Under the Medicare home health prospective payment system (HH PPS), payments for 60-day episodes are higher for patients with greater care needs as identified by the comprehensive patient assessment tool mandated for use by Medicare home health agencies, the Outcome and Assessment Information Set (OASIS). Since the implementation of HH PPS in 2000, one component of HH PPS has been a "high-therapy case-mix adjustment" (a single payment of approximately $2,500) that is added to the base payment of a 60-day episode if the patient receives at least ten therapy visits in any combination of SLP/PT/OT services.
The Centers for Medicare and Medicaid Services (CMS) describes the proposed rule as the first significant modification of HH PPS since its inception—the proposed elimination of the single payment adjustment for 60-day episodes with at least ten therapy visits. The revision is based largely on the CMS determination that the ten-visit threshold has been an incentive for home health agencies (HHAs) to encourage therapists to render more visits than necessary in order to qualify for the high therapy adjustment. In a sample of recent HHA services (i.e., post-HH PPS), CMS found that for all episodes at or above the therapy threshold of 10 visits, half were concentrated in the ranges of 10 to 13 visits. In contrast, an analysis of the period immediately preceding HH PPS indicated the highest concentration of 60-day periods had therapy in a range of only 5 to 7 visits.
CMS proposes new therapy payment thresholds at 6, 14, and 20 visits for each 60-day episode. After the 6th and 14th visits, payment gradations will occur. For example, during each of the first two 60-day episodes, 6 therapy visits would yield a payment of $500, 7 to 9 visits would be $935, and 10 visits would be $1,375. CMS acknowledges that cases in the 20-visit threshold are rare, but the threshold will ensure access to appropriate treatment in these cases where such intensive treatment is necessary.
As has been the case since the inception of HH PPS, if there are less than five total home health visits in an episode, PPS payment will be bypassed and there will be a fixed payment per visit based on historic per visit costs by discipline. The proposed per visit rate for speech-language pathologists is $125.55 compared with $115.63 for physical therapists and $116.42 for occupational therapists (geographically adjusted).
The base episode payment rate for 2008 is proposed at $2,334 (before case-mix adjustment and before geographic wage index adjustment). The rate is based on a 2.9 percent inflationary adjustment and other negative adjustments in the HH PPS methodology.
The proposed HH PPS rule can be found on the Federal Register Web site. The agency will accept public comments through July 3, 2007. For further information, please contact Mark Kander, ASHA's Director of Health Care Regulatory Analysis, via e-mail at mkander@asha.org or by phone at 800-498-2071, ext. 4139.
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