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The American Journal of Managed Care October 2018
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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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Michael L. Barnett, MD, MS; Zirui Song, MD, PhD; Asaf Bitton, MD, MPH; Sherri Rose, PhD; and Bruce E. Landon, MD, MBA, MSc

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.
We also observed that increases in the percentage of African Americans and other racial/ethnic minority populations were negatively associated with patient experience measures, with 1 exception (discussion). Our findings are consistent with evidence from a recent patient-level study, which indicated that minority home health beneficiaries had lower patient experience rates in professional way and communication than home health beneficiaries who were non-Hispanic whites.25 Evidence from the same study also showed that Hispanic, African American, Asian, and Native Hawaiian or Pacific Islander home health beneficiaries had better experience measures in discussion than the non-Hispanic white population.25 The coefficients for discussion in our study are positive but not statistically significant. It is unclear why minorities gave a high rating for their home health providers discussing medicines, pain, and home safety but gave a low rating for the other measures. This may be explained by cultural differences among racial/ethnic groups regarding pain tolerance and differing attitudes among patients or informal caregivers about medication or patient safety. However, future studies that focus on the cultural differences affecting the rating of patient experience are needed.

Evidence from other studies showed that compared with not-for-profit agencies, for-profit agencies provided higher-cost and lower-quality home health care, including worsened process of care, poor functional improvement, and high rates of avoidable hospitalizations and bedsores.33 Our study found that compared with public and not-for-profit agencies, for-profit agencies had poorer patient experience performance in all 5 measures. We also found that increases in the number of tenured years with the Medicare program increased patient experience measures by about 0.01% to 0.04%. Over the past decade, the number of home health agencies increased dramatically, from about 7500 in 2000 to about 12,400 in 2014. This increase was partly due to the high profit margin from therapy visits in the Medicare home health payment system.7 Among all new home health agencies, 95% were for-profit entities, which are more likely to target therapy visits with high profit margins.34 The Medicare program is the primary payer for home health care and paid about $18 billion in 2015.7 The Medicare program strives to improve the quality and efficiency of care for Medicare home health beneficiaries. However, with the high cost and lower quality of care associated with for-profit agencies and with the rapidly growing number of for-profit agencies, CMS’ efforts to improve quality while controlling rising home health costs are limited because the license approval system and regulations for home health agencies occur at the state level. To overcome this problem, both payment reforms at the federal level and modifications at the state level for licensure and regulation are necessary to improve the quality and control the cost of home health care.


Our study has limitations. First, we used data at the agency level. The patient experience measures are based on the HHCAHPS survey from nonhospice, nonmaternity home health patients who are 18 years or older.39 However, CMS HCC risk scores are based on Medicare beneficiaries who are 65 years or older.31,32 Although the sources of patient data provided by the HHCAHPS survey and the CMS HCC risk score were not completely the same, the majority of home health beneficiaries in our sample were Medicare beneficiaries who were 65 years or older11 and were more likely to be in the random sampling of the HHCAHPS survey. Therefore, the inconsistent patient sources among the HHCAHPS survey and CMS HCC risk scores are less likely to affect the estimates in our study. However, we recommend that future studies use patient-level data to examine CMS HCC risk scores and patient experience measures.

Secondly, due to missing data, we excluded 119 home health agencies that qualified for the HHCAHPS survey. These agencies were more likely to be for-profit home health agencies with lower patient volume than those included in our study. Additionally, the HHCAHPS survey exempted home health agencies that had fewer than 60 patients per year, and thus these agencies were excluded from our study.


Our findings have research and policy implications that apply to the 5-star patient survey rating system and the HHVBP pilot program. In terms of research, access to care for minorities and beneficiaries with complicated clinical conditions needs to be carefully monitored under the 5-star patient survey rating system and the HHVBP pilot program. Additionally, it is necessary to investigate the practice patterns of home health agencies and the home health market and to determine how home health agencies with a high proportion of beneficiaries who have advanced clinical and functional conditions fare. In terms of policy implications, the current risk factors used to adjust patient experience measures need to be modified. The CMS HCC risk score is based on Medicare home health beneficiaries’ enrollment data and inpatient and outpatient claims data.30 The enrollment data are collected by CMS, and inpatient and outpatient claims data are provided by hospitals and physicians, so there is little chance for home health agencies to practice upcoding that may affect the CMS HCC risk score. Thus, it is feasible to include the CMS HCC risk score of a home health beneficiary as a risk factor in the current risk adjustment for patient experience measures in an effort to avoid potential unintended consequences.


