AMRPA Magazine August 2017 by AMRPA

August 2017 â&#x20AC;¢ Vol. 20, No. 8

YES, HEALTHCARE IS COMPLICATED

Volume 20, Number 8

Contributors Bruce Gans, MD Chair, AMRPA Board of Directors, Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation, and National Medical Director for Rehabilitation, Select Medical Martha Kendrick, JD Partner, Akin Gump Strauss Hauer & Feld LLP Peter Thomas, JD Counsel to the AMRPA Consumer and Clinical Affairs Committee, Principal, Powers Pyles Sutter & Verville, PC Lisa Werner, MBA, MS, SLP Director of Consulting Services for FlemingAdvanced Outcomes Design

Letter from the Chair........................................................................................... 3 AMRPA Legislative Update................................................................................. 4 Analysis of Patient Engagement and Patient-Reported Outcomes in Primary Care Practices of ACOs.................................................. 8 MACPAC’s 2017 Report to Congress Focuses on Changing Health Care System, Addresses Opioid Misuse.............................. 9 AMRPA Joins 60 Rehabilitation and Disability Organizations to Host Successful Congressional Briefing...................................................... 14 CMS Transmittals of Interest for Medical Rehabilitation Providers .............. 16

Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA

Researchers Examine Venous Thromboembolism Prophylaxis in Major Orthopedic Surgery............................................................................ 17

Jonathan M. Gold, JD Regulatory and Government Relations Counsel*, AMRPA

Latest Research Findings.................................................................................. 18

Mimi Zhang Policy and Research Associate, AMRPA Lovelyn Robinson Editorial and Research Assistant, AMRPA *Admitted Only in Illinois. Supervision by Carolyn C. Zollar, J.D., a member of the D.C. Bar

AMRPA Magazine, Volume 20, Number 8. AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA). AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities.

Quality Indicator Commonly Asked Questions Phase 2 ............................... 21 Study Shows Affordable Care Act’s Insurance Marketplace Continues to Stabilize ...................................................................................... 23 Difference Between Medicare Payment and Provider Cost for FY 2018 ..... 27 CMS Issues Proposed Rule for Second Year of Quality Payment Program ................................................................................ 28 Medicare Advantage Enrollees Could Significantly Reduce Medical Costs by Switching Plans, AHRQ Study Finds ................................. 33

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AMRPA Magazine August 2017

LETTER FROM THE CHAIR

Letter from the Chair Bruce M. Gans, MD, Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation and National Medical Director for Rehabilitation, Select Medical bgans@kessler-rehab.com

“We knew how complicated healthcare was.”

ne of the most striking statements to come out of the conversation about efforts to repeal and replace the Affordable Care Act was about the complexity of health care. Despite the President’s statement that “nobody … knew how complicated healthcare was,” healthcare providers and practitioners do know that it is COMPLICATED. In particular, our world of rehabilitation hospitals and other postacute care providers (PAC) is arcane, complex, confusing and poorly understood by most people – even those within the health care arena, let alone people who are outside of it. How common is it for us to deal with acute care clinicians, discharge planners, insurance company representatives, and patients and families who do not understand the gross, let alone subtle differences among settings in terms of appropriateness and value?

Every day, AMRPA members fight to justify the wisdom of offering your services to patients because of their needs – not your prices, flat screen televisions or free parking. And that is advocacy in its purest form. While AMRPA is leading the effort to educate elected officials and staff in Washington to protect our field, every patient and family member you encounter can become a voice supporting our need to exist, and the need for a fair and equitable payment system in your own communities. As all politics are local, so, too, all health care is local. Use these opportunities to educate, promote and defend our field. Help make it a bit less complicated and a lot more compassionate.

AMRPA LEGISLATIVE UPDATE

By Martha M. Kendrick, Esquire, Partner, Akin Gump Strauss Hauer & Feld LLP

Senate Health Reform Bill pon release of Senate Republicans’ updated discussion draft of the Better Care Reconciliation Act (BCRA) on July 13, it was not clear that Senate Majority Leader McConnell (R-KY) had the votes to even advance to a procedural vote to consider the legislation. Conservative Senator Rand Paul (R-KY) quickly confirmed he would

• • • • • •

people would increase to 32 million by 2026 under the bill, relative to current law. CBO also projects deficits would decrease by $473 billion over the 2017-2026 period. After an intense day of lobbying by President Trump who has threatened to allow Obamacare to “implode” while also encouraging that the Senate move forward with a replacement plan before departing for the August recess, a late

Senate in limbo on how to move forward on an ACA repeal and replace plan. Senate Majority Leader McConnell (R-KY) announces plan to delay the Senate’s August recess to allow more time to consider critical legislation and vote on pending nominations. FY 2018 Appropriations continues with both House and Senate approving individual bills to fund the federal government, including passage of the FY 2018 Labor HHS bill. The Government Accountability Office (GAO) found that some low quality hospitals received bonuses through the Hospital Value Based Purchasing Program due to the methodology used to calculate their total performance. Medicare Trustees Report indicates that the Independent Payment Advisory Board (IPAB) will not be triggered until 2021. CMS releases CY 2018 Physician Fee Schedule and CY 2018 OPPS Proposed Rules, containing larger than expected provider cuts.

vote against bringing the bill to the floor, as would moderate Senator Susan Collins (R-ME). Sen. Paul has been steadfast in his opposition to the bill because it does not go far enough in repealing the Affordable Care Act (ACA), while Sen. Collins has expressed concerns about the deep cuts to Medicaid. Sen. Mike Lee (R-UT), often a conservative ally of Sen. Ted Cruz (R-TX), also withdrew his support for the BCRA despite inclusion of an amendment they authored that would allow insurers to sell deregulated plans as long as they also sell at least one ACA-compliant plan.

Other Senators began to announce their opposition, and it became evident that Leader McConnell did not have the 50 votes needed to proceed to consideration of the bill. On the evening of July 17, Leader McConnell confirmed the Senate’s inability to repeal and replace Obamacare and announced that the Senate would take up a full repeal of the ACA. However, Sens. Collins, Moore Capito (R-WV), and

Lisa Murkowski (R-AL) all declared they will not vote for the motion to proceed to an ACA repeal-only plan, leaving the Majority without enough votes to move onto debate. Regardless, Leader McConnell still plans to hold a vote on a full ACA repeal the week of July 24. On July 19, the Senate Budget Committee released text for the Obamacare Repeal Reconciliation Act (ORRA), which would repeal the Affordable Care Act (ACA) and give Congress two years to develop a replacement plan. Under this proposal, the Congressional Budget Office (CBO) estimates that the number of uninsured

night gathering of Republican Senators to hash out differences did not appear to develop a breakthrough on any type of replacement plan. On July 19, the Senate Parliamentarian determined that a number of provisions in BCRA violate the Byrd Rule and may be struck from the bill absent 60 votes, according to a document released by Democrats on the Senate Budget Committee. Therefore, Senate Republicans are more likely to take up a clean repeal bill during the week of July 24. Should the vote fail as expected, Leader McConnell AMRPA Magazine August 2017

will likely allow some time to lapse before even attempting discussions with Democrats on an ACA “repair” bill. Some of those discussions have already started between moderate Senate Republicans and Democrats. Upon conclusion of the current Senate debate and a potential shift to repairing the ACA, bipartisan support may exist to advance targeted proposals. These could include funding for costsharing reduction payments; allowing the purchase of off-exchange health plans in Obamacare “deserts;” a permanent reinsurance program; increased state flexibility to regulate insurance markets; and/or repeal of the Independent Payment Advisory Board and unpopular ACA taxes (e.g., medical device excise tax and Cadillac tax). One marker to watch in terms of President Trump’s threat to let Obamacare fail is the Administration’s handling of the cost sharing subsidy payments. As we go to process, the July 20 payment was made but uncertainty remains about future payments, so this remains a significant bellwether.

HHS has been promoting the use of ACA section 1332 “state innovation waivers” and Medicaid Section 1115 waivers to advance state reform initiatives. The Administration also may consider new demonstrations under the auspices of the Center for Medicare and Medicaid Innovation. Further, CMS has already issued several Medicare payment regulations this year that include proposals for broad-ranging payment and delivery system reforms.

In the House, Republicans are moving forward with a FY 2018 Budget Resolution that includes significant entitlement reforms to Medicare and Medicaid. It is also important to remember that Health and Human Services (HHS) Secretary Tom Price retains broad authority to advance major health care reforms. For example,

Meanwhile, House Appropriators are moving forward on a number of individual spending bills, largely ignoring the levels proposed in the President’s Budget request. Several of the FY 2018 bills have all been marked up by the Appropriations Committee, including the FY 2018 LaborHHS spending measure, which proposed

2018 Fiscal Year Budget Bills Move Through Legislative Process House Budget Committee Chairwoman Diane Black (R-TN) has committed to advance a Fiscal Year (FY) 2018 Budget Resolution that includes more than $200 billion in mandatory spending cuts. Chairwoman Black hopes to hold a markup in July. Centrist House Republicans, including Members of the Tuesday Group, are railing against the draft Budget, saying the spending cuts are “not practical” and may endanger tax reform efforts.

