Re: Medicare Program; Town Hall Meeting on the Outcome Assessment and Information Set (OASIS), CMS-1227-N
Liberty Place, Suite 700
325 Seventh Street, NW
Washington, DC 20004-2802
(202) 638-1100 Phone
Wednesday, July 31st 2002
Division of Ambulatory and Post Acute Care
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Mail Stop S3-06-26
Baltimore, Maryland 21244
Dear Ms. Laschinger:
The American Hospital Association (AHA) welcomed Secretary Thompson’s June 10, 2002 announcement that the Centers for Medicare & Medicaid Services (CMS) intends to propose changes to the Outcome Assessment and Information Set (OASIS) and related procedures for home health agencies. The Secretary’s announcement, which alluded to reducing both the number of items on the form as well as the frequency of submissions, also requested that CMS solicit further public input in development of these changes. The stated intent of these changes is to free “caregivers from burdensome paperwork so they can focus their energies on direct patient care.” The AHA concurs with this goal and has strongly supported the Secretary’s regulatory reform process. We are pleased to submit the attached comments in response to the request for input published in July 17, 2002 Federal Register.
In addition to representing nearly 5,000 hospitals, AHA represents approximately 2,400 hospital-based home health agencies, accounting for one-third of Medicare program payments and about 40 percent of beneficiaries who use Medicare-covered home health care annually. Over the last several years, the AHA has actively participated in efforts to streamline OASIS. Recent efforts include:
- submission of a five point OASIS streamlining plan to the Secretary in July, 2001;
- participation in a provider consensus process culminating in a detailed letter to CMS in October, 2001; and
- participation in a follow-up meeting with CMS staff in March, 2002 during which a list of short- and longer-run suggestions was shared with key CMS staff.
Our comments today are intended to be an up-to-date supplement to the above efforts. AHA’s main concerns about OASIS continue to be the depth and breadth of the information requirements and the inflexible procedures pertaining to submission of the data. Complete records and documentation are necessary for patient safety and quality care. But complying with the numerous regulations issued by CMS and other federal, state and local regulatory agencies should not dominate a caregiver’s day, nor should it unduly intrude on a patient’s time and privacy. Moreover, the sheer length and frequency of the required forms undermine the reliability of all of the data being collected, reducing its value for all purposes.
Thank you for the opportunity to provide input to CMS on this important issue. If you have any questions, please contact me at (202) 626-2320.
Brian D. Ellsworth
Senior Associate Director
Recommendations to Reduce the Administrative Burden of the Outcome Assessment and Information Set (OASIS) for Home Health Care
American Hospital Association
July 31, 2002
Reduce the amount of required information on the OASIS form. The total amount of information required for Medicare patients should be pared down to that absolutely necessary for payment and those items for which clear consensus exists about their necessity, reliability and utility.
- In determining the necessity of a given item, AHA recommends that CMS conduct, with public input, a “zero-based” review of the Adverse Event Reports and the Outcome Based Quality Improvement (OBQI) measures. These OASIS-driven reports, which result in 54 separate outcome measures, were added by CMS over the last year with little prior review by the general public (or independent researchers) and are now being cited as justification for many of the OASIS items. Deletion of some outcome measures may allow, in turn, some OASIS items to be deleted.
- The AHA is also concerned that, outside of one small study, an independent analysis of the statistical reliability of OASIS items has not been performed. The reliability study conducted by the creators of OASIS contains more optimistic reliability results than does the sole independent study. Historically, when an independent entity reviews an assessment instruments developed by others, the reliability results are less optimistic (see for example, Joan Buchanan’s study comparing the MDS-PAC and the FIM, issued in March, 2001). Any item that does not meet commonly accepted levels of reliability, after independent review replicating conditions in the field, is a candidate for deletion.
- Specific OASIS items that are initial candidates for deletion are listed in the October 11, 2001 provider consensus letter to CMS Administrator Scully. AHA views those recommendations as a good starting point. Some items could be left on the form, but their completion be made voluntary.
Reduce the frequency of required information. The requirements for submission of information, especially after the initial comprehensive assessment, should be pared down to those items necessary to calculate PPS rates and consensus outcome measures.
- The potential elimination of two assessments, alluded to in the Secretary’s June 10, 2002 announcement, is a good start.
- Items used to risk adjust the outcome measures should not be needed after the initial start of care assessment since risk adjustment is, by definition, a fully prospective concept. Experimentation with refining and streamlining the risk adjustment methodologies should be done with a development data set explicitly designed for such purpose (see comment below).
- Follow-up information deemed essential could be collected on the final claim for each 60-day episode (or at discharge, if relevant). CMS should design its computer systems to integrate the initial OASIS, CMS’ 485 form (home health plan of care) and final claim information to develop a profile of the patient that does not require the submission of redundant information. An information system that integrates data would also provide a more accurate view of the patient’s care delivery over time and eliminate some of the guesswork required by certain OASIS questions.
Eliminate application of Medicare requirements to non-Medicare PPS patients. The OASIS form should only be required for fee-for-service Medicare patients receiving Medicare-covered home health care.
- The requirements for OASIS information on Medicare+Choice (M+C) enrollees should be left to negotiation between the M+C plans and the home health agencies.
- The CMS position that OASIS is a Condition of Participation (COP) and therefore should be required of all patients (as other COPs) employs faulty circular logic. CMS’ sole justification for making OASIS a COP in 1999, on an emergency basis, was that the items might be needed in the forthcoming Medicare PPS. We now know that only 23 items are needed for such purposes - therefore the rest of the items on the form as well as the application to non-Medicare patients are subject to question.
Use samples for research & development purposes. CMS should use explicitly designed research samples, instead of collecting OASIS data from all 7,000+ Medicare-certified home health agencies, where the ultimate use and burden of the information collection requirements are not yet clear.
- A random stratified (voluntary) sample of providers could collect extensive case mix information, cost data and other relevant information and provide it to CMS in an electronic, integrated format. The agencies voluntarily participating in such an effort should have their costs of participation separately reimbursed from a dedicated data development account within CMS.
Refine the home health PPS to further reduce the administrative burden of OASIS, improve the PPS’ clinical relevance and synchronize reporting requirements with the Health Insurance Portability and Accountability Act (HIPAA). The Medicare prospective payment system should be refined in a way that further reduces redundant data collections and simplifies the operation of PPS.
- The AHA would like to see a consistent set of ICD-9-CM coding rules applied to assessment forms and claims. The current OASIS reporting requirements for diagnostic information conflict, in some cases, with longstanding ICD-9-CM coding rules and will eventually be in conflict with the spirit, if not the letter, of HIPAA requirements for uniform code sets. AHA has been working with CMS over the last year to develop a cross-walk between the existing PPS requirements for diagnostic information and those that would be consistent with coding guidelines. We hope that this process will result in a more consistent application of coding rules to home health care.
- CMS should examine the necessity for the significant change in condition (SCIC) payment adjustment. This adjustment requires multiple repeated data collections, often resulting in a lowering of a provider’s rate. This retrospective adjustment results in extra burden of OASIS.