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CMS HCC Risk Scores and Home Health Patient Experience Measures
Hsueh-Fen Chen, PhD; J. Mick Tilford, PhD; Fei Wan, PhD; and Robert Schuldt, MA
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CMS HCC Risk Scores and Home Health Patient Experience Measures

Hsueh-Fen Chen, PhD; J. Mick Tilford, PhD; Fei Wan, PhD; and Robert Schuldt, MA
Risk adjustment for patient experience measures needs to be modified by including the CMS Hierarchical Condition Categories (HCC) risk scores of home health beneficiaries.
RESULTS

There were 7756 home health agencies with data for patient experience measures available in the Home Health Compare file. Due to missing data, such as the agency-level CMS HCC risk score or race/ethnicity, the total number of observations included in our analytical models was 7637.

Table 1 presents descriptive statistics. For the overall patient experience measures, the average of rating with score 9 or 10 was about 84%, and the average of recommendation with “definitely yes” was about 79%. For the composite measures, the averages of professional way, communication, and discussion were 88%, 85%, and 84%, respectively. The average agency-level HCC risk score was 2.14. Home health agencies, on average, had 16% African American and 10% Hispanic beneficiaries, and about 2% of beneficiaries identified their race/ethnicity as other or unknown. Among our study sample, 21% of home health agencies were not-for-profit, and 6% of home health agencies were public. Home health agencies had an average of about 18 tenured years with the Medicare program.

The results from the fixed-effects models, in Table 2, showed that increases of 1 SD in agency-level CMS HCC risk scores (0.37 in Table 1) significantly lowered rating by about 0.75% (coefficient, –2.04, multiplied by 0.37) (P <.001) and recommendation by about 1% (P <.001), as well as professional way, communication, and discussion by about 0.6% (P <.001 for all 3 measures).

For the control variables related to race/ethnicity, increases in the percentage of African American beneficiaries were negatively associated with patient experience measures in rating (–0.06; P <.001), recommendation (–0.07; P <.001), and communication (–0.05; P <.001). Similarly, an increase in the percentage of beneficiaries of other racial/ethnic group was negatively associated with patient experience measures in rating (–0.08; P <.001), recommendation (–0.11; P <.01), professional way (–0.10; P <.001), and communication (–0.08; P <.001). We did not observe a significant association between the percentage of Hispanic beneficiaries and patient experience measures.

Characteristics of home health agencies were also associated with patient experience measures. Not-for-profit home health agencies had patient experience measures that were about 1 to 3 percentage points higher than for-profit home health agencies in all aspects: rating (1.74; P <.001), recommendation (2.92; P <.001), professional way (1.20; P <.001), communication (1.48; P <.001), and discussion (1.28; P <.001). Public home health agencies had patient experience measures that were about 2 to 4 percentage points higher than for-profit home health agencies in all aspects: rating (3.34; P <.001), recommendation (4.49; P <.001), professional way (1.97; P <.001), communication (1.77; P <.001), and discussion (2.10; P <.001). Increases in years tenured with the Medicare program were significantly associated with more positive patient experience measures of rating (0.03; P <.05), recommendation (0.04; P <.001), and communication (0.02; P <.01).

DISCUSSION

Our findings showed that increases in agency-level CMS HCC risk score were significantly associated with lower scores for all 5 patient experience measures. The findings indicated that current risk factors insufficiently adjust for the variation in beneficiaries’ clinical and functional conditions that affects patient experience. The differences in patient experience based on current risk factors partially reflect the differences in case mix among home health agencies.

CMS uses risk-adjusted patient experience to construct the 5-star patient survey rating system posted on the Home Health Compare website. The system was developed in an effort to improve the quality of home health care by allowing consumers the opportunity to find information on their community’s providers and choose the best providers. However, the CMS 5-star patient survey rating system of home health based on current risk factors could be misleading. Evidence shows that CMS public reporting affects market shares for health plans, hospitals, and nursing homes.36-38 Future studies examining how the CMS 5-star patient survey system affects market shares for home health agencies with high and low HCC risk scores are recommended.

Risk-adjusted patient experience is part of quality metrics in the HHVBP pilot program that have a financial impact on home health agencies. Considering the negative association between agency-level CMS HCC risk score and patient experience measures, home health agencies with a high proportion of clinically complicated beneficiaries are likely to be financially penalized under the HHVBP pilot program. Home health agencies can also simply dump or avoid beneficiaries with complicated conditions to improve their performance in patient experience measures, rather than investing resources in truly improving patient experience. Access to care for beneficiaries with complicated clinical and functional conditions can become problematic, given the fact that more than 80% of home health agencies are for-profit entities that pursue profit maximization.7


 
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