$77.6 billion for HHS, a decrease of $542 million below last year’s enacted level and $14.5 billion above the President’s budget request. The bill also provides the National Institutes of Health with a $1.1 billion funding boost for a total of $35.2 billion, $8.6 billion above the President’s Budget request. It is likely all twelve Appropriations bills will have gone through the Committee process before the August Congressional recess. As we go to print, House Leadership is pushing forward a four-bill “Minibus” Appropriations package (Defense, EnergyWater, Legislative Branch, and Military Construction –VA) despite policy concerns from the conservative Freedom Caucus and Democrats. House Health Committees Considers Medicare Legislation On July 13, the House Ways and Means Committee held a markup to consider legislation that aims to strengthen Medicare. Introduced by Reps. Pat Tiberi and Sander Levin (D-MI), H.R. 3168 extends and strengthens Medicare Special Needs Plans (SNPs), one of several programs in need of reauthorization before the end of the year. The bill was ordered favorably reported to the House of Representatives as amended by a voice vote. The House Ways and Means Oversight Subcommittee Chairman Vern Buchanan (R-FL) held a hearing, entitled “Efforts to Combat 5

Waste, Fraud, and Abuse in the Medicare Program” on July 19. The hearing focused on how the Centers for Medicare and Medicaid Services (CMS) identifies and combats waste, fraud, and abuse, in both traditional Medicare and the Medicare Advantage program. The hearing notice highlighted that the Department of Health and Human Services’ (HHS) FY 2016 Agency Financial Report estimated that $59.6 billion was spent on improper payments program-wide, the majority of which occurred in traditional Medicare. On July 20, the House Energy and Commerce Subcommittee on Health held a hearing titled, “Examining Bipartisan Legislation to Improve the Medicare Program.” This hearing is the Committee’s initial review into developing proposals that address expiring Medicare extenders, including the therapy caps which need to be reauthorized by December 31, 2017. Dr. Moore urged Congress to permanently eliminate therapy caps, stating that the pattern of yearly exceptions extensions creates uncertainty for providers and beneficiaries. Dr. Justin Moore, CEO of the American Physical Therapy Association, testified that a permanent fix should: 1) ensure patient access without unnecessary delays; 2) implement a targeted approach to oversight of outpatient therapy spending; and 3) align with value-based and performance-based payment models. Medicare Trustees Report Confirm IPAB Will Not Be Triggered This Year On July 13, the Medicare Trustees projected in their 2017 Report that the Independent Payment Advisory Board (IPAB) will not be triggered until 2021. Last year, the Trustees forecasted that increased Medicare spending would trigger IPAB in 2017 for the first time. The 2017 Report also predicts that the Medicare Trust Fund will be exhausted by 2029. The report states that health care spending grew at a slower rate than expected, although Part B expenditures were slightly higher this year due to increased spending on physicianadministered drugs and outpatient hospital services. Physician Fee and Outpatient Proposed Payment Rules Released On July 13, the CMS released the Calendar Year (CY) 2018 Physician Fee Schedule (PFS) Proposed Rule and the CY 2018 Hospital Outpatient Prospective Payment 6

(OPPS) Proposed Rule. Comments for both proposed rules are due by September 11, 2017. As expected, CMS included a Request for Information (RFI) and encouraged feedback on positive solutions to better achieve transparency, flexibility, program simplification, and innovation. The overall update to PFS payments based on the proposed CY 2018 rates and required adjustments by law would be +0.31 percent. The proposed 2018 PFS conversion factor is $35.99, a slight increase from 2017’s PFS conversion factor of $35.89. Unexpectedly, CMS is proposing to reduce current PFS payment rates for non-excepted off-campus provider-based hospital departments by 50 percent. CMS currently pays for these services under the PFS based on a percentage of the OPPS payment rate. The proposed rule would change the PFS payment rates for these services from 50 percent of the OPPS payment rate to 25 percent of the OPPS rate. CMS is recommending this adjustment to “encourage fairer competition between hospitals and physician practices by promoting greater payment alignment.” CMS also proposes to add several codes to the list of telehealth services, including CPCS code G0506 (Care Planning for Chronic Care Management). CMS estimates an overall 2.0 percent payment update for hospitals paid under the OPPS in CY 2018. The regulation proposes to reduce the Medicare reimbursement for hospitals that participate in the 340B program as a way to address increasing drug prices. GAO Report on HVBP Program On June 28, the Government Accountability Office (GAO) released a report that found that some hospitals with low quality scores received bonuses through the Hospital Value-based Purchasing (HVBP) program because they had high efficiency scores. The GAO analyzed CMS documentation and data on performance scores and payment adjustments for the past five years and recommends that CMS revise how the agency calculates performance scores and its method of accounting for missing quality scores. The GAO recommends that CMS revise the methodology used to calculate total performance scores. After analyzing CMS documentation and data on performance scores of hospitals, the GAO found that a hospital’s efficiency scores have a greater impact on total

performance because of the methodology that CMS uses. Therefore, when hospitals were missing one or more quality scores, their overall score was misleading of their true performance. Hospitals with incomplete scores were more likely to receive bonuses than hospitals with complete scores. For the 2017 fiscal year, 2,952 hospitals participated in the HVBP program: 1,343 hospitals received a penalty, 1,264 hospitals received a bonus with composite quality scores above the median, and 345 hospitals received a bonus with composite quality scores below the median. To ensure that the HVBP program accomplishes its goal to minimize the payment of bonuses to hospitals with lower quality scores and balance quality and efficiency, the GAO recommends CMS to take two actions: •

Revise the formula for the calculation of hospitals’ total performance score or take other actions so that the efficiency score does not have a disproportionate effect on the total performance score; and

•

Revise the practice of proportional redistribution used to correct for missing domain scores so that it no longer facilitates the awarding of bonuses to hospitals with lower quality scores.

*** As Members of Congress return to their home Districts and States for the August recess, we encourage you to voice concern for the needs of the elderly, disabled and vulnerable patients whom rehabilitation hospitals and units serve. Lawmakers will likely have open office hours, community town hall meetings, and also have the ability to make visits to your rehabilitation hospital and/or facility within their Districts and States. Please take the time now to request that Members of Congress visit you and get a chance to see the meaningful impact your services are having on patient’s lives! Please be in touch if we can help you in any way in your advocacy outreach. With thanks for all you do -Regards, Martha M. Kendrick

AMRPA Magazine August 2017

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ANALYSIS OF PATIENT ENGAGEMENT AND PATIENT-REPORTED OUTCOMES IN PRIMARY CARE PRACTICES OF ACOS

he growing movement toward more accountable care delivery and an increase in the number of persons with chronic illnesses underscores the need for primary care practices to engage patients in their own care, according to a study published in the Journal of General Internal Medicine. The researchers examined the relationship between selected practice characteristics, patient engagement and patient-reported outcomes of care for adult primary care practices seeing patients with diabetes and/or cardiovascular disease (CVD). The study consisted of 16 randomly selected practices in two large accountable care organizations (ACOs). Eligible patients with diabetes and/or CVD (n = 4368) were randomly selected to complete a patient activation and PRO survey (51 percent response rate; n = 2176). For each of the 16 practices, patient-centered culture and the degree of relational coordination among team members were measured using a clinician and staff survey that assessed practice culture, relational coordination and teamwork (86 percent response rate; n = 411). Patient-reported outcomes included: • 8

Depression (PHQ-4)

•

Physical functioning (PROMIS SF12a)

•

Social functioning (PROMIS SF8a)

•

Patient Assessment of Chronic Illness Care instrument (PACIC-11)

•

Patient Activation Measure instrument (PAM-13)

Finding: •

Patient-level factors included: •

Patient age

•

Gender

•

Education

•

Insurance coverage

•

Limited English language proficiency

•

Blood pressure

•

Hba1c LDL-cholesterol

•

Disease comorbidity burden

Results The study found that: •

Having a patient-centered culture was positively associated with fewer depression symptoms

•

Patient activation was positively associated with fewer depression symptoms better physical health and better social health functioning

•

Patient activation (PAM-13) mediated the positive association between patients’ experience of chronic illness

Diabetic and CVD patients who received care from ACOaffiliated practices with more patient-centered cultures reported better physical functioning

care and each of the three patientreported outcome measures: fewer depression symptoms, better physical health and better social health •

Practice-reported relational coordination and shared decision-making activities were not significantly associated with higher patient-reported outcome scores

The study concluded that diabetic and CVD patients who received care from ACOaffiliated practices with more developed patient-centered cultures reported lower PHQ-4 depression symptom scores and better physical and social outcomes of care. As payment reform policies such as MACRA evaluate patient outcomes, the study finds that practices should focus on activating patients and developing patient-centered cultures to improve quality of care.

AMRPA Magazine August 2017

MACPAC’S 2017 REPORT TO CONGRESS FOCUSES ON CHANGING HEALTH CARE SYSTEM, ADDRESSES OPIOID MISUSE

n June, the Medicaid and CHIP Payment and Access Commission (MACPAC) released its annual “Report to Congress on Medicaid and CHIP.” Medicaid now serves more than 70 million low-income individuals, including children and their parents, pregnant women, frail elderly individuals and persons with disabilities. The program has evolved in terms of the populations it covers, the organization of its delivery systems, and in response to secular changes in the health care system and the broader society. MACPAC states that this changing composition of the program’s beneficiaries reflects both changes in federal policy to expand eligibility as well as the actions of states to adopt new optional pathways. Also, the list of mandatory and optional services has evolved, reflecting changes in medical practice and the shift in long-term care (LTC) from institutions to community and home-based settings.

and Commerce Committee, and the Energy and Commerce subcommittees on Health and Oversight and Investigations for an in-depth look at Medicaid coverage of optional eligibility groups and benefits and the resources associated with them.

•

Seven in 10 (71.1 percent) beneficiaries were mandatory, and 28.9 percent were optional.

•

The largest share of mandatory enrollees were children.

•

The share of individuals enrolled under mandatory and optional pathways varies by eligibility group. For example, of 32.2 million child enrollees, 86.0 percent were mandatory. By contrast, slightly more than half (55.2 percent) of adults eligible on a basis other than disability were optional, including 4.6 million beneficiaries who were receiving family planning services only.

•

1. Spending on Medicaid’s mandatory and optional populations and services 2. The program’s response to the opioid epidemic 3. Federal and state activities to ensure program integrity in Medicaid managed care

Chapter 1 Mandatory and Optional Enrollees and Services in Medicaid Chapter 1 analyzes spending on Medicaid’s mandatory and optional populations and services and responds to a request from the chairmen of the Senate Committee on Finance, the House Energy

•

Key Points

The report examines three present-day responsibilities of the partnership between states and the federal government:

This article highlights some of the key findings:

Highlight:

•

The distribution of mandatory and optional enrollment varies by state, reflecting both state decisions to adopt optional pathways and the demographics of each state. For example, in Vermont, about onethird (34.8 percent) of enrollees were mandatory, while almost all (95.8 percent) enrollees were mandatory in Nevada. Maine had the largest share of enrollees eligible on the basis of age, and West Virginia had the largest share of enrollees eligible on the basis of disability. About half (47.4 percent) of Medicaid benefit spending was for mandatory populations receiving mandatory services. Approximately 21 percent of spending was for mandatory populations receiving optional services. The remaining 31.5 percent of spending was for optional populations receiving mandatory or optional services.

Acute services, including inpatient hospital and physician services, accounted for the largest share of mandatory spending (40.8 percent); and long-term services and supports accounted for the largest share of optional spending (52.2 percent).

•

Across states, the share of Medicaid spending on mandatory populations receiving mandatory services ranged from a high of 74.1 percent in Arizona to a low of 27.1 percent in North Dakota.

