October 15 2025
OASIS Answers
Categories: HHVBP

Claims-Based Measures in HHVBP: What’s Now and What’s Next

by Lori A Marmon, PT, MBA, COS-C

What Are Claims-Based Measures in Home Health?

There are measures in the Home Health Quality Reporting Program that don’t use OASIS assessment data but instead are calculated using data from Medicare fee-for-service claims. There are 2 types of claims-based measures:

Claims-based utilization measures – which provide information related to the use of health care services like hospitals or emergency departments
Claims-based cost/resource measures – which assess the Medicare spending of a home health agency

Two Types of Claims-Based Measures: Utilization and Cost

For performance year 2025 (CY 2025) there are two (2) claims-based measures in the HHVBP applicable measure set. HHA’s performance on these utilization claims-based measures could impact an agency’s Total Performance Score (TPS) and ultimately their Adjusted Payment Percentage (APP).

Assuming that an agency has sufficient data for these measures (remember the data for these measures comes from Medicare FFS claims), HHA performance on the claims-based measures could account for 35% of the TPS calculation in HHVBP for agencies in the larger-volume cohort and 50% for agencies in the smaller-volume cohort.

The CY 2025 claims-based measures for the Expanded HHVBP Model are:

Home Health Within-Stay Potentially Preventable Hospitalization (PPH)
Discharge to Community-Post Acute Care (DTC-PAC)

Let’s do a quick breakdown of each measure!

Breakdown of CY 2025 HHVBP Claims-Based Measures

The PPH measure is an HHA’s rate of potentially preventable (unplanned) hospitalizations, such as in an ACH or LTCH, or observation stays that occur within a home health stay. This measure is risk adjusted and uses, in part, ICD-10 diagnosis codes to determine the classification of the hospitalization or observation as unplanned or potentially preventable.

The DTC-PAC measure reflects the HHA’s percentage of home health stays where the patient was discharged to the community AND did not then have an unplanned admission (to an ACH or LTCH) OR die in the 31 days following discharge from the agency. This measure is also risk adjusted and the classification of “community” for this measure comes from the Patient Discharge Status code on the Medicare FFS claim.

As mentioned earlier, these are both utilization measures with an agency’s “success” with these measures relying on their ability to manage their patients’ conditions and health status to keep them out of facilities both during and after their home health stay which, overall, reduces the utilization of more costly health care services.

There are additional calculation considerations and exclusions that also factor into these measures and additional information regarding these details can be found on the Home Health Quality Measures webpage.

Upcoming CY 2026 Claims-Based Measure: MSPB-PAC

The CY 2026 Proposed Rule proposes that beginning in performance year 2026 (CY 2026) the cost/resource claims-based measure Medicare Spending Per Beneficiary Post-Acute Care (MSPB-PAC) would be added to the HHVBP applicable measure set.

The MSPB-PAC measure assesses the Medicare spending or resource use of an HHA and compares that use relative to the resource use of the national average (median) of all home health providers.

With this proposed addition to the applicable measure set used to determine an agency’s TPS (and possibly their annual payment adjustment), the expanded HHVBP Model would not only consider patient outcomes but to also factor in achievement of those outcomes at a lower cost.

What does this mean for HHAs?

HHAs may have the impression that their ability to impact their performance on claims-based measures is limited. The claims data source is not available for the same type of review or audit check as the assessment based (OASIS) data. Fundamentally though, focused best practice care principles that are directed toward optimal patient outcomes, often result in the desired outcomes from a utilization perspective.

By directing attention to the right care being delivered to the right patient at the right time, there can be a positive correlation between positive patient outcomes, patient satisfaction AND reduced cost and resource utilization. HHA efforts that capitalize this approach are aiming for the maximum return on their investment.

The Expanded HHVBP Model and claims-based measure are similar in their integral emphasis on high quality care and cost efficiency. By prioritizing the essential components of care planning, care coordination and care delivery, HHAs give themselves the best opportunity to be successful within both the measures and the Model.