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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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Response: We recognize that vendors will charge different amounts for the survey, and highly recommends that home health agencies “shop around” for the best value for their agency. The vendor list is available on www.homehealthcahps.org. Currently,

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additional vendors will be approved in the coming months.

Therefore, for the final rule, only HHCAHPS-approved vendors may be used to conduct the HHCAHPS survey for participating home health agencies.

Comment: We received multiple comments about cost to the HHAs, and burden to the HHAs. We received feedback from one commenter who wrote that the HHCAHPS implementation process has not been well explained or thought through in terms of impacts on agencies; a number of commenters were concerned about the financial burden, particularly when reimbursements are decreasing. Another felt that software reprogramming costs and fees were not accurate in the burden estimates. Another commenter asked that CMS clarify whether CMS or HHAs will be paying vendors for their services. A number of commenters wrote that a policy which imposes a mandatory requirement but makes non-compliance subject to a penalty should be funded by CMS.

Another commenter asked that we cap the amount that vendors would charge HHAs and allow HHAs to claim the cost as allowable on their cost reports.

Response: We are fully appreciative of the comments concerning cost burdens to the HHAs with the implementation of

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around” for the best value by researching as many vendors as possible that are listed on the vendor list on www.homehealthcahps.org. We are confident that there are reasonable choices for the HHAs with the current list of vendors. We have limited the initial data collection to Medicare and/or Medicaid patients to reduce the burden of providing administrative data on private pay patients. We will also accept V codes instead of ICD-9 codes if the agency does not have ICD-9 codes for particular patients. All of the administrative variables should be available on OASIS and should require minimal reprogramming for the HHAs to provide patient information to their survey vendors. HHAs will be paying vendors for data collection and processing services and we will be paying for training, technical assistance, oversight of vendors, and data analysis of the HHCAHPS data. In response to the comment that this is a mandatory requirement that makes noncompliance subject to a penalty, we respond that the expanded requirements concerning the collection of quality data were stated in the CY 2008 Home Health Payment Rule and in the CY 2009 Home Health Notice of October 31, 2008. The expanded requirements concerning quality data for home health agencies

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of quality data for similar CAHPS surveys, such as the Hospital CAHPS survey, follow the same model wherein the health care providers pay the approved survey vendors for the data collection costs and we pay for the training, technical assistance, oversight of vendors, and data analysis costs. HHAs are strongly encouraged to report their respective HHCAHPS cost on their cost reports but should note that these costs are not reimbursable under the HH PPS.

Comment: We received comments asking whether HHCAPHS participation is really a voluntary program.

Response: The first year of the HHCAHPS is entirely voluntary. Once data collection is tied to the annual payment update for CY 2012 (voluntary data collection begins October 2010), agencies may choose to participate. Moreover, agencies may still choose not to participate in the survey if they believe that the costs of participating will exceed the two percent reduction the full annual payment update they would otherwise receive.

Comment: While commenters were generally supportive of the survey, and of quality improvement measures in home health, many requested a delay in the implementation of the survey.

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requirement at the same time as the rollout for OASIS-C. They wanted home health agencies to have additional time to select a vendor to conduct the survey for them. Commenters were concerned about not accounting for this expense in their 2010 budgets, and wanted additional time to evaluate and pilot the survey on their own.

Response: CMS has carefully considered the comments it received, and is delaying the linkage of HHCAHPS data to the quality reporting requirements for the annual payment update by 6 months. This will allow home health agencies to first fully implement OASIS-C before being required to implement the HHCAHPS survey for payment considerations. As such, agencies will be required to do a dry run for at least one month in third quarter CY 2010, and to begin data collection on an ongoing basis in October 2010. With this change, HHAs will be required to submit dry run data from the third quarter of CY 2010 to the Home Health CAHPS Data Center by 11:59 p.m. EST on January 21, 2011.

Similarly, HHAs will be required to submit data for the fourth quarter of CY 2010 to the Home Health CAHPS Data Center by 11:59 p.m. on April 21, 2011. With this delay, HHCAHPS will be a requirement for agencies to receive their full 2012 annual

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As a result of this rule’s final provision to tie the HHCAHPS to the CY 2012 annual payment update (rather than to the CY 2011 annual payment update), home health agencies certified on or after April 1, 2011 will be excluded from the HHCAHPS reporting requirement for CY 2012 as data submission and analysis will not be possible for an agency this late in the CY 2012 reporting period. Agencies should begin HHCAHPS data collection as soon as possible to meet HHCAPS reporting requirements for future years. Additionally, by June 16, 2010, HHAs need to provide CMS with patient counts for the period of April 1, 2009 through March 31, 2010. CMS will post a form that the HHAs will use to submit their patient counts via the website, www.homehealthcahps.org. This requirement pertains only to Medicare-certified HHAs with fewer than 60 eligible, unduplicated patients for that time period. Such agencies would be exempt from conducting the HHCAHPS survey for the annual payment update in CY 2012. Agencies that have fewer than 60 eligible, unduplicated patients would be exempt from data collection from third quarter CY 2010 through second quarter CY 2011.

Comment: We received comments about the HHCAHPS data

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diagnosis. It was proposed in the Protocols and Guidelines Manual and also in CMS training that ICD-9 codes be used in patient mix adjustment to ensure the HHCAHPS results are comparable across agencies. However, commenters wrote that over 40 percent of home health agencies use V-codes to indicate a patient’s primary diagnosis. Home health agencies however, are in agreement that V codes do not accurately reflect the medical conditions of their patient population.

