New Study Calls Home Health Star Ratings into Question

McKnight’s Home Care | By Adam Healy
 
A comparison of agency-reported functional measures and claims-based hospitalization measures raises doubts about the value of star ratings as a means of evaluating home health agency (HHA) quality.
 
The study, published Wednesday in JAMA Network Open, analyzed differences between claims-based and agency-reported outcomes for nearly 23 million patient episodes before and after the introduction of the star ratings system to compare changes over time. The researchers found that observed improvement in agency-reported functional measures had corresponding increases in hospitalization rates and less timely initiation of care. The data included claims-based hospitalization measures (both during the patient spell and 30 days after HHA discharge). Agency-reported functional measures included improvement in ambulation, bathing and bed transferring.
 
“The observed functional improvement was dampened by corresponding increases in more objective measures, such as hospitalizations and declines in timely initiation of care,” study authors Amanda C. Chen, Christina Xiang Fu, PhD, and David C. Grabowski, PhD, wrote. “This raises concern about how HHA-reported outcomes should be interpreted and used to assess quality.”
 
These discrepancies are not a surprise to home care providers. The Centers for Medicare & Medicaid Services uses Outcome and Assessment Information Set (OASIS) survey responses, an agency-reported measure, and medical claims data, to determine agencies’ star ratings. The OASIS portion is not objective, affirmed Mary Carr, vice president for home health regulatory policy at the National Association for Home Care & Hospice.
 
“The disparity in OASIS-based measures [versus] claims-based measures is not surprising,” she said in a statement to McKnight’s Home Care Daily Pulse. “Responses to the OASIS items for the functional measures can be very subjective and influenced by the accuracy of the assessor when completing the item.”
 
“And, as the author(s) noted, data does not capture more recent changes for HHAs, such as the Patient-Driven Groupings Model or nationwide expansion of the Home Health Value-Based Purchasing Model, which might contribute to changes in HHA behavior and performance,” she added. 
 
The study also found that the introduction of the star ratings was associated with sustained increases in the hospitalization rate and functional improvement measures for patients with Alzheimer’s disease, those who are dual-eligible, and those who are Black and Hispanic. 
 
A widening gap between self-reported and objective measures
 
CMS launched the 5-star rating system on Care Compare to provide summary information using the number of stars to denote quality. The system began with a quality of patient care star rating in July 2015 and added a patient satisfaction star rating in January 2016.
Since the introduction of quality of patient care star ratings, the differences between agencies’ self-reported measures of patient improvement and more objective measures has only widened, study co-author Amanda Chen told McKnight’s Home Care Daily Pulse.
“In the pre-period before the star ratings were introduced, we kind of see some of these trends,” she said. “But it’s really magnified after the star ratings were introduced.”
 
Agencies might be incentivized to inflate functional improvement scores on OASIS surveys to achieve higher scores, according to the researchers. 
 
“Once these star ratings were introduced, I think there was an incentive for home health agencies to prioritize perhaps, achieving high performance on some measures that allow them to have a higher star rating,” Chen said. “Particularly, we see these in terms of self-reported measures by the agencies. So again, it’s these OASIS-based measures. And so I think it’s a little bit easier to move the needle on measures that you’re reporting yourself as a home health agency versus something that is collected — what we’re calling a little bit more of these objective measures — like hospitalization rates.”
 
She added that these issues are not unique to home care. Other healthcare sectors that use self-reporting to inform quality measures, such as nursing homes, have also seen subjectivity influence results…
 
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