Re: CMS-1224-P - Medicare Program/ Nondiscrimination in Post-hospital Referral to Home Health Agencies and Other Entities (67 Federal Register 70373), November 22, 2002

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Tuesday, January 21st 2003

Thomas A. Scully, Administrator
Centers for Medicare & Medicaid Services
Room 445-G Hubert H. Humphrey Building
200 Independence Avenue
Washington, DC 20201

Dear Mr. Scully:

On behalf of our nearly 5,000 hospitals, health systems, networks, and other providers of care,  the American Hospital Association (AHA) is pleased to submit comments to the Centers for Medicare & Medicaid Services (CMS) on the proposed rule concerning hospital referrals of Medicare patients to home health agencies.  Our members operate more than 2,000 home health agencies (HHA), caring for one-third of the Medicare beneficiaries who benefit from Medicare-covered home health care.

As required by Section 4321 of the Balanced Budget Act of 1997 (BBA), the proposed rule would establish processes for collecting and disseminating referral data, including:

  • the nature of financial interests between hospitals and HHAs and other entities to which they refer;
  • the number of beneficiaries requiring home health services upon discharge; and
  • the percentage of beneficiaries receiving services from an HHA in which the hospital has a financial relationship.

While the implementation of the proposed rule would not require hospitals to submit additional data – a positive aspect of the rule – it will be important to place the reported data in a context that helps Medicare beneficiaries and their families interpret it in a meaningful way.  The key variables that affect hospital discharge choices need to accompany the mandated data in order to provide a more complete picture of home health options that are available in a local area than would be possible if the data is limited to that prescribed by Section 4321.

Patient choice must be fully honored during all aspects of the health care experience.  Patients receiving quality care during an inpatient visit often choose to continue their relationship with a health system by selecting its HHA, thereby maintaining a connection with their caregivers and benefiting from continuity of care.  As such, Section 4321 should not be implemented in a way that implies that patients who receive care from a hospital-owned HHA are being treated inappropriately, have been misguided, or receive lower quality care.  This point is stated in the proposed rule and should be upheld in a sensitive and diligent manner.

Our members are committed to facilitating patient choice upon discharge to an HHA.  This value is demonstrated by attentive implementation of Subsection A of Section 4321, which requires that a list of Medicare-certified HHAs be given to beneficiaries upon discharge.  To add value to this process, the data disseminated under Section 4321 should be augmented with relevant information that enhances its practical utility by telling a more complete story about local home health choices.  Supplemental information can aid families during discharge, which can be a complex and intimidating process, by placing the data within a context that more thoroughly and clearly illustrates the nature of options available.  We suggest this additional information:   

Statements to Provide a Context for Publicly Reported Data.  The following messages provide a useful context for the quantitative information to be provided under the proposed rule, and should be included with the disseminated data:

  • For medically complex patients, care must be provided by an HHA that provides clinically appropriate care given the condition/s of the patient and advanced needs with regard to medical personnel.  For example, patients requiring wound care, tube feeding, multiple therapies, and/or extensive personal needs may have limited options among local HHAs, although on the surface there may seem to be an abundant supply of HHAs. 
  • Physician guidance is often the key factor in the selection of an HHA due to the physician's knowledge of specific patient needs and the unique clinical competencies of local HHAs.
  • Some areas, such as rural communities, have very limited, if any, home health care options.
  • A patient’s previous experience with an HHA is often a key influence in their decision. 
  • A beneficiary’s Medicare+Choice insurer may restrict the HHAs covered by the plan.

Additional Data Should be Reported as a Complement.  In addition to the principles noted above, further information should be presented with the hospital-specific data required under the proposed rule, to the extent that CMS can retrieve such data from current CMS databases and avoid requiring additional reporting by hospitals or HHAs.  The AHA opposes any recommendations that require new data to be submitted by hospitals or HHAs.  Specifically, with regard to the percentage of beneficiaries receiving services from a HHA in which the hospital has a financial relationship, that number can only indicate a relative proportion of referrals in the local market if the total number of Medicare-certified HHAs in the area is also provided.  This is of particular importance for hospitals making home health referrals in communities with few or no HHAs.  It may also be helpful to report total HHA visits and each HHA's share of local Medicare visits to indicate an HHA’s role within its community.  Information to be publicly shared via the Home Health Quality Initiative (HHQI), scheduled for launch in November 2003, may also add value by contributing depth to the data. 

Distribution of the information required under Section 4321 of the BBA would be appropriately accomplished via the Internet, to allow for widespread access to the data by beneficiaries and providers.  The CMS Web site is already a repository of information intended for Medicare beneficiaries, such as quality data related to nursing homes.  In the future, the site will also be the mechanism for reporting data generated by the Home Health Quality Initiative.  Use of this Web site for dissemination purposes would allow for efficient data updates and corrections. 

Thank you for consideration of the above issues.  If you have any questions about these comments, please contact me or Rochelle Archuleta, senior associate director for policy, at (202) 626-2320.


Rick Pollack
Executive Vice President


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