Medicare Compliance & Reimbursement

As promised, the Bush administration has taken its health care quality improvement efforts into the home-health arena. Starting April 1, the Centers for Medicare & Medicaid Services will begin publishing results on 11 risk-adjusted outcomes measures for Medicare-certified home health agencies in eight states, Health and Human Services Secretary Tommy Thompson announced Feb. 20.

CMS will go national with the effort in the fall. In the meantime, the results will be available in newspapers and over the Internet in Florida, Massachusetts, Missouri, New Mexico, Oregon, South Carolina, Wisconsin, and West Virginia. Medicare’s quality improvement organizations will work with HHAs to improve quality, and will help disseminate the indicators and explain them to the public.

The 11 measures are a subset of the existing Outcome and Assessment Information Set, or OASIS, that all HHAs already submit to CMS. Many HHAs have complained that collecting the data is too burdensome, and CMS administrator Tom Scully, while praising OASIS in general, said he has tried to address those concerns by reducing the number of OAISIS elements and letting providers collect them fewer times during a care episode. He also said CMS was considering whether it needs to continue collecting OASIS data on private-pay patients. As with prior announcements of a nursinghome quality initiative and a voluntary hospital effort, representatives of consumers, industry, and government followed Thompson to the podium to enthuse about the quality effort and each other.

AARP’s top lobbyist John Rother said he was “delighted” to support “the very important objective of providing consumers with timely and accurate” information, although he noted that, “because home health users are such a vulnerable group, we still need to have our ongoing regulatory oversight programs in place.” Andy Stern, president of the Service Employees International Union, said he hoped that lessons learned in the Medicare arena could be applied “to a growing, more unregulated field, which is Medicaid home care.”

How quickly CMS moves to mandatory reporting for hospitals, Scully said, will depend on the extent of hospitals’ voluntary cooperation, which he characterized as good so far. He said the ultimate goal in the hospital arena — “whether that’s in six months, or two years, or three years” — remains a set of mandatory measures similar to those now in place for nursing homes and HHAs. The only reason CMS hasn’t yet put the same arrangement in place for hospitals is “because we don’t have the database, we don’t have the confidence in the measures, or the risk adjusters, or anything else to do it.”

Focus On Outcome Measures

Four of the OASIS measures to be publicized involve improvements in mobility, such as getting better at walking and getting in and out of bed without help. Four involve improvements in meeting basic daily needs, such as bathing and getting dressed.

Two additional measures relate to medical emergencies, looking at whether the patient had to be hospitalized or needed emergency room care. The last metric gauges mental-health improvement by reference to how often the patient becomes confused. These indicators measure health outcomes, rather than adherence to appropriate clinical processes.

Because process measures are “less controversial” and “not quite as judgmental” Scully said CMS had earlier used those types of measures, for instance in a recently launched voluntary hospital quality initiative.

But he said the availability of OAISIS made settling on outcomes measures easier in the homehealth context, and he added that consumer groups prefer outcomes measures. Rother praised outcomes metrics as “the kind of measures that we know our members understand and care about.”

CMS Director of Quality Measurement Barbara Paul, MD, noted that process measures are sometimes used for the sake of prompt feedback in areas like cancer care, where outcome data may not be available for several years. In contrast, she noted, the 11 OASIS measures would all be manifest by the end of each home-health episode of care.

David Schulke, MD, head of the American Health Quality Association, said QIOs succeeded in helping HHAs improve quality through an “Outcome-Based Quality Improvement” process during a one-year pilot program involving 400 agencies in Maryland, Michigan, New York, Rhode Island, and Virginia. The OBQI approach features a “seamless connection” between outcomes and processes, Schulke explained.

For example, he said, many home-care agencies with high hospitalization rates “found that a lot of patients had cardiac problems; they traced it back further to people who had heart failure.”

Agencies then looked at whether they were daily monitoring weight gain in these patients, and whether the patients knew to first call the home care agency when they felt bad so the agency could investigate remedial steps short of hospitalization. Following this process successfully reduced hospitalization rates, said Schulke.