Home Health & Hospice Week

From regulatory overreach to distortion of outcomes data, the negative consequences are legion.

Home health agencies and their representatives spend lots of time in their proposed rule comment letters laying out the many, many reasons that all-payer OASIS is ill conceived and should be scrapped. The question is, will Medicare officials listen?

Recap: In its home health 2023 proposed rule issued June 17, the Centers for Medicare & Medicaid Services proposed expanding OASIS data collection to all patients. “For the CY 2025 [Home Health Quality Reporting Period], the expanded reporting would be required for patients discharged between January 1, 2024, and June 30, 2024,” CMS said in the rule published in the June 23 Federal Register. “Beginning with the CY 2026 HH QRP, HHAs would be required to report ... data on all patients, regardless of payer, for the applicable 12-month performance period (which for the CY 2026 program, would be patients discharged between July 1, 2024, and June 30, 2025).”

Among the 900 comment letters received on the rule were scores that roundly criticize the proposal. Some of the most fiery rebuttals question whether CMS even has the authority for such a move.

For example: It “is outrageous to collect [OASIS] on every patient without regard to their acuity,” condemns Bara Alsalaheen from Michigan in his comment letter.

“This will create an additional administrative burden for providers in reporting on so many additional patients” and is “regulatory overreach,” blast officials from Gunderson Health System in La Crosse, Wisconsin, in the system’s comment letter.

“Here we go again with CMS requiring HHAs spend time and effort collecting OASIS data on a segment of the population which does not appear it will be paid for by anyone,” slams CPA John Reisinger with Innovative Financial Solutions for Home Health, in his comment letter. “How can Medicare not pay for activities required by Medicare? This seems unconscionable,” he exclaims.

“There are … serious questions as to whether the OASIS expansion is within the statutory authority of CMS,” observe National Association for Home Care & Hospice officials in the trade group’s comment letter.

“We question whether CMS has met the statutory threshold for expanding OASIS completion and submission for non-Medicare and non-Medicaid patients,” adds The Partnership for Quality Home Healthcare CEO Joanne Cunningham in the lobbying group’s comment letter.

The expansion “seems a bit totalitarian in application,” Reisinger says.

Regulatory encroachment is just one of many reasons HHAs cited in criticizing the proposal. Others include:

• Patient privacy. This expansion “could be seen by many non-Medicare/Medicaid patients as an infringement on their privacy, as the OASIS information is not required for treatment, payment, [or] operations, but rather a requirement from another payer — CMS,” points out Donna Wilhelm with Trinity Health at Home, Livonia, Michigan-based Trinity Health’s home health service line.

“The proposal of making OASIS submission on all patients from all payers is a severe violation,” blasts Ellen Durrence with PHC Home Health in Charleston, S.C. “CMS does not have the need nor the right to receive information on patients that CMS has nothing to do with,” Durrence insists in her comment letter. “This is a definite violation of all HIPAA laws. The patients’ privacy should be honored,” she tells CMS.

Due to such privacy concerns, “would patient level affirmation such as consent or release forms be necessary to submit data to CMS?” asks Katy Barnett with LeadingAge. “Has CMS assessed the burden of this type of patient-level authorization?” Barnett questions in the association’s comment letter.

• Unfunded mandate. Lack of payment for the change was a common point of contention. The expansion “amounts to an unfunded mandate since CMS cannot require payers to increase reimbursement rates,” maintains Kelli W. Davis, owner and administrator of Well-Done Home Care in Jacksonville, Florida, in her comment letter.

“While CMS acknowledges that this will result in a cost of $267 million in 2023 alone, there will be no added reimbursement for agencies to collect this data,” observes Kay Findlay from Kansas in her comment letter. “Non-Medicare payers are not going to increase their payment just because agencies have to collect additional data on their patients,” Findlay stresses.

• Climbing costs. The lack of funding will be even more critical as OASIS costs rise. “Adding commercial insurance to OASIS requirements will only drive agency costs up even more,” Melanie Keller in Tennessee notes in her comment letter. “The tool is time consuming and requires specialized training, thus increasing staff costs and decreasing productivity,” Keller tells Medicare.

The proposal “will create significant additional costs for home health agencies,” underscores Joan Doyle, CEO of Penn Medicine at Home, Penn Medicine’s home health business, in its letter. “It does not reflect a realistic understanding of how much work would be involved documenting every single patient encounter,” Doyle says.

“The proposed OASIS expansion comes at a cost equivalent to 1.7 percent of Medicare home health services revenues,” NAHC highlights.

The costs will be especially high because of the added complexity of the OASIS-E instrument, many agencies point out (see related story, p. 249).

• Apples and oranges. Using OASIS to collect data on non-Medicare and non-Medicaid patients doesn’t make much sense, due to how different the patient populations are, many agencies brought up.

“There are significant differences between non-Medicare/ Medicaid patients and Medicare/Medicaid patients in terms of diagnosis, patient characteristics, and patient outcomes, as well as services needed, and frequency of services authorized,” highlights Jennifer Elder with the Texas Association for Home Care & Hospice in the trade group’s comment letter. “Current risk adjustment models do not account for all of the sources in variation of outcomes across the different payer groups, which means comparisons of agency performance based on data that are aggregated across non-Medicare/Medicaid, Medicare, and Medicaid patients will produce misleading information, particularly if the comparisons are made between agencies with large differences in the quantity of non-Medicare/Medicaid patients,” Elder cautions.

The change will “result in skewed data for patient outcomes,” Findlay predicts.

• Staffing. The crushing workforce crisis many HHAs face will only be exacerbated by shoveling more unnecessary work on their clinicians’ plates, many providers emphasize.

“We project that we would need to hire two additional clinicians to help support the review of our OASIS data, and in particular data associated with our Medicare Advantage, Medicaid, and Medicaid managed care patients,” Penn

Medicine at Home’s Doyle relates. “And … we will need to replace at least some of our non-clinical coders with registered nurses — registered nurses whose salaries will be more than twice those of the people they replace, if not more in light of the current high demand for RNs,” Doyle continues. “This is a significant financial burden, and it would be demanded of the very providers that are doing the most to care for the most vulnerable among us and who have the fewest available resources to invest in collecting additional data when such resources would be far better spent providing more and better care,” she criticizes.