Home Health Agencies-Perspectives on CMSs Quality of Care Evaluation

Home Health Agencies (HHAs), part of the post-acute care segment of the healthcare industry are already feeling the expected pinch from the financial reform hitting them in CY 2023 (Average Medicare Margin for HHAs in 2020 was 20.2%, compare that with Acute Care Hospitals at -8.5% Medicare Margin). Home Health (HH) services are covered under Medicare Part A and as supplemental insurance in Part B and consists of part-time, medically necessary, skilled care (nursing, physical therapy, occupational therapy, and speech-language therapy) that is ordered by a physician. A handful of patients and select HH advocacy organizations are currently in-the-news for suing HHS Secretary Xavier Becerra for who they say is responsible for the department that is initiating policies in limiting their access to the services they are eligible for and covered under Medicare. While CMS is ushering change in the HH industry by incentivizing through payments that aim to value quality over volume, some patients seem to be caught in the middle. Hope that all boats rise to the occasion of the impending transformation of the HH industry, and the end result is accountable, quality care provided at a reasonable cost and help keep Medicare sustainable for years to come.

According to the CMS, "Across the country, most home health agencies fall “in the middle” with 3 stars—delivering good quality of care"

45.5% of Medicare certified HHAs in the United States have a Quality of Patient Care (QoPC) star rating of 3 and over. Medicare beneficiaries are expected to avail home health services through these certified HHAs only or pay for these services themselves.

54.5% of all HHAs in the United States have a QoPC star rating below 3, which means that the HHAs performance was below the average in a nation-wide comparison or have not qualified to receive a rating.

There are approximately 11,482 Medicare certified Home Health Agencies (HHAs) in the United States. CMS evaluates these agencies routinely through a variety of measures from quality, process, outcome, utilization, cost, and patient experience. The outcome of the evaluations via quality of care and patient experience measure domains are separately reported public information, seen as “Star Ratings” for Quality of Patient Care (QoPC) and Patient Survey via HHCAHPS. The ratings range from a min-max of 1-5 (see the list of measures in the "References" section below). CMS specifies that these ratings are attributed to the HHAs based on a comparison of how individual HHA performs in comparison to other like HHAs and therefore there are ranked either lower, same as or higher than their comparisons. This kind of evaluation therefore is dissimilar to the ratings we see of consumer goods in the free market. The takeaway is that these ratings paint a picture of how each HHA is performing in comparison to their peers. CMS further elaborates that a star rating of 3, in the middle is a good average score, anything above that is great and below that is not so great.

Why could a Medicare Certified HHA not receive a QoPC Star Rating?

The Quality of Patient Care (QoPC) Star Rating is based on OASIS (The instrument/data collection tool used to collect and report assessment data by home health agencies is called the Outcome and Assessment Information Set (OASIS) ) assessments and Medicare claims data, updated Qtly. According to the CMS, "All Medicare-certified HHAs may potentially receive a Quality of Patient Care Star Rating. HHAs must have data for at least 20 complete quality episodes for each measure to be reported. To have a Quality of Patient Care Star Rating computed, HHAs must have reported data for 5 of the 7 measures (see the list of measures in the "References" section below) used in the Quality of Patient Care Star Ratings calculation. The current methodology for calculating the Quality of Patient Care Star Rating can be accessed via the Downloads section in Home Health Star Ratings CMS. Each HHA gets provider preview reports showing the Quality of Patient Care Star Ratings and rating calculations about 3.5 months before the ratings are posted."

The number(s) of HHAs relative to the total population of the elderly and the proportion of elderly to the total population within the states across the United States is presented to better understand the picture of access to HHA services to the elderly. This table is an extension of Table 1 in the previous blog-Numiny - Strategies in Population Health Management with the last two columns added to indicate volume of HHAs across the country

Overall, most states show the number of Medicare certified HHAs within their states are in line with the proportion or volume of the elderly within their states.

Exceptions were noted with certain states noted in the last two columns in red font include-MA, OK, CO, LA, NV, KS with higher proportion of HHAs than anticipated and NC, NY, SC, OR, NJ with lower proportion of HHAs than anticipated which could indicate potential access to services issues.

For a review of the most populous states within Tiers 1, 2, 3 and 5, please visit the previous blog-Numiny - Strategies in Population Health Management

32 states out of the total 50 or 64% of the country has the most elderly population and fall within the tiers-1,2,3 and 5

25 out of the 32 states or 52% of the country have between 39 - 76% of the HHAs with either a <3-star rating or no star rating at all from the Medicare. See the analysis presented below

"Blue" Tiers:

High Performing: 70-94% of the HHAs within 15 States -WV, MS, NJ, AL, MD, SC, GA, LA, KY, TN, WA, NC, ID, AR, and UT have their QoPC star ratings that are 3 and over (between 3 and 5)
Needing Improvement: 30-67% of the HHAs within 14 States- AK, MT, VT, OR, NV, MN, IL, NM, CT, IA, ME, HI, NE, and WY have their QoPC star ratings that are under 3 (below the average of their peers for performance measures in quality)
Needing Significant Improvement: 34-65% of the HHAs within 8 States-OH, MA, TX, DE, PA, CO, CA, and MN were not able to get a star rating from the CMS as they were not able to meet the reporting requirements (see the description above)

The "Green" tiers (after the "blue" states described above) fall next in line (descending order) as "Groups" for the descriptions above and the "Yellow" tier states fall below the "Green" groups. Yellow is a positive indicator for the descriptions of star ratings that are under / < 3 and no star ratings at all. This means these states have fewer HHAs with these not so good scenarios. Whereas the opposite is true in the first group with star ratings-3 and over where the States in "Yellow" have between 23-49% of the HHAs (a higher proportion) have a star rating that is either under 3 or have no star rating at all.

In the most populous tiers (1,2,3 and 5) with the elderly in the country, WV, NJ, SC, GA, NC, WA, and UT demonstrate exemplary performance, with 70-94% of HHAs within these states have a QoPC star rating of 3 and over
FL, PA, MI, AZ, OH, CA, TX, NY, IL, VA, ME, VT, DE, MT, HI, NH, RI, WY, SD, ND, AK, OR, CT, IA, and NM in these tiers (1,2,3 and 5) have between 39-76% of HHAs that have a less than 3 QoPC star rating or no star rating at all from the Medicare.

Accountable Care Organizations, Medicare and Medicare Advantage Insurers along with private health plans on the hook or have goals to demonstrate value through cost, access, satisfaction of services rendered could be at a disadvantage when the choice of partnership is limited.

HHAs are at a significant turn in their transformation journeys, either through rapid adoption of technologies and or looking for efficiencies of scale, must accelerate their pace to see safely what is ahead on the path for them.

If you are a HHA, with QoPC ratings below the average or do not have a star rating at all and want to share some of the challenges you are facing, please feel free to write to me at suma@numiny.com

References

QoPC Measures Home Health Star Ratings | CMS

The 7 measures that are part of the Quality of Patient Star Rating are:

Timely Initiation of Care (process measure)
Improvement in Ambulation (outcome measure)
Improvement in Bed Transferring (outcome measure)
Improvement in Bathing (outcome measure)
Improvement in Shortness of Breath (outcome measure)
Improvement in Management of Oral Medications (outcome measure)
Acute Care Hospitalization (claims-based) (outcome measure)

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