Home Health & Hospice Week

HHAs already hard at work on outcomes.

The feds can find no reason to complain about home health agencies' care quality when they look at hospital and emergency room visit benchmarks.

So concludes an HHS Office of Inspector General report that analyzes rehospitalizations and emergency department visits for home health patients before and after the prospective payment system took effect. "Increases in readmission rates or emergency department visits could indicate poor quality care," the OIG warns in the new report (OEI-01-04-00160).

The OIG found the rehospitalization rate remained at 47 percent from 2000 (before PPS took effect) throughout the next three years of PPS. The ED visit rate increased slightly from 29 percent in 2000 to 30 percent by 2003. The number of avoidable adverse events also remained very low for home health patients.

The study shows "home care is a bargain with decent quality outcomes in spite of ever lowering reimbursement," notes consultant Regina McNamara with LW Consulting in Harrisburg, PA. "The quality ... is still quite high."

No Fuzzy Math, Rather Different Calculations

These outcome statistics may seem significantly higher than what HHAs are used to seeing, notes Bob Wardwell with the Visiting Nurse Associations of America. In Home Health Compare, the national rehospitalization rate is 28 percent and the national unplanned medical care rate is 21 percent.

The differences are due to the OIG's methodology in counting patients. In forming an overall pool, researchers included beneficiaries who started a new episode and had no home care at least 60 days prior to the start date. Of those, the OIG included only patients who had been discharged from the hospital up to 30 days before admission.

And the rehospitalization or ED visit could occur during the 60-day episode or up to 30 days after the episode ended. "We extended the length of time to capture any beneficiary whose hospital readmission or emergency department visit occurred in the month immediately following the conclusion of his or her home health services," the report explains.

OASIS vs. claims data: OASIS inaccuracies also could account for some of the difference, the OIG notes. OASIS data relies on what agencies record in assessments, while the OIG looked at paid claims data. The Centers for Medicare & Medicaid Services plans to link OASIS and claims data eventually for more accurate patient outcomes, CMS says in a response letter included with the report.

Even though the OIG report numbers differ significantly from the ones agencies usually track for Home Health Compare, they're still useful, McNamara maintains. HHAs can compare themselves to the national benchmark for both sets of numbers, she suggests.

And HHAs will welcome a link between OASIS and claims data, McNamara predicts. OASIS coding mistakes are to be expected. "Agencies should want accurate data to show where they are doing well and where they need improvement," she tells Eli.

Red Flag For At-Risk Patients

Despite holding steady overall, rehospitalization and ED visit rates have increased slightly for certain at-risk populations, the OIG warns in the report. Beneficiaries with a primary diagnosis of renal failure, pulmonary disease or multiple sclerosis showed increases in both rates.

The industry, with the help of the Quality Improvement Organizations, is already hard at work on improving hospitalization and ED visit outcomes, Wardwell notes. Many agencies currently target quality improvement programs specifically toward the at-risk patients the OIG highlights, McNamara says.

Roadblocks: Agencies planning interventions to improve these outcomes often are stymied by their fellow medical professionals, Wardwell notes. Some physicians "resort to rehospitalization or emergency room usage much too readily, despite the efforts of the agency to avoid unnecessary use."

The benchmarks can also point to hospital quality of care as well as HHA care, McNamara adds. Higher rates might indicate "rather too quick and less well thought-out discharges from acute care when patients are not yet stable."

P4P possibilities: These wrinkles should highlight to policymakers that hospitalization and ED visits aren't yet ready for use as the basis of a pay for performance reimbursement structure, Wardwell cautions. Accurate risk adjustment to compensate for the many other factors besides HHA care must be in place first.

"The success of P4P, both in terms of producing the desired outcomes and gaining agency acceptance, will hinge on producing data that genuinely reflects difference in agency performance," Wardwell predicts. The data shouldn't reflect "geographic locality, Medicaid population, physician practice patterns, comorbidities or any of the other factors that impact outcomes beyond the control of the agency." 

Note: The OIG report is at www.oig.hhs.gov/oei/reports/oei-01-04-00160.pdf.