Home Health & Hospice Week

Ambulation measure problematic too.

The new pay for performance demonstration is likely to reward providers most for hospital and emergent care outcome measures, and that's a big problem.

So said numerous providers and industry representatives participating in the Dec. 13 special Open Door Forum on the P4P demo.

When allocating incentive payments for outcomes, the Centers for Medicare & Medicaid Services and P4P demo contractor Abt Associates plan to pay the most for the measure on acute care hospitalization at 25 percent of the incentive payment pool. They propose to pay the next-most for the measure on any emergent care at 15 percent, while the rest of the measures each will receive 10 percent.

Problem: "Those two measures are not really always reflective of the home health agency action," consultant Judy Adams insisted in the forum. Instead, they often reflect "the practice of physicians and hospitals in an area."

The measure may say more about the physicians' ER referral patterns and the hospitals' excess bed capacity than HHA care quality. "There's nothing the agency can do about that," even when they try to implement outcomes-boosting strategies, stressed Adams, with LarsonAllen based in Charlotte, NC.

The question: One HHA caller asked if hospitalizations unrelated to the reason for home care could be excluded from the demo calculations. An example would be if a patient was a passenger in a car accident. The caller also sought exclusion for planned treatments like chemotherapy.

The answer: No, because there's no practical way to exclude that data. If OASIS doesn't capture it, the demo can't evaluate it, Abt's Henry Goldberg noted.

HHAs have long protested the use of the hospitalization and emergent care measures. That's because of the big influences on the outcomes are out of agencies' control.

Whether CMS and Abt will take those protests into consideration in drafting the final format of the demo remains to be seen. Abt did say that having measures under an agency's control was one of the criteria for selecting them for the demo.

Data Accuracy Questioned

Providers also aren't happy with the inclusion of the measure on ambulation. "Patients can make huge improvements from using a walker to only requiring a single point cane for safety," Adams tells Eli. But "these improvements do not show up because of the scoring limitations in M0700"--the OASIS item on ambulation.

And at least one caller was concerned about the lack of safeguards in the proposed demonstration plan. Richard Block, the CEO of Woodinville, WA-based Assured Home Health & Hospice questioned how CMS and Abt plan to keep providers from gaming the demo for financial gain. For instance, they need to guard against agencies scoring patients low on admittance so their outcomes looked more improved upon discharge, Block cautioned.

"The worst thing in the world is to have a system out there ... that people can figure out ways around," Block said.

"This is an issue we'll have to be aware of," Goldberg said. But the demo largely has to rely in the integrity of the OASIS data HHAs are reporting, he added.

Another caller wondered how the demo would motivate those agencies that already have high patient outcomes to do better. The demo will pay them for what they already are doing, but not to improve, said Steven Lazarus from the Visiting Nurse Service of New York.

And a caller asked whether agencies would have a chance to improve their outcomes over the duration of the demo. CMS and Abt plan to update providers quarterly on where their outcomes stand in the demo, the Abt official said.