What’s the upside to the new COPs? Not much, say some home care experts

HCFA’s outcomes approach comes with a price

Rumbling out of Baltimore like an avalanche, the proposed Medicare Conditions of Participation (COPs) promise to increase your load of paperwork — as if you didn’t have enough already. Why, it took the Health Care Financing Administration (HCFA) more than 58 pages just to explain what they were changing and why. Add into that the Outcomes and Assessment Information Set (OASIS) proposal and 79-item survey tool, and you’re well above the 100-page mark just to keep up with what’s going on. (A basic outline of the proposed COPs and OASIS rules are inserted in this issue of Hospital Home Health.)

The new regulations will hit smaller hospital-based agencies especially hard, predicts Bill Cabin, a veteran home care attorney based in Totowa, NJ.

"A lot of hospital-based agencies are small and inefficient," he says, defining a small agency as one that makes fewer than 30,000 annual patient visits. "They in particular will have a tougher time getting resources to cope with things like background checks, which will mean help from human resources [departments], and OASIS, which will require assistance from information services."

The paperwork will also cause headaches for even the bigger hospital-based agencies and systems by disrupting the delicate relationship between home care and its most important internal customers: physicians. Greg Solecki, administrator of Henry Ford Home HealthCare in Detroit, calls this dissatisfying the internal customer.

"When physicians tell us to get rid of paperwork, we can’t. When you’re a freestanding agency, your customers don’t feel they have any control. With a hospital, your internal customers feel they can change your operation when it makes sense to change it, but when they can’t they often become dismayed."

Changes will affect everyone

However, even though hospital-based providers face some issues other home health providers don’t face, Solecki asserts that the proposed changes to Medicare’s COPs will cut across the entire industry.

Home health is a field already beset with mandatory compliance issues, he argues, which always translates into more paperwork, whether the mandate comes from the Joint Commission on Accreditation of Healthcare Organizations or HCFA.

The new COPs appear to be process-driven, despite the Department of Health and Human Services’ statements to the contrary about quality of care, Solecki says.

"[Compliance] makes us all crazy and neurotic. It drives staff away, it pushes physicians away. It scares me to death to think someone could accuse us of practicing fraudulently because I’m missing a document. Acts of omission should not be viewed as acts of commission. My problem with it is the whole ‘Show me the piece of paper that proves you’ve been doing this.’ The paper shuffle is one of the largest barriers we have to face," complains Solecki, whose agency is affiliated with one of the largest tertiary care hospitals in the country.

"I don’t have a problem with criminal background checks, outcomes measurement, specific time frames for the initial assessment," he says. "We all should be dealing with those things anyway. Many are. But it becomes a paper compliance issue. Success in the home health industry as deemed by accreditation groups, auditors, the government, seems to focus on paper compliance. We’re having difficulties managing the amount of paper that comes to our shop."

Solecki notes that a recent process improvement survey done by Henry Ford Home HealthCare turned up telling facts. The system’s in-house print shop "had difficulty in understanding why we were their largest customer. Our home health agency was spending more on printed forms than Henry Ford Hospital did. The amount of paper is mind-boggling for home health agencies, freestanding or hospital-based.

"It’s like the government says, ‘What can we think of today that will further alienate the clinical staff from the administration, the physicians from the clinical staff?’ It’s a way of dismantling the home health benefit," Solecki says. "It’s almost as if it has been set up to fail."

Solecki warns that automation will be forced on agencies because of OASIS, but automation will not mean the end of the paper trail, he says. "You’re still collecting data. That will eventually mean bigger computer systems, more memory. It never ends."

Kevin O’Donnell, president of Healthcare Resources of America, a home care consulting firm based in Lewisville, TX, argues that the government has no strategy for home health care. The proposed changes and the OASIS mandate are reactionary, he says.

"There’s no carrot, just sticks. Sticks are all over the place. Any good executive knows that you’ve got to have incentive. It all goes back to the rapid growth in home care. But is growth bad? They [HCFA] don’t have any strategy. They just don’t want people to get sick. They’re like HMOs: Their favorite home care patient is between the ages of 2 and 12 and never gets sick."

Just what does HCFA want, anyway?

The Conditions of Participation revision is based on four core requirements: patient rights, comprehensive assessment, patient care planning and coordination, and quality assessment and performance improvement. Some of the more significant changes in the COPs proposal are:

• a requirement for criminal background checks of home health aides as a condition of employment;

• a requirement that within three years, HHAs must provide at least 50% of total skilled professional services directly;

• a mandate to implement the Outcomes and Assessment Information Set (OASIS) to collect outcomes data.

Other specific steps are:

• Current qualifications of home health aides should be expanded to include nurse aides who have completed appropriate nurse aide training or competency evaluation requirements.

• Agencies must discuss with patients the expected outcomes of care so patients can be more involved in care planning.

• Agencies must coordinate all care that physicians prescribe for their patients, thus preventing the current practice of several agencies serving one patient without care coordination.

