Medicare Compliance & Reimbursement

Risk adjustment problems keep 5 NQF-endorsed standards on the sidelines.

Home health providers won't have to worry about publicly reported outcomes that aren't risk adjusted when the major revision to Home Health Compare hits this fall.

That's thanks to a decision by the Centers for Medicare & Medicaid Services not to adopt five of the 15 measures endorsed by the National Quality Forum for CMS' comparison of home health agency patient outcomes.

CMS says it will adopt 10 of the measures NQF endorsed Feb. 7. But it won't take up four outcome-based quality monitoring measures, otherwise known as adverse events.

"We will not post four of the OBQMs in their present format," a CMS official tells MLR. "We will revisit how we can present the data on those in a way useful to consumers." And that probably won't happen any time soon.

The adverse events on pressure ulcers and different types of emergent care aren't risk adjusted, notes John Beard, president of Alacare Home Health & Hospice in Birmingham, AL. As such, they could reflect an agency's patient population more than its quality of care.

Brian Ellsworth of the Connecticut Association for Home Care cheers CMS' decision to exclude these measures from Home Health Compare. "Adverse events were never conceived for the purposes of public reporting," Ellsworth says. They are supposed to be red flags for further investigation, he insists, not quality measures. "Until CMS can cope adequately with ... these low-frequency events," it is wise to keep them off the Home Health Compare list, Ellsworth judges.

Surgical Wound Measure on Hold

In addition to the OBQMs, CMS also is waiting to include a measure on improvement of status in surgical wounds. The agency wants to "take a closer look at the risk adjustment before we go live with it," the CMS official says. It appears the measure will be on a faster track than the OBQMs, however, since it already has a risk adjustment model.

And as announced last December, CMS will remove four measures that NQF didn't endorse, or even propose, for public reporting. The dropped measures address upper body dressing, bathing, toileting and confusion frequency.

Grand total: That leaves HHAs with a total of 10 Home Health Compare measures to live up to once CMS makes its revision this fall.

Keeping the outcomes number small makes for less of a burden on HHAs, notes Stephen Connor with the National Hospice and Palliative Care Organization. Agencies should like this set better than the 28 measures NQF originally considered, notes Connor, who serves on NQF's Home Health Steering Committee.

Risk Adjustment Needs Tweaking

But leaving out adverse events and the surgical wound measure doesn't fix all of the problems with the new outcomes, Ellsworth cautions. "We want better risk adjustment for acute care hospitalization and emergent care," he demands.

Under the current risk adjustment formula, HHAs' outcomes look worse if they have a large proportion of patients dually eligible for Medicare and Medicaid, Ellsworth insists. Dual eligibles who live alone, have multiple comorbidities and have noncompliance with care plans are at much greater risk for hospitalization, he warns.

CMS' current risk adjustment formula doesn't take those issues into account, he criticizes. Thus an agency is penalized for accepting dually eligible patients.

But the problem is "eminently fix-able," Ellsworth maintains. CAHC calls on CMS to improve the risk adjustment formula for those measures before adding the standards to Home Health Compare.

Future implications: With pay-for-performance looming in agencies' future, CMS needs to make its risk adjustment formulas as good as practically possible, urges Bob Wardwell with the Visiting Nurse Associations of America.

Legislators, the Medicare Payment Advisory Commission and CMS seem hot on the P4P model. Once HHAs' payments - not just their reputations - are on the line, providers should be able to expect an accurate reflection of their quality of care, Wardwell notes.

Information on the Home Health Compare changes is at www.cms.hhs.gov/quality/hhqi/Endorsement.pdf.