CMS-R-245.Supporting Statement Part A

Supporting Statement – Part A

Supporting Statement for Paperwork Reduction Act Submissions

Renewal to the Outcome and Assessment Information Set (OASIS) for Collection by Home Health Agencies – OASIS-C

A. Background

This request is for OMB approval to continue to require the Outcome and Assessment Information Set (OASIS-C) data set that home health agencies (HHAs) are currently mandated to collect in order to participate in the Medicare program. There are no proposed revisions to this OASIS-C data set. The current version of the OASIS-C data set was approved by OMB on July 27, 2009 and has been in use since January 2010. OMB approval expires on July 31, 2012.

Collection and Use of OASIS Data

Since 1999, the Conditions of Participation (CoPs) at § 484.55 have mandated that HHAs use the OASIS data set when evaluating adult non-maternity patients receiving skilled services.¹ The OASIS is a core standard assessment data set that agencies integrate into their own patient-specific, comprehensive assessment to identify each patient’s need for home care that meets the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. CMS sees the OASIS as one of the most important aspects of the HHA’s quality assessment and performance improvement efforts:

“By integrating a core standard assessment data set into its own more comprehensive assessment system, an HHA can use such a data set as the foundation for valid and reliable information for patient assessment, care planning, and service delivery, as well as to build a strong and effective quality assessment and performance improvement program.” ²

HHAs are required to collect the OASIS data at specific time points (admission, resumption of care after inpatient stay, recertification every 60 days that the patient remains in care, transfer, and at discharge). HHAs are also required to encode and transmit patient OASIS data to the state OASIS repositories. State survey agencies are responsible for collecting OASIS data from HHAs and making OASIS-based outcome reports available to HHAs. Through the state system, an HHA is able to obtain online outcome reports based on its own OASIS data submissions, and comparative state and national aggregate reports. Individual HHAs thus have on-line access to case mix reports, adverse event reports, and annualized risk-adjusted outcome reports based on their own reported OASIS data. CMS regularly collects OASIS data from the states for storage in the national OASIS repository, and measures of patient outcomes are made available to consumers and to the general public through the Home Health Compare website maintained by CMS.

Since 2000, elements of the OASIS data have also served as the basis for the Prospective Payment System (PPS) that determines home health reimbursement for Medicare patients. Using the same data elements for both quality monitoring and payment allows CMS to ensure that HHAs are not maximizing profits at the expense of beneficiary outcomes while realizing the efficiency of using a single data source.³ OASIS is also instrumental in assisting CMS to address the new challenges presented by Pay for Reporting (as mandated in the Dec. 2005 Deficit Reduction Act), which dictates that “for 2007 and each subsequent year, in the case of a home health agency that does not submit data to the Secretary in accordance with subclause (II) with respect to such a year, the home health market basket percentage increase applicable under such clause for such year shall be reduced by 2 percentage points.” Additional information about the legal basis for OASIS data collection is presented in Section B.1: Need and Legal Basis; additional information about OASIS data use is presented in Section B.2: Information Users.

Previous OASIS Refinement Efforts

In 2002, CMS introduced the “reduced-burden” OASIS that was a product of the Secretary’s Regulatory Reform Advisory Committee to help guide HHS’s broader efforts to streamline unnecessarily burdensome or inefficient regulations that interfere with the quality of health care. The Advisory Committee studied OASIS and recommended deleting those items and assessments not used for payment, quality measurement, or survey purposes in an effort to ease paperwork burden on HHAs and their clinicians. This resulted in a burden reduction of 28 percent, and the revised OASIS was implemented in December 2002.

After the 2002 revision, CMS continued soliciting input on potential refinements and enhancements of the OASIS instrument from HHAs, industry associations, consumer representatives, researchers, and other stakeholders. Work carried out under a previous contract by University of Colorado Health Sciences Center (UCHSC) included gathering suggestions for OASIS revisions, synthesizing and consolidating suggestions for review by a technical expert panel and CMS staff, performing data analysis to inform the review process, and developing a series of potential OASIS enhancements for consideration by CMS. Abt Associates and its subcontractors UCHSC and Case Western Reserve University were awarded a contract by CMS in September 2006 to continue the process of refining the OASIS data set, as well as for the testing of the instrument and analysis of the impact of proposed changes. A revised draft OASIS-C data set was developed and published in the Federal Register for public comment July 2007. Modifications to item wording were then made based on public comment and internal review. A further revised draft OASIS-C was published in the Federal Register in October 2007, and this version was used for field testing.