• Agencies must provide their staffs with continuous feedback on qualifications and performance as part of their continuous improvement programs.

Published in the Federal Register on March 10, the proposed COPs will be made a final rule by HCFA following the 90 days of discussion scheduled to end June 9. Cabin predicts objections from the home care industry will accomplish little because of the Clinton administration’s and Congress’ push to reduce Medicare spending.

"There will be a lot of yelling, screaming, and complaining, but what will happen with OASIS is the government will tinker with the shorter version [OASIS B]. That’s what they’ll do. It’s all so predictable and so counter to the needs of business, it boggles the mind. But it keeps a lot of people employed."

Cabin points out three changes he thinks will increase costs for the average home health agency. "These cut across all auspices, whether hospital-based or freestanding," he says:

Background checks. "This is new. Now, I’m not saying it isn’t necessary, but it will cost agencies more."

OASIS. "Again, I’m not saying something like it in theory isn’t necessary, but it will be an enormous cost increase between lower productivity and the cost of added paperwork."

Planned reduction in reimbursement outlays. "As usual, there is nothing in the conditions that says they would recommend an add-on to cost limits. This should be considered.

"This happens at a time when you have the president proposing to pull back cost limits and then implement PPS [prospective payment system], and you’re having the HCFA administrator saying that if PPS doesn’t come in some form [by 1999], he will achieve outlay reductions anyway. This is the usual uncoordinated way the government tends to put things out. It’s business as usual."

About the requirement that agencies provide 50% of all skilled professional services themselves, Cabin says, "To me, having been in this business for 15 years, that requirement more than any other displays how ignorant the federal government is of the business side of home care. I don’t understand what the point is. I can see it if you subcontract everything, but the amount of the [services] mix has to do with the marketplace availability of the labor pool. To publish these restrictions without knowing anything about the marketplace is ignorant."

Cabin says the new approach to outcomes, coupled with the requirement for OASIS and the lowering of Medicare cost limits, are especially nettlesome for an industry trying to find solid footing in the flood of reform proposals sweeping over it. A month before the new Conditions of Participation came out, the Clinton administration announced its intention to carve $14 billion out of Medicare spending on home health over the next five years, and to introduce a prospective payment system to replace cost reimbursement.

Greater burdens, lower reimbursement

"Clearly there appears to be a conscious effort on the part of the government to tighten eligibility coverage and increase the administrative burdens on Medicare-certified home health agencies," asserts Cabin. "At the same time, they plan to ratchet down reimbursement levels."

HCFA plans to implement OASIS in stages. Home health agencies must incorporate it into their current assessment processes when the proposed regulations are published as a final rule. Later, HCFA plans to publish another proposed rule requiring agencies to report OASIS data electronically.

"They [HCFA] sit around like lazy bureaucrats and let the Medicare program go along as it has been. Then the program draws some attention because of the levels of outlays, home care industry growth, OIG [Office of Inspector General] fraud reports, and so forth, and they swing the pendulum the other way overnight without any reasonable lead time or financial incentives," complains Cabin. "This places burdens on agencies."

Not everyone contacted by Hospital Home Health for this report expressed alarm over the new Conditions of Participation, however. Kathryn S. Crisler, MS, RN, senior research associate at the Center for Health Policy Research in Denver, even managed to put a positive spin on the proposal.

"I was really struck by the different mood that HCFA seems to be interested in creating," she says. "This seems to be a real attempt to allow some flexibility on the part of home health agencies. I think agencies that are currently doing a good job should welcome it. It focuses on the endpoint; it’s where we all want to get to.

"In the past, HCFA has been very rigid," she says. "There’s a little of that in there still, but less of Big Brother telling you how to provide care, than saying, ‘OK, show us what you’re doing. You have the responsibility to provide good care. If you don’t, we won’t pay you.’ "

Standards require performance improvement

Cathy Nielsen, RN, CPHQ, vice president of clinical services for In-Home Health in Minnetonka, MN, compares the government’s quality aim with current quality requirements of the major health care accreditation organizations.

"It’s very similar to the language they use in the Joint Commission standards for home care, with the emphasis on performance improvement. That’s very good.

"If an agency is Joint Commission-accredited, then they’ve been exposed to all these issues," says Nielsen.

Background checks of home health aides drew wide support among the experts, who agree the requirement both is necessary and desirable.

"Criminal background checks is a very good idea," says Nielsen. "However, they are difficult to do right. Agencies have to be taught. They need to find out where an employee lived in all the prior years they worked, because there is no national repository. It’s all state by state. All they have to do on an application is leave out one state."

Cathy Frasca, RN, BSN, FACHCA, executive director of South Hills Home Health in Homestead, PA, sees the requirement as necessary. "Our state home care association has already developed a software package that’s available to members."

Frasca, however, does not believe criminal background checks should stop with home health aides. "I’d like to see it on all staff, not just home health aides. Of course, professionals have other types of monitoring systems."