In October 2000, the Centers for Medicare & Medicaid Services (CMS), known at the time as the Health Care Financing Administration (HCFA), implemented a per-episode prospective payment system (PPS) for home health care (HHC) services as a provision of the Balanced Budget Act of 1997 (BBA '97).1-3 The PPS was created to answer rising concerns about the viability of the Medicare Trust Fund and to address increasing costs associated with providing health care to seniors and citizens with disabilities.1,4 Turnbull1 projected that the percentage of aging adult persons in the US population would increase from 13% to 20% by the year 2030 and, given this anticipated increase and the fiscal demands this would create, suggested that a major role of the BBA '97 was to reduce the potential for fraud and abuse of the Medicare program. To substantiate this claim, the author highlighted the estimate that in 1997, 11% of Medicare fee-for-service payments were inappropriate.1
Between 1986 and 1991, there was a steady increase in the number of home health visits per patient across the professions of nursing, physical therapy (PT), and home health aide. In 1986, the average number of visits per patient was 24.0, and in 1991, this number increased to 44.5.5-8 In 1994, Goldberg and Schmitz9 found that the average duration of an episode of care was 157 days. Furthermore, Horowitz10 identified an increase in the utilization of therapy visits in New York State's certified home health agencies (HHAs) between 1985 and 1996: 579 319 PT visits in 1985, 623 188 visits in 1990, and 1 469 527 visits in 1996. The shifting age distribution of the US population and incentives inherent to Medicare's hospital PPS were influential in the increased demand for skilled home care services.11 Under the PPS, patients are often discharged to their homes “quicker and sicker.”6 This rapid rise in the number of home health visits served as an impetus for the federal government to change the Medicare home health reimbursement structure from a per-visit to a per-episode method of payment.5,12
The BBA '97 established the interim payment system (IPS) to bridge the gap during the creation and implementation of the PPS.3,5 According to Utterback,3 the IPS created a new cost limit on the basis of the aggregate number of patients served per year by a given agency by lowering the per-visit cost limit. Gerding13 examined the impact of the IPS on HHAs across the state of Ohio, by comparing caseload and utilization variables from 1996 (pre-IPS) and 1999 (post-IPS). The results showed that there was a shift in utilization variables, with a decrease in the number of existing HHAs as well as in the number of services provided. However, these changes also brought about improvements in more efficient clinical practices, such as case management, supervision of alternative disciplines, and expedited accomplishment of goals by way of patient and caregiver exercise instruction.13
Within the last 2 decades, HHC has gone through major changes in payment system.2,14 Few studies have examined the relationship between the decline in the number of home health provider visits with the current payment system since its enforcement in October 2000.15–18 It is necessary for health care professionals to be aware of how policies can affect both the quality and quantity of care services delivered to patients.14
Overutilization and underutilization of Medicare services are considered fraud and abuse by the General Accountability Office (GAO) of the federal government. Overutilization occurs when a beneficiary receives more services (treatment visits and/or services) than are required to reach patient goals or when the clinician increases the duration of episode of care beyond what is necessary. Underutilization occurs when a health care professional chooses to reduce the number of disciplines or treatment sessions provided to meet patient goals or opts for 1 episode of care versus 2 episodes of care. Underutilization of PT services under the PPS is also a serious concern, as stated by Boling19 and Anemaet et al.20,21
Under the existing system, a total of 5 visits by 1 or more disciplines are required to receive full-episode reimbursement for the admission of a patient. Prior to January 1, 2008, a total of 10 visits by 1 or more rehabilitation discipline provided greater reimbursement than single discipline care or combined discipline care for fewer than 10 visits.20,21 The potential existed for health care professionals to increase the number of visits provided to gain a financial advantage.20,21
However, on January 1, 2008, the CMS established and implemented Home Health Prospective Payment System Refinement standards that created new and refined ways to improve the current payment system.22,23 This included a new Health Insurance Prospective Payment System (HIPPS) code set, which is a refined case-mix system with episode sequencing and resulting grouping steps to determine payment.24 HHAs now have to adjust to new billing software and codes for appropriate payment.
This study used the Outcome and Assessment Information Set (OASIS)25-29 to collect data regarding the utilization variables (ie, admission/discharge dates and visits provided by individual disciplines), functional outcomes, and comorbidities. OASIS is a federally mandated clinical assessment tool. Outcome data from OASIS are used in determining payment amounts under PPS for Medicare beneficiaries.
