Chapter 4 – Home Health and CMS (Centers for Medicare & Medicaid Services)

The Centers for Medicare & Medicaid Services are federal agencies within the U.S. Department of Health and Human Services that administer the Medicare program. They work with other federal agencies to ensure that people have access to health care.

Quality control

Among the many responsibilities of the Centers for Medicare & Medicaid Services (CMS) is the development of quality measures. CMS uses these measures in its public reporting and pay-for-reporting programs. The agency is also responsible for overseeing and investigating complaints of fraud and abuse. It also aims to provide high-quality care to Medicare beneficiaries and their families.

Advocates and consumers are increasingly interested in quality in healthcare. Quality is integral to understanding who receives care, ensuring appropriateness and promptness of care, and exploring systemic reasons for quality issues. Quality standards can be translated into practiced norms by creating a culture that encourages quality care and patient safety.

While pay-for-performance initially promoted as a quality improvement method, it has now been embraced as a cost containment tool. Many health plans believe that rising health care costs are the result of overutilization and are therefore trying to limit unnecessary medical procedures

Quality measures

As the home health industry continues to move toward value-based care, payers must be aware of the quality measures available to measure performance. Historically, CMS has been an early adopter of these measures, but private payers are not bound to replicate them. Quality measures in home health are based on the six domains of health care quality identified by the Institute of Medicine. They focus on patient-centeredness, patient engagement, and effectiveness of outreach strategies.

The quality measures for home health should include a number of specific and reliable measures, which are designed to measure the quality of care provided. Process measures may include timely initiation of care, depression assessment, fall risk assessments, medication education, and influenza immunization status. The quality measures must also adjust for member characteristics, since the reasons for readmission can vary widely. In addition, CMS requires providers to report claims data, which are used to determine quality.

In March 2019, CMS released details on its planned changes to quality measure rating thresholds. The new thresholds would increase every six months by 50% of the rate at which QM ratings improve. That would increase the threshold by 1%, for example. The goal is to encourage continuous quality improvement and limit future threshold adjustments. These threshold changes were originally scheduled for April 2020, but were halted due to the COVID-19 Public Health Emergency.

You can also find more information about the measures by reading the Technical Documentation for OASIS-based Measures. Alternatively, if you aren’t familiar with PAE measures, you can consult the Outcome-Based Quality Monitoring Manual. It lists the requirements for home health agencies and allows you to compare them nationally. 

CMS has been delaying the release of its updated OASIS. Home health agencies will be required to begin collecting data on the updated item sets on January 1, 2023. While the new quality measures are still in development, there are already a few benchmarks in place. Using these metrics will help payers better understand the quality of their care and identify areas for improvement. You can find the Final Rule in the Federal Registrar.