•

Nationally, the largest share of both mandatory spending (34.1 percent) and optional spending (56.8 percent) was for people eligible on the basis of disability.

•

Acute services, including inpatient hospital and physician services, accounted for the largest share of mandatory spending (40.8 percent); and long-term services and supports (LTSS) accounted for the largest share of optional spending (52.2 percent).

Overall, the findings showed that approximately 70 percent of enrollees were mandatory, and almost half of benefit spending was on mandatory services for these enrollees. Less than one-third of enrollees were eligible on an optional basis, and less than one-third of spending was on services to them. This division reflects federal and state policy decisions as well as the characteristics of state populations and health care markets, as discussed in more detail below. •

In FY 2013, children comprised the largest population enrolled in Medicaid, illustrating the dominant 9

role that Medicaid plays in providing coverage to the majority of lowincome children (MACPAC 2016b). The largest share of spending were for persons with disabilities, despite the fact that they made up a smaller share of enrollment. •

Spending by service type varied across the enrollee populations, but did not vary based on mandatory or optional status (Table 1-4). As noted above, the vast majority of services for children are mandatory because of requirements to cover EPSDT services, including 100 percent of non-waiver acute care services and managed care capitation payments.

•

For both mandatory and optional populations of children, spending on mandatory services was about evenly split between acute services and managed care, with little spent on mandatory LTSS. All of the optional spending for children was for services provided through HCBS waivers.

•

As with children, spending on mandatory services for adults was about evenly split between acute services and managed care, regardless of mandatory or optional enrollment status.

•

On the other hand, the majority of

spending on mandatory services for people eligible on the basis of disability was for acute services and the majority of spending on optional services was for LTSS, regardless of enrollment status. For those age 65 and older, the majority of both mandatory and optional spending

was for LTSS—most likely for nursing facilities and HCBS. Chapter 2 Medicaid and the Opioid Epidemic This chapter focuses on how Medicaid is evolving to keep pace with a changing health care system.

AMRPA Magazine August 2017

reviews, utilization management techniques such as quantity limits or prior authorization requirements for prescription opioids, and the use of non-opioid pain management therapies. Even so, many Medicaid enrollees with an opioid use disorder are still not receiving treatment. Barriers to care include individuals not perceiving the need for treatment or fearing the stigma of having a substance use disorder, a fragmented and poorly funded delivery system, privacy regulations that limit care coordination, a shortage of Medicaidparticipating providers and providers trained in MAT, and gaps in the continuum of care associated with both restrictive coverage policies and the institution for mental diseases (IMD) payment exclusion.

Key Points •

•

The opioid epidemic, which has reached most communities across the U.S., disproportionately affects Medicaid beneficiaries. For example: Medicaid beneficiaries age 18–64 have a higher rate of opioid use disorder than privately insured individuals, comprising about 12 percent of all civilian, non-institutionalized adults in this age group, but about onequarter of those with an opioid use disorder. Medicaid beneficiaries are prescribed pain relievers at higher rates than those with other sources of insurance. They also have a higher risk of overdose and other negative outcomes, from both prescription opioids and illegal opioids such as heroin and illicitly manufactured fentanyl. But Medicaid beneficiaries with an opioid use disorder have higher treatment rates than privately insured adults with the same condition. State Medicaid programs are responding to the opioid crisis by covering treatment, innovating in the delivery of care and working to reduce misuse of prescription opioids. Medicaid programs cover many components of medicationassisted treatment (MAT), the recommended treatment for opioid use disorders under current evidencebased guidelines. However, there is considerable variation in available services across states, since many are optional under the Medicaid statute. States are using a variety of legal authorities to expand both the availability of treatment and the number of individuals eligible for such care. They are also working to organize and integrate physical health and substance use disorder treatment delivery systems to provide more effective care. These mechanisms include Section 1115 waivers, the health homes option, and the rehabilitation option. States are also focused on identifying opioid overprescribing in order to prevent opioid use disorders from developing. These approaches include prescription drug monitoring programs, patient review and restriction programs, drug utilization

Medicaid’s Response to the Opioid Epidemic Medicaid is fighting the opioid epidemic on a variety of fronts. State Medicaid programs cover substance use disorder treatment and supportive services to varying degrees. They are working to integrate care for physical health and treatment for substance use disorders across providers and with other social programs. They also are implementing programs to reduce opioid overprescribing in order to prevent opioid use disorder from developing in the first place. Many of these efforts are being undertaken in conjunction with other state and federal initiatives, such as the National Governors Association’s Compact to Fight Opioid Addiction and the Centers for Medicare & Medicaid Services (CMS) Opioid Misuse Strategy (CMS 2017a, NGA 2016).

are meant to ensure that taxpayer dollars are spent appropriately on delivering accessible, high-quality and necessary care. •

Comprehensive managed care is now the primary Medicaid delivery system, accounting for nearly onehalf of federal and state spending on Medicaid and about 60 percent of beneficiaries in 2015. However, managed care program integrity issues have not traditionally received the same focus as those in fee for service.

•

States require that Medicaidmanaged care organizations (MCOs) proactively minimize fraud, waste and abuse. Risk-based payments also create financial incentives for MCOs to minimize improper payments.

•

There is considerable variation among states in program integrity requirements for Medicaid MCOs, state oversight of MCO program integrity activities, and the extent to which states and MCOs work together to reduce fraud, waste and abuse.

•

While many program integrity practices are perceived to be effective, there are few mechanisms for measuring return on investment or for sharing best practices. In addition, there is a need for greater coordination among state staff assigned to managed care and program integrity functions, as well as better data on managed care encounters.

•

Federal regulations for Medicaid managed care were updated in 2016, including more detailed provisions relating to program oversight and program integrity. Many stakeholders believe the changes will strengthen managed care program integrity and lead to greater consistency across states. However, the Centers for Medicare & Medicaid Services is still in the process of developing guidance and implementing major portions of the rule, so it is too early to assess the complete effects of the new rule.

•

Looking ahead, the Commission may examine other areas of program integrity in managed care, such as:

Chapter 3 Program Integrity in Medicaid Managed Care This chapter examines program integrity activities in Medicaid-managed care drawn from interviews with states, managed care organizations, relevant agencies within the U.S. Department of Health and Human Services, and other federal and state experts. Key Points •

Program integrity consists of initiatives to detect and deter fraud, waste and abuse, as well as routine oversight to ensure compliance with state and federal law. These activities

– how states validate their encounter 11

data for future rate setting – incentives for MCOs to make investments in prepayment auditing – mechanisms for sharing provider screening data among states and programs – how to measure the effectiveness and impact of program-related activities and best practices •

The Commission may also consider how well current program integrity rules apply to new value-based purchasing models, particularly the use of accountable care organizations and managed long-term services and supports plans.

The study found that while the prevalence of managed care has grown over the last 15 years, making it a major Medicaid delivery system today, only recently have managed care program integrity issues received the same amount of focus at the state and federal level as program integrity in FFS. There is considerable variation among states in program integrity requirements for Medicaid MCOs, state oversight of MCO program integrity activities, and the extent to which states and MCOs work together to reduce fraud, waste, and abuse. Many program integrity practices are perceived by states and MCOs to be effective, but states have few mechanisms for measuring the return on investment of program integrity activities or for sharing best practices. Most states and plans interviewed for this study commented that the updated regulations, which incorporate many prior recommendations made by federal oversight agencies and adapt practices from leading states, are likely to strengthen managed care program integrity. States

indicated

they

are

already

operating largely in compliance with some provisions in the new rule, while other provisions will require them to make substantial operational changes. CMS is still in the process of developing subregulatory guidance to assist states and MCOs in complying with the updated program integrity provisions, and states are still in the process of assessing the new rule, implementing changes where necessary while awaiting additional guidance from CMS. It is too early to assess the complete effect of the new rule. The primary differences between FFS and managed care delivery systems—in particular the payment and contracting arrangements—create new or different kinds of program integrity risks that require program-specific safeguards (Table 3-1).

issued in 2016 by the Centers for Medicare & Medicaid Services (CMS) create a new framework for addressing the program integrity risks specific to managed care. As CMS is still in the process of implementing major portions of the rule, it is too early to assess the rule’s full effect, the report adds. MACPAC’s analysis found that states and plans are generally supportive of the provisions affecting program integrity but continue to seek more guidance, and are interested in learning more about practices that provide return on investment; state Medicaid personnel indicated that additional guidance, training, and tools to support information sharing could strengthen their managed care program integrity efforts. To download the June 2017 Report to Congress on Medicaid and CHIP please see macpac.gov.

MACPAC noted that new regulations

AMRPA Magazine August 2017

15TH ANNUAL AMRPA EDUCATIONAL CONFERENCE & EXPO

OCTOBER 23-25, 2017 • SWISSÔTEL

We're bringing together the most influential voices in rehab for a deep dive into industry trends and issues. View the speaker line-up on our website! This is your chance to: • • • •

Get a firsthand look at new technologies and innovative strategies Advance the interests of your practice Network with key individuals and influencers Positively influence patient care

Learn from other rehab professionals' experiences with issues impacting the post-acute care industry. Questions? Please contact Rachel Koresky, AMRPA Member Services Coordinator, at rkoresky@amrpa.org. To discuss exhibit and sponsorship opportunities, contact Samantha Schwarz at sschwarz@amrpa.org or 202-207-1132.

