Initial home health outcomes under prospective payment

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

The three utilization outcomes shown at the bottom of Table 3 are, as noted above, proxy measures for possible changes in health status not captured by the preceding measures. Under PPS, hospitalization and emergent care rates decreased while the community discharge rate increased. These findings suggest positive changes under PPS and are counter to the hypothesis that fewer visits are likely to lead to more hospitalizations and emergent care. However, it will be important in the future to verily the hospitalization and emergent care results derived from OASIS data against claims data. (We were not able to explore this question because the claims data used for this study pertained only to home health use.) In addition, subsequent Medicare service use (in particular, hospital and skilled nursing facilities use) by home health patients discharged to the community should be compared with the pre-PPS period to determine whether the posthome health use of such services increased.

As noted earlier, six CMS outcome models are stratified, and the PPS coefficients for pooled versions of those models are presented in Table 3. For comparison, Table 4 provides both the pooled and stratified PPS coefficients. (In the table, higher baseline levels indicate greater dependency or severity at SOC.) For three of the outcomes (improved in urinary incontinence and confusion frequency and stabilized in housekeeping), the PPS effects measured by the odds ratios are in the same direction for the pooled model and each stratified model. In contrast, the other three outcomes show mixed results by stratum.

For improved in transferring, the odds ratios for the pooled model and all levels except level 2 are less than one (and the odds ratios for the higher levels are marginally significant). The pooled model result thus reflects the situation for the majority of episodes, as shown by the sample sizes. For stabilized in transferring, the pooled model results also reflect the situation for the majority of episodes (with odds ratios greater than one), although a substantial minority at the least dependent level at SOC (level 0) have a greater likelihood of worsening in the PPS period. For dyspnea, the PPS result is significant only for the lowest initial severity (level 1) and indicates a greater likelihood of improvement under PPS. The odds ratios for the other levels are all less than one but not statistically significant. The pooled model odds ratio is greater than one and, as noted above, close to significance at p = .055. The more favorable outcome under PPS suggested by the pooled dyspnea model thus appears to pertain to the minority (46 percent) of episodes at the lowest baseline severity level.

Although differences exist between some of the stratified and pooled results, the pooled results generally reflect the PPS impacts for either all or most episodes. Dyspnea is the exception; the higher improvement rate under PPS suggested by the pooled model reflects the situation of the minority of episodes at the least severe baseline dyspnea level. Such differential findings suggest that analyzing more outcomes by strata may provide information useful for targeting quality improvement programs on specific SOC severity levels.