Initial home health outcomes under prospective payment

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

DISCUSSION

The generally small changes in outcomes associated with visit reductions suggest a possible gain in system-level cost effectiveness during the first year under PPS (i.e., similar outcomes, lower cost). However, underlying this overall result are varied results across outcomes. The changes for functional measures, particularly improvement in ADLs, are positive. Additional positive findings are the utilization outcome changes, particularly the lower hospitalization rates. However, as mentioned above, subsequent hospitalization and other service use after the home health episode should be examined.

In contrast to the positive changes, the reductions in improvement rates for urinary incontinence and all four cognitive and emotional/behavioral outcomes suggest the possibility that patients with these typically chronic care problems may be more negatively affected by PPS than other patients. Analyses of changes for specific diagnoses could shed light on whether outcome effects under PPS differ by condition, with possibly more negative consequences for chronic care patients. The association between higher improvement rates for ADLs under PPS and more therapy visits should also be further explored.

The outcomes analyzed in this study are those used in the current national outcome reporting system. Additional outcome measures should be developed and analyzed, including aggregate outcomes combining the individual measures currently in outcome reports, variants based on the degree of change (rather than the current dichotomies), and measures using additional information from the OASIS items. Future outcome analyses should also explore the inclusion of risk factors beyond those in the current CMS models.

This analysis pertains to the first few years of OASIS data collection and the first calendar year under PPS. Since data inaccuracies are likely to be more prevalent in new than in mature systems, later time periods should also be studied, in addition, recently introduced quality improvement initiatives such as the OBQI approach are intended to encourage outcome enhancement efforts by home health agencies. The provision of outcome reports to home health agencies by CMS began in 2002 and represents the initial step in the OBQI process. Nationwide training efforts organized and funded by CMS have concentrated on how agencies can use outcome reports to improve care and patient outcomes. Also, public reporting of 11 outcomes began for eight states in May 2003, and was implemented nationally in late 2003 (http://www.medicare.gov/HHCompare). The publicly reported outcomes are a subset of those included in agency outcome reports (see Table 3), and are likely to receive particular attention from agencies as they implement OBQI. Future analyses should assess these and other developments as both PPS and OBQI evolve.