided in 2011 by 26 non-profit home healthcare agencies across the United States. The results showed that: Medicare Home Health PPS episodes for clinically complex patients tend to have significantly greater costs relative to reimbursement, 40 percent of episodes for the most vulnerable patients have costs that exceed reimbursement. Clinically complex patients with limited caregiver assistance tend to receive more skilled nursing and less therapy services.
The study found that Medicare Home Health PPS episodes for patients with the following characteristics tended to have significantly lower reimbursement compared to cost:
- Communities with lower median household incomes
- Poorly controlled chronic conditions (e.g. hypertension, diabetes, PVD)
- Treatments including respiratory and IV/ Infusion therapy as well as parenteral nutrition
- Clinically complex post-acute and community admissions
- Serious or frail overall status
- Problematic (higher stage) pressure ulcers
- Urinary and bowel incontinence
- No caregiver assistance for ADL/IADL, medication admin, or medical procedure
Further analyses revealed that episodes for patients with these characteristics tended to receive more skilled nursing visits and fewer therapy visits compared to patients without these characteristics, indicating that their particular service needs may drive costs higher.
Based on these results, VNAA recommend that CMS closely examines how clinical complexity and other characteristics of vulnerable populations affect reimbursement. Many indicators of clinical complexity measured on the OASIS-C are not accounted for in the current Medicare PPS. Revisions to the Medicare PPS should take into account the influence of these factors on skilled nursing utilization and provider costs.
For more information about this study, please contact Robert Rosati at VNA Health Group (Robert.Rosati@vnahg.org) or Molly Smith (firstname.lastname@example.org) at VNAA.
Financial assistance for this study was provided by CHAP.