In 1999, after having passed several previous demonstration trials, the federal government required every HHA to use the OASIS data collection form as a basis for the outcome-based quality improvement program.30,31 The OASIS questionnaire is currently used to assess patients upon admission, discharge, transfer, or resumption of care.2,14,32 Transfer refers to being admitted to another service of care (ie, another HHA or hospital); resumption of care is used when a patient is admitted to a hospital during a home health episode of care and returns home and begins receiving HHC services again within that episode.33 OASIS has become a significant form of data collection for the federal government to monitor health care provided by the home health industry.
The few existing utilization studies have looked at the number of visits, the length of the episode of care, and the number of minutes the health care professional spent in the patient's home.11,34 Adams and Michel34 used the number of visits, length of stay (LOS), and total direct care time to find the correlation among these 3 measures. Total direct care time was defined as “the time spent in the patient's home,” whereas length of stay was defined as the “length of the home health episode.”34 A high correlation (r = 0.96) was found between the number of visits and total direct care time, whereas there were moderate correlations between the number of visits and LOS (r = 0.65) and between total direct care time and LOS (r = 0.63). The authors concluded that the number of visits and direct care time might display redundancy in measurement, meaning that the 2 variables reflected similar information.
Adams et al11 also evaluated the utilization of services between April 1997 and March 1998. The investigators gathered information on 1704 home health episodes and studied the relationship between generic patient outcomes and service utilization. They found that patients received a mean of 2.3 PT visits, whereas the total number of visits was 17.0 per episode, with nursing being the most frequent discipline going into the home. The average duration of an episode was 42.3 days. A limitation of this study was the lack of investigation related to specific diagnosis or medical condition. Analysis of “service utilization and condition-specific outcomes in distinct diagnosis groups” is warranted.33
A paucity of research exists on functional outcomes following the delivery of home health PT.2,35 Piyabanditkul36 observed the relationship between utilization and functional outcomes in patients with heart failure. The author used Donabedian's Structure-Process-Outcome framework37 and Andersen's Behavioral Model of Health Services Utilization38,39 as the basis of his study. Donabedian's model proposes that quality of care results from the combined effect of the resources associated with the provision of care, the process of providing care, and the outcomes of the care provided. Andersen's model aims to identify characteristics that predict one's use of health care services. The study concluded that with more total home visits (PT and speech-language pathology visits), the patients increased their functional ability at the end of the episode of care.36 Because the outcome tools utilized in this study were designed to measure behavioral outcomes, the findings are restricted in scope and may have limited applicability in an analysis of the PPS.
In general, there is a limited amount of published data regarding the utilization of PT in HHC. Most of the home health utilization studies grouped PT with nursing, other therapies (occupation and speech), and home health aide, making it impossible to retrieve specific data on how often patients utilized PT services and for which treatment interventions.5 In addition, the medical conditions and patient outcomes were generalized in published studies, making it too vague to apply their results to a certain population of patients.33,34 The aim of this study was to collect baseline data on the duration and number of visits within an episode of care in a sample population with a specific diagnosis and evaluated by a specific health discipline, as suggested by Teenier.40 Furthermore, the purpose was to evaluate the efficacy of PT intervention on patients' functional outcomes, using the OASIS data.
This study used a consecutively selected, retrospective chart review of 99 patients who completed an episode of care managed by a certified HHA in York, Pennsylvania. All patients had a secondary orthopedic diagnosis (ie, osteoarthritis, osteoporosis, degenerative joint disease, fractures in lower/upper extremity or spine), and some subsequently underwent either upper or lower extremity surgical procedures (ie, total hip replacement [THR], total knee replacement [TKR], open reduction internal fixation [ORIF], amputations). All patients participated in PT treatments and were admitted and discharged between January 1 and December 31, 2005. Data were not collected from any chart that had more than 1 episode of care (more than 60 days) or from any chart in which discharge occurred because of transfer to an inpatient facility or because of death. The administrator of the HHA granted permission to perform these chart reviews. Charts were reviewed solely by the primary author.