Response: Based on feedback from the proposed rule, we have modified the specifications to allow for the submission of V codes if those are the only available data. However, we strongly encourage the submission of ICD-9 codes if feasible.

The reason for collecting diagnosis codes that are not V codes is to distinguish patients who, because of their underlying condition, may have very different attitudes about the health care they receive and who also may respond very differently to the questions on the HHCAHPS. Prior research has shown that patients rate the care they receive differently based on their characteristics. For example, older patients tend to rate more favorably than younger patients, but sicker patients tend to rate less favorably than relatively healthier patients.

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the V57 rehabilitation codes; however, one has had knee surgery and the other has had a stroke. These two patients will potentially have different perspectives and opinions about the home health care they receive, and these perspectives will affect how they respond to the HHCAHPS survey items. The V code in this example does not indicate the severity of the illness/condition. For this reason, we urge survey vendors to provide ICD-9 codes whenever possible, so that survey results can be statistically adjusted to account for any differences in responses based on patient characteristics. Therefore, for the final rule, we will allow V codes if those are the only available data.

Comment: We received feedback from a commenter that the requirements for HHCAHPS include reporting ADL scores from OASIS, but OASIS is not required for non-Medicare, non-Medicaid patients. HHAs that do perform an OASIS assessment on these patients do not enter the information into their electronic files since HHAs are prohibited from reporting these data to the State repository.

Response: We are appreciative of this comment and for the final rule have limited data collection to Medicare and/or

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ICD-9 data are unavailable for the HHCAHPS patients.

Comment: We received a comment suggesting that we reevaluate patient data submission requirements, and streamline the amount of information essential to the accurate reporting of patient experiences.

Response: We appreciate this comment concerning a reevaluation of the patient data submission requirements for HHCAHPS. Accordingly, we have revised the data submission requirements with two significant changes in this final rule.

The first change is that only Medicare and/or Medicaid patients are in the HHCAHPS. The second change is that HHAs may submit V codes if ICD-9 codes are unavailable.

Comment: We received several comments concerning the survey modes and the need for 300 completed surveys a year. We received several comments that HHCAHPS should only be administered by mail mode to ensure comparability. Similarly, we received requests that HHCAHPS be only available in the telephone mode for comparability. Finally, we received comments that only one survey mode should be accepted for use for HHCAHPS, no matter what the mode choice was, for comparability across all agencies nationally.

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all related to the same goal to ensure comparability of the survey results for all participating HHAs. HHCAHPS, as a part of the CAHPS program, is always striving to ensure comparability in all steps of the survey implementation and analysis of results. We realized that to limit the survey mode to only one type (for example, telephone only) could be limiting the HHAs in choosing survey vendors.

We dealt with a similar issue with the Hospital CAHPS survey, for which several modes of administration were ultimately permitted. While patient responses did vary based on the survey mode employed, it was possible to adjust for these differences statistically. We are therefore conducting a randomized mode experiment to test the effect of using three data collection modes: mail only, telephone only, and mixed mode (mail with telephone follow-up of non-respondents). If the mode experiment suggests that the method of data collection has a significant impact on the survey responses, then we will use the results from the mode experiment to make appropriate adjustments in the reporting of the survey responses. When the mode experiment is concluded and all results, conclusions and recommendations are available, the results as well as the

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official website of the Home Health Care CAHPS survey. In the meantime, for the final rule, the HHCAHPS will allow three survey modes as proposed.

Comment: We received comments that questioned the advisability of requiring a total of 300 completed surveys since this number will have varying statistical validity for small versus large agencies. Further, HHAs serving populations that tend to be poor respondents will be unable to meet this total number, particularly if the agencies themselves are small in size. In addition, commenters were concerned about the validity of data comparing small agencies (that may need to survey 100 percent of the patients in order to meet the required target) with large agencies (which may be able to survey as few as 1 percent of their patients and reach the target).

Response: We understand concerns about the sample size.

In the practice of statistics however, it is established that the sample size in absolute numbers is more important than the proportion of the population surveyed. Surveying a sample of 300 will produce the same level of precision whether the sample is 10 percent, 1 percent or even 0.01 percent of the total population. We understand that 300 may be higher than

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sample (even if less than 300), the less the variability in an agency’s ratings over time. Therefore, in the final rule we are moving forward with the sample sizes for HHCAHPS as proposed.

Comment: We received feedback from a commenter that suggested that CMS base compliance with the requirement on whether HHAs submitted appropriate numbers of patient files for their size, rather than on the number of patients that responded to surveys.

Response: We appreciate this question clarifying whether agencies must submit 300 completed surveys on an annual basis.

In the proposed rule and in this final rule, we emphasized that HHAs should target 300 completes annually which averages about 25 completes a month. However, we equally emphasized that smaller agencies that are unable to reach 300 survey completes by sampling should survey all HHCAHPS eligible patients. We will accept less than 300 survey completes annually if an agency is unable to achieve that number. Compliance is based on whether the agency did the survey and followed the protocols.

It is not based on the number of patients that responded to the survey.

Summary of Final Rule Changes for HHCAHPS

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