Understanding the New Claims-based Measures for Hospitalization and ED Use
Monday, January 14, 2013
by: VNAA Education and Quality Team

Section: Quality and Educational Programming




On January 17, 2013 new claims based hospitalization measure data in home health compare will be updated. The VNAA continues to update the information we have been able to obtain on the new claims based measures for hospitalization and Emergency Department use. This new information is from the Center for Medicare and Medicaid Services (CMS), on the comparison with the OASIS–based hospitalization measure and is supplemented by a detailed description of the new measure.
 
With this information, VNAA has created a summary of the following changes:  

  1. Updated summary article by the VNAA on the hospitalization measure
  2. Summary of new hospitalization measure: A Comparison of Claims-Based and OASIS-Based Measures(CMS)
  3. Claims-Based Measures (CMS)
  4. Overview of Claims based measures (CMS-Table)

 

1. Changes to Hospitalization Rates posted on Home Health Compare beginning January 2013

In the Centers for Medicare and Medicaid Services (CMS) final rule for the CY 2013 home health prospective payment system update, effective January 1, 2013, there will be significant changes in how the home health hospitalization rates are calculated. Rates will be calculated using Medicare claims instead of using OASIS data. Specifically, the Acute Care Hospitalization and Emergency Department (ED) Use without Hospitalization measures will replace the OASIS-based measures, and will use the Medicare claims data as the data source.

Some significant changes are:

  • Claims-based measure is based on the Start of Care (SOC) date instead of the transfer/discharge date.
  • The measures address outcomes of HHA patients in a fixed interval after the start of their home health care, regardless of the length of their home health stay.
  • Planned hospitalizations are excluded from the acute care hospitalization claims-based measure numerator.
  • Observation stays that begin in a hospital emergency department but do not result in an inpatient stay within the 60 days after the start of home health care are counted in the ED Use without Hospitalization measure.
  • Observation stays that result in an inpatient stay within the 60 days after the start of home health care are counted in the Acute Care Hospitalization measure even if the patient is discharged from the home health agency.
  • The claims measure denominator is the number of all home health stays.
  • Claims-based measure applies to Medicare Fee-for-Service (FFS) patients only, while the OASIS-based measure applied to Medicare FFS, Medicare Advantage, and Medicaid patients.
  • Exclusions include LUPAs, Home Health Stays in which the patient receives service from multiple agencies during the first 60 day episode, and Home Health Stays for patients not continuously enrolled in fee-for-service Medicare for 6 months prior to the Home Health Stay.

There is significant difference in the two sources of data for these measures and so the results from the claims-based measure will probably not be comparable to the OASIS-based measure results. However, the information that an agency obtains through the CASPER reports includes the claims-based rate as well as the OASIS-based rate in individual reports. The OASIS-based result will continue to be reported on the CASPER Reporting System. More detailed information on the comparison of OASIS-based measure and Claims-based measure for hospitalization is described below.

Review this section on page 67092-67094 of the final rule.   
 

2. Comparison of Claims-Based and OASIS-Based Measures:

The claims-based utilization measures use Medicare claims data to tell you about what types of care a patient required beyond home health care. For example, did the patient require care in an Emergency Department during the home health episode of care? To determine what types of additional care a patient received, the claims-based measures use Medicare claims data. In order to be paid for services they provide for Medicare Part A and B beneficiaries, all health care providers must submit claims to CMS for every patient encounter. Claims data are reliable because providers are required to submit claims to receive payment.
 
The Acute Care Hospitalization (ACH) and Emergency Department Use without hospitalization claims-based measures calculate the percentage of home health stays in which patients utilized these two types of care. The measure numerators are the number of home health stays for patients who have a Medicare claim for an admission to an acute care hospital or for an outpatient emergency department visit, respectively, in the 60 days following the start of the home health stay. The measure denominators are the number of home health stays that began during the reporting period. A home health stay is a sequence of home health payment episodes separated from other home health payment episodes by at least 60 days.
 
The acute care hospitalization (ACH) claims-based measure is different from the acute care hospitalization OASIS-based measure. First, the claims-based measure is based on the start date of the patient’s home health care, while the OASIS-based measure is based on the end date of the patient’s home health care. Thus, if a patient was cared for by a home health agency starting in January and ending in March, that patient’s outcome would be included in the claims-based calculation in the January reporting period. In the OASIS-based calculation, it would be included in the March reporting period. Second, the claims-based measure may include different patients than the OASIS-based measure.  For instance, the OASIS measure applies to Medicare FFS, Medicare Advantage and Medicaid patients while the claims-based measure applies only to Medicare FFS patients. Third, the claims-based measure has a fixed observation period of 60 days after the start of home health care while the OASIS-based measure has a variable observation period based on when the patient leaves home health care.
 
A home health agency cannot directly compare their ACH claims-based rates with their ACH OASIS-based rates. To make an indirect comparison, the agency can select a reporting period for the OASIS-based measure that starts and ends two months earlier than the claims-based measure. This indirect comparison is possible because most home health episodes of care last 60 days.
 

3. CLAIMS-BASED MEASURES

  • Use Medicare claims data.
  • Acute Care Hospitalization (ACH) and Emergency Department use without hospitalization claims-based measures calculate the percentage of home health stays in which patients utilized these two types of care.
  • Numerator = the number of home health stays for patients who have a Medicare claim for an admission to an acute care hospital or for an (outpatient) emergency department visit  in the 60 days following the start of the home health stay.
  • Denominators = the number of home health stays that began during the reporting period.
  • A home health stay is a sequence of home health payment episodes separated from other home health payment episodes by at least 60 days.


Differences between the acute care hospitalization (ACH) claims-based measure and the ACH OASIS-based measure: 

  1. The claims-based measure is based on the start date of the patient’s home health care, while the OASIS-based measure is based on the end date of the patient’s home health care. Example: if a patient was cared for by a home health agency starting in January and ending in March, that patient’s outcome would be included in the claims-based calculation in the January reporting period and in the OASIS-based calculation in the March reporting period.
  2. The claims-based measure may include different patients than the OASIS-based measure. For instance, the OASIS measure applies to Medicare FFS, Medicare Advantage and Medicaid patients while the claims-based measure applies only to Medicare FFS patients.
  3. The claims-based measure has a fixed observation period of 60 days after the start of home health care while the OASIS-based measure has a variable observation period based on when the patient leaves home health care.

  
A home health agency cannot directly compare their ACH claims-based rates with their ACH OASIS-based rates. To make an indirect comparison, the agency can select a reporting period for the OASIS-based measure that starts and ends two months earlier than the claims-based measure. This indirect comparison is possible because most home health episodes of care last 60 days.
 
CASPER currently reports:

  • the OASIS-based ACH measure and
  • the claims-based ACH measure and
  • the claims-based ED Use Without Hospitalization measure.
  • These measures appear on their own separate page in CASPER. The initial dates were April 2011 to March 2012. The OASIS-based Acute Care Hospitalization measure will continue to be reported on CASPER, the OASIS-based ED Use Without Hospitalization measure is no longer reported.
  • HHC currently reports only the OASIS-based ACH measure. The claims-based ACH measure will replace the OASIS-based ACH measure on HHC in January 2013.

 
(CASPER shows HHA’s observed rate vs. national adjusted rate. HHC: the HHA rate is risk adjusted & national rate depicts the average rate)
 
 Specifications for Home Health Claims-Based Utilization Measures

  • Overview of Measures
  Emergency Department Use without Hospitalization Acute Care Hospitalization
Measure Description Percentage of home health stays in which patients used the emergency department but were not admitted to the hospital during the 60 days following the start of the home health stay. Percentage of home health stays in which patients were admitted to an acute care hospital during the 60 days following the start of the home health stay.
Numerator Number of home health stays for patients who have a Medicare claim for outpatient emergency department use and no claims for acute care hospitalization in the 60 days following the start of the home health stay. Number of home health stays for patients who have a Medicare claim for an admission to an acute care hospital in the 60 days following the start of the home health stay.
Numerator Details The 60 day time window is calculated by adding 60 days to the “from” date in the first home health claim in the series of home health claims that comprise the home health stay. If the patient has any Medicare outpatient claims with any ER revenue center codes (0450-0459, 0981) during the 60 day window AND if the patient has no Medicare inpatient claims for admission to an acute care hospital (identified by the CMS Certification Number on the IP claim ending in 0001-0879, 0800-0899, or 1300-1399) during the 60 day window, then the stay is included in the measure numerator. The 60 day time window is calculated by adding 60 days to the “from” date in the first home health claim in the series of home health claims that comprise the home health stay. If the patient has at least one Medicare IP claim from short term or critical access hospitals (identified by the CMS Certification Number ending in 0001-0879, 0800-0899, or 1300-1399) during the 60 day window, then the stay is included in the measure numerator.
Numerator Exclusions None. Planned hospitalizations are excluded from the numerator.
Denominator Number of home health stays that begin during the 12-month observation period. A home health stay is a sequence of home health payment episodes separated from other home health payment episodes by at least 60 days. Number of home health stays that begin during the 12-month observation period. A home health stay is a sequence of home health payment episodes separated from other home health payment episodes by at least 60 days.
Denominator Details See below for details about home health stay construction. See below for details about home health construction.
Denominator Exclusions
  1. Home health stays for patients who are not continuously enrolled in fee-for-service Medicare for the 60 days following the start of the home health stay or until death.
  2. Home health stays that begin with a Low Utilization Payment Adjustment (LUPA) claim.
  3. Home health stays in which the patient receives service from multiple agencies during the first 60 days.
  4. Home health stays for patients who are not continuously enrolled in fee-for-service Medicare for 6 months prior to the home health stay. 
  1. Home health stays for patients who are not continuously enrolled in fee-for-service Medicare for the 60 days following the start of the home health stay or until death.
  2. Home health stays that begin with a Low Utilization Payment (LUPA) claim.
  3. Home health stays in which the patient receives service from multiple agencies during the first 60 days.
  4. Home health stays for patients who are not continuously enrolled in fee-for-service Medicare for the 6 months prior to the home health stay.
 
 
Acumen, LLC Home Health Claims-Based Measure Specifications August 21, 2012  
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