Patient charts were reviewed to identify the number of PT visits, duration of episode of care, diagnoses, presence of comorbidities, and the OASIS functional activity scores. The reviewed forms included the OASIS admission and discharge forms, PT evaluation forms, PT progress notes, and PT discharge summaries. The total number of visits was calculated by combining the total number of visits recorded on the PT evaluation forms, progress notes, and discharge summaries. The length of episode of care was calculated by counting the admission and discharge dates, as well as the number of days between those 2 dates, on the OASIS admission and discharge forms. Comorbidities that were orthopedic in nature were recorded from both the OASIS admission forms and PT evaluation forms.
The 3 functional outcomes of interest were toileting, transferring, and ambulation/locomotion. Toileting was defined as the ability to get to and from the toilet or bedside commode. Transferring activities include the ability to move from bed to chair, on and off toilet or commode, and into and out of tub or shower and (if bedfast) the ability to turn and position oneself in bed. Ambulation/locomotion was defined as the ability to either walk safely (once in a standing position) or use a wheelchair (once in a seated position), across a variety of surfaces. Functional scores for each activity were recorded from the OASIS admission and discharge forms. Possible scores ranged from 0 (completely independent) to 4 (completely dependent).
The WinStat version 2.1 software was used for all data analysis. Descriptive statistics were calculated for the number of visits, the duration of episode in days, the number of comorbidities, and the average number of visits per week. Nonparametric Wilcoxon test was used to compare the nominal-level OASIS functional scores of interest at the start and the end of the episode of care. The Pearson product moment correlation (r) evaluated the strength of relationships among variables of interest. Analyses were conducted for all subjects (group A, N = 99) and for subgroups on the basis of location of impairment and level of independence (group B–lower extremity diagnosis, n = 57; group A1–all not independent at baseline, n = 46; group B1–lower extremity diagnosis not independent at baseline, n = 23) (Table 1).
The most common lower extremity diagnoses included TKR, THR, or ORIF of fracture in the lower extremities. Forty-two individuals receiving home care had upper extremity impairment or other medical diagnoses. The information from those not independent at baseline was used to evaluate how much improvement was made with PT intervention in each of the 3 functional activities. Individuals who were independent in a certain functional activity at both the start and end of care (ie, scores of “0” at both the admission and discharge of the patient) were excluded.
Table 1 summarizes the level of independence for the patients based on the OASIS rating at admission for each functional activity. All of the subjects, across subgroups, were not independent in ambulation at baseline.
Table 2 summarizes comorbidities, number of PT visits, episode duration, and average weekly visits for all patients and for subgroups of patients. Mean and standard deviations of total number of visits and duration of care were similar for all subjects [A: 5.7 (3.2) total visits, 20.5 (10.6) days of care] and the lower extremity orthopedic diagnosis subgroup [B: 5.8 (3.0) total visits, 17.5 (7.6) days of care]. Range of duration of care was greater for all subjects (3–56 days) than for the lower extremity subgroup (3–37 days). For the entire sample (A), the mean number of visits per week was 2.1 (0.9), with a range of 0.2 to 4.6 visits, and the mean number of comorbidities was 5.2 (2.2) per patient. For those with lower extremity orthopedic diagnoses (B), the most frequent number of visits per episode was 4 (21% of patients), followed by 6 (14%) and 5 (11%) (Figure 1). The most common duration of episode of care was 10 to 15 days and 15 to 20 days (both 14% of patients) and 20 to 25 days in 13% of patients (Figure 2). No patient in group B was seen over 40 days.
Nonparametric Wilcoxon tests compared the 3 functional abilities at admission and after intervention at discharge. There was significant improvement in all comparisons (Table 3). The magnitude of score change varied with the functional task. In toileting, 17 of 22 patients (77%) improved by 1 score, 3 (14%) patients improved by 2 scores, and 2 patients' (9.1%) scores did not change. Improvement of 1 score in transferring ability was achieved by 28 of 48 patients (58%), whereas 3 (6.25%) gained 2 points and 17 (35%) did not gain any points. Improvement in ambulation/locomotion was the least evident, as 38 of 57 (66%) did not improve their score. Sixteen patients (28%) improved by 1 score, and 3 patients gained 2 points on the ambulation scale.
Among the various correlates of functional activity scores for subjects with lower extremity diagnosis who were not independent on admission (group B1), the Pearson correlation values (r) that reached statistical significance (P < .001) included “toilet admission” and “toilet discharge” (r = 0.66), “toilet admission” and “ambulation admission” (r = 0.67), “toilet discharge” and “ambulation discharge” (r = 0.52), and “transfer admission” and “ambulation admission” (r = 0.58). There were no significant correlations between the number of PT visits, comorbidities, and the 3 functional outcomes.
