A proposed rule that updates Medicare home health prospective payment system rates for 2011 would change the assessment frequency for home health care patients. It is unclear, however, who would assess patients receiving more than one type of treatment (e.g., speech-language treatment, occupational therapy, and/or physical therapy). ASHA has submitted comments outlining its concerns about functional reassessment and other issues to the Centers for Medicare and Medicaid Services (CMS).
CMS estimates that the combined policies of the rule—which cover all home health care services, not just speech-language treatment—would decrease Medicare payments to home health agencies by $900 million (4.75%) for calendar year 2011. The proposed rule sets the base payment for a 60-day episode at $2,198, a rate 4.94% lower than the 2010 rate. The proposed rule maintains the three thresholds (six, 14, and 20 total therapy visits) for adjustments to the base rate.
The proposed per-visit amount for individual speech-language pathology visits is $132.66 (geographically adjusted) when the visits in an episode total fewer than five. This rate compares with $122.91 for occupational therapy and $122.09 for physical therapy visits.
Concerns About Functional Reassessment
Of particular concern are regulations concerning functional reassessment. The proposed rule calls for reassessments of the patient's functional abilities on the 13th and 19th visits and at least every 30 days. For patients receiving multiple therapies, however, it does not clarify if the reassessment interval is per therapy or for all therapies combined, and does not state who should conduct the reassessment if all therapies are combined.
In its comments, ASHA raised the following concerns:
- It is clinically inappropriate—and outside the scope of practice according to most state licensure boards—for one discipline to perform a reassessment for another discipline.
- Progress or lack of progress in one discipline cannot be assumed to apply to other disciplines. A patient could be making measurable progress toward goals in speech-language pathology, for example, but not in physical therapy. The functional progress indicated by the reassessment could vary significantly depending on the discipline of the provider conducting the reassessment.
- A patient receiving occupational therapy, physical therapy, and speech-language pathology services would have received only a limited number of treatment sessions from each discipline at the 13th visit. Performing a reassessment in one or all three disciplines after such a short treatment interval is not an effective use of that treatment visit.
To alleviate these concerns, ASHA recommended adding "per discipline" after "at least every 30 days." The 13- and 19-visit intervals would not significantly improve detection of unnecessary care, ASHA commented, and are more difficult to schedule and track than a standard 30-day interval.
Rebecca Skrine is a speech-language pathologist and the rehabilitation services manager at Baptist Hospital East Home Health Agency in Louisville, Ky., as well as a certified home health and hospice executive. She noted that the proposed rule contains additional key points for speech-language services:
- The rule emphasizes the use of objective measurements at admission and at reassessment intervals to measure patient progress.
- Goals must be measurable and functional and directly related to the patient's current illness or condition. The plan of care and assessment must be included in the patient's clinical record.
- Treatment must follow accepted standards of clinical practice.
- If objective measurements at reassessment do not reveal progress toward goals, the SLP together with the physician will determine if treatment is still effective or should be discontinued.
- If treatment is continued, documentation is required that anticipated improvement is attainable in a reasonable and generally predictable period of time.
- If an individual's expected rehabilitation potential would be insignificant in relation to the extent and duration of treatment services required to achieve such potential, treatment would not be considered reasonable and necessary and would not be covered.
ASHA supports the proposed additional requirements for documentation of the patient's clinical record. The additional documentation elements in the proposed regulation reflect the professional standards for the practice of speech-language pathology.
The proposed rule adds one measure to and deletes three measures from the 12 outcome measures posted on Medicare's website, a website that includes detailed information—including outcome measure performance—for every Medicare-certified home health agency in the United States. None of the measures addresses improvement in communication or swallowing. The omission of communication and swallowing items is problematic because although the proposed regulations are designed to curb overutilization of Medicare services, there are no attempts by CMS to prevent underutilization.
ASHA has received reports from SLPs contracted by home health agencies (HHAs) of the HHAs' failures to authorize needed services. If an agency does not have an SLP qualified to provide a service—augmentative and alternative communication services, for example—it neither provides the services nor contracts out to do so. The patient simply goes without services in home health until the 60-day episode ends.
Other underutilization complaints include HHAs refusing referral for a hospital-based videofluoroscopic swallowing assessment or failing to approve additional speech-language treatment visits when the number of visits by other disciplines elevates the patient to a new payment tier.
The proposed rule was published July 23, 2010, in the Federal Register [PDF, 3.2MB]. ASHA's comments are available on ASHA's website [PDF].