Home health providers caring for more patients who are harder to treat generally receive lower 5-Star ratings and pay, while agencies serving easier-to-manage patients earn more money and receive higher Home Health Compare 5-Star ratings. This problem and other findings concern the "Quality of Patient Care Star Ratings Technical Expert Panel" (TEP).
The panel met May 2-3, 2016 in Maryland to discuss data analyses of Home Health Compare's about-one-year-old 5-Star rating system for home health agencies, according to meeting minutes distributed by Abt Associates.
The TEP discussed worries that disparity between the effort required to care for patients and the financial and reputation pay-offs may decrease access to care for challenging patients who aren't expected to improve functionally, such as those with palliative-care needs or who are headed toward hospice, and those with severe chronic conditions.
The group discussed potential solutions that could improve QOPC star-rating-calculation methods without increasing agency data collection burdens. For instance, re-examining relationships between the number of agencies that serve patient populations using patient location instead of agency location may help. And considering how such relationships would change if the most volatile measure, hospitalization data, were omitted from formulas may help expose weaknesses in current methodology.
Doctors and hospital discharge planners may not understand themselves, and may not explain to their patients what agency attributes the 5-star ratings compare between home-health providers, panel members stated. And relevance is challenging to comprehend between data for PS ratings, since they're pulled from a different set of 12 months than the data for QOPC ratings.
TEP-recommended solutions to address problems above:
- Explore adding data sources or quality measures that are not based on self-reported OASIS data, or consider weighting measures differently based on their data source.
- Explore ways of capturing provider improvement or change in ratings on the website so that consumers have a better historical view of a provider’s rating.
- Explore new ways of presenting the information on Home Health Compare to make the information more accessible to consumers.
- Explore whether the risk adjustment algorithm is behaving appropriately given the transition to ICD-10 in October 2015.
- Explore the addition of resource-use measures in the QOPC star rating methodology when these measures are available.
- Apply the HHCAHPs clustering algorithm used in the Patient Survey star rating methodology to the QOPC methodology and examine correlation between the two ratings.
Summary of TEP Member Comments on QOPC calculation methods
TEP members raised concerns about the inclusion of the flu vaccine measure in the QoPC star rating methodology, citing cultural elements and varying state regulations as barriers for home health providers to provide the flu vaccine.
The TEP discussed the QoPC Provider Preview reports, and discussed ways to make the reports clearer and more useful to providers. There was widespread agreement that the reports could be leveraged as quality improvement tools to help providers prioritize their QI efforts based on their agency’s data.
Some TEP-suggested considerations for calculating Quality of Patient Care ratings
- Rotate quality measures included in calculations to guard against data manipulation.
- Explain Provider Preview reports information in clearer language.
- Consider tracking, and maybe eliminating suppression requests to decrease the data lag.
- Use the Provider Preview reports as an educational/quality improvement tool.
- Compare other home health quality resources to the star ratings, or conducting independent site visits to evaluate quality, to evaluate QOPC star ratings validity.
- Consider normalizing measures or ratings by relevant subgroups, instead of nationally, to allow examining Medicare fee-for-service episodes apart from Medicaid or Medicare Advantage episodes.
TEP recommendations on improvements under consideration
- Explore developing and adding maintenance measures without assuming that for some group of patients improvement is not possible. Abt Associates agreed to further analyze and reconvene the TEP for a teleconference to discuss this further.
- Increase episode length to greater than 90 days to identify patients with chronic conditions with maintenance-oriented goals.
- Remove the flu vaccine measure from the QOPC rating methodology
- Consider adding the ED Use without Hospitalization measure or the Improvement in Oral Medication Management measure in the QOPC rating methodology
- When possible, align any new measures across other initiatives such as Home Health Value-Based Purchasing or the Quality Reporting Program
- To improve the functionality of the Home Health Compare website, consider:
- Allowing comparison of more than three agencies at a time
- Allowing consumers to search/sort based on star ratings
- Clarify the meaning of the QOPC star rating
- Allow consumers to search/sort based on categories of interest (i.e. post-surgical, dementia, caregiving issues)
- Improve search tools at Home Health Compare so consumers can filter for their specific needs (i.e. post-surgical, chronic conditions, orthopedic)
- Utilize best practices from the Medicare Plan Finder star ratings to improve the user experience on Home Health Compare
- Add historical performance of an agency on the star ratings so consumers can see how a provider has trended over the past year
- Add a short video or other resources to guide consumer use of star ratings
- Align all quality measures and other incentives, then combine and share in one place.