Section: 2. Proposal for Revision of Case-Mix Weights Page(s):  41004 Column(s): 2 & 3 Paragraph(s): 1+

Excerpted from Fed’l Reg:

While we plan to address their concerns in a more comprehensive way in future years, for CY 2012 we propose to revise the current case-mix weights by lowering the relative weights for episodes with high therapy and increasing the weights for episodes with little or no therapy. It should be noted that we propose to revise the case-mix weights in a budget neutral way. In other words, this proposal would redistribute some HH PPS dollars from high therapy payment groups to other HH PPS case-mix groups, such as the groups with little or no therapy. We believe this proposed revision to the payment weights would result in more accurate HH PPS payments for targeted case-mix groups while addressing MedPAC concerns that our reimbursement for therapy episodes is too high and our reimbursement for non-therapy episodes is too low. Also, we believe our proposed revision of the payment weights will discourage the provision of unnecessary therapy services and will slow the growth of nominal case-mix.

Comment(s):

While I commend CMS’s actions to try to make the case-mix weights more equitable between the “High-Therapy” and the “High-Clinical, Low/No Therapy” episodes, I do so with some reservations.  As you noted above, this is supposed to be a budget-neutral revision (i.e., just a re-allocation of resources from Therapy-Intensive episodes to Clinical-Intensive, Low-Therapy episodes).  However, what checks and balances and/or controls are in place to ensure that this is the case?  I understand that in a revision such as this, ‘budget-neutral’ is an expectation, not a guarantee.  But what concerns me for the industry, is what happens if this does not have a neutral effect on Total Reimbursement, but in-fact, reduces  reimbursement to the industry by 1%; 3%, 5+% because of “unintended consequences”?  When changes are made to this industry, they have historically been those of “subtraction” (e.g., reducing benefits/resources to the industry and thereby to the beneficiaries we serve), not of “addition”.  I do understand that the reverse could happen and the industry be reimbursed at a greater rate than intended and I would imagine that there would quickly be a plan implemented to recover (in some manner or form) that excess reimbursement.  Therefore, what will CMS do if the industry is under-reimbursed because the “budget-neutral” effect of this revision does not hold true?