This study provides specific baseline data on the number of PT visits and the duration of episode of care for home health care patients receiving services from one HHA under the PPS in 2005. Regression analysis revealed a strong relationship (R2 = 0.57) between the number of PT visits and episode duration (Figure 3). The average number of PT visits was similar whether the entire sample or any subset of data was considered. Although the mean number of PT visits was slightly higher in group B (those who underwent a TKR, THR, or ORIF of the lower extremities), the mean duration of the episode of care was shorter than that for group A by approximately 3 days. Patients with either upper or lower extremity orthopedic diagnoses received about the same number of PT visits in this study.
One of the primary objectives of PT is to improve functional ability and independence in activities of daily living of patients with musculoskeletal, orthopedic impairments of the lower extremities.41-43 The improvements in the OASIS functional rating identified in this study support the efficacy of PT intervention provided in the home. Most patients made improvements in their ability to get to and from the toilet, whereas fewer patients improved on transferring from one position to another, and even fewer improved their ambulation scores. These findings were similar to the data reported by Adams et al.11
The majority of patients did not demonstrate improvement in their ambulation score on OASIS. The reasons for this are unclear. Potentially, the duration of episode of care may not have been sufficiently long for these patients to reach a higher level of independent walking. It is well established that recovery after THR and TKR is a slow process, particularly in the presence of other comorbidities.44-48 Both group A (patients with both upper and lower extremity deficits) and group B (patients with only lower extremity deficits) received a very similar number of PT visits. Perhaps, those who underwent lower extremity surgeries required more visits to attain a higher level of ambulatory independence.
Another probable reason for the apparent absence of improvement in ambulation may be the lack of sensitivity of the OASIS functional scale scores in detecting changes in independence level. Forty-six of 56 patients in group A1 and 34 of 38 patients in group B1 scored 1 at both admission and discharge; the remaining patients scored either 2 or 0. A score of 1 is defined as requiring the use of a device (ie, cane, walker) to walk alone or requiring human supervision or assistance to negotiate stairs or steps or uneven surfaces. To improve the score from 1 to 0, the patient is required to regain concurrent abilities, an apparent nonlinear system measured by a linear scale. To be fully independent, with a score of 0, the patient has to walk without any assistive device or any supervision or assistance from another person. During an episode of care, the patient may have begun using a walker and subsequently progressed to a single-point cane by discharge. Although this reflects improvement in functional status in terms of need for support, the OASIS outcome score would remain the same. Some patients may have improved and no longer required an assistive device inside the home for safety but continued to require some supervision when performing outdoor locomotion on uneven surfaces. Despite the clear improvement, the score would still be the same and thus insensitive to meaningful changes. To solve this problem, the CMS is currently considering the addition of a response to M0700 (the OASIS question on ambulation), which would allow the patient to demonstrate functional improvement with ambulation when progressing from a walker to a cane.49 The wordings in the questions and responses may affect functional outcome.
Currently, there is limited research using OASIS to examine PT in home health, compared with home health utilization of nursing. Most of the available research in nursing pertains to depression and wound care, which are other sections within the OASIS.50-53 This study analyzed patients' functional outcomes on the OASIS, providing specific insight into PT utilization and intervention in HHC. Our data analysis showed that patients improved in all 3 functional activities—toileting, transferring, and ambulation/ locomotion—with PT intervention.
FitzGerald et al15 performed a national study that included all patients covered by Medicare who underwent orthopedic procedures (elective joint replacements and surgical repairs of hip fractures) between January 1996 and December 2001. They undertook a month-by-month analysis of home health utilization before and after the implementation of IPS and PPS reimbursement systems. The authors identified a decline in the number of total visits made by the HHA practitioners, first with the change in the IPS reimbursement system in 1997 and then a greater reduction in 2000 with the PPS. These changes seemed to affect the more vulnerable patient age group (>75 years old) with larger reductions in care. For example, in the group with elective joint replacement, the adjusted mean number of visits per patient in March 1996 was 36.2, which dropped to 24.7 by August 2001. In the same age group that underwent surgical repair of fractured hips, 54 visits were made in March 1996 and only 31.4 visits were made by August 2001. The investigators further concluded that the HHAs made swift changes in the utilization of HHC services with each Medicare policy change.15 In this current study, only the number of PT visits was recorded. Although the sample population in the study by FitzGerald et al15 also included patients with joint replacements and ORIF, the utilization comprised all health disciplines and did not specifically detail PT visits.
