Why Average Scores Earn Zero in Home Health Value-Based Purchasing

Picture a home health agency that lands right at the national average on every quality measure. Its star rating looks respectable, and its leaders feel confident heading into the new year. Then the annual performance report arrives with 0 value-based purchasing (VBP) points and a negative 5% payment adjustment.

It sounds impossible, but it's how the model is built. Under VBP, being "pretty good" across the board is one of the most expensive places your agency can be.

Why Average Earns You Nothing

Star ratings are forgiving. Even a below-average agency can earn credit that rolls into its overall rating. VBP works differently.

You earn points on each measure in 1 of 2 ways:

1. Achievement points compare you to every other agency in your cohort. You only earn them once you clear the achievement threshold, which sits at the middle of the pack. Reach the benchmark, the average of the top 10% of agencies, and you earn the maximum of 10 points.
2. Improvement points compare you to your own baseline year, currently 2023. They cap at 9 points, so achievement always offers more upside.

For each measure, you receive whichever score is higher. That flexibility helps, but it also exposes a hard truth. If you perform at the national average on every measure and don't beat your own baseline, you earn 0 points and face the maximum negative adjustment of 5%.

That's why agencies with strong star ratings can still land in the bottom quartile of VBP. Under this model, it's better to be great in a few areas than average in all of them.

You're Chasing a Moving Target

VBP is relative. Every agency is improving, so standing still means falling behind.

From the start of 2023 to the end of 2024, the median total performance score across the large-volume cohort climbed roughly 10 points. That cohort includes 93% of agencies serving 99.5% of patients, so the bar moved for nearly everyone. At the end of 2025, the median jumped another 2 points in a single quarter.

To improve your payment adjustment, you have to improve faster than everyone else. Slow, steady progress can still leave you outpaced.

What Changed in 2026 and What Holds for 2027

The 2026 model reshaped where your points come from:

• Discharge function score and potentially preventable hospitalizations dropped from nearly 50% of your score to about 30% combined.
• The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey now counts for 20% of your score and includes only 2 measures, overall rating and willingness to recommend, at 10% each.
• Improvement in bathing returned at 3.5%, with upper and lower body dressing at 1.75% each.
• Medicare spending per beneficiary (MSPB) arrived at 10%.

MSPB captures more than your own visits. It includes Medicare Part A and B claims from start of care through 30 days after discharge. Since you control only your own utilization, the best move is often restraint. If you're at or slightly better than average, protect your visit patterns and focus on keeping patients out of the hospital. That lowers MSPB naturally, and the other 90% of your score matters more.

The good news: 2027 brings no changes. For the first time in years, you get a full year on one model, one set of weights, and one shot at building sustained improvement.

Don't Boil the Ocean

When everything is a priority, nothing is. Your clinicians already carry heavy caseloads, and asking them to improve on every measure at once rarely moves any of them.

Instead, choose 2 focus areas, never more than 3. Balance speed against impact:

1. Outcome and Assessment Information Set (OASIS)-based measures move fastest. Better start-of-care capture, accurate discharge scoring, and focused case conferencing can show results within 30 to 60 days, and they now make up 40% of your score.
2. Claims-based and HHCAHPS measures move slower, often 6 months or more, since you wait on claims processing and survey returns. They may still represent your biggest opportunity. 

The right mix depends on where your data says you'll gain the most.

Manage by Exception 

Agency-wide education produces an early bump, then a plateau. Sustained gains come from managing by exception at 3 levels:

1. By measure: Find the widest gap between your performance and the benchmark.
2. By team: Pinpoint which teams handle the most OASIS assessments while trailing your organizational average.
3. By clinician: Identify the individuals who represent your biggest opportunity, then coach them in small groups.

Small-group coaching lets you show each clinician their own trend, set realistic goals of 2% to 5%, and track progress monthly over a trailing 12-month window. Once a group improves, you move to the next. That iterative rhythm is how you outpace the curve.

One agency used this approach on discharge function score by aligning each patient's discharge goals with their GG item scores and revisiting them at every interdisciplinary team conference. Another lifted a flat oral medication trend by accurately capturing patients who can't improve, such as those with dementia, so risk adjustment worked in its favor. 

Crack the HHCAHPS Code 

HHCAHPS rewards only top-box answers: a 9 or 10 on overall rating, or "definitely" on willingness to recommend. A 7 or 8 earns nothing.

Machine learning can reveal which survey questions drive those top-box scores for your agency. For one organization, patients who said clinicians "usually" or "always" listened carefully had an 84% probability of answering "definitely" on willingness to recommend. When they also felt informed about arrival times, that probability jumped to 90%.

Those 2 behaviors are coachable. Document patient questions and revisit them later in the visit or on the next one. Widen arrival windows where needed, and tell patients early when a visit runs ahead or behind. The drivers differ by agency and region, so let your own data set the priority.

Know Where You'll Land Before CMS Tells You

VBP creates real financial uncertainty. One agency's total performance score jumped from 24.6 to 41.1 when the claims-based measures changed, moving it from the 27th to the 74th percentile and its projected adjustment from negative 1.2% to positive 1.5%. It has since built that to 2.9%.

Forecasting your adjustment ahead of your annual performance report helps your finance team budget with confidence and shows you where quality improvement dollars will earn the strongest return.

Take the Next Step 

Change isn't finished. CMS is exploring new measures, including falls with major injury and single-item HHCAHPS measures, and a new baseline year is likely within 3 years. The agencies that win will be the ones that already know their data.

With SimiTree VBP IQ, you can see exactly where your points are hiding. It breaks down your performance by measure, team, and clinician, forecasts your payment adjustment before your annual performance report arrives, and pinpoints the HHCAHPS behaviors that drive top-box scores.