By: Thomas Wert
Historically, reimbursement for home health services from the US Centers for Medicare and Medicaid Services (CMS) has been largely based on volume instead of value. Due to increased utilization of home health services, home health payments increased by 4.3% yearly from 2016 to 2018. If that trend continues, the increases will nearly double the estimated growth in US gross domestic product (GDP) and will be greater than the increase in overall healthcare spending (3.9%).1 One attempt to target these increases is The Bipartisan Budget Act, which details a new reimbursement model, known as the Patient-Driven Groupings Model (PDGM). PDGM will reduce overall reimbursement in most cases and will also hold home health agencies to specific quality measures, such as hospital readmissions or patients changing home health agencies.2 The focus of home health agencies must shift from providing a high quantity of interactions to high quality interactions, leaving many home health agencies scrambling to adjust to ensure that they meet these new standards. However, an oft-overlooked member of the healthcare team is well-poised to help home health agencies adapt to PDGM – the pharmacist.
One of the key new components of PDGM is a set of 12 clinical groupings, seven of which are classified as “MMTA” or Medication Management, Teaching, and Assessment.2 The opportunity for collaboration with pharmacy is clear as the patients in 58% of the clinical groupings would benefit from being assisted by a professional who is a trained medication expert, i.e., a pharmacist. Many home health agencies do not have the resources to build medication-related services from scratch, but pharmacists already embedded in the healthcare system are poised to jump in and help home health patients. Pharmacists’ training is exclusively centered around medication management, making them among the most qualified and appropriate healthcare professionals to care for the patients found within the seven MMTA groupings.
Home health agencies must use and value each member of the healthcare team in order to provide their patients with the best and most complete care possible. Case management, physical/occupational therapy, medicine, and pharmacy all have roles in the healing process for home health patients. No longer can the goal most home health visits be successfully achieved with input from just one or two healthcare professionals. PDGM is driving home health agencies to treat entire patients and not just one or two illnesses that those patients may have.2 Home health agencies must change their strategy to bring in all of the professionals necessary to make certain that their patients are treated effectively, safely, and holistically. Pharmacists and pharmacy technicians can take ownership of managing the patients’ medications so that other professionals can focus on the areas wherein they are specifically trained. Collaboration between pharmacy and home health will allow each party to utilize its expertise to the best of its ability while providing even better services to patients. All of the individual healthcare disciplines working together can provide patients with the best possible home health experience and optimal health outcomes.
With the new changes (effective January 1, 2020), home health agencies must adjust to better serve their patients. Pharmacists are uniquely trained to effectively manage medication-related health concerns and promote medication adherence, leading to improved overall health outcomes. The PDGM is the biggest change in reimbursement structure that home health agencies have seen in years, and this change cannot be approached without input from each and every member of the healthcare team, including pharmacists.
- National Health Expenditures 2017 Highlights. cms.gov. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf. Accessed January 16, 2020.
- Centers for Medicare & Medicaid Services Patient-Driven Groupings Model. cms.gov. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Overview-of-the-Patient-Driven-Groupings-Model.pdf. Accessed January 23, 2020.
About the Author: Thomas Wert is a third-year pharmacy student at the UNC Eshelman School of Pharmacy and a student intern in the UNC Center for Medication Optimization.