AMRPA JOINS 60 REHABILITATION AND DISABILITY ORGANIZATIONS TO HOST SUCCESSFUL CONGRESSIONAL BRIEFING By Peter W. Thomas, Principal, counsel to the AMRPA Consumer and Clinical Affairs Committee

n Tuesday, June 27th, a group of rehabilitation and disability advocacy organizations, including AMRPA, raised their voices on Capitol Hill with a single and powerful message: Any version of health reform that emerges from Congress must preserve and protect access to rehabilitation and habilitation services and devices so that individuals with injuries, illnesses, disabilities and chronic conditions can regain and/or maintain their maximum level of health and independent function. The Coalition to Preserve Rehabilitation (CPR), the Independence Through Enhancement of Medicare and Medicaid Coalition (ITEM) and the Habilitation Benefits Coalition (HAB) hosted a bipartisan and bicameral Congressional Briefing on the Value of Rehabilitation and Habilitation in America’s Health Care

System. As a fitting backdrop for the event, Senate Majority Leader Mitch McConnell (R-KY) was in the process of attempting to bring his Better Care Reconciliation Act (BCRA) of 2017 to a floor vote that same day. However, shortly after the briefing, he was forced to postpone the vote until July, citing a lack of support. Sen. Tammy Duckworth (D-IL), an Iraq War veteran, Purple Heart recipient and former Assistant Secretary of the Department of Veterans Affairs and Rep. Glenn Thompson (R-PA) addressed a packed hearing room of 200+ Congressional staffers, advocates, rehabilitation professionals and members of the public in the Dirksen Senate Office Building. Sen. Duckworth and Rep. Thompson were joined by panelists Eric LeGrand, a former Rutgers University football player who sustained a spinal cord injury during a game, Roseann Sdoia, a Boston Marathon bombing survivor who uses an artificial leg, Lisa Smith, the mother of a recipient of habilitation services and Gregory J. O’Shanick, MD, President

Rep. Glenn Thompson (R-PA) addresses an audience of 200+ attendees at a bipartisan and bicameral Congressional Briefing on the Value of Rehabilitation and Habilitation in America’s Health Care System. (Photo: Leif Brierley) 14

and Medical Director at the Center for Neurorehabilitation Services. Peter Thomas, AMRPA counsel and coordinator of the three coalitions that hosted the briefing, performed the role of emcee. Panelists spoke passionately about their experiences accessing, using and paying for habilitative and rehabilitative services and devices. As a wounded warrior, Sen. Duckworth recalled having access to state-of-the-art rehabilitative care and technology, including the prosthetic C-Leg. She was injured in the Iraq War in 2004, long before the passage of the Affordable Care Act and the Patient Protection Act. As a Veteran and wounded warrior, the Senator receives excellent health care coverage. She remembered meeting fellow amputees across the country who could not afford or access the types of services or technology she received because they did not have the same high quality health care coverage. “I realized how different the world was for people who have access to the care that they need, and those, who are the majority of Americans who don’t; and that’s not right,” she said. In addition to the speakers’ powerful testimonials on the value of rehabilitation and habilitation services and devices, the Briefing also featured demonstrations of assistive devices and technologies including: Otto Bock’s BeBionic prosthetic arm, Ossur’s POWER Knee, complex rehab technology (CRT) wheelchairs, the EksoGTTM wearable exoskeleton to assist those with spinal cord injury and stroke, a cochlear implant to address hearing loss and a speech generation device (SGD). Briefing attendees were able to experience how these technologies work and discuss their value with actual users of these rehabilitative devices. AMRPA Magazine August 2017

serious threats to access to rehabilitative and habilitative services and devices.

Sen. Tammy Duckworth (D-IL) discusses the value of rehabilitative and habilitative services and devices. (Photo: Leif Brierley)

As already noted, the Briefing was hosted by three coalitions dedicated to preserving access to rehabilitative and habilitative services and devices: CPR, the HAB Coalition and the ITEM Coalition. AMRPA is a member and major contributor to CPR’s efforts. The CPR steering committee started planning the Hill day and Congressional Briefing in April 2017, when it became clear that major protections in the Affordable Care Act might be jeopardized through efforts to repeal and replace the ACA. CPR is a 50-member coalition comprised of national consumer, clinician, and membership organizations dedicated to advocating for policies to ensure access to rehabilitation care for people with brain and spinal cord injuries, limb loss, neurological disorders, and other disabling conditions. Mimi Zhang and Jonathan Gold of AMRPA sat on the Congressional Briefing planning committee and participated in weekly meetings with other members of the CPR, HAB and ITEM Coalitions. AMRPA was one of 18 organizations to sponsor the Briefing, contributing funds to cover the cost of catering, promotional materials, travel expenses for speakers, video and live stream coverage and sign language interpreters. Forty-two (42) other organizations, including Autism Speaks, the American Heart Association, United Spinal, the therapy organizations, the Multiple Sclerosis Society, the Brain Injury Association of America, and many other organizations endorsed the Briefing. AMRPA also donated to the cause the cost of communications services provided

by its association management company, the Kellen & Company. Kellen worked with the Powers firm and Briefing Planning Committee to develop and implement a social media and press strategy, as well as videotape and live streaming of the Briefing. Through Kellen, Briefing coordinators at Powers created a highlight reel for each speaker. These clips were posted on the CPR, HAB and ITEM websites and distributed to coalition members who could publish the clips on their websites and social media platforms, increasing the reach of the Briefing. Links to the clips were also distributed to over 700 health care staffers on Capitol Hill. To amplify the impact of the day’s events, members of the CPR, HAB and ITEM Coalitions, alongside members of the Powers firm, attended 50 hill visits with Senate health care staff, a total of 30 Democratic offices and 20 Republican offices. At the Hill visits, attendees shared their personal stories accessing rehabilitative and habilitative services and devices and encouraged members of Congress to protect access to these services as the Congressional debate on health care reform continues. While Sen. McConnell’s decision to delay a health care vote until after the July 4 recess marked a small victory in efforts to preserve access to habilitative and rehabilitative care, Congressional efforts to repeal and replace the ACA are not over. Both the House Draft—the American Health Care Act, which passed by a slim majority on May 4, 2017 and the Senate Bill—the Better Care Reconciliation Act of 2017, pose

Both pieces of legislation erode the essential health benefits (EHB) package established by the ACA which require Medicaid expansion plans as well as individual and small group plans to cover certain health benefits, including rehabilitative and habilitative services and devices. Erosion of the federal standard for rehabilitation coverage would be a huge loss compared to current law. In addition, both bills propose significant changes to the Medicaid program under the ACA including transforming the financing system for Medicaid from an entitlement program to a “per capita cap” model. This would effectively reduce federal financing for the Medicaid program by approximately $800 billion over the next ten years. Multiple speakers at the briefing stressed that access to rehabilitative and habilitative services and devices is necessary to provide every American with high quality, effective and humane care. “When we save a life, we do so with the intent to have that life be one of quality and dignity” said Dr. Gregory J. O’Shanick, MD, President and Medical Director at the Center for Neurorehabilitation Services. “Rehabilitative and habilitative services and devices are a continuation of the contract we make as physicians when we save the life of the person in the emergency room,” he said. “Rehabilitation allows us to finish the job for patients.” The CPR, HAB and ITEM Coalitions will continue to advocate for the preservation of access to rehabilitative and habilitative services and devices in the American health care system as the Senate continues to consider health care reform legislation. For more information about the Briefing, including highlight clips from each speaker and a video of the entire Briefing please visit the Briefing Page on the CPR website at: https://preserverehab.org/advocacy/ CongressionalBriefing Contributing author: Jill O’Brien, Health Policy Intern, Powers Firm

CMS TRANSMITTALS OF INTEREST FOR MEDICAL REHABILITATION PROVIDERS

August 2017

Note: The Centers for Medicare and Medicaid Services (CMS) daily publishes official transmittals used for communicating reminder items, requests for action or information to fiscal intermediaries and carriers. In this section of the AMRPA magazine you will find specifically selected transmittals listed that would be of interest to medical rehabilitation providers. To view the entire lists please see: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals.html Transmittal #

Issue Date

Subject

Implementation Date

R3805CP

2017-07-11

Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)

2017-08-11

R199NCD

2017-07-11

Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)

2017-08-11

R289FM

2017-07-11

Notice of New Interest Rate for Medicare Overpayments and Underpayments -4th Qtr Notification for FY 2017

2017-07-18

R1862OTN

2017-06-30

Introductory Letters for Suppliers and Providers Related to the Prior Authorization for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items

2017-07-31

R1863OTN

2017-06-30

The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2015 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCH)

2017-07-31

R3801CP

2017-06-28

Extension of the Transition to the Fully Adjusted Durable Medical Equipment, Prosthetics, Orthotics and Supplies Payment Rates under Section 16007 of the 21st Century Cures Act

N/A

R3802CP

2017-06-28

Qualified Medicare Beneficiary Indicator in the Medicare Fee-For-Service Claims Processing System

A/N

R3797CP

2017-06-16

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2017

2017-10-02

R3798CP

2017-06-16

Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - October 2017

2017-10-02

R3799CP

2017-06-16

Annual Update of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

2017-10-02

R3795CP

2017-06-16

Updates in the Fiscal Intermediary Shared System (FISS) Inpatient and Outpatient Provider Specific Files (PSF)

2018-01-02

R3796CP

2017-06-16

Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer Update FY 2018

2017-10-02

R726PI

2017-06-16

Comprehensive Error Rate Testing (CERT) File Layout for Social Security Number Removal Initiative (SSNRI)

N/A

Updated as of July 15, 2017

AMRPA Magazine August 2017

RESEARCHERS EXAMINE VENOUS THROMBOEMBOLISM PROPHYLAXIS IN MAJOR ORTHOPEDIC SURGERY

ajor orthopedic surgeries, such as total knee replacement (TKR), total hip replacement (THR) and hip fracture (HFx) surgery, carry a high risk for venous thromboembolism (VTE) – deep vein thrombosis (DVT) and pulmonary embolism (PE). The purpose of the review, which was first conducted in 2012, was to compare interventions to prevent VTE after TKR, THR and HFx surgeries. The authors searched four databases and other sources through June 3, 2016, for randomized controlled trials (RCTs) and large nonrandomized comparative studies (NRCSs) reporting postoperative VTE, major bleeding, and other adverse events. Overall, 127 RCTs and 15 NRCSs met the criteria.

The review found that VTE prophylaxis after major orthopedic surgery trades off lowered VTE risk with possible adverse events—in particular, for most interventions, major bleeding. •

•

In total hip replacement, low molecular weight heparin (LMWH) has lower VTE and adverse event risks than unfractionated heparin (UFH), low molecular weight heparin and aspirin have similar risks of VTE and major bleeding, direct thrombin inhibitors (DTI) has lower DVT risk than low molecular weight heparin but higher major bleeding risk, and higher dose LMWH has lower DVT risk but higher major bleeding risk than lower dose. In total knee replacement, vitamin K antagonists (VKA) has higher DVT risk than low molecular weight heparin but lower major bleeding risk, and

higher dose DTI has lower DVT risk but higher major bleeding risk than lower dose. •

In hip fracture surgery and for other intervention comparisons, there was insufficient evidence to assess both benefits and harms, or findings are inconsistent.