Data collection was initiated in spring 2008, as soon as OMB approval of the PRA package was received, and it was continued through November 2008. Testing was conducted at 11 agencies in three states to evaluate validity, reliability, burden, feasibility, and usability. Testing included time analysis and inter-rater reliability of paired assessments, medical record review, and clinician focus groups. By September 2008, the data collection goals of 180 OASIS-C time study assessments and 160 pairs of inter-rater assessments were met.

A revised version of the OASIS-C was published in the Federal Register for public comment on November 14, 2008, and 142 comments were received. Each of these comments was reviewed and evaluated, and further revisions to the OASIS-C data set were made when appropriate. These modifications resulted in the version of OASIS-C that is currently approved by OMB. Data collection using OASIS-C began on January 1, 2010. This request seeks approval to continue requiring OASIS-C data collection once the current approval expires on July 31, 2012. It does not propose any additional changes to the OASIS-C data set.

B. Justification

1. Need and Legal Basis

Section 1861(o) of the Act (42 U.S.C. 1395x) specifies certain requirements that a home health agency must meet in order to participate in the Medicare program. (Regulations at 42 CFR 440.70(d) specify that HHAs participating in the Medicaid program must also meet the Medicare CoP.) In particular, section 1861(o)(6) of the Act requires that an HHA must meet the CoP specified in section 1891(a) of the Act and such other CoP as the Secretary finds necessary in the interest of the health and safety of its patients.

Section 1891(a) of the Act establishes specific requirements for HHAs in several areas, including patient rights, home health aide training and competency, and compliance with applicable federal, state, and local laws. Section 1891(b) of the Act states that the Secretary is responsible for assuring that the CoPs, and their enforcement, are adequate to protect the health and safety of individuals under the care of an HHA, and to promote the effective and efficient use of Medicare funds. To implement this requirement, state survey agencies generally conduct surveys of HHAs to determine whether they are complying with the CoPs. Section 1891(b) of the Act (42 U.S.C. 1395bbb) requires the Secretary to assure that the CoPs and their requirements adequately protect the health and safety of individuals under the care of a home health agency, and 1891(c)(2)(C)(i)(II) requires that a standard HHA survey shall include a survey of the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care. In accordance with section 1891(d)(1), we are required to monitor the quality of home health care with a “standardized, reproducible assessment instrument.” Based on industry input, we selected the OASIS as the instrument to improve the quality of care and to comply with the law. The use of OASIS is a requirement that HHAs must meet to participate in the Medicare program (See 42 CFR § 484.55).

The conditions of participation (42 CFR §484.200 - §484.265) that require submission also provide for exclusions from this requirement. Under the CoPs, agencies are excluded from the OASIS reporting requirement on individual patients if:

• Those patients are receiving only non-skilled medical services,

• Neither Medicare nor Medicaid is paying for home health care (patients receiving care under a Medicare or Medicaid Managed Care Plan are not excluded from the OASIS reporting requirement),

• Those patients are receiving pre- or post -partum services, or

• Those patients are under the age of 18 years.

Section 4603 of the Balanced Budget Act of 1997 (BBA) created section 1895(a) of the Act, which required the development of a prospective payment system (PPS) for HHAs beginning October 1, 2000. Specifically, section 1895(b)(4)(C) of the Act requires the Secretary to establish appropriate case-mix adjustment factors for home health services in a manner that explains a significant amount of the variation in cost among different units of services. Section 4601(d) of the BBA provided the statutory authority for the development of a case-mix system by requiring the Secretary to expand research on a PPS for HHAs under the Medicare program that ties prospective payments to a unit of service, including an intensive effort to develop a reliable case-mix adjuster that explains a significant amount of the variances in costs. Further, section 4601(e) of the BBA provides the authority for the submission of data for the case-mix system, effective for cost reporting periods beginning on or after October 1, 1997, by permitting the Secretary to require all HHAs to submit additional information necessary for the development of a reliable case-mix system. Regulations implementing these requirements are codified at 42 CFR 484 Subpart E. We have plans to eventually link beneficiary information across provider settings with other administrative data (for example, payment and utilization data). Beneficiaries may have very complex service delivery histories, moving among various services and benefits. If OASIS data are not collected, it would be difficult to track outcomes and facilitate administrative tasks involved with integrating the care of individuals in our data systems, including the Minimum Data Set (MDS) for nursing home residents.

