Maine Sen. Collins Calls on CMS to Revisit PDGM Behavioral Assumption Cut

Situation Report | October 19, 2020

Maine Senator Susan Collins is calling on the U.S. Centers for Medicare and Medicaid Services (CMS) to revisit the home health “behavioral assumption” cuts incorporated as part of the Patient Driven Groupings Model (PDGM), especially in light of the COVID-19 public health emergency and recent evidence that home health spending is substantially lower than CMS’s own projections. 

Her letter joins similar recent outreach by Florida Congressman Vern Buchanan who has also voiced concerns about PDGM. 

The “behavioral assumption” cut — currently at 4.36 percent — has long been a focus of industry advocacy in: HCA’s comments to CMS (including most recently in August),  several grassroots advocacy campaigns, outreach to New York’s Congressional Delegation, and media pieces, like a Times Union op-ed by HCA President Al Cardillo last year.

The “behavioral adjustment” cut is so named because it assumes that providers would alter their coding and other claimsubmission practices in order to achieve higher payments. As Collins and others note, CMS’s assumptions about spending haven’t borne out.

“In light of the lack of definitive data supporting the 4.36 payment reduction and a subsequent third-party analysis suggesting that Medicare home health spending is trending below projections, CMS should revisit the calculation of the behavioral assumption rate reduction,” writes Senator Collins, who also cosponsored legislation — the “Home Health Payment Innovation Act of 2019” — that would require Medicare to institute rate adjustments only upon evidence that home health agency behavioral changes actually occurred (based on real “observed evidence”). The bill would also require the phase-in of any necessary rate increases or decreases to be no greater than 2 percent.

HCA joins our national partners, including the Partnership for Quality Home Healthcare and the National Association for Home Care and Hospice (NAHC), in applauding the Senator’s outreach, and we will be further urging support from New York’s Congressional Delegation for a more responsible approach to payment policy.