Medicare Compliance & Reimbursement

Get ready for the statistical clustering technique.

If you thought that surveys were your only headache, just wait until the Centers for Medicare & Medicaid Services’ (CMS’) recently announced new survey-based star rating hits your agency.

CMS held a Special Open Door Forum on May 7 to discuss and clarify issues regarding its initiative to post star ratings for home health agencies (HHAs) based on HHCAHPS patient survey data. This January, the “patient survey star rating” will join the “quality of patient care star rating” that CMS will begin posting in July. 

2 Different Ratings — For Now

Starting in January, Home Health Compare will display a star rating for quality measures based on OASIS and claims data, and a separate star rating based on HHCAHPS patient survey data, confirmed CMS’s Liz Goldstein in response to an HHA’s question. In the call, multiple agencies mixed up the two star rating systems.

“I think that would be a little confusing,” the HHA caller said in the question-and-answer portion of the call. “How are you going to make that clear to patients?”

“It’ll be clear on the website that one is related to the patient experience of care information where the other one is related more to the clinical measures,” Goldstein responded. CMS is still working on the exact language the HH Compare website will use to make that distinction.

You can expect the overall site language to be similar to that for Medicare’s other Compare websites, Goldstein told another caller. Medicare currently has compare sites for hospitals, physicians, nursing homes and dialysis facilities.

Example: For its summary star rating for patient surveys, the Hospital Compare chart says “Patient survey summary star rating. More stars are better” with a “Learn More” link under it. If you click on the link, a lengthier explanation of the ratings includes this statement at the end: “The HCAHPS star ratings compare hospitals to each other. A 1-star rating does not mean that you will receive poor care from a hospital. It means that hospitals that received 2 or more stars performed better on this particular measure of patient experience of care. For this reason, we suggest that you use the star rating along with other quality information when making decisions about choosing a hospital.”

HHAs and their potential referral sources and patients may not have to deal with two separate ratings for long. “Initially when we roll out these star ratings … there will be two summary star ratings,” Goldstein said in the call. “CMS will be working in the future to see if we could eventually create an overall rating. More work would need to be done in that area.”

Drill Down For Individual Measure Scores

In addition to the summary star rating, CMS will post ratings for these measures:

• Care of Patients

• Communication Between Providers and Patients

• Specific Care Issues

• Overall Rating of Care Provided by the HHA.

When the patient survey ratings go live in January, they will cover the HHCAHPS reporting period from July 2014 to June 2015. Agencies must have at least 40 completed surveys from that reporting period to receive a patient survey star rating.

CMS will assign number scores to survey responses, and will adjust star scores for patient characteristics. Then it will use a “statistical clustering technique” to designate the cut off points for each star level, explained Laura Smith with CMS’s HHCAHPS contractor RTI in the forum.

Be aware: The cut off points for each star level may change from quarter to quarter, depending on the star rating levels the categories include. That means even if your HHCAHPS scores stay the same, your star rating could change based on the data from your fellow HHAs.

At least for the time being, Medicare does not plan to include half-stars in its patient survey star rating system, Goldstein said in response to a suggestion to do so by Eric Berger of the Partnership for Quality Home Healthcare. CMS added half-stars to its other HHA rating system after industry protest about the system’s methodology.

CMS based its decision on the data. “We don’t feel, looking at the data and the distribution, that we could create meaningful distinctions across agencies by doing half stars,” Goldstein told forum attendees. “We don’t feel that we would be giving true differences in performance.”

Other topics covered in the forum include:

• Timeline. While the patient survey star ratings will go live in January, HHAs will have a chance to review an earlier version of their data in October, Smith explained. CMS will conduct a dry run covering data from the April 2014-March 2015 reporting period. Agencies can see star ratings on the four measures and survey summary stars in a preview report. “The star ratings will not be publicly reported in October,” Smith emphasized. “This is just an opportunity for agencies to see the stars that would have been assigned based on the data that are still going to be reported on Home Health Compare in that month.”

• Recommendation star omitted. You won’t see a star assigned to the currently reported HHCAHPS measure “Would patients recommend the home health agency to friends and family.”

Why? The recommendation measure had a very similar score to the overall agency rating, Goldstein explained to a caller. CMS doesn’t want to double count very similar measures.

• CAHPS surveys. Remember that the patients your vendor chooses to interview for the CAHPS survey are randomly selected, Goldstein noted. “The agencies are not involved in choosing the patients.” 

Note: Find out more about both star ratings online at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIHomeHealthStarRatings.html. The Forum’s slides that include patient survey star rating calculation details are in the “Downloads” section on that page.