OASIS is also instrumental in assisting CMS to address the challenges presented by Pay for Reporting (as mandated in the Dec. 2005 Deficit Reduction Act [DRA]). Specifically, section 5201(c)(2) of the DRA added section 1895 (b)(3)(B)(v)(II) to the Social Security Act, requiring that “every home health agency [HHA] shall submit to the Secretary [of Health and Human Services] such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.” In addition, section 1895 (b)(3)(B)(v)(I), as also added by 5201 (c)(2) of the DRA, dictates that “for 2007 and each subsequent year, in the case of a home health agency that does not submit data to the Secretary in accordance with subclause (II) with respect to such a year, the home health market basket percentage increase applicable under such clause for such year shall be reduced by 2 percentage points.”

2. Information Users

• HHAs: Individual HHAs use the patient-specific information in the OASIS data set to conduct patient assessment, care planning, quality assessment, and program improvement activities. Using Outcomes-based Quality Improvement (OBQI) reports based on the OASIS data set, HHAs are able to examine their specific care domains and types of patients and can compare present performance to past performance with national performance norms. HHAs use the outcome reports to evaluate the effectiveness of care provided to specific types of patients and, in the context of investigating processes of care, to individual patients. They also use the data from outcome reports to continuously monitor quality improvement outcomes over time, and to objectively assess their own strengths and weaknesses in the clinical services they provide. These outcome reports inform the HHA of the care-related areas, activities, and/or behaviors that result in effective patient care, and alert them to needed improvements. Such information is essential to HHAs in initiating quality improvement strategies. They can also be used to improve HHAs’ financial planning and marketing strategies.

• State Agencies/CMS: Agency profiles are used in the survey process to compare an HHA’s results with its past performance. The availability of performance data enables state survey agencies and CMS to identify opportunities for improvement in the HHA, and to evaluate more effectively the HHA’s own quality assessment and performance improvement program. CMS and state agency surveyors use the reports off-site in a pre-survey protocol to target areas of concern for the on-site survey. The surveyors look at how the HHA uses OASIS data internally, and they use the information to more effectively target survey activities.

• Accrediting Bodies: Upon specific request, national accrediting organizations such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) the Community Health Accreditation Program (CHAP), and the Accreditation Commission for Health Care, Inc. (ACHC) are able to access the information only for the facilities they accredit and that participate in the Medicare program by virtue of their accreditation (deemed) status. CMS provides OASIS information to these national accrediting bodies to enable them to target potential or identified problems during the organization’s accreditation review of that facility.

• Beneficiaries/Consumers: Since November 2003, a subset of the OBQI outcomes have been publicly reported on the Home Health Compare website available to consumers on www.Medicare.gov. From January 2010 through July 2011, this website underwent a transition as CMS revised the Home Health Compare website to include outcome, utilization, and potentially-avoidable event measures calculated based on OASIS-C data and incorporated 13 NQF-endorsed process measures. The website provides information for consumers and their families about the quality of care provided by individual HHAs, allowing them to see how well patients of one agency fare compared to other agencies and to the state and national average. The website presents the quality measures in consumer-friendly language and provides a tool to assist consumers in the selection of an HHA. As with the nursing home quality initiative, the home health agency initiative uses quality measures to assist consumers in making informed decisions when choosing a home health agency; to monitor the care their home health agency is providing; and to stimulate home health agencies to further improve quality. The addition of process items to OASIS provided consumers with another tool to identify agencies that practice processes of care recognized as optimal practice.

3. Use of Information Technology

The OASIS represents uniform formulations for collecting data items that are customarily collected in the course of the clinician’s assessment of adult patients receiving skilled home health care in order to create or update the plan of care, or to document the patient’s status during an episode of care. The data are generally collected in the patient’s home, though some items require consulting of patient records or data received from the patient’s previous health care providers (such as the hospital discharge summary.) As such, the OASIS items are integrated into home health agencies’ clinical records, and the modality of data collection is dictated by agencies’ choices of documentation systems. Many home health agencies utilize electronic point of care technology (laptop computers, handheld devices, or other technology) that allows for assessment data to be entered electronically as it is collected. Other agencies’ clinicians utilize a paper form in the home, and the data are later entered into an electronic system.

