Home Health & Hospice Week

CMS report serves as an accusation, industry expert says.

You’d better make sure your OASIS functional item coding can pass muster. So indicates a new Medicare Innovation Center report on the Home Health Value-Based Purchasing pilot that wrapped up in 2021.

In the 198-page report, the Centers for Medicare & Medicaid Services reviews findings from the model’s six-year run and final year in 2021. CMS touts that over the course of the program, “Medicare spending decreased $2.63 per day, or 1.9 percent for the home health episode plus the 30 days following, resulting in cumulative savings of $1.3 billion.” Those savings are mostly due to reduce inpatient hospital and skilled nursing facility stays, the report notes.

VBP’s money-saving ability when it ran in nine states from 2016 to 2021 is one of the major reasons CMS expanded the program nationwide with a pre-implementation year in 2022 and its first performance year this year. Those 2023 VBP scores will affect agencies’ rates nationwide for the first time in 2025.

While CMS seems happy to trumpet VBP’s financial success, HHAs may want to pay closer attention to information buried further down in the lengthy document.

“There continues to be a strong pattern of relatively small but positive effects of HHVBP on the Outcome and Assessment Information Set (OASIS)-based outcome measures used to calculate [Total Performance Score] through the end of the original model,” CMS reports. This seems like it would be a positive, pointing to the program’s beneficial impact on patient conditions.

But the report later says “we find that measures of clinical care delivery — including timing, intensity, and type of visits — are unable to substantially explain trends in improvement in functional status.” Instead, “our findings suggest that changes in how HHAs document functional status in the OASIS assessment are an important driver of reported functional status improvements which also has potential implications for the interpretation of these OASIS-based measures.”

More specifically, “this finding reinforces our results in previous annual reports suggesting that changes in how home health agencies complete the OASIS start of care assessment are an important driver of reported functional status improvements,” CMS says. “We previously investigated whether the declines in reported functional status at SOC could be attributed to HHAs seeing a different/sicker case-mix of beneficiaries and concluded that changes in health status could not explain reported functional status declines,” the report adds.

Further, “interviews with agencies suggest there have been changes in agency perspectives on administering OASIS assessments which may also have influenced results,” the report continues.

Conclusion: “If we observe that the delivery of care — in terms of the timing, intensity, or mix of visits — is not associated with improvements in functional status, then instru­mentation (that is, how the OASIS assessment is administered) is a likely driver,” CMS suggests. “This, in turn, could have potential implications for how the evaluation interprets OASIS measures and, ultimately, overall results,” it says.

CMS does leave the door open to more than coding updates at best and upcoding at worst. “What remains unexplained about functional measure improvements over time may reflect influence from other drivers that the data are unable to assess. These drivers could include changes in clinical care unobservable in the data … and additional payer-incentivized or agency quality programs to improve care quality (e.g., improving care coordination, transitions of care, health risk management programs, and reducing missed service delivery) which, in turn, may explain the greater extent of improvement reported between SOC and EOC,” the report allows.

However, “changes in how HHAs train and instruct staff to complete OASIS assessments” is also another possibility, CMS spells out.

The report also touches on how this issue could affect equity among agencies in the program. “To the extent that increased emphasis on OASIS coding and documentation is not uniform across all types of agencies (e.g., more pronounced in large agencies or agencies that are chain-affiliated), but rather correlated with agency resources, then the system risks penalizing certain types of agencies that continue to conduct assessments without modifications, with implications for how payment systems may affect care delivery,” CMS observes.

Bottom line: This report “suggests that CMS is accusing us of upcoding, which is not surprising” considering the agency’s past behavior in home health, the National Association for Home Care & Hospice’s Mary Carr tells AAPC.