Section: Case-Mix Measurement Page(s):  40090-90 Paragraph(s): ALL

Excerpted from Fed’l Reg:

Every year, since the HH PPS CY 2008 proposed rule, we have stated in HH PPS rulemaking that we would continue to monitor case-mix changes in the HH PPS and to update our analysis to measure change in case-mix, both real changes in case-mix and changes which are unrelated to changes in patient acuity (nominal). We have continued to monitor case-mix changes, and our latest analysis continues to support the need to make payment adjustments to account for nominal case-mix growth.  etc…..


This is still the same, very biased argument supporting CMS’s/MedPac’s contention of Case-Mix Creep and the industry (not just a handful of agencies, but the entire industry!) gaming the system for sole benefit of increasing reimbursement in unwarranted manners.  And the industry has NEVER been given a fair chance to present its’ counter-argument because the arbiters’ in this matter (CMS/MedPac) have a vested interest contradictory to the industry’s!  I am not saying that there were not agencies out there doing what they could to maximize
reimbursement, exclusive of sound and reasonable medical decisions; but they were the minority; not the industry as CMS/MedPac have Congress believing.  A great deal of this so-called Case-Mix Creep is because the original basis (the denominator) upon which this whole argument is built was flawed from the onset. Programmers have an eloquent phrase that describes this situation aptly; and that is: Garbage In – Garbage Out.

When PPS was being developed and later revised by CMS (previously known as HCFA), the industry was excluded from the design aspect of PPS, and therefore, the group that knew the most about how to manage the industry was excluded from the decision making process; and the industry is still having to pay a heavy price for that decision.   I know that CMS will counter that there were many agencies involved in this development, but that is liken to saying that the test-subjects in a medical trial have an integral involvement in developing what that medical trial is testing.  In discussion with several individuals that were intimately involved in that development process, I was to learn that more often than not, any questions, concerns and errors that they noted throughout the process that they brought to the developers attention were completely ignored.  Therefore, if the foundation upon which the OASIS was developed was flawed, it would be expected that when it was rolled out, there would be significant variations in actual results; but the industry did a poor job in trying to bring this issue forward and making its’ case.