For purposes of reporting, the Medicare Conditions of Participation for home health agencies (42CFR484.20) require that the OASIS items collected for Medicare or Medicaid patients be submitted electronically to the appropriate state agency. CMS provides the HAVEN software free of charge for agencies to use in electronically encoding and submitting these data, though some agencies have clinical and billing systems or vendors that perform this function for them. 100% of responses are submitted electronically.

OASIS data do not require a signature from the respondent.

4. Duplication of Efforts

The OASIS C does not duplicate any other collection data sets and the information cannot be obtained from any other source. It uses elements that are currently collected as part of the condition of participation at § 484.55, which has required a standardized assessment to be integrated into the HHA's current patient data collection and care planning processes since July 1999.

5. Small Businesses

Since OASIS data collection was mandated in1999, CMS has taken steps to reduce OASIS-related burden to all providers, including those that are small businesses. For example, we provide a hotline for troubleshooting purposes and free software to HHAs. This software, containing the data items to be completed at each of the OASIS data time points, is available at no charge, and can be downloaded from our website. There is also a training page on the website, along with an OASIS Q&A mailbox. Additionally, the entire OASIS User’s Manual is available on our website at no cost to HHAs. CMS has also provided training through its OASIS contractors either directly or via satellite.

6. Less Frequent Collection

Frequency of collection will not change from the currently mandated OASIS time collection requirements. Since one of the purposes of this data collection is to assess patient outcomes, and since outcome quality measures quantify change in patient health status over time, data must be gathered at a minimum of two time points. Therefore, patient health status data obtained through the OASIS are collected at least twice (i.e., at admission and discharge for patients seen by the HHA for less than 60 days), and at 60-day intervals for patients receiving care for longer periods. Sixty-day intervals correspond to other data collection points required by the Medicare program (i.e., for prospective payment). Since the average length of stay in Medicare home health care is less than 60 days, the majority of data collection will be completed at two time points.

7. Special Circumstances

Under the Medicare Conditions of Participation (42CFR484.20), Medicare-certified Home Health Agencies must report OASIS data electronically to the appropriate state agency or CMS OASIS contractor within 30 days of the assessment completion date. This allows OASIS data to be available from the state and national repositories on a timely basis for a number of key CMS functions, thus avoiding separate (and duplicative) data collection efforts:

• OASIS data can be accessed from the repositories by staff from the Home Health and Hospice Medicare Administrative Contractors (HH&H MACs) for use in assuring the accuracy of case-mix classification for payment;

• OASIS data can be accessed from the repositories by state survey and certification staff for use in surveys to assure home health agency compliance with the CoPs;

• OASIS data can be accessed from the repositories by CMS to assess home health agency compliance with the Pay for Reporting requirements of section 5201(c)(2) of the December, 2005 Deficit Reduction Act.

Less frequent reporting of OASIS data would require that separate systems of data collection be established to collect the required data, which would increase the burden on home health agencies.

We continue to believe that if data collection occurs less frequently than the specified time points, as stated in § 484.55, the ability to make proper Medicare payments and to evaluate the quality of care provided by HHAs to Medicare and Medicaid beneficiaries will be compromised.

8. Federal Register/Outside Consultation

The 60-day Federal Register notice published on December 16, 2011.

Since August 2002, CMS has consulted with various industry associations such as the National Association for Home Care and the Visiting Nurses Associations of America to solicit input on proposed changes to the OASIS instrument. A CMS Technical Evaluation Panel composed of home health agency professionals, experts in quality measurement, payment indicators, and systems, and a beneficiary representative also provides advice on OASIS refinement. Researchers from UCHSC, Case Western Reserve University and Abt Associates assisted CMS in designing, conducting field testing, and analyzing results of testing the OASIS-C instrument. In addition, comments from clinicians who participated in the field testing of OASIS-C were obtained via debriefing and discussion groups following data collection during the fall of 2008, and their recommendations were incorporated into the OASIS-C. In October-November 2008, a set revised/updated and new quality measures calculated using items from the proposed OASIS C data set were submitted for review and endorsement by the National Quality Forum (NQF). Based on feedback from the NQF Steering Committee, some additional changes were made to the OASIS-C items in order to support the generation and public reporting of endorsed quality measures. Finally, the publication of the proposed OASIS-C in the Federal Register for public comment on November 14, 2008 resulted in the submission of comments from numerous individuals, providers, state associations, professional associations, and home health industry organizations.

