Home Health & Hospice Week

Home health is ready for P4P, report to Congress says.

Patient outcomes won't be the only thing setting your pay level under pay-for-performance, if the Medicare Payment Advisory Commission gets its way.

As far back as 2003, the influential advisory body to Congress recommended that Medicare use a portion of payments to reward providers for furnishing high-quality care or improving patient care, MedPAC notes in its June report to Congress. In 2005, the Commission specifically urged Congress to implement P4P for home health agencies.

A ready-made set of patient outcome measures is already available, MedPAC notes in the report. The Agency for Healthcare Research and Quality, the National Quality Forum and the Centers for Medicare & Medicaid Services agree on a core set of measures agencies already report via OASIS. HHAs are likely to see these consensus measures as the first candidates for P4P use, experts predict.

More patients included: But including pro-cess measures is important as well, MedPAC contends in the report. "Unlike measures of functional improvement, process measures could address the quality of ongoing efforts ... to prevent the deterioration of health for patients who are not improving," the Commission says. That means all patients would be represented in the system, not just those who are improving.

Providers also have more control over process measures versus outcome measures, the report notes.

MedPAC stops short of recommending the process "best practices" its expert panel generated on wound care and fall prevention. That may be because MedPAC commissioners expressed reservations about the body developing quality measures itself.  (see Eli's HCW, Vol. XV, No. 13).

Bottom line: Instead, the Commission outlines the three falls prevention best practices and three wound care practices its expert panel offered. And it "encourage(s) CMS to use measurement development experts to translate fall prevention and wound care best practices into process measures and to validate those measures."

HHAs Face Challenges In Quality Measures

While a timeline isn't set, federal officials seem certain that Congress soon will require P4P for HHAs (see Eli's HCW, Vol. XV, No. 13).

P4P fears: "This past year's wrestling with P4P has illustrated that there is a huge gulf between wanting to reward outcomes and knowing how to do it properly," worries Bob Wardwell with the Visiting Nurse Associations of America. Wardwell hopes Congress will allow pilot testing of different home health P4P structures before applying one to the entire industry.

Get going: Providers shouldn't wait for P4P to materialize before addressing patient outcomes. "All HHAs should be working on improving outcomes," urges consultant Ronald Clitherow with LarsonAllen based in Charlotte, NC.

Clitherow hopes MedPAC's recommendations to Congress will help the industry focus more on best practices and outcomes. "As an industry with 7,500 Medicare-certified providers, we are a long way from where we need to be on best practices and creating true value for payers."

The big challenge for home care providers is improving outcomes for elderly patients with multiple chronic conditions and multiple physicians, Clitherow says. Medicare reimbursement currently doesn't encourage disease management or care coordination of these high-risk, high-cost patients.

Medicare coverage policy is another problem providers will face in implementing process measures, Wardwell adds. Currently Medicare doesn't cover the falls prevention practices listed in the MedPAC report because they are preventative, the Commission notes.

"The CMS Administrator promotes prevention on Monday, MedPAC points to falls prevention as a key measure of home health quality on Tuesday and CMS' contractors deny payment for the service on Wednes-day," quips Wardwell, a former top CMS official. "Does anybody see a problem with this picture?"

Note: For a list of MedPAC's process measure best practices, including specific steps for each practice, email editor Rebecca Johnson at rebeccaj@eliresearch.com with "MedPAC Quality Measures" in the subject line.