The authors state that most studies evaluate “total DVT” (an outcome of unclear clinical significance since it includes asymptomatic and other low-risk DVTs), but relatively few studies evaluate pulmonary embolism and other clinically important outcomes. Thus, this limitation yields a high likelihood of selective outcome reporting bias and there is also little evidence on interventions other than low molecular weight heparin.

LATEST RESEARCH FINDINGS THE VITAL ROLE OF MEDICAL REHABILITATION IN DISASTER RELIEF

he Journal of Rehabilitation Medicine reported that with the increase in natural disasters, there has been greater focus on the importance and role of rehabilitation services in disaster management. In past disasters, rehabilitative needs were often neglected, with emphasis on acute response plans focused on saving lives and treating acute injuries. There are also inadequate, rehabilitation-inclusive disaster response plans and rehabilitation services in many disaster-prone developing countries. The World Health Organization (WHO) Emergency Medical Team (EMT) initiative recognizes rehabilitation as an integral part of medical response and patient-centered care in disaster settings. Current developments under this initiative include the development of

minimum standards for rehabilitation in emergencies to allow rapid, professional, coordinated medical response by both national and international EMTs. These guidelines ensure that EMTs deliver effective and coordinated patient care during disasters and continuum of care beyond their departure. The aim is to strengthen national capacity, foster an environment of self-empowerment of EMTs and local health services, and work in rehabilitation within defined coordination mechanisms in disasteraffected areas. The brief discuses an overview of rehabilitation in natural disasters; highlights current developments, challenges; and gaps in the implementation of WHO guidelines for Minimum Standards for Rehabilitation in Emergencies in order to improve care for victims of future disasters.

STUDY ASSESSES COMORBIDITY MEASUREMENTS IN PATIENTS WITH NONTRAUMATIC BRAIN INJURIES

he American Journal of Physical Medicine and Rehabilitation published a recent review of comorbidity measurements used on patients with nontraumatic brain injuries (NTBI) in inpatient rehabilitation and describes findings on measurement validation and comorbidity profiles. Comorbidity has been measured using various methods, including the number and type within various classification systems, such as the International Disease Classification (IDC) system, Charlson comorbidity index, Centers for Medicare and Medicaid Services (CMS) comorbidity tiers and patient comorbidity and complexity level values and subsets of diagnoses within nonadministrative data studies. MEDLINE and MEDLINE In-Process, EMBASE, PsycINFO, the Cochrane Database of Systematic Reviews, Health,

and Psychosocial Measurement Instruments were searched. Two reviewers screened results according to predefined inclusion and exclusion criteria. Population, statistical methods, comorbidity measurement, justification of its use and results involving comorbidity were extracted. Of the 9,476 articles retrieved, 16 were included. No studies have assessed the predictive ability of the comorbidity measurements for inpatient rehabilitation outcomes in this population. The reviewers stated that because comorbidities are common among the nontraumatic brain injury population, the predictive validity of comorbidity measurements should be assessed to determine the most appropriate measure to predict or risk adjust rehabilitation outcomes, which has implications for the development of clinical guidelines, and to inform health service research, planning and delivery.

AMRPA Magazine August 2017

Now Accepting Award Nominations! Recognize Your Colleagues with an AMRPA Leadership Excellence Award *Nomination Forms Due August 25* Do you know a deserving individual who exemplifies outstanding service to the association and the industry? Submit a nomination for the AMRPA Leadership Excellence Award! Nominees should demonstrate leadership, integrity, vision, dedication and excellence in the field of medical rehabilitation in two or more of the following areas: Transformative leadership Professional excellence Life-long service in the field Advocacy at the local and national level Mentorship of future leaders Improved patient outcomes Research and critical analysis Education and advancement of the field Contribution of time and energy to improve the quality of patient care

NEED HELP WITH MEDICARE AUDITS AND APPEALS? Powers Pyles Sutter & Verville has successfully assisted inpatient rehabilitation hospitals and units in thousands of coverage appeals resulting from payment denials by Recovery Audit Contractors, Medicare Administrative Contractors, Zone Program Integrity Contractors, and other Medicare auditors. The Powers team of experienced attorneys works with all provider types but specializes in IRF claims. We understand both the legal standards for IRF payment and the errors that auditors typically make when reviewing IRF claims. We can help you navigate through the fivelevel Medicare appeals process. Our services are tailored to the particular needs of each IRF and can include any of the following: • • • • • • • • • • •

Representing IRFs and other providers at all levels of administrative appeal Preparing witnesses for Administrative Law Judge hearings Developing audit and appeal strategies Creating customized appeal “templates” for IRF use Revising appeal documents prepared by the IRF Writing appeals and organizing exhibits Developing and implementing proactive compliance measures Advising on report and repay requirements Counseling on fraud, abuse, and overpayment allegations Appealing extrapolated denials Training medical staff on Medicare documentation requirements

Powers also represents IRFs in the federal courts on Medicare coverage matters. The firm has represented IRFs in the U.S. Courts of Appeals in challenges to RAC audit procedures and delays in Administrative Law Judge decisions.

FOR MORE INFORMATION, CONTACT: PETER THOMAS Peter.Thomas@PowersLaw.com 202-872-6730

Powers Pyles Sutter &Verville PC 20Powers

RONALD CONNELLY Ron.Connelly@PowersLaw.com 202-872-6762

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@PowersLawFirm

AMRPA Magazine August 2017 Pyles Sutter & Verville |1501 M Street NW | Seventh Floor | Washington, DC 20005 | (202) 466-6550

QUALITY INDICATOR COMMONLY ASKED QUESTIONS PHASE 2 By Lisa Werner, MBA, MS, CCC-SLP

he last time I wrote about quality indicators, we had one-quarter of data gathered. After three quarters, I thought it would be a good time to revisit this topic and analyze the trends.

acute care, opting instead to code based on the last available documentation. Remind staff of this rule and make sure that the PPS coordinators override any instance of this coding so that discharge scores reflect 88 for each item.

9 indicates that the patient neither completed an activity prior to admission nor is expected to complete it following discharge. To use a specific example: if a patient is currently unable to complete the stairs assessments but climbed stairs at home prior to their hospitalization, 9 is not the appropriate code if you wish to indicate that stairs assessments were not tested. Car transfers are the only exception to this rule. If you are unable to assess a car transfer because you do not have access to a car simulator or another car, CMS recommends using code 9.

Make sure that data on the IRF-PAI is consistent. If you test all items and record In general, how cases are coded for FIM scores on the day of evaluation, you patients who arrive and leave on the should have enough information to code same day without a full assessment similar quality items like toileting, toilet continues to be a widespread area transfers or bathing. To check whether or of difficulty. While the items on the not you already do this, in the IRF-PAI, Cognition tab in eRehabData® must look for a code of 88 on quality items be completed at admission, it is not with an FIM score. possible to select code 88 when, On the topic of car simulators, the because of a medical illness, these items rules state that you should cannot be tested. Staff must only code for a car transfer understand the importance of if a simulator or actual car is completing the Brief Interview used. If you attempt to create of Mental Status (BIMS) as a setting that mimics entering close to the time of admission In general, how cases are coded or exiting a car, regardless of as possible. If staff are unable for patients who arrive and leave its accuracy, it does not count to complete this assessment on the same day without a full as a car transfer assessment. because the patient is found CMS indicated that if a car to be inappropriate for assessment continues to be a transfer could not be assessed inpatient rehab, they should widespread area of difficulty. for lack of a simulator or a car, consider defaulting to the code 9 should be used. Staff Assessment for Mental Status (SAMS) instead. Staff Also, remember to complete stair members may be able to find this assessments consecutively, starting with Entering a score of 1 means that, if a information in other sections of the one step, then four steps, and finally patient attempted the item, they could record if it was properly documented. 12 steps. Because these assessments not successfully complete it without Be mindful that, in eRehabData®, if test the patient’s ability to both ascend comprehensive assistance. If the patient question C0100 (“Should Brief Interview and descend the stairs, each separate was unable to complete the activity for Mental Status be conducted?”) is assessment should be tested individually. (meaning the activity did not occur at answered with “No,” you must skip all), then a score of 1 is not appropriate. directly to the questions under C0900. When assigning a code for footwear For example, if it was medically unsafe You should not answer C0600, which asks items, remember to factor in the amount for a patient to walk 150 feet, code 88 whether or not it is necessary to conduct of assistance required with compression should be used in place of code 1. the Staff Assessment for Mental Status. stockings. Since this is different than an FIM assessment, it should be reviewed For Function items, I often see improper Providers often forget that CMS Q&A with therapy staff. The same is true for usage of code “9-Not applicable” directs staff members to code section upper body orthotics like TLSO braces. in many records. Remember, code GG items as 88 when patients transfer to

Consider how much help the patient needs to apply the brace and document it in the upper body dressing item.

eRehabData® provides a list of patients whose assessments were missing data. There are valid reasons for an assessment to be closed with incomplete data, but, regardless, it is imperative that you know how many times this has occurred since

higher than 95 percent. You must do this in order to avoid a 2-percent payment penalty for all Medicare and Medicare Advantage discharges in the next fiscal year.

Remember, if your number of assessments with incomplete QRP data Visit the (where dashes are used to indicate missing information) exceeds 5 percent of your discharges, it will result in a 2-percent payment penalty for an Visit the thread in the eRehabData® entire year. Many of you are trying to avoid the use of Users Forum entitled “IRF-PAI V1.4” dashes, but regardless of to pose questions and share answers your efforts, they may still be with each other. You may find necessary in some cases. If an item is not assessed and no the expertise of others in the information on the patient’s industry quite helpful. functional level is available in the record, you will not be able to fully complete a patient assessment. You cannot provide October 1, 2016. If the average number a score if it is not supported by the of Medicare and Medicare Advantage documentation. To find out how many, IRF-PAIs closed with incomplete data if any, of your assessments were closed at your facility exceeds 5 percent, you by the PPS coordinator with incomplete have only a short time to restore your data, the QRP Override Report in complete assessments to a percentage

thread in the eRehabData® Users Forum entitled “IRF-PAI V1.4” to pose questions and share answers with each other. You may find the expertise of others in the industry quite helpful. Along with your own experiences and expertise, our cooperative efforts to share information with each other can provide a great resource for all of us in the industry. Remember, we are all in this together.