The authors thank Madison Hedrick, MA, of the Science Communication Group at the University of Arkansas for Medical Sciences, who provided editing for the original version of the manuscript.

Author Affiliations: Department of Health Policy and Management (H-FC, JMT, RS), and Department of Biostatistics (FW), College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (H-FC, FW); acquisition of data (H-FC, RS); analysis and interpretation of data (JMT, FW); drafting of the manuscript (H-FC, JMT); critical revision of the manuscript for important intellectual content (H-FC, JMT, FW, RS); statistical analysis (H-FC); and provision of patients or study materials (RS).

Address Correspondence to: Hsueh-Fen Chen, PhD, Department of Health Policy and Management, College of Public Health, University of Arkansas for Medical Sciences, 4301 W Markham St, Mail Slot 820-12, Little Rock, AR 72205. Email:

1. Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients’ perception of care and measures of hospital quality and safety. Health Serv Res. 2010;45(4):1024-1040. doi: 10.1111/j.1475-6773.2010.01122.x.

2. Carter J, Ward C, Wexler D, Donelan K. The association between patient experience factors and likelihood of 30-day readmission: a prospective cohort study. BMJ Qual Saf. 2018;27(9):683-690. doi: 10.1136/bmjqs-2017-007184.

3. Glickman SW, Boulding W, Manary M, et al. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2010;3(2):188-195. doi: 10.1161/CIRCOUTCOMES.109.900597.

4. Home Health Care CAHPS Survey. Home Health Care CAHPS Survey website. Accessed August 5, 2017.

5. Home health star ratings. CMS website. Accessed August 10, 2017.

6. CMS, HHS. Medicare and Medicaid Programs; CY 2017 Home Health Perspective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements: final rule. Fed Regist. 2016;81(213):76702-76797.

7. Chapter 8: home health care services. In: Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Washington, DC: MedPAC; 2016:206-234.

8. Ellenbecker CH, Frazier SC, Verney S. Nurses’ observations and experiences of problems and adverse effects of medication management in home care. Geriatr Nurs. 2004;25(3):164-170. doi: 10.1016/j.gerinurse.2004.04.008.

9. Cannon KT, Choi MM, Zuniga MA. Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis. Am J Geriatr Pharmacother. 2006;4(2):134-143. doi: 10.1016/j.amjopharm.2006.06.010.

10. Caffrey C, Sengupta M, Moss A, Harris-Kojetin L, Valverde R. Home health care and discharged hospice care patients: United States, 2000 and 2007. Natl Health Stat Report. 2011;(38):1-27.

11. The Alliance for Home Health Quality and Innovation. The Medicare home health benefit: program costs and beneficiary characteristics. Almost Family website. Published July 15, 2009. Accessed April 10, 2017. Available at Wayback Machine at:

12. Cho E, Kim EY, Lee NJ. Effects of informal caregivers on function of older adults in home health care. West J Nurs Res. 2013;35(1):57-75. doi: 10.1177/0193945911402847.

13. Zaslavsky AM, Zaborski LB, Ding L, Shaul JA, Cioffi MJ, Cleary PD. Adjusting performance measures to ensure equitable plan comparisons. Health Care Financ Rev. 2001;22(3):109-126.

14. O’Malley AJ, Zaslavsky AM, Elliott MN, Zaborski L, Cleary PD. Case-mix adjustment of the CAHPS Hospital Survey. Health Serv Res. 2005;40(6, pt 2):2162-2181. doi: 10.1111/j.1475-6773.2005.00470.x.

15. Hall JA, Milburn MA, Roter DL, Daltroy LH. Why are sicker patients less satisfied with their medical care? tests of two explanatory models. Health Psychol. 1998;17(1):70-75.

16. Martino SC, Elliott MN, Kanouse DE, Farley DO, Burkhart Q, Hays RD. Depression and the health care experiences of Medicare beneficiaries. Health Serv Res. 2011;46(6, pt 1):1883-1904. doi: 10.1111/j.1475-6773.2011.01293.x.

17. Johnson ML, Rodriguez HP, Solorio MR. Case-mix adjustment and the comparison of community health center performance on patient experience measures. Health Serv Res. 2010;45(3):670-690. doi: 10.1111/j.1475-6773.2010.01101.x.

18. Paddison C, Elliott M, Parker R, et al. Should measures of patient experience in primary care be adjusted for case mix? evidence from the English General Practice Patient Survey. BMJ Qual Saf. 2012;21(8):634-640. doi: 10.1136/bmjqs-2011-000737.