This current study complements the investigation formerly conducted by Lin and Meit,16 who evaluated 10 HHAs in rural Pennsylvania, reporting that the average number of PT visits per patient was 3.5 in rural Pennsylvania (November 2000–June 2002) and 4.2 nationally (January–June 200). Our results demonstrate an average number of PT visits of 5.7 (3.2) per patient (January–December 2005), an increase of 2.2 over the rural mean and 1.5 over the national mean. Whether these additional visits per patient are statistically different or whether they have impact on outcome of care to the findings of Lin and Meit16 is not clear.
Lin and Meit16 also reported that the total number of visits per patient (October 2000–June 2002) was 16, whereas the statewide average was 22 visits. These values are slightly lower than the 24.7 visits reported in the study by FitzGerald et al.15 The number of PT visits increased by 8% and occupation therapy visits by 1%, while visits decreased for nursing, medical social work, speech-language pathology, and home health aide.16 After PPS was implemented in 2000, physical therapists were required to perform OASIS assessments at the start of care for any patient case where skilled nursing was not ordered by the presiding physician. Therapists were required to act as both treating therapist and case manager.3 As case managers, physical therapists now visit the patient for the initial interview, discharge interview, and/or recertification visit, which may account for a small increase realized in the number of PT visits in their study but may actually decrease the time devoted for functional training.
Coincidentally, Schlenker et al18 also found that the number of PT visits in their study increased by 8% after the PPS implementation, although the total visits per episode had decreased by 16.6%. The authors concluded that patients received an average number of 5.4 therapy visits prior to PPS and 6.2 following PPS implementation. The authors grouped PT, occupation therapy, and speech- language pathology together. These data contrasted with our finding of 5.7 visits of only PT.
McCall et al17 used data from the CMS Standard Analytic Files before and after the BBA '97 and found that there were 39% less number of visits for any HHC service per user after the implementation of the act. PT visits were the least affected, with a 7% decline, from 6.0 visits in 1997 to 5.6 thereafter. This may be somewhat consistent with the number of PT visits after the implementation of PPS, as observed in our study and other studies noted earlier. FitzGerald et al,15 Lin and Meit,16 McCall et al,17 and Schlenker et al18 all reach the same conclusion: there was an overall decline in the number of visits patients received following the implementation of the PPS. Caution must be exercised in how payment policies can affect service delivery by health care professionals.
A number of limitations in the current study warrant mention. The sample population of 99 patients from 1 HHA in southeast Pennsylvania may not represent the general population of HHC patients in the rest of the state or nationally. The study's exclusion criteria (not including charts with multiple episodes of care during the study period or with discharge to inpatient facility or death) might bias data to reflect a smaller number of total PT visits and total duration of episode of care. Intertester reliability among the different physical therapists who recorded data by using the OASIS questionnaire may have been low.28,54–56 In addition, no data regarding specific PT intervention was collected. In the absence of specifics about intervention, one cannot demonstrate the cause and effect of intervention on functional outcomes. The interventions performed by each physical therapist may have been dissimilar because of the varied environments in which care was provided as well as variation in baseline health and functional status, even if the patients all had orthopedic diagnoses. Age and gender were not recorded, leaving the potential impact of these variables on the outcome measures unknown. Finally, no data were collected on the reason for patients' discharge from treatment or on patients' status beyond discharge.
This study highlights significant functional gains seen in homebound patients receiving home health PT during one episode of care. It also adds to the current existing literature on the utilization of PT services in HHC and provides a framework and baseline data for future comparisons. Future exploration of other potentially important functional outcomes and cost benefits under PPS is warranted to better understand the value of HHC rehabilitation services, to the public and to the PT profession. Health care professionals must continue to examine and reevaluate health care system payment policies for their influences on the quality and quantity of health care services provided by PT to patients.
The authors thank Chris Chimenti, MSPT, and Roger Herr, PT, MPA, COS-C, for assistance with the manuscript review.
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