AMRPA Magazine August 2017

STUDY SHOWS AFFORDABLE CARE ACT’S INSURANCE MARKETPLACE CONTINUES TO STABILIZE By Mimi Zhang, Policy and Research Associate, AMRPA

recent report from the Henry J. Kaiser Family Foundation (KFF) finds the individual insurance marketplace under the Affordable Care Act (ACA) continues to stabilize and become profitable for insurers, with no evidence of a potential market collapse. Using first quarter 2017 data, researchers found that the percentage of enrollee premiums being paid out in claims continues to decrease and growing per enrollee per month margins are growing, both signs of an increasingly healthy market. The findings are informative for policymakers and inpatient rehabilitation providers in light of recent concerns surrounding the stability and sustainability of the ACA’s individual insurance marketplace. Medical Loss Ratios KFF used recently-released 2017 data reported by insurance companies to the National Association of Insurance Commissioners to evaluate trends in average premiums, claims, medial loss ratios (MLR), gross margins and enrollee utilization from Q1 2011 to Q1 2017. The researchers had previously found that insurer financial performance, as measured by MLRs, worsened in the earliest years of the ACA but has improved in more recent years. MLRs are the proportion of health premiums being paid out as enrollee claims. Higher MLRs mean more of insurers’ income is being paid out as claims and, according to the KFF, it is unlikely for insurers to be profitable when MLRs exceed 85-90 percent due to the relatively high cost of administering individual market plans.

MLRs began declining in 2015 but have significantly improved recently due to significant increases in 2017 premiums for individual plans. MLRs averaged 75 percent in Q1 2017, continuing the downward trend and indicating that individual market insurers are likely to regain profitability this year (see Figure 1). The researchers attribute this stabilization to insurers being more experienced with the individual market and having sufficient actuarial data to better predict costs. Per Enrollee Margins The study further assessed the individual market’s financial performance by looking at the average gross margins per member per month (PMPM). This is the average amount by which the income from premiums exceeds the

Highlights: •

•

Financial performance indicators show that the ACA’s individual marketplace (“exchanges”) continue to stabilize in 2017, following multi-year trend Insurer participation in the exchanges for 2018 remains to be seen

cost of claims paid out by insurers in a given month. In Q1 2017, average gross margins grew to $99 per enrollee from a recent low of $36 in Q1 2015 (see Figure 2). Although gross margins can serve as an indicator of performance, positive margins do not account for administrative costs and, therefore, do not necessarily mean profitability.

Enrollees in 2017 were not noticeably sicker than previous years, as evidenced by the stable enrollee hospitalization rate; on average, the number of days spent by individual market enrollees in a hospital in Q1 2017 was similar to 2015 and 2016 rates. This data suggests that the individual market risk pool is relatively stable, though sicker on average than the pre-ACA market, which is not unexpected since people with preexisting conditions were not guaranteed coverage prior to the ACA. Losses and Future Insurer Participation While insurer performance has on average improved in recent years, insurance company losses have led some to exit the individual marketplace this year. For 2017, 58 percent of enrollees (living in about 30 percent of counties) had a choice of three or more insurers, compared with 85 percent of enrollees (living in about 63 percent of counties) in 2016. Insurer participation varies greatly within states, and rural areas tend to have fewer insurers. On average, metro-area counties have 2.5 insurers participating in 2017, compared to 2.0 insurers in non-metro counties. KFF analysis of preliminary insurer filings for 2018 participation found that 38 counties across Nevada, Ohio and Indiana are at risk of having no insurer available on the ACA exchanges next year. The Department of Health and Human Services (HHS) will finalize insurer participation for the 2018 individual marketplace later this fall. References: 1. Cynthia Cox and Larry Levitt, Individual Insurance Market Performance in Early 2017, The Henry J. Kaiser Family Foundation, July 10, 2017.

Nonetheless, the study concludes that growing gross margins PMPM are another sign that financial performance for individual marketplace insurers are on course to return to pre-ACA levels of profitability.

The improved financial performance is attributed to higher premiums in 2017 and the simultaneous slower growth of claims expenses. Between 2016 and 2017, enrollee premiums grew 20 percent on average while per-enrollee claims grew 5 percent (see Figure 3).

2. Cynthia Cox and Larry Levitt, Insurer Financial Performance in the Early Years of the Affordable Care Act, The Henry J. Kaiser Family Foundation, April 21, 2017.

AMRPA Magazine August 2017

EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE

JOIN TODAY!

In addition to advocacy and representation, AMRPA offers a wide range of member benefits and services designed to provide its members with the knowledge and tools to navigate the challenges facing medical rehabilitation providers and adapt to the changing federal regulatory environment. AMRPA keeps members informed of all significant policy, legislative and regulatory issues affecting medical rehabilitation providers through: OFF THE RECORD (OTR) Members receive “Off the Record,” a weekly electronic newsletter, which provides up-to-date summary information on legislative and regulatory issues affecting Medical Rehabilitation providers. MAGAZINE Members receive a subscription to the monthly AMRPA Magazine which reports on Medical Rehabilitation issues and trends including in-depth analysis of legislative, regulatory and operational issues affecting Medical Rehabilitation providers. ACTION ALERTS AMRPA issues Action Alerts to its Members which are specialized, timely electronic alerts and/or calls to action designed to mobilize national member responses to critical issues requiring Congressional action. ADVOCACY SUPPORT AMRPA promotes grassroots efforts among its Members on critical legislative issues. AMRPA counsel and staff are also available to provide support and assistance to members in grassroots efforts to educate members of Congress. MEMBERSHIP CALLS Members are invited to participate on AMRPA-sponsored “Membership Calls” which are held as needed and are designed to provide timely communications with members on emerging developments and issues affecting the field. SOCIAL MEDIA GROUP SITE on LINKEDIN AMRPA Members receive access to AMRPA’s social media group on LINKEDIN which is designed to provide information and opportunities for members to network with each other. ANNUAL FALL EDUCATIONAL CONFERENCE, LEADERSHIP FORUM, REGIONAL SEMINARS and WEB- BASED SEMINARS Educational sessions are held throughout the year and are designed to provide the latest intelligence, information and facts about “hot” issues impacting medical rehabilitation providers.

WEBSITE (www.amrpa.org) For members only and includes complete access to all information, presentations, documents, materials, data and communications on the AMRPA website. COMMITTEES Members are eligible to serve and participate on the Committees of the AMRPA Board of Directors and are invited to increase their involvement in shaping AMRPA’s Advocacy Agenda. BOARD OF DIRECTORS Members are eligible to be nominated to serve on AMRPA’s Board of Directors. TOOLS AMRPA researches, develops and distributes specialized toolkits to support and assist members with key issues, such as the Medicare Appeals Process. STAFF AMRPA staff are available to facilitate access to information or expertise on a broad range of issues and business challenges. MEMBERSHIP SURVEYS Regular surveys of the membership are conducted on key issues of interest or concern as well as for assessing the overall level of satisfaction with AMRPA benefits and services. eRehabData® AMRPA sponsors the highly-acclaimed eRehabData® for use by the field, produces regular reports on data trends, distributes data analysis of national and regional trends in medical rehabilitation to all members and incorporates eRehabData trends and analysis in all AMRPA advocacy and educational initiatives. RESEARCH AMRPA promotes the funding of research to advance the field and to develop evidence-based practice and public policy through the ARA Research Institute.

AMRPA: Working Together Toon Preserve Access To Medical Rehabilitation · Maggie Rachel Ramirez · Koresky, Vice President of Membership Services · 347-573-3732 · mramirez@amrpa.org For information AMRPA membership, please contact AMRPA Member Services Coordinator,

at 202-591-2469 or rkoresky@amrpa.org. 25

CHICAGO

15TH ANNUAL AMRPA EDUCATIONAL CONFERENCE & EXPO

OCTOBER 23-25, 2017 • SWISSÔTEL REGISTER ONLINE AT WWW.AMRPA.ORG

THINK ABOUT IT…

Are you receiving your Off the Record (OTR), Action Alerts and other email from AMRPA? On January 1, AMRPA changed vendors for the distribution of its Off the Record, Action Alerts, and other email communication and we want to make sure you aren’t missing these important messages. Our email analytics show that a few institutions’ servers are blocking AMRPA email, probably without knowing it. Don’t miss important deadlines, events or AMRPA news, whitelist (or add to your safe sender list) the following elements to ensure AMRPA email gets to you. • Whitelist the return email address: info@amrpa.org • Whitelist these domains: @informz.net and @informz.ca (Informz is our new email system) • Whitelist the IP address that these emails are coming from: 64.128.232.14 If you know there are multiple AMRPA contacts at your institution, ask your IT staff to help you do this whitelisting at the institutional level so that your colleagues can receive the same benefit! Keep your membership up to date – current members receive AMRPA magazine, the weekly enewsletter and other benefits – renew today if you haven’t already.

AMRPA Magazine August 2017

DIFFERENCE BETWEEN MEDICARE PAYMENT AND PROVIDER COST FOR FY 2018

BASED ON FY 2018 IRF PPS PROPOSED RULE (INCLUDES OUTLIER PAYMENTS)

Difference Between Medicare Payment and Provider Cost for FY 2018 Based on FY 2018 IRF PPS Proposed Rule (includes outlier payments) WA MT OR

ID WY

PA IN

MD WV

NH MA CT RI

NJ DE

KY NC

SC MS

IA IL

Payment is lower than cost Payment is higher than cost Changes from 2017 to 2018 MI, NC, SD, WY DE

: AMRPA analyzed the FY 2018 proposed rates for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PP Medicare payment versus provider cost for FY 2018. The rate setting data files for the proposed rules can be found at Editor’s Note: AMRPA analyzed the FY 2018 proposed rates for the Inpatient Rehabilitation Facility Prospective Payment System Copyright 2017, AMRPA, Washington, DC (IRF PPS) to compare the adequacy of Medicare payment versus provider cost for FY 2018. The rate setting data files for the proposed rules can be found at https://tinyurl.com/CMSIRFRates.

CMSIRFRates.