19. Goldstein E, Elliott MN, Lehrman WG, Hambarsoomian K, Giordano LA. Racial/ethnic differences in patients’ perceptions of inpatient care using the HCAHPS survey. Med Care Res Rev. 2010;67(1):74-92. doi: 10.1177/1077558709341066.

20. Price RA, Haviland AM, Hambarsoomian K, et al. Do experiences with Medicare managed care vary according to the proportion of same-race/ethnicity/language individuals enrolled in one’s contract? Health Serv Res. 2015;50(5):1649-1687. doi: 10.1111/1475-6773.12292.

21. Merlino JI, Kestranek C, Bokar D, Sun Z, Nissen SE, Longworth DL. HCAHPS survey results: impact of severity of illness on hospitals’ performance on HCAHPS survey results. J Patient Exp. 2014;1(2):16-21. doi: 10.1177/237437431400100204.

22. Thiels CA, Hanson KT, Yost KJ, Zielinski MD, Habermann EB, Cima RR. Effect of hospital case mix on the Hospital Consumer Assessment of Healthcare Providers and Systems star scores: are all stars the same? Ann Surg. 2016;264(4):666-673. doi: 10.1097/SLA.0000000000001847.

23. Cowen ME, Czerwinski J, Kabara J, Blumenthal DU, Kheder S, Simmons S. The risk-outcome-experience triad: mortality risk and the Hospital Consumer Assessment of Healthcare Providers and Systems survey. J Hosp Med. 2016;11(9):628-635. doi: 10.1002/jhm.2611.

24. Patient-mix adjustment factors for Home Health Care CAHPS Survey results publicly reported on Home Health Compare in October 2017. Home Health Care CAHPS Survey website. Published October 2017. Accessed December 18, 2017.

25. Smith LM, Anderson WL, Kenyon A, et al. Racial and ethnic disparities in patients’ experience with skilled home health care services. Med Care Res Rev. 2015;72(6):756-774. doi: 10.1177/1077558715597398.

26. Medicare provider utilization and payment data: home health agencies. CMS website. Updated April 5, 2018. Accessed June 15, 2017.

27. About Home Health Compare data. CMS website. Accessed June 15, 2017.

28. Medicare Fee-For-Service Home Health Agency Utilization & Payment Public Use File: a methodological overview. CMS website. Published August 2018. Accessed September 5, 2018.

29. Steps for calculating global ratings and composite scores for the Home Health Care CAHPS Survey. Home Health Care CAHPS Survey website. Accessed December 18, 2017.

30. Acumen, LLC. Specifications for home health claims-based utilization measures. CMS website. Published August 21, 2012. Accessed December 18, 2017.

31. Risk adjustment. CMS website. Updated July 31, 2018. Accessed December 18, 2017.

32. Claims-based AC and ED use measures: technical documentation and risk adjustment. CMS website. Updated August 27, 2018. Accessed December 20, 2017.

33. Cabin W, Himmelstein DU, Siman ML, Woolhandler S. For-profit Medicare home health agencies’ costs appear higher and quality appears lower compared to nonprofit agencies. Health Aff (Millwood). 2014;33(8):1460-1465. doi: 10.1377/hlthaff.2014.0307.

34. Kim H, Norton EC. Practice patterns among entrants and incumbents in the home health market after the prospective payment system was implemented. Health Econ. 2015;24(suppl 1):118-131. doi: 10.1002/hec.3147.

35. Home health agency reimbursements per enrollee, by adjustment type. The Dartmouth Atlas of Health Care website. Accessed December 20, 2017.

36. Werner RM, Konetzka RT, Polsky D. Changes in consumer demand following public reporting of summary quality ratings: an evaluation in nursing homes. Health Serv Res. 2016;51(suppl 2):1291-1309. doi: 10.1111/1475-6773.12459.

37. Reid RO, Deb P, Howell BL, Shrank WH. Association between Medicare Advantage plan star ratings and enrollment. JAMA. 2013;309(3):267-274. doi: 10.1001/jama.2012.173925.

38. Romano PS, Marcin JP, Dai JJ, et al. Impact of public reporting of coronary artery bypass graft surgery performance data on market share, mortality, and patient selection. Med Care. 2011;49(12):1118-1125. doi: 10.1097/MLR.0b013e3182358c78.

39. CMS. Home Health Care CAHPS Survey: protocols and guidelines manual: version 10.0. Published January 2018. Accessed September 5, 2018.
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