9. Payments/Gifts to Respondents

There are no payments or gifts to respondents.

10. Confidentiality

We pledge confidentiality of patient-specific data as provided by the Privacy Act of 1974 (5 U.S.C. 552a).

11. Sensitive Questions

There are no sensitive questions.

12. Burden Estimates (Hours & Wages)

Although minimal, we acknowledge that there is a small burden associated with the on-going use of the existing OASIS instrument when collecting OASIS information as part of the comprehensive assessment, and collecting the information for PPS. Our estimates of time, cost, average HHA size, and staff salaries are calculated as indicated below, based on historical information from the industry, consultation with the University of Colorado, assistance with statistical information from our contractors at Stepwise Systems, as well as use of updated information from additional sources, as noted.

For the period July 2010 through June 2011, there were a total of 16,476,008 OASIS assessment submissions. There were approximately 11,495 agencies active during that period. Therefore we estimate the average size HHA submits 1,433 (=16,476,008 / 11,495) assessments annually.

Based on the most recent available salaries for home health clinicians from the Bureau of Labor Statistics, and the distribution of OASIS completion across disciplines, we estimate an average hourly salary of $29.47 per clinician and $20.57 per administrative assistant.

Since the number of assessments completed per agency has remained essentially constant, we retain the previous PRA package’s estimate of the average-sized HHA as having 18 clinicians and thus use the previous estimates of data collection time, data entry time, and ongoing training time.

• Data Collection: We estimate that HHA clinicians spend 55 minutes (0.9167 hours) per assessment to collect OASIS data. The total annual burden of data collection is thus: (0.9167*16,476,008) = 15,103,007 hours per year for data collection. Using an average hourly salary of $29.47 for clinicians, this corresponds to $445,085,626 of assessment collection costs for all HHAs per year.

• Data Entry: We estimate that HHA administrative assistants spend 5 minutes (0.0833 hours) per assessment to process OASIS data. The total annual burden of data entry is thus: (0.0833*16,476,008) = 1,373,001 hours per year for data entry. Using an average hourly salary of $20.57 for administrative assistants, this corresponds to $28,242,624 of training costs for all HHAs per year.

• Ongoing Training: Training clinicians in newly certified HHAs and new staff in existing HHAs on the use of OASIS is an ongoing process. We estimate that HHAs spent 8 hours per year for ongoing training: (8*11,495) = 91,960 hours per year for ongoing training. Using an average hourly salary of $29.47 for clinicians, this corresponds to $2,710,061 of training costs for all HHAs per year.

The total burden for ongoing training, assessment data collection, and data entry per year is estimated to be (91,960+ 15,103,007+ 1,373,001=) 16,567,968 hours. This corresponds to an annual total cost of $476,038,311.

1,433 assessments @ 1 hr/assessment (55 minutes for data collection and 5 minutes for data entry) = 1,433 hrs + 8 hours per year per agency for training new staff = 1,441 hours per agency per year, or overall 1.006 hours per assessment.

13. Capital Costs

At the time of the OASIS implementation, there was a one-time start-up cost for HHAs in the first year. After the first year of OASIS implementation, existing HHAs experience an ongoing cost of reporting the gathered information to the state or OASIS contractor. We continue to acknowledge that the time frames required by § 484.55 serve as a strong performance expectation for HHAs. In identifying standardized data elements that fit within the HHA’s overall comprehensive assessment responsibilities, the OASIS includes only information necessary to measure outcomes of care for quality indicators and for HHAs to continue to receive payment through the prospective payment system. Therefore, we require that HHAs use the current version of the OASIS as specified in §484.55(e). We believe this requirement is necessary to continue to build a valid, reliable, comparable data set of outcomes.

We do not believe that the ongoing collection of OASIS-C data will require new capital expenditures on the part of home health agencies. CMS will continue to provide and update HAVEN software free of charge for agencies.

14. Cost to Federal Government

In the previous PRA submission, a statement of costs to the federal government was erroneously omitted. The Agency now seeks to remedy this oversight. It is important to note that these costs are not new, but have been associated with the use of the OASIS data collection instrument since it was first introduced in 1999.