CMS ISSUES PROPOSED RULE FOR SECOND YEAR OF QUALITY PAYMENT PROGRAM By Jonathan M. Gold, JD, Regulatory and Government Relations Counsel*, AMRPA

Calendar Year (CY) 2018, referred to as are considered MIPS-eligible clinicians he Centers for Medicare and performance year 2018, will be used to (MECs), or they are Qualifying Providers Medicaid Services (CMS) on adjust payments for 2020, referred to as (QPs) in an Advanced Alternative June 30 published proposed payment year 2020. Payment Model (Advanced APM). updates to the Quality Payment Program (QPP) for Advanced APMs are essentially an Under MIPS, physicians and other calendar year (CY) 2018 in the Federal alternative track to MIPS, and QPs eligible clinicians are evaluated across Register. Comments on the proposed rule participating in an Advanced APM are four performance categories: (1) Quality; are due Aug. 21.This article summarizes eligible to receive a five percent bonus (2) Cost (resource use); (3) Improvement key issues of interest in the proposed rule payment in a payment year. An Advanced Activities; and (4) Advancing Care to be considered by AMRPA’s Outpatient APM is defined by three criteria: 1) the Information (ACI), a replacement of and Therapy Committee as AMRPA model must require the use of certified the EHR Incentive Program. Physicians prepares its formal comment letter. EHR; 2) the model must provide for receive a total score based on the Perhaps most notable for the medical payment based on quality measures reporting categories, which will result in rehabilitation field is that CMS did not similar to those used under MIPS; and a positive, neutral, or negative payment provide guidance on any future plans to 3) the clinicians must bear more than adjustment. The payment adjustment expand MIPS to other types of clinicians, nominal financial risk, as defined by CMS. such as therapists. AMRPA has urged CMS to include clinicians There are several key like therapists as soon as features in the proposed rule statutorily available (2019), pertaining to MIPS, including and provide as much notice as AMRPA has urged CMS to include a significant elevation of possible to allow clinicians to the low-volume exclusions prepare for inclusion. clinicians like therapists as soon as thresholds and further statutorily available (2019), adjustments to the weighting The QPP is currently in its and provide as much notice as of scoring categories. CMS is first year, after the Medicare also proposing a plan to allow and CHIP Reauthorization Act possible to allow clinicians to clinicians who are facilityof 2015 (MACRA) repealed prepare for inclusion. based to use their facility’s the sustainable growth score for parts of their MIPS rate (SGR) formula that was score. However, the proposal used to update physician only allows for metrics from the Hospital currently ranges from an adjustment in payments under Medicare Part B. The Value Based Purchasing Program to be either direction of up to five percent of QPP replaces several existing programs, used. Since this is a program for general total payments, and is set to increase including the Physician Quality Reporting acute care hospitals, and not Inpatient annually as the program advances System (PQRS), the Physician ValueRehabilitation Hospitals/Units (IRFs), it until leveling off at plus-or-minus based Payment Modifier (VM), and the does not appear clinicians who are IRFnine percent. Unlike its predecessor Medicare Electronic Health Record based will be eligible. programs, MIPS adjustment payments (EHR) Incentive Program, often referred apply to billed services and separately to as “Meaningful Use.” Physicians and CMS also provided proposed updates billed items, such as Part B drugs. Similar other clinicians currently covered by to Advanced APMs as it moves closer to other CMS programs, MIPS generally the QPP fall under two tracks. Either to implementing All-Payer Advanced uses a two year delayed payment system they participate in the Merit-Based Alternative Payment Models. The agency so that services and scores achieved in Incentive Payment System (MIPS) and 28

AMRPA Magazine August 2017

provided more details on how it plans to implement those models to provide more options for clinicians to be exempt from MIPS and eligible for the Advanced APM incentive payments.

The table below displays the proposed changes in category weighting.

Finalized and Proposed Weights by MIPS Performance Category Performance Category

The proposed rule provided an estimate of MIPS’ impact on various specialties, including Physical Medicine and Rehabilitation (PM&R), which showed the PM&R specialty anticipated to fare below average in payment adjustments. CMS estimates that approximately 90 percent of PM&R specialists can expect a positive or neutral payment adjustment, which is below the total average for all MECs of 96.1 percent. CMS says the PM&R specialty can expect $6.4 million in positive payment adjustments and $5 million in negative adjustments. Included below is more in-depth information on some the key proposals in the proposed rule. Performance Categories Weighting CMS finalized a proposal for CY 2017 that made a MEC’s Composite Performance Score (CPS), the final score a MEC receives to determine their payment adjustment, heavily dependent on Quality performance (60 percent), with the rest of the CPS divided between Advancing Care Information (ACI) performance (25 percent) and Improvement Activities performance (15 percent). The Cost performance category was weighted at zero percent for the initial “transition year” so that MECs would have time to understand the category. For CY 2018, CMS believes that still more time is needed for MECs to become proficient in the Cost performance category, and is proposing it remain at zero percent for CY 2018, and also proposes to leave the other performance categories the same as they were in CY 2017. CMS notes that by CY 2019, it is statutorily obligated to weight Cost performance at 30 percent. Since this would create a sharp change from one year to the next, CMS seeks comments on whether it should weight the Cost performance at 10 percent of the CPS, with Quality being reduced to 50 percent and ACI and Improvement Activities remaining at 25 and 15 percent respectively for CY 2018.

on expanding the patient data available for reporting under CAHPS. This would

Quality

Transition year (final) (%)

2020 MIPS payment year (proposed) (%)

2021 MIPS payment year and beyond (final) (%)

Cost

Improvement Activities

Advancing Care Information

Quality Performance Category Criteria and Reporting CMS proposes limited changes to the Quality Performance Category criteria and data reporting requirements. For CY 2018, MECs would continue to be required to report six quality measures, including at least one outcome or other “high-priority” measure. Alternatively, MECs may choose one MEC specialty set to report. Regardless of the makeup of the specialty set, the MEC must still report one outcome measure, or, if no outcome measures are available in the measure set, the MEC will report another high priority measure, such as an appropriate use, patient safety, efficiency, patient experience, or care coordination measure. In the CY 2017 proposed and final rules, CMS discussed adding a requirement for MECs to report at least one cross-cutting measure and solicited feedback on the idea. CMS states it received mixed feedback about the extra burden and questions on the applicability of crosscutting measures to certain specialties. The proposed rule again solicits feedback on how cross-cutting measures could be incorporated in to the Quality reporting requirements. For MECs reporting as groups, they are currently permitted to use patient feedback as one quality measure through the Consumer Assessment of Healthcare Provider and Systems (CAHPS) tool, which also qualifies as a high priority measure. Further, groups of 16 or more MECs are also judged on one population measure, all-Cause Rehospitalization, if they have at least 200 cases. CMS is not proposing changes to this policy for CY 2018. However, it is seeking comment

include adding more open ended questions to obtain patient narratives on their experience. CMS is also lowering its previously established data completeness threshold for individual MECs. In the CY 2017 rule, it had stated that MECs would need to submit data on 60 percent of all patients for CY 2018, regardless of payer. However, CMS is now proposing to maintain that threshold at 50 percent, the same as it is for CY 2017, and raise the threshold to 60 percent in CY 2019 instead. While CMS is proposing to freeze the threshold, it is also proposing a change to the scoring based on data completeness. For CY 2017, MECs will receive three points for data submitted that did not reach the threshold. For CY 2018, CMS proposes that those MECs who do not meet the threshold would receive only one point per quality measure, except for small practices, who will continue to receive three points. There are a number of new quality measures as well as changes to quality measures within the Physical Medicine & Rehabilitation specialty. These proposed changes can be found on in Table B.15 page 30373 of the proposed rule. Cost (Resource Use) Performance Criteria and Reporting For CY 2017, Cost performance is determined by two metrics: the total per capita costs for all attributed beneficiaries (Total Per Capital Cost) measure, and the Medicare Spending Per Beneficiary (MSPB) measure. CMS also included 10 episode-based measures from the Supplemental Quality and Resource Use Reports (sQRURs) for CY 2017. However for CY 2018, CMS is proposing to

eliminate the episode-based measures as it works with experts to develop more comprehensive measures, and rely solely on the Total Per Capita Cost and MSPB measure for CY 2018. As with this year, the cost measures will be determined through claims data, so no reporting will be required of MECs. CMS plans to issue feedback reports to MECs to help them better understand the MIPS scoring systems and evaluate their performance Improvement Activities Performance Category Criteria and Reporting CMS is proposing minimal changes to the Improvement Activities performance criteria, which will count as 15 percent of the CPS in CY 2018. One change of note is that CMS is proposing to finalize a subregulatory process for submitting new improvement activities, which would be similar to the process used during the transition year, where experts could nominate proposals through the CMS website. MECs will continue to self-certify the activities completed or have a contractor certify on their behalf. The performance period will continue to be 90-days for Improvement Activities, so a MEC may structure the activity in any way they choose, so long as it occurs for a minimum of 90 consecutive days. MECs will need to achieve 40 points total by selecting from a combination of high-weighted activities (20 points) or medium-weighted activities (10 points). Non-patient-facing clinicians; small, rural, or Health Professional Shortage Areas (HPSA) practices have a reduced threshold at 50 percent of the standard level. CMS is proposing a number of new high-weighted activities that can be found in Table F on the proposed rule on page 30479. For CY 2017, there are 14 high-weighted activities and 78 mediumweighted activities. CMS proposes to add 20 new activities to the inventory and to modify 27 activities. With little change to this category, CMS has requested comment on a number of issues that will shape their future changes under this category. The Agency states it would like to move towards methods that better measure actual improvement, rather than relying on tracking participation in certain activities. CMS is also considering making the 30

performance period a more extended period of time. CMS seeks comment on suggestions for how that could be accomplished, including through the use of information technology, with an emphasis on ensuring a minimal burden on MECs. CMS also seeks comment on establishing a threshold for group submissions in the Improvement Activities category, specifically how many MECs within a group must have completed an activity for the group to receive the full score for completion. Advancing Care Information (ACI) Performance Category Criteria and Reporting CMS is proposing a number of changes to the ACI category scoring, which will be weighted at 25 percent for those MECs not exempted, just as it was for CY 2017, and as required by statute. After previously stating that for CY 2018 MECs would need to use 2015 edition Certified EHR technology (CEHRT), CMS will allow for MECs to still achieve a base score of 50 percent by using 2014 CEHRT. However, CMS will award 10 bonus points for MECs who report measures using only 2015 CEHRT. CMS seeks comments on whether this bonus should be limited to only new or small MECs. The performance period is proposed to be 90-consecutive days, which is the same as it was for CY 2017. CMS is also seeking to amend its previous rule that MECs receive up to 10 points for reporting on the Immunization Registry Reporting Measure. CMS proposes to allow MECs who cannot use that registry to report via another public health registry. MECs will receive five bonus points per registry, up to ten points total. Further, CMS is continuing the policy of allowing up to 10 bonus points for MECs who report pre-approved improvement activities using CEHRT. The agency has proposed a number of new improvement activities that would count towards this bonus, and they are displayed in Table 6 of the proposed rule on page 30060 of the proposed rule. CMS is proposing changes to its exemptions under the ACI performance category. It will extend a hardship exemption to small group MECs (15 or fewer MECs), and reweight their ACI performance to zero percent. Hospital-

