The average cost of delivering home health services to Medicare beneficiaries fluctuates by hundreds of dollars from state to state, and the government is paying significantly more for some bundled home-care services than others, according to newly published CMS data.
The federal agency posted a fee-for-service utilization and payment dataset that details how much federal money home health agencies received for patient care in 2013.
While the standard payment per episode of patient care averaged $3,037 nationally, the averages topped $3,200 in Florida, Georgia and Idaho, and dipped to $2,600 in California, Illinois, North Dakota and Texas.
The calculations were derived from more than 6 million claims that accounted for $18.1 billion in federal payments to about 11,000 home health agencies in 2013.
The CMS posted the payment data as part of a broader effort over the past few years to provide greater transparency and support initiatives that improve care delivery and assess costs.
The public file contains information on Medicare payments, services and charges, and is categorized by provider, state and home health resource group.
William Dombi, vice president for law at the National Association for Home Care and Hospice, said the data give the industry and policymakers a more granular understanding of utilization variation across states and providers.
“You can compare by types of episodes and identify anomalies that might indicate whether there is widespread abuse or widespread underutilization,” Dombi said.
Certain patients confined to their homes are eligible to have staffers from home health agencies make residential care visits. Services can include physical, occupational and speech therapy, and social work, nursing and other assisted-care services.
About 3.4 million beneficiaries used home health care in 2012, according to a report from the Medicare Payment Advisory Commission.
Medicare pays for home health services in units of 60-day episodes that capture differences in expected resource use. If a patient receives four or fewer visits during that time period, the provider receives a low-utilization payment adjustment that is paid on a preset dollar amount per visit.
However, patients needing five or more visits are tracked through one of more than 150 home health resource groups (HHRG), depending on the type of clinical care provided, the patient's functionality and number of visits needed. One such HHRG accounted for $1.19 billion in payments, but the CMS fact sheet did not provide more specifics about that group.
More than four home visits in a two-month period can also trigger an outlier payment, a mechanism that pays more to providers caring for the most challenging patients. Facilities can receive a maximum of up to 10% of their total reimbursement as outlier payments.
According to the CMS, Florida, New York and Utah had particularly high levels of outlier claims, with several agencies in those in those states reaching the maximum. A Modern Healthcare analysis, however, also identified about seven providers that had surpassed the maximum, one reaching up to 19%.
While the new data do not explain why some providers and states had more outlier payments than others, the difference could stem from lack of understanding of benefits by patients, providers being in regions with higher rates of chronic conditions such as diabetes and heart disease, or from abuse of the system.
The possibility of fraud and abuse could lead Medicare contractors to target those facilities for audits, Dombi warned. “I'd make sure my documentation to support the claims is 100% perfect,” he said.
Outlier payments above about 5% are generally considered high. A total of 2,030 providers had payments above that mark, with the most in California (379), Florida (590) and Texas (521).
Molly Smith, vice president of policy and Innovation for the Visiting Nurse Associations of America, said she encourages all members to compare their results with others across the nation to inform their performance improvement efforts.
"However, all data must be evaluated in context," she added. "We are looking in more detail to ensure that variations due to underlying factors outside of a provider's control are understood and accounted for when the data is used—either by patients, referring providers or payers.”
