Initial home health outcomes under prospective payment

Health Services Research, Feb, 2005 by Robert E. Schlenker, Martha C. Powell, Glenn K. Goodrich

Overall, most outcome rate changes between the two periods are relatively small (based on either the unadjusted or adjusted PPS rates), although even a small change in percentage rates translates into a large number of patient episodes nationwide. The majority of outcomes relate to functional status as measured by ADLs and instrumental activities of daily living (IADLs). All but one of these measures are risk adjusted, and the adjusted ADL and IADL outcome rates and odds ratios are in most cases higher than their unadjusted counterparts (consistent with the shift toward greater functional dependency in the PPS period suggested in Table 2). All (adjusted) ADL changes are statistically significant except for improvement in bathing, which is close to significance (p = .0502), and all but two ADL improvement and stabilization rates are higher in the PPS period. (The exceptions are significant reductions for improvement in transferring and eating.) The pattern is weaker for IADLs. Most (four of six) adjusted IADL improvement rates are not statistically significant, and the two that are--shopping and telephone use--move in opposite directions. The four significant IADL stabilization rates (using the unadjusted change for management of oral medications) are higher under PPS and the other two are not significant. Overall, for the ADLs and IADLs, most PPS outcome rates are higher than or not significantly different from the pre-PPS rates. An interesting question that this suggests for possible future study is whether the better functional outcomes are owing at least in part to the greater amount of physical therapy provided under PPS.

The changes for physiologic, cognitive, and emotional/behavioral outcomes are less favorable. Although CMS risk models have not been established for 10 of these outcomes, the unadjusted and adjusted odds ratios are very similar for the five with risk models. This suggests that unadjusted outcome rates present a reasonable initial approximation of changes under PPS. For this group of outcomes, the three (unadjusted) stabilization rates all are statistically significant and higher under PPS, but all improvement rates but one are either lower or not significantly different from the pre-PPS rates. The greatest reductions are for the two surgical wound measures, urinary incontinence, and behavioral problem frequency. The change for dyspnea may be positive; the unadjusted odds ratio is significant and the adjusted odds ratio is close to significance (p = .055, see Table 4). However, findings for the stratified dyspnea models, discussed below, suggest that this result may pertain to only a minority of dyspnea cases.

The drop in the surgical wound improvement rates may be because of data quality problems, since providers have had difficulty understanding the wound-related OASIS items. Alternatively, the change may be because of more accurate reporting under PPS. Since the wound item affects the HHRG classification and payment amount, the importance of accurate reporting on wounds increased substantially after PPS implementation. The lower improvement rates under PPS for urinary incontinence and all four cognitive and emotional/behavioral improvement measures may point to areas warranting increased quality improvement attention, particularly since those improvement rates were not high in the pre-PPS period (43-66 percent).