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Home Health & Hospice Week

Quality:

Pay For Performance Waits In The Wings

Published on Fri Dec 17, 2004

Are you ready to stake your reimbursement on your patients' outcomes?

Now that you've finally gotten the hang of the prospective payment system, you'll probably have a whole new - and possibly drastic - payment change to deal with ahead.
 
The Medicare Payment Advisory Commission wants your Medicare payments to be based on OASIS-based patient outcomes. MedPAC is poised to recommend to Congress that home health agencies' payments be linked to performance via outcomes, according to the advisory body's Dec. 9 meeting in Washington, DC.
 
At first, only 1 to 2 percent of payments would hinge on outcomes. But that ratio would increase over time, MedPAC implied at the meeting.
 
The commission plans to recommend functional improvement and stabilization measures as well as clinical improvement measures as a "starter set" for payment consideration, staffer Susan Cheng noted. But adverse events such as rehospitalization and emergency room use and process-based or patient satisfaction measures are candidates for later inclusion, Cheng added.
 
"Pay for performance is a done deal," observes Bob Wardwell with the Visiting Nurse Associations of America. The Centers for Medicare & Medicaid Services already bases a portion of hospital payments on whether they report quality outcomes, and legislation has been proposed to influence nursing home payments based on quality, notes the American Association for Homecare. Groups ranging from the Joint Commission on Accreditation of Healthcare Organizations, the Institute of Medicine and the National Quality Forum have weighed in on pay for performance strategies, AAH notes.
 
"Pay for performance is a concept whose time has arrived, whether or not the health care industry is ready to embrace it," the association says in a message to members.
 
Many home care providers support increased pay for good outcomes, notes Wardwell, a former CMS top official. But "there are real questions about taking money away from everyone when it's not clear that the outcome measurement system is sophisticated enough to redistribute it fairly," he tells Eli.
 
Here are some of the problems with using outcomes to influence HHA payment:

 

  • Accuracy. Agencies' ability to correctly record outcomes via OASIS is still questionable, Wardwell notes. Possible assessment errors could increase when OASIS revisions come down the pike in coming months, AAH says.

     
  • Reliability. No studies of OASIS reliability have been conducted for almost eight years, AAH points out.

     
  • Adverse events. Major refinement of adverse events must take place before they can be used for payment. The measures need to account for situations over which HHAs have no control, AAH insists. And adverse events indicate only possible problems, the association adds.

     
  • Risk adjustment. Agencies still don't believe CMS' risk adjustment of patient outcomes takes all relevant factors into account.
     
    An AAH task force is developing a pay for performance model to recommend to Congress, it says.

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