based MECs – those who furnish 75 percent or more of their services at Point of Service (POS) Codes 21 (inpatient hospital), 22 (on-campus outpatient hospital) or 23 (emergency room) – will also have their ACI scored reweighted to zero, unless they choose to submit ACI measures. Further, CMS is proposing to amend its definition of a hospital-based MEC to also include POS 19, which is defined as an off-campus outpatient hospital. Due to the 21st Century Cures Act, CMS will also reweight Ambulatory Surgery Center (ASC) based MECs’ (POS Code 24) ACI score to zero, including retroactively for the CY 2017 performance year, unless MECs choose to submit ACI measures. CMS is also proposing a time-limited hardship exemption for those who have their EHR decertified by the Office of the National Coordinator (ONC). Finally, CMS is proposing some minor changes to the measures for MECs to use for their ACI scores. The new measures begin on page 30068 of the proposed rule. MIPS Requirements for Participants in Alternative Payment Models (MIPS APMs) CMS has developed modified requirements for MECs who participate in APMs with Medicare. It is important to distinguish participation in MIPS through an APM with those clinicians that are exempted from MIPS for participating in Advanced Alternative Payment Models (Advanced APMs). That system is discussed separately in this article. CMS identified the Comprehensive ESRD Care Model, the Comprehensive Primary Care Plus Model (CPC+), the Oncology Care Model, the Medicare Shared Savings Program and the Next Generation ACO as MIPS APMs for CY 2017. Generally, all MIPS requirements will continue to apply for APM participants unless they are specifically modified for this group. As in previous years, the Cost performance category will be weighted to zero for APM participants and MECs will not need to submit any data on cost. Further, the Improvement Activities category will be worth 20 percent of an APM participating MEC’s score, but it will be based off of the APM model and MECs will not need to submit any data. AMRPA Magazine August 2017

Under the Quality performance category, which will be worth 50 percent of the MEC’s score, there are a few modifications for CY 2018. For MECs participating in the Medicare Shared Savings Program and the Next Generation ACO models, submissions via the CMS Web Interface will continue to be the sole source of quality metrics. For these web-interface reporting MECs, CMS is also proposing to use the CAHPS as part of the Quality score, which was not included in CY 2017. For MECs participating in other APMs, CMS is proposing to use a unique set of quality measures for each APM. CMS proposed four criteria for determining inclusion in an APMs quality measure set: 1) If payment is tied to that measure under the APM; 2) If the score will be available in a timely manner; 3) If there is at least 20 cases available for reporting; and 4) There is an available benchmark. In Table 14 on page 30091 of the proposed rule, CMS lists the proposed quality measures to be used for each APM. Under the ACI category, MIPS APM MECs will need to submit ACI performance data (unless exempted) and the APM as an entity will be assigned an ACI score based on an average score of all MECs in the APM entity. The ACI category will be weighted as 30 percent of the total score. For those MECs who qualify to have their ACI performance score weighted at zero percent, their Quality performance score will be weighted at 80 percent and their Improvement Activities score will be weighted at 20 percent. Performance Thresholds For CY 2017, CMS set a performance threshold floor that a MEC was required to meet in order to earn a neutral or positive payment adjustment. On the 0-100 scale the threshold for the transition year was three points. CMS proposed to raise that threshold to 15 points for CY 2018. Further, CMS determined an exceptional performance threshold of 70 for CY 2017 that was the minimum score to make MECs eligible to share in a pool of $500 million, on top of their other payment adjustments. CMS proposed to keep the exceptional performance threshold at 70 for CY 2018. Facility-Based Scoring CMS proposes to allow clinicians it

defines as “facility-based” to have the option to use their facility’s Hospital Value Based Purchasing Program (VBP) scores as a total substitute for the MIPS Quality performance category and Cost performance score. To be considered a facility-based MEC and eligible to use a facility’s VBP score, a MEC must furnish 75 percent or more of services at POS codes (as used in HIPAA standard transactions) 21 (inpatient hospital) or 23 (emergency room). CMS states it is considering whether a MEC would need to affirmatively opt-in to the program or whether CMS would automatically calculate a MEC’s score using the VBP and apply it to the MEC’s score if it would result in a higher score than using data submitted by the MEC. The VBP score would be translated to the Quality and Cost score for the MEC under MIPS using a percentile calculation. To account for the harsher scoring under the VBP, the MEC would be awarded the percentile in which the facility falls in the VBP, so if a MEC works at a facility that scores in the 75th percentile in the VBP, he or she would receive the score corresponding to the 75th percentile in the Quality and Cost performance measures for that CY. MECs who use the facility-based measures would not qualify for certain bonuses, including for reporting additional quality measures and end-to-end electronic reporting. The proposal only calls for metrics from the Hospital Value Based Purchasing Program to be used. Since this is a program for general acute care hospitals, and not Inpatient Rehabilitation Hospitals/Units (IRFs), it does not appear clinicians who are IRF based will be eligible. However, CMS does request comment on what other programs should be included in future years. CMS explains that it chose the VBP because it believes the VBP program to be the most analogous to the MIPS program in its focus on quality and operation as a pay for performance rather than a pay for reporting program. Low-Volume Exclusion During the transition year rule, CMS excluded MECs with equal to or less than $30,000 in Part B allowed charges or equal to or less than 100 Part B beneficiaries during a determination period. CMS

is seeking to significantly expand the threshold so that MIPS would exclude MECs with equal to or less than $90,000 in Part B allowed charges or equal to or less than 200 Part B beneficiaries during a determination period. Further, CMS is proposing that starting with CY 2019, low volume MECs could opt-in to MIPS if they exceed one of the thresholds. CMS is also proposing a third low-volume threshold that would be based on items and services provided, which would take effect in CY 2019. CMS says that if this proposal is implemented, a MEC could also opt-in if they exceed this threshold but do not meet the others. Reporting Mechanisms For the transition year, MECs had a full array of reporting mechanisms available to them within all four performance categories. However, MECs were required to use only one submission mechanism per performance category, with very narrow exceptions. CMS is proposing to revise this policy so that MECs may submit information via multiple mechanisms for the Quality, Improvement Activities and ACI categories. The proposal states that CMS will not have the ability to aggregate the same measure submitted by multiple mechanisms and will only apply the highest score for the same measure submitted via two different methods. Virtual Groups CMS is proposing a new method of participation in MIPS for CY 2018 called Virtual Groups. Under the proposal, these Virtual Groups may be composed of solo practitioners or groups who come together under this clause in order to create efficiencies. In order for solo practitioners to be eligible to join a Virtual Group, they would need to meet the definition of a MEC and not be excluded from MIPS. In order for groups to be eligible to participate in MIPS as part of a Virtual Group, groups would need to exceed the low volume threshold at the group level and consist of no more than 10 MECs. A group that is part of a Virtual Group may include clinicians who do not meet the definition of a MEC or are excluded from MIPS. If the group chooses to join or form a Virtual Group, all clinicians under the TIN would be part of the Virtual Group. The Virtual Groups would be assessed 31

collectively under MIPS and subject to a payment adjustment as a Virtual Group. Although a group joining a Virtual Group may consist of non-eligible clinicians, the non-eligible clinician payments would not be subject to adjustment. Adjustments to Final Score CMS has proposed a number of adjustments to the final MIPs score for CY 2018. CMS is proposing to offer a Complex Patient Bonus for MECs. This bonus would be based on the Hierarchical Condition Category (HCC), which is used to evaluate risk in Medicare Advantage plans and other programs, as a proxy for medical complexity. The HCC approach would average the HCC scores of patients treated by the MEC to assign the score (which ranges from approximately one to three) to the final MIPS score. CMS is also seeking comments on an alternative approach which would use the percentage of patients treated by the MEC who are dual-eligible for Medicare and Medicaid. For this approach, the percentage of dual-eligible beneficiaries in the MECâ&#x20AC;&#x2122;s patient mix would be multiplied by five, and that would be added to the final MIPS score. The proposal includes the Complex Patient Bonus only in CY 2018, and not in subsequent years. CMS is also proposing to add a small practice bonus of five points to the final MIPS score of MECs who participate in groups of 15 or less MECs. In order to receive the bonus, the MECs would need to submit data on at least one of the

performance categories. This proposal is a one year proposal to be used in CY 2018, and not anticipated to continue beyond that year.

Advanced APMs that are Medical Home Models, as it discussed in CY 2017, due to these entitiesâ&#x20AC;&#x2122; inexperience with risk sharing and other characteristics.

For future years, CMS is seeking comment on whether the agency should account for social risk factors MIPS scores, and if so, what methods would be most appropriate for incorporating these factors in to the final MIPs score. CMS is also seeking comment on which social risk factors are most appropriate for use in this calculation.

Currently, only APMs that are Medicare APMs can be Advanced APMs. Beginning in CY 2019, CMS is establishing eligibility standards for becoming a QP by participating in an All-Payer or OtherPayer Advanced APM. To qualify as an Other-Payer or All-Payer Advanced APM, the entities or clinicians must submit information to CMS indicating they meet similar standards that apply to Medicare Advanced APMs. The proposed nominal risk standard is marginal risk of 30 percent, a minimum loss rate of no more than four percent and a total risk of at least three percent of expected expenditures. The threshold for payment amounts is proposed to be 50 percent from either the Medicare or other payer, and a minimum of 25 percent of payments coming from the Medicare Advanced APM. CMS proposes to raise to the threshold to 75 percent for total payments from any Advanced APM payer by 2021. Also notable is that CMS proposes to make determinations of QP eligibility under the All-Payer option at the individual clinician level, and not the group level like it does for many Medicare Advanced APMs.

Advanced Alternative Payment Models (Advanced APMs) As previously discussed, clinicians can be exempt from MIPS by participating in an Advanced Alternative Payment Model (Advanced APM) as a qualified participant (QP). A QP receives a five percent positive adjustment on allowable charges in the applicable payment year. To determine if an entity qualifies as a QP, the entity must meet a certain threshold of payments or patients through the Advanced APM, and also must bear beyond a nominal amount of risