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«DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 409, 424, and 484 [CMS-1560-F] RIN 0938-AP55 Medicare ...»

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We recognize that HH providers compete with the rest of the health care industry for nurses, physical therapists, and other health care personnel. To the extent that the cost structure of the HH industry changes over time, such as a greater share of expenses being devoted to wages and salaries, for example, that change in share is picked up during the rebasing process of a market basket. It has been our experience that the cost structure of the HH industry does not vary substantively from year to year. As a matter of practice, however, CMS periodically rebases its market baskets to reflect updated cost structures. The current HH market basket is based on Medicare cost report data from 2003 and, we believe, reflects the appropriate cost composition of the industry. We will continue to closely monitor the cost structure of the HH industry and will propose to rebase the market basket, as appropriate.

Notably, the final update contained in this rule does reflect the expected competitive wage pressures associated with hiring

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Comment: One commenter stated support for our proposal to provide the full market basket update of 2.2 percent in CY 2010.

The commenter stated that this measure provides relief to HHAs that have been subject to market basket cuts for several years including a 0.8 percent reduction in the market basket for 2004 (July to December) and 2005, and a full 3.6 percent market basket reduction in 2006 (per provisions of section 5201 of the DRA of 2005).

Response: We appreciate the commenter’s support. We will incorporate the final market basket update of 2.0 percent into the CY 2010 HH PPS rates.

2. Home Health Care Quality Improvement As part of the CY 2010 proposed rule, we proposed to consider OASIS assessments submitted by HHAs to CMS in compliance with HHA conditions of participation for episodes beginning on or after July 1, 2008 and before July 1, 2009 as fulfilling the quality reporting requirement for CY 2010. We proposed to reconcile the OASIS submissions with claims data in order to verify full compliance with the quality reporting requirements in CY 2010 and each year thereafter on an annual

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the reporting requirements would be eligible for the full home health market basket percentage increase. HHAs that do not meet the reporting requirements would be subject to a 2 percent reduction to the home health market basket increase.

In the proposed rule we described the impending transition from OASIS-B1 to OASIS-C. This revision to the current OASIS version B-1 has undergone additional testing, and has been distributed for public comment and other technical expert recommendations over the past few years. CMS received OMB approval to modify the OASIS data set and will require that this new version of OASIS (OMB # 0938-0760) be collected on episodes of care beginning on or after January 1, 2010.

In the proposed rule we also noted that as a result of implementing OASIS-C, we will update Home Health Compare to reflect the addition of the following 13 new process of care


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Also under consideration are three additional process of care measures that may be added to home Health Compare based on results of consumer testing. Those additional process measures


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physician contact during episode Comment: One commenter stated that he believes a six to twelve-month delay in implementation of OASIS-C would be necessary to accommodate a reasonable phase-in of such a significant change in OASIS. The commenter stated that the vendor community reports that it is not yet ready for OASIS-C.

As a result, agencies can neither test the software changes needed nor can they begin training their clinical and information systems staff on the changes. As of mid-September 2009, CMS had not released the final interpretive guidelines for OASIS-C. There is simply not enough time to do all the planning, testing and training needed to successfully implement OASIS-C on January 1. The commenter believed outcome measurement is far too important to be implemented without adequate training and testing, and wrote that changes in OASIS implementation of this magnitude deserve a proper implementation process. He felt that the home health community has waited for many years for some of these changes, so waiting a few more months to do it right would be prudent.

Another commenter stated that our proposal to require home health agencies to transition patient assessment data collection

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an appropriate timeline when proposed. However, he felt that in light of the recently issued version OASIS-C (August 2009) and the fact that guidance and Q&As have not yet been made available, this would no longer be an appropriate target timeline. The commenter wrote that this timeline would not give software vendors and home health agencies sufficient time to complete programming, testing and education of clinicians. The commenter appreciated that CMS is undertaking several venues for educating providers on OASIS-C to ensure that all home health agencies have access to free training, but stated that there are too many unresolved issues to meet a January 1, 2010 implementation date. The commenter requested that CMS delay implementation of OASIS-C implementation until April 1, 2010.

Response: We appreciate the magnitude of the effort required to transition to OASIS-C, but we believe that it will offer substantial benefits, in terms of improved support for agency quality improvement efforts and provision of enhanced quality information for providers and beneficiaries. The new data set also incorporates process of care items that measure agencies' use of evidence-based practices that have been shown to prevent exacerbation of serious conditions, can improve care

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agencies on how to improve care and avoid adverse events. Making these improvements is a high priority for CMS, which is why we have proceeded on a well-considered course of data set development and field testing, solicitation of public comment, and revision of the data set, on a deliberate schedule over the past 4 years. Our experience in field testing showed that agency staff could be trained on the new and modified items in a relatively short period of time, and welcomed the improvements to the data set. We released the post-testing version of the data set in March, 2009, and the initial OASIS Data Specifications on July 1, 2009, so that vendors could begin to develop the needed system changes. CMS has not received feedback from the vendor community to date, relating to lack of readiness for OASIS-C. We believe that software vendors who took timely advantage of the resources made available will be prepared for the OASIS-C transition. In addition, the State systems are being configured to accept OASIS-C as of January 1, 2010, as is the updated home health PPS grouper software. While such a major change will never be easy, we believe that the benefits to be realized and the burdens of delaying the process at this point, and argue for proceeding with this transition as

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instrument is to understand what the new, changed and deleted items are. This information has been available since August.

