MedPAC’s home care representative tables list of PPS concerns
MedPAC’s home care representative tables list of PPS concerns
By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON The Medicare Payment Advisory Commission (MedPAC) tabled five draft recommendations for home health at its Jan. 13 meeting, including implementation of the Health Care Financing Administration’s (HCFA; Baltimore) prospective payment system (PPS) on Oct. 1, 2000. The recommendations are tentative, however, and Carol Raphael, the home care industry’s representative on the commission, used the meeting to voice several industry concerns.
In its preliminary recommendation to Congress last month, MedPAC opted not to recommend a transition to PPS despite signaling at its meeting in December that it might do so.
In addition to recommending that HCFA implement the proposed PPS, MedPAC plans to recommended that the Secretary of Health and Human Services (Washington) vigorously monitor home health agency behavior under the 60-day episode PPS. The commission also plans to recommend that Congress require the agency to establish a two-part prospective pricing system that blends fixed-episode payments and per-visit payments.
Finally, MedPAC plans to recommend that the secretary refine the home health PPS case-mix adjustment prior to its implementation and use routine data collection to update the case-mix weights over time and use a home health agency wage index to adjust the PPS rates for local wages.
Commissioner John Rowe of the Mount Sinai School of Medicine in New York countered that MedPAC should instead recommend the secretary implement a PPS that includes case mix refinement instead of recommending implementation and refinement separately. "Otherwise, somebody could pick up one [recommendation] and not the other and ignore it," he warned.
Meanwhile, Commissioner Judith Lave of the University of Pittsburgh suggested there might be alternative ways of monitoring beneficiaries at home apart from visits. "It may be the administration of telemedicine," she said. "There can be a number of other things that take place."
Raphael picked up on that theme and said she hopes that in the future, the home care industry will get away from a sole focus on visits. "What we really are going to try to produce is rehabilitation, restoration, or, in some cases, maintenance of the best quality of life possible," she said. "That is what we are trying to measure rather than all of these inputs, which I think will change over time."
She added that expanded use of technology will lead to substitution of technology and said there should be room for innovation.
Raphael also said that while she strongly favors a standardized rate, she does not favor a rate based on discipline because of labor shortages. "Now [the shortage] is on the paraprofessional side," she said. "Before, it was in physical therapy."
Raphael also said home health agencies face two significant costs travel and security that should be accounted for. "Travel costs have a great effect on productivity and your ability to schedule cases and can vary dramatically depending on whether you are in an urban, suburban, or rural community," she said.
Security costs are also significant, she added. Raphael noted that her Visiting Nurse Service of New York employs no fewer than 230 security staff. "I think there are a number of other organizations working in inner-city communities that also have that as a significant factor," she argued.
Finally, she argued that because most clinicians are trained in inpatient settings, home health agencies have to do their own training. "That is a very significant cost for us," she told the panel.
Commissioner Peter Kemper of the Center for Studying Health System Change (Washington) also questioned whether using charges to update the system is feasible and whether charge data accurately reflect intensity of service use.
"I guess I am skeptical about it," he said. "My inclination would be to take that out unless we really had some sense that it was a promising way to go on the update."
The commission will formalize its recommendations to Congress in the spring.
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