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PPS Reform: Analysis and Guidance

Speak Now on OASIS-C or Prepare to Live with It

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Beacon Health Briefing
Mequon, Wisconsin - April 1, 2009

Almost two years ago, the Centers for Medicare and Medicaid Services (CMS) released the first version of a revised OASIS data set, which has since come to be known as OASIS-C. Since that time, Beacon Health has been alerting homecare providers to the increased burdens and survey traps that this data set could present.

On March 18, CMS posted on its quality initiative Web site a 73-page document with a summary of the public comments submitted on OASIS-C and CMS’ rebuttal. It’s not surprising that the public had few positive things to say about OASIS. There were fewer than two pages of comments, mostly about improvements to data elements. There are 22 pages of concerns, most relating to best practices. Many of those comments addressed Beacon Health’s biggest concern; being that best practices do not belong in the OASIS.

As your agency prepares its response to CMS (due April 8), review this document. (Find it at http://www.cms.hhs.gov/HomeHealthQualityInits/Downloads/HHQIResponsesToPublicComments.pdf.) Then consider these issues.

• Concern: CMS should not dictate what interventions are appropriate for specific patients. Agencies, not the government, should drive best practices.
  CMS’ rebuttal: Completion of the data elements on screenings/assessments and implementation of best practice interventions are optional. CMS also notes there is a response option (No) to indicate that these processes were not conducted.
  Beacon Health’s response: It is good to know that the agency has the option not to complete the assessments or implement interventions. However, to prevent issues with surveyors, CMS should make it very clear in the written instructions for OASIS that these data elements are optional.

There are other comments in this document that the CMS must incorporate into the instructions for OASIS-C and the various data elements. These include the following:

- On page 6, CMS notes that agencies “should remember that all items that ask for documentation of this information require agencies to respond to the best of their ability.”
- On page 7, OASIS-C incorporates a two-question depression screening (the PHQ-2© from Pfizer) “for agencies that choose to use it.”
- On page 8, “in all instances, agencies have the opportunity to opt-out of these screening items on OASIS-C by responding that the screening was not done.”

• Concern: Documenting processes in the OASIS goes beyond the scope of the data set.
  CMS’ rebuttal: CMS is committed to developing and reporting process measures that support evidence-based best practices. CMS will use the information reported in OASIS-C to recognize agencies that have incorporated best practices into their processes.
  Beacon Health’s response: There are other best practices that agencies may choose to incorporate into their processes. However, because these best practices would not be captured through the OASIS and subsequently publicly reported, would the public perceive these agencies not to be as quality-conscious? If that were to become true, agencies will be forced to implement the process elements in OASIS-C in order to avoid any negative perceptions as to what they do or don’t do.
  
  
• Concern: Medicare would not cover some of the process interventions these data elements address.
  CMS’ rebuttal: Some of these best practice assessments and interventions fall under assessment, teaching and training, and management and evaluation of a care plan.
  Beacon Health’s response: Medicare coverage criteria dictate that inventions, including assessment and teaching, must be reasonable and necessary for treatment of a patient’s medical condition. If the patient does not have a pressure ulcer or there is no risk for falls, related interventions would be preventive in nature, not treatment for the patient’s medical condition, and therefore not covered by Medicare. Management and evaluation of a care plan focuses on implementation of an unskilled plan if there is an unstable caregiving situation for a patient at risk. In most cases, it would be inappropriate to use management and evaluation to address the best practice issues in OASIS-C. (To learn more about what management and evaluation is and is not, read this article in Beacon Health’s knowledgebase - Click Here.)
  
  
• Concern: Responding to process items at recertification, transfer, and discharge will be difficult to operationalize.
  CMS’ rebuttal: Agencies are already collecting some of these data, so completing the data elements would not be difficult. The 60-day summary report and the discharge summary include information on patient status and interventions implemented.
  Beacon Health’s response: The Conditions of Participation define the 60-day summary report as a report sent to the attending physician containing facts from clinical and process notes. The Interpretive Guidelines simply say that the discharge summary includes information about the patient’s medical and health status at discharge. There is nothing in writing that either of these reports must include interventions implemented. It is up to the homecare agency to determine content in these two summary reports. CMS’ statement in this document is not supported by regulation. If this statement reflects policy CMS intends to establish, it would create additional burden.
  
  

One more issue: CMS is sticking to its original burden estimate. OASIS-C will not have an impact on the time necessary to complete assessments or the associated burden. It continues to overlook the burden associated with developing the infrastructure for the supposedly optional best practice data elements.

Beacon Health has posted two articles to the PPS Reform Web site that include details on submitting comments. To find these articles, go to — Briefing Archives — and then click on the links for March 17 and March 25, 2009.

To download the CMS’ most recent OASIS-C package, including supporting statement, and burden estimate, go to — http://www.cms.hhs.gov/PaperworkReductionActof1995/PRAL/list.asp#TopOfPage — and click on CMS-R-245.

To find the latest OASIS-C, CLICK HERE.

You have until April 8 to respond

Study the information and then send in your comments by April 8 to:

OMB, Office of Information and Regulatory Affairs
Attention: CMS Desk Officer.
Fax Number: (202) 395–6974
E-mail: OIRA_submission@omb.eop.gov.

The Beacon Health seminar, “Mastering Medicare,” (next stop — Nashville on April 20 and 21) addresses OASIS-C and other important topics.  For more information, click on — http://www.beaconhealth.org/mastering_medicare/seminars09.html.

© 2009 Beacon Health. All Rights Reserved.

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