Home Health & Hospice Week

CMS should define ‘unplanned,’ industry tells Medicare officials.

HHAs will need to get used to two more quality measures on rehospitalization starting next year, if the home health prospective payment system rule for 2014 is finalized as proposed.

Refresher: The Centers for Medicare & Medicaid Services proposes adding "Rehospitaliza-tion during the first 30 days of HH" and "Emergency Department Use without Hospital Readmission during the first 30 days of HH," according to the proposed rule published in the July 3 Federal Register (see Eli’s HCW, Vol. XXII, No. 24). CMS would apply the measures to patients who had an acute inpatient hospitalization in the five days before the start of a home health stay. CMS would base both measures on claims, not self-reported data.

Timeline: CMS would start reporting data on the measures to HHAs in 2014 and would publicly report them on Home Health Compare in 2015, it proposes in the rule.

Recently hospitalized patients are at an in-creased risk of hospital use, CMS notes in the rule. "Addressing unplanned hospital readmissions is a high priority for HHS as our focus continues on promoting patient safety, eliminating healthcare associated infections, improving care transitions, and reducing the cost of healthcare," the agency says. "Rates of rehospitalization remain substantial with 14.4 percent of HH patients experiencing an un-planned rehospitalization in the first 30 days of care."

CMS will continue to publicly report agencies’ current ACH and ED measures, which have a 60-day timeframe. "These measures apply to all home health patients and will continue to be useful in selecting a home health agency," the agency says. "The proposed rehospitalization measures will allow HHAs to further target patients who entered HH after a hospitalization."

The California Hospital Association likes the idea of using a shorter timeframe. "Moving to a 30-day interval allows for more informed discussions with acute care and other post-acute partners," the hospital trade group says in its comment letter on the proposed rule.

But the two proposed measures have not received National Quality Forum endorsement, CHA notes. "We were unable to find any testing of the measures in the home health setting," it says. "CHA believes that measures under consideration for public reporting programs should be put forward for review by the NQF so that the measures are vetted for scientific validity, reliability, feasibility and usability — before full implementation and public reporting."

Risk Adjustment Explanation Draws Ire

Commenters are particularly concerned about the risk adjustment for the measures. The measures will include "unplanned, all-cause hospital readmissions," according to the rule. But similar measures for other provider types have specified what "unplanned" means, while this rule does not, says Barbara McCann with Interim Healthcare in the franchise company’s letter commenting on the rule. "’Unplanned’ readmission measures in other regulations clarify the definition of ‘unplanned’ either as a list of ‘planned’ admission DRG codes or diagnoses as in the inpatient acute hospital regulation, or as a statement of clarification that unpreventable, unavoidable cases such as an accident would be excluded as presented in the SNF regulations," McCann observes. "We would support the same degree of clarity by diagnosis or ‘unpreventable’ statement as published in regulations for other settings."

CMS’s description of the measures as "risk-standardized" instead of "risk-adjusted" is also confusing, she adds.

"We request that the algorithm for the 30-day re-hospitalization measure explicitly exclude planned hospitalizations," adds the National Asso-ciation for Home Care & Hospice in its comment letter on the rule.

HHAs Are On Measure Overload, Commenters Tells CMS

Multiple commenters spoke out against CMS retaining the 60-day measures in addition to adding the 30-day measures. "CMS should strongly consider removal of the two similar 60-day measures in the home health program if the 30-day measures are included in the program," CHA urges. "Two competing measures will be confusing for both providers and for the public, and we urge CMS to consider only one measure."

"There are too many measures to be reasonably handled by the typical home health agencies," Interim says in its letter. "We count 54 separate measures in the new OASIS C-1 noted as ‘quality measures.’ We are drowning in data that is difficult to attribute to the wide spectrum of the home health population from which it is abstracted."

Interim suggests narrowing the focus of the measures by selecting certain high-risk and high-cost diagnosis groups for inclusion. "In actively working with hospitals over the time period that their efforts have been concentrated on readmissions related to heart failure, AMI, and pneumonia, the disease focus has allowed us to more quickly identify the inpatient and community physicians and clinicians to target improved care for these patients," the chain relates. And because "these index discharge diagnoses represent the greatest original Medicare expenditure, any improvement that can more quickly be facilitated at the disease level would still offer the greatest savings to Medicare."

Limiting quality measure data by payor source also would help agencies in their improvement efforts, Interim advises.

Keep an eye out: CMS’s decision on the suggestions will be in its home health PPS final rule expected in November (see related story, p. 291, for more information on the rule’s due date).

Note: The proposed rule is at www.gpo.gov/fdsys/pkg/FR-2013-07-03/pdf/2013-15766.pdf. To read the 96 comment letters submitted, go to www.regulations.gov/#!docketDetail;D=CMS-2013-0140 and scroll down to the "Comments" section.