Agencies will not be introduced to new quality measures until September 2010 and additional resources related to these will be made available. We will shortly be posting the final OASIS-C User Guidance Manual, and we will be offering free training teleconferences through the Medicare Learning Network. We urge all providers or vendors who have questions about OASIS-C or the transition to take advantage of all of the resources that CMS has provided, which can be accessed through the CMS web site, the Quality Improvement Evaluation System (QIES) Technical Support Office (QTSO) web site, and our state OASIS Education Coordinators.

Comment: One commenter stated that it is his understanding that the current number of quality measures available through Outcome-Based Quality Improvement (OBQI) is 41, rather than 54, with plans by CMS to expand to 54 once process measure data are available from OASIS-C data collection. The commenter recognized the value of adding process measures to Home Health Compare as additional consideration by the public in search for home health services. However, the commenter believed that 13

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publicly reported, will only serve to overwhelm beneficiaries.

He wrote that the important considerations related to processes are assessment of need and implementation of interventions.

The commenter recommended that measures related to “plan of care” not be publicly reported since this is information not essential to the agency selection process. He added that current regulations require that all services, regardless professional practice requirements, be included in the plan of care.

Response: We agree that assessment of need and implementation of interventions are important considerations related to processes, but we also believe that proactive planning for appropriate interventions is an indicator of quality care. HHA clinicians play a key role in the formulation of the plan of care and when interventions such as diabetic foot care or falls prevention are stated clearly in the plan of care, they are available for reference by all staff who provide care for the patient, thereby ensuring that efforts are coordinated effectively. The seven process measures related to the plan of care are National Quality Forum (NQF) endorsed measures of

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recommendations for best clinical practice which we believe is an essential piece of the agency selection process.

Comment: One commenter suggested that CMS use caution when selecting indicators which may focus solely on processes that may not have been tested to be predictors of quality.

Response: The new process measures are NQF–endorsed, in addition to extensive testing and evaluation of CMS based on criteria that include, but are not limited to: addressing a national health goal or priority area, consistency with clinical practice guidelines and action-ability of the measures that is, the measures’ susceptibility to experiencing improved outcomes through intervention). CMS will continue to provide meaningful, relevant, timely, and consensus-based measures.

Comment: CMS received several comments supporting the value of adding the new process measures.

Response: We appreciate the industry’s willingness and encouragement regarding adopting these new methods of reflecting the quality of care provided to Medicare beneficiaries.

Comment: One commenter urged CMS to provide guidance to Home Health Agencies on the use and role of physical therapists.

Response: Though we recognize the valuable role of

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process measures as well as the provision of home health care to multiple patient populations including those with wounds, heart failure, and those in need of medication management, we hesitate to make recommendations on issues relating to staff use. Each HHA must review the needs of its patient population and evaluate the best way to achieve the appropriate level of care based on the competency of its staff.

Comment: Several commenters noted that their memberships believe that the OASIS-C instrument is an improvement over the existing OASIS-B1, but that many HHAs still have questions regarding the new tool and request information regarding training on its use.

Response: CMS believes that HHA’s questions have been answered with the release of the OASIS-C Guidance Manual on October 9, 2009, the content of the OASIS-C presentation at the NAHC annual conference on October 10, 2009, and within the National Provider Calls that started on October 22, 2009.

Comment: Two commenters requested a delay in the public reporting of process measures. One requested delay until January 2012 to allow time for implementation, development of

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Response: Process measures are derived directly from OASIS-C data and by nature do not require risk adjustment. We began providing education on OASIS-C starting in October, 2009.

Comment: One commenter requested a delay in the public reporting of process measures until June 1 (no year was included in the request).

Response: CMS plans that the process measures will be reported on Home Health Compare no earlier than October 2010.

Comment: Several commenters expressed concern with specifics related to the addition of the 13 new process measures.

One commenter mentioned the lack of a timeframe for these measures and the perception that some measures (pneumococcal vaccine ever received and depression assessment conducted and influenza immunization received) are above and beyond what an agency is expected to do. One commenter recommended that questions related to “potential medication issues identified” and “timely physician contact” should not be included in public reporting since the outcome of those measures is largely determined by physician response.

Response: We believe strongly that the addition of process

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of care provided to beneficiaries. Process measures assess adherence to recommendations for clinical practice based on evidence or consensus. Measures based on data items that align with those used across other provider settings (such as pneumonia vaccine received) will promote systematic use of evidence-based practices with the aim of improving population health. To a greater extent than outcome measures, process measures can identify specific areas of care that may require improvement and give credit for good care provision. Data related to the process measures will be collected in the OASIS-C instrument beginning January 1, 2010 and the first reports on process measures are projected to be available to agencies in September 2010.

Comment: One commenter requested definitions of various terms used within the process measure descriptions.

Response: The OASIS-C Guidance Manual contains detailed information for the clinician in order to be able to respond to these items accurately.

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