Fact Sheets
SUMMARY OF FINAL HH PPS REFINEMENTS COMPARED TO CURRENT HH PPS PAYMENT SYSTEM
Summary of Final HH PPS Refinements Compared to
Current HH PPS Payment System
(Glossary of Acronyms can be found at bottom of page)
Current HH PPS | Final Rule with Comments |
Home health disciplines included in the National 60-Day Episode rate: · Skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, and medical social services | Home health disciplines included in the National 60-Day Episode rate: · Unchanged |
For eligible beneficiaries under a home health plan of care: · National 60-day episode prospective payment for covered home health services, adjusted for case mix and wage index · LUPA, SCIC, PEP, and outlier adjustments allowed | For eligible beneficiaries under a home health plan of care: · Unchanged
· LUPA, PEP, and outlier adjustments allowed; SCIC adjustment eliminated |
Average case-mix weights per episode: · Since the inception of the HH PPS, the increase in the average case mix, nominal case-mix growth (which is the change that is not due to changes in the underlying health status of Medicare home health patient) is 11.75 percent.
| Average case-mix weights per episode: · To account for the 11.75 percent increase in the nominal case-mix growth, we are finalizing the proposed 2.75 percent reduction of the national standardized 60-day episode payment rate for first 3 years beginning in 2008 and a 2.71 percent reduction in the fourth year, 2011. |
National 60 Day Episode rate ($2,339.00 for CY 2007) · Includes home health market basket increase (3.3% for CY 2007) · Adjusted for case-mix and wage-index | National 60 Day Episode rate ($2,270.32 for CY 2008) · Includes home health market basket increase (3.0% for CY 2008) · Adjusted for case-mix and wage-index, and further adjusted for aggregate changes in case mix for the nominal case-mix growth(2.75 percent reduction per year for the first 3 years, 2008, 2009, and 2010, and 2.71 percent reduction for 2011. |
Home health market basket: · Labor portion = 76.775% · Non-labor portion = 23.225% | Home health market basket: · Labor portion = 77.082% · Non-labor portion = 22.918% |
Case-mix regression model: · Single therapy threshold at 10 visits · Did not account for the timing of episodes
· Single equation model for weight calculation, with a single set of case mix scores and single therapy threshold
· Model r-squared = 0.29, initial episodes, .21 total episodes · Large increase in payment for delivering at least 10 therapy visits in a 60-day episode · 80 case-mix groups | Case-mix regression model: · Therapy thresholds at 6, 14, and 20 visits · Accounts for early episodes (the first or second episode in a sequence of adjacent episodes) and later episodes (third or subsequent episodes in a sequence of adjacent episodes), regardless of whether the same home health agency provided care for the entire series of episodes. · Four-equation model for weight calculation with scores allowed to vary by episode type and with classification of episodes as follows: 1) < 14 therapy visits occurring in early episode; 2) ≥ 14 therapy visits occurring in early episode; 3) < 14 therapy visits occurring in later episode; 4) ≥ 14 therapy visits occurring in later episode · Model r-squared = 0.45
· Gradual increase in payment between first and third therapy thresholds
· 153 case-mix groups |
Case-mix model variables: · M0110 did not exist
· Included M0175 (inpatient facility discharge), M0530 (incontinence) & M0610 (behaviors observed) · Excluded M0800 (injectible medications) · Included M0230/240
· Included M0245
· M0825: included (exists as a “yes”/”no” question as to whether or not the projected number of therapy visits for the episode meet the threshold for a Medicare high-therapy case mix group) · Scores not given for infected surgical wounds, abscesses, chronic ulcers, gangrene, dysphagia, tracheostomy, cystostomy · Did not include gastrointestinal, pulmonary, cardiac, hypertension, cancer, blood disorders, or affective and other psychoses diagnosis groups · Points not given for secondary diagnoses · Points not given for combinations of conditions in the same episode | Case-mix model variables: · Creates M0110 for new item to identify early and later episodes · Excludes M0175, M0530 M0440& M0610
· Adds M0800
· Modifies format of M0230/240 to accommodate changes to payment diagnoses
· M0246 replaces M0245 and now allows for multiple coding for both primary and secondary diagnoses · Includes M0826 and replaces M0825 (identifies the number of projected therapy visits for the episode, which affects the particular case-mix group for which that episode will be grouped) · Includes scores for infected surgical wounds, abscesses, chronic ulcers, gangrene, dysphagia, tracheostomy, and cystostomy.
· Adds gastrointestinal, pulmonary, cardiac, hypertension, cancer, blood disorders, and affective and other psychoses diagnosis groups · Assigns points for some secondary diagnoses · Assigns points for some combinations of conditions in the same episode |
Wage Index: · Routine update based on most recently available pre-floor/pre-reclassified hospital wage index | Wage Index:
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Non-routine supplies (NRS): · Included in national episode rate as a fixed amount of $49.62, updated annually as part of the national episode rate
· Case-mix adjusted as part of the national 60-day episode rate
· Updated annually, as part of the national episode rate, by the home health market basket factor | Non-routine supplies (NRS): · Based on a NRS conversion factor of $52.35. (The original $49.62 from the July 3, 2000 final rule, updated to 2008, adjusted to account for the outlier target of 5%, and adjusted for the nominal change in case-mix) · Case-mix adjusted separately based on 6 NRS severity groups payments ranges from $14.12 to $551 per episode
· Unchanged
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LUPA Adjustment:
| LUPA Adjustment :
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PEP adjustment calculation:
| PEP adjustment calculation:
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Outlier adjustment:
| Outlier adjustment:
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Quality Data Reporting:
| Quality Data Reporting:
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Average case-mix under the current case-mix system, based on 20% sample of 2005 data:
| Average case-mix under the revised case-mix system, based on a 20% sample of 2005 data:
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Glossary of Acronyms
LUPA = Low utilization payment adjustment
SCIC = Significant changes in condition
PEP = Partial episode payment