The national association representing home care and hospice providers responded with concerns about the methodology, which allots only a certain percentage of facilities into each star-rating category. They also expressed concern about measures they say do not truly reflect the needs of the population being served.
Each home health agency received a single, summary star rating based on their performance on nine (out of nearly 30) quality measures already posted on Home Health Compare, the CMS' consumer-facing comparison tool.
The summary rating is based on providers' outcomes for three process measures and six outcome measures. On average, providers nationwide scored higher on processes than on outcome.
That's not surprising. In March, a CMS comprehensive evaluation of the effects of hundreds of measures used across a total of 25 federal quality-reporting programs— including hospitals, nursing homes, home health agencies and clinician offices—found in general U.S. healthcare facilities are improving more rapidly on process measures, which some said have a limited life span.
The process measures include the timely initiation of care; education provided to patients or caregivers about their medications; and the administration of flu shots. The national average for achieving those measures was 91.7%, 92.8% and 72.8% respectively, according to the CMS data.
Percentages were lower in terms of how often patients improved on certain measures. They saw improvements getting in and out of bed 58.6% of the time; walking or moving around, 63.1%; breathing, 65%; had less pain when moving around, 67.9%; and bathing, 68.2%. However, home health patients had to be admitted to the hospital only 15.8% of the time.
However, the average Medicare home health beneficiary is 85 years old with multiple chronic illnesses that are not necessarily going to improve, said William Dombi, vice president for law at the National Association for Home Care and Hospice. "It's more a matter of maintaining their function and capabilities, and preventing deterioration, rather than trying to restore capabilities,” he said. The patient population is acute, in terms of restoration potential, and chronic, meaning the goal maintenance. “The measures should reflect the population intended to be served and we hope that is something the CMS continues to work towards.”
Medicare pays for home health services for about 3.5 million beneficiaries at a cost of $17.9 billion, the agency says. The ratings were calculated using information from patient assessments performed by the home health agencies and from claims the agencies submitted to Medicare.
The CMS says star ratings can help consumers more quickly identify differences in quality and make use of the information when selecting a healthcare provider. The update for home health agencies is part of broader plan to adopt ratings across all Medicare.gov Compare websites. The agency has used a similar system to rate nursing homes since 2008. They were expanded to physician groups in February 2014 and to dialysis facilities in January 2015.
Similar to dialysis facilities, the home health community also expressed frustration over a methodology used by CMS, which only allots a certain amount of facilities into each category. For example, only 2.6% can receive five stars and 0.1% can receive one star, while 22.6% can receive three stars.
“But to get three stars you still need pretty significant high-quality performance,” Dombi said, equating the difference to driving a middle-of-the-road Mercedes versus a middle-of-the-road Yugo. “We see home care as middle-of-the-road of a Mercedes as opposed to middle-of-the-road of a car that you wouldn't want to get into.”
The home healthcare industry has faced particular scrutiny. Claims of theft, sexual violence and mistreatment have plagued workers.
In 2014, a study of home care visits in the U.S., Canada, the United Kingdom and several other countries found no evidence that home care visits actually help the elderly to live longer or more independent lives, when compared with seniors who have not been visited. Advocates in the U.S. called the results misleading and baffling, warning that, without context, the study could derail future improvement efforts.