CMS will incur costs associated with the collection and handling of OASIS-C data for several reasons. First, providers can submit their OASIS-C data using a CMS sponsored web-based program known as HAVEN. The federal government will incur costs associated with the maintenance and upkeep of this web-based computer program. In addition, the federal government will also incur costs for the help-desk support that must be provided to assist providers, not only with the OASIS-C data collection process, but also the data submission process.

Secondly, once OASIS-C data has been submitted by HHA providers, it is then transmitted to a CMS contractor for processing and analysis. Thereafter, the data is stored by another CMS contractor for future use. There are costs associated with the transmission, analysis, processing and storage of the OASIS-C data by the CMS contractors.

Thirdly, pursuant to §1895 (b)(3)(B)(v)(I) of the Social Security Act, HHAs that do not submit OASIS-C data will receive a 2 percentage point reduction of their home health market basket percentage increase. There are costs associated with the tabulation of the data necessary to determine provider compliance with the reporting requirements mandated by §1895 (b)(3)(B)(v)(I) of the SSA.

The total estimated annual cost to the federal government for the handling of OASIS-C data is $1,500,000. These costs are itemized below:

ESTIMATED ANNUAL COSTS TO FEDERAL GOVERNMENT:

Conduct State OEC Training $100,000

Update OASIS-C Web-Based Training $150,000

Update OASIS-C Q&As $100,000

Update OASIS-C Manuals and Materials $100,000

Contractor Costs for Receipt and Storage of OASIS-C Data $550,000

Costs for Upkeep & Maintenance of HAVEN Software by CMS/DNS $500,000

TOTAL COST TO FEDERAL GOVERNMENT: $1,500,000

15. Changes to Burden

Since we are not proposing any changes to the OASIS data collection that is currently approved by OMB, there are no anticipated changes to burden per task. However, the training burden has been adjusted downward as it was previous was submitted at the provider level rather than at the HHA facility level. Previously, the calculations were based on 18 responses per respondent. However, we have now corrected the calculations based on single response from each HHA and assigned 8 hours to each response.

16. Publication/Tabulation Dates

These information collection requirements do not employ sampling techniques or statistical methods. While the patient-level OASIS-C data is not published, CMS does publish a set of quality measures derived from OASIS-C assessments on the Medicare Home Health Compare web site. The OASIS-C data used to calculate the quality measures are updated quarterly and represent a rolling 12 months of data. Data for all episodes of care that end within that 12-month period are included regardless of when the episode of care began. The most recent update occurred on October 13^th, 2011 and includes episodes ending between July 1, 2010 and June 30, 2011. Additional details about the measures are available on the CMS Home Health Quality Initiative web site: https://www.cms.gov/HomeHealthQualityInits/10_HHQIQualityMeasures.asp

17. Expiration Date

This collection does not lend itself to the displaying of an expiration date.

18. Certification Statement

There are no exceptions to the certification statement.

1 In meeting the CoPs, HHAs are expected to collect OASIS data on all of the patients served by the agency with the following exceptions: 1) maternity patients; 2) those under 18; and, 3) those receiving only personal care services (e.g., housekeeping, chore services). In 2003, Section 704 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) temporarily suspended OASIS collection for non-Medicare/non-Medicaid patients until the outcome of an OASIS study is presented to Congress. This study was completed in December 2005 and has been submitted to Congress.

2 Medicare and Medicaid Programs: Use of the OASIS as Part of the Conditions of Participation for Home Health Agencies, 42 CFR Part 484 [Final Rules], Federal Register, Volume 64, Number 15, January 25, 1999, Pages 3747-3784.

3 Sections 4602 and 4603 of the Balanced Budget Act require the implementation of a home health prospective payment system (PPS) to replace an interim payment system. In defining PPS for home health agencies (HHAs), the statute requires the Secretary to consider an appropriate unit of service, the number, type and duration of visits provided within that unit of service, and their cost. Payment for a unit of service was modified by a case-mix adjustor, set by the Secretary, to explain a significant amount of the variation in the cost of different units of services. The home health PPS was implemented October 1, 2000.

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Supporting Statement For Paperwork Reduction Act Submission – Page 11

Form# CMS–R–245 (OMB# 0938–0760) – OASIS-C 11/01/2011