HCFA’s OASIS changes fail to satisfy home health industry
By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON The Health Care Financing Administration (HCFA; Baltimore) announced modest changes in its Outcome and Assessment Information Set (OASIS) at a Senate hearing last week, but the home care industry remains adamant that more far-reaching changes are still warranted.
HCFA told the Senate Special Committee on Aging May 24 that it plans to leave the current OASIS requirements almost completely intact, but that it will no longer require data on non-Medicare and non-Medicaid patients in identifiable form. That change was designed to head off a heavy volume of criticism that surfaced earlier this year over patient confidentiality. But critics say it does not alleviate the primary concerns of the home care industry, namely the time and cost associated with administering the new instrument.
For his part, Senate Special Committee on Aging Chairman Sen. Charles Grassley (R-IA) said that "abandoning OASIS is not an option." Instead, Grassley argued that "the issue is making it work in the right way so that it gives us what we need without unduly burdening home health agencies and their patients.
"The current payment scheme for home health is a disaster," said Grassley. He quickly added that meeting the October 2000 deadline for implementing the prospective payment system (PPS) for home healthcare is critical. "We must meet the PPS deadline," said Grassley. "Getting OASIS data on Medicare patients is essential for that goal and the sooner it is done the better the PPS will be.
"In the worst case scenario, if HCFA misses the deadline there will be an automatic 15% cut in the current payment levels," Grassley said. "That would drive the situation from bad to worse."
HCFA announces new privacy protections
HCFA’s Jeff Kang, director of the Office of Clinical Standards and Quality, told Grassley’s committee that the agency "has taken great pains" to protect patient privacy and agreed that stronger privacy protections must be built into the new system. In addition to prohibiting the transmission of patient identifiable information on non-Medicare and non-Medicaid patients to states or the agency, Kang announced these changes:
• A notice to all Medicare beneficiaries carefully explaining why OASIS data is being collected, and informing patients of their right to see and request corrections of the data.
• Limitations on the "routine uses" of data under the Privacy Act so that personally identifiable data will only be used where statistical information is not sufficient. For example, personally identifiable data will no longer be available to accrediting organizations such as the Joint Commission for Accreditation of Healthcare Organizations.
• Acceleration of efforts to encrypt data during transmission to provide "another level of protection." (Kang said HCFA expects to complete these efforts within a year).
However, Kang added that after giving "careful attention to each question" in the OASIS data, the agency decided to retain all but one question "on grounds of assuring quality of care and appropriate reimbursement."
Kang also reported that HCFA is making "special efforts" to help home health agencies learn how to use OASIS. "We have learned through a demonstration of OASIS that once home healthcare providers learn how to use OASIS, it actually slightly reduces the total time it takes to conduct a thorough patient assessment," Kang said. "Because OASIS is structured in a checklist format, home health staff using it spend less of the total evaluation time writing out a narrative of their assessment findings and more time with the patient," he said.
According to Kang, HCFA’s OASIS demonstration was used by 162 home health agencies around the country and tested in a national Outcome-Based Quality Improvement demonstration involving 50 agencies of all sizes. "OASIS provides a standardized format for the patient assessments that home health agencies have been doing all along," Kang said. "It does not require additional effort for agencies that have been conducting the thorough patient assessments that are needed in order to provide appropriate care."
As evidence, Kang presented the committee data from the demonstration that claimed the average time expended on initial patient assessments declined from 161 minutes without OASIS to 154 minutes using OASIS. For discharge assessments, he said the time spent declined from 68 minutes to 67 minutes.
Kang also reiterated HCFA’s familiar arguments that OASIS performance reports will allow agencies to identify weaknesses, improve quality, and eventually give consumers the opportunity to make informed choices about the agency they select.
In addition, Kang said OASIS data are critical to the development and implementation of accurate payment under the PPS. "We need to collect OASIS data as soon as possible in order to develop prospective payment rates and estimate their impact based on comprehensive national data," said Kang. "Doing so based on the limited OASIS research data available to us now could jeopardize our ability to pay accurately and to understand in advance how different types of agencies across the country will be affected."
Kang’s prediction in this area echoed those of other senior HCFA officials questioned about the possible effect the delay for OASIS would have on development of the PPS. "We are still on time," said Kang. He told the committee the agency could publish a proposed rule of "rough methodology" without the OASIS data, but that it will require these data "before we go final to perfect the system."
Peter Shaughnessy, director of the Center for Health Services and Policy Research, also defended of the current OASIS tool. Shaughnessy, who has been heavily involved in the development of OASIS, told the committee the current OASIS tool is "nowhere near the problem we are hearing about." He argued that the most vociferous complaints are coming from people that have yet to actually use it. "It is just a gut reaction," he argued.
For example, Shaughnessy argued, the current OASIS requirements could be included in a 10-page document as opposed to the dozens of pages OASIS critics say will be required. "If this wasn’t worth it, I wouldn’t be here today," he said.
According to Shaughnessy, OASIS is the the only major data set ever developed for a large component of the United States healthcare delivery system that has been focused "first and foremost" on measuring and improving outcomes on behalf of patients.
He also told the committee that it is a "significant misconception" that OASIS is a ponderous data set that includes over 80 new items. "In fact," he said, "OASIS contains very few new items that are not already part of an agency’s clinical record on a patient. It simply contains the same item in a more precise form."
Shaughnessy also sought to obliterate the argument that OASIS data collection should be restricted to Medicare and Medicaid patients. "Without OASIS data collected on Medicare and non-Medicare patients alike, PPS may create a two-class home care delivery system for public vs. nonpublic-pay patients," he said.
Industry holds out for further reforms
Most of the home care industry’s continued objections were summed up by Jim Pyles, counsel to the Home Health Services and Staffing Association (HHSSA; Alexandria, VA). Pyles, who is widely credited with bringing about the current delay in OASIS, told the committee that feedback from home health agencies that tried to collect the OASIS data earlier this year showed that many patients refused to furnish sensitive information and that caregivers simply supplied the responses that were necessary to preserve access to the services.
Pyles also argued that HCFA "grossly underestimates" the operational and financial burden that OASIS places on agencies. Pyles urged the committee to suspend collection of OASIS data from non-Medicare patients and narrow the OASIS data down to "just the core data that are absolutely essential" for the establishment of a case mix adjuster for PPS. He further argued that these data should be collected in a non-identifiable form and that agencies should be appropriately reimbursed.
Pyles concluded by pointing out that HCFA may have to revisit the OASIS tool yet again if Congress meets the Aug. 21 deadline it is currently facing to establish privacy standards. This will further jeopardize the agency’s ability to meet the ambitious schedule it is already facing to implement PPS by Oct. 1, 2000.
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