CMS Requests Information on Home Health Aide Services, Quality Measures

Posted July 12, 2023

In addition to a broad array of policy proposals in the proposed home health rate update rule, the Centers for Medicare & Medicaid Services (CMS) has included two requests for information (RFI): Access to Home Health Aide Services and Principles for Selecting and Prioritizing HH QRP Quality Measures and Concepts under Consideration for Future Years.

In the RFI related to home care aide services CMS is seeking information around the continued decrease in utilization of home care aide services. This request is also likely in response to a law suit the Centers for Medicare Advocacy filed against CMS related to the lack of available home health aide services for high acutely beneficiaries.

CMS is requesting information on the following:

  • Why is utilization of home health aides continuing to decline if the need for these services remains strong?
  • To what extent are higher acuity individuals eligible for Medicare (for example, individuals with multiple co-morbidities or impairments of multiple activities of daily living) having more difficulty accessing home health care services, specifically home health aide services?
  • What are notable barriers or obstacles that home health agencies experience relating to recruiting and retaining home health aides? What steps could home health agencies take to improve the recruitment and retention of home health aides?
  • Are HHAs paying home health aides less than equivalent positions in other care settings (for example, are aides in the inpatient hospital setting or nursing home setting paid more than in home health)? What are the reasons for the disparity in hourly wages or total pay for equivalent services?
  • In what ways could HHAs ensure that home health aides are consistently paid wages that are commensurate with the impact they have on patient care that they provide to Medicare beneficiaries?
  • How effective is the coordination between Medicare and Medicaid to ensure adequate access to home health aide services? Please share insights on the level of utilization of Medicaid benefits by dually eligible beneficiaries for additional home health aide services that are not being provided by Medicare.
  • Are physicians’ plans of care less reliant on home health aide services in the past, or are HHAs less willing/able to provide these services? If so, what are the primary reasons why such services are not provided?
  • What are the consequences of beneficiary difficulty in accessing home health aide services?

The National Association for Home Care & Hospice (NAHC) will be reaching out to providers over the next couple of months to help inform public comments NAHC will be submitting on the proposed rule.

In the RFI on the HH QRP quality measures and concepts, CMS is seeking input on existing gaps in HH QRP measures and soliciting public comment on either fully developed home health measures, fully developed measures in other programs that may be appropriate for the HH QRP, and measurement concepts that could be developed into HH QRP measures, to fill these measurement gaps.

Through the National Quality Strategy, CMS intends to move towards a building-block approach to streamline quality measures across CMS quality programs for the adult and pediatric populations. This “Universal Foundation” of quality measures will focus provider attention, reduce burden, identify disparities in care, prioritize development of interoperable, digital quality measures, allow for cross-comparisons across programs, and help identify measurement gaps.

CMS has identified a set of principles to guide future HH QRP measure set development and maintenance. Specifically, measures incorporated into the HH QRP should meet the following four objectives:

  • Actionability – Optimally, HH QRP measures should focus on structural elements, healthcare processes, and outcomes of care that have been demonstrated, such as through clinical evidence or best practices, to be amenable to improvement. In other words, activities or approaches that contribute to improvement on a measure have been established and are feasible for providers to implement.
  • Comprehensiveness and Conciseness – QRP measures should assess performance of all HH core services using the smallest number of measures that comprehensively assess the value of care provided in HH settings. Parsimony in the QRP measure set minimizes provider burden resulting from data collection and submission.
  • Focus on Provider Responses to Payment – The HH PPS shapes incentives for care delivery. HH performance measures should neither exacerbate nor induce unwanted responses to the payment systems. As feasible, measures should identify and mitigate adverse incentives of the payment system.
  • Alignment with CMS Statutory Requirements and Key Program Goals – Measures must align with CMS statutory requirements, such as the IMPACT Act of 2014 and the Meaningful Measures Framework as well as align across PAC programs where possible.

CMS is seeking input on the following questions:

Principles for Selecting and Prioritizing HH QRP Measures

  • To what extent do you agree with the principles for selecting and prioritizing measures?
  • Are there principles that you believe CMS should eliminate from the measure selection criteria?
  • Are there principles that you believe CMS should add to the measure selection criteria?
  • How can CMS best consider equity in measures?

HH QRP Measurement Gaps

  • CMS requests input on the identified measurement gaps, including in the areas of cognitive function, behavioral and mental health, and chronic conditions and pain management.
  • Are there gaps in the HH QRP measures that have not been identified in this RFI?

Measures and Measure Concepts Recommended for Use in the HH QRP

  • Are there measures that you believe are either currently available for use, or that could be adapted or developed for use in the HH QRP program to assess performance in the areas of: (1) cognitive functioning; (2) behavioral and mental health; (3) chronic conditions; (4) pain management; or (5) other areas not mentioned in this RFI?

CMS also seeks input on data available to develop measures, approaches for data collection, perceived challenges, or barriers, and approaches for addressing challenges.

NAHC is interested in learning from home health providers that may have done work, or have relevant information, on this area to help inform our comments on the proposed rule.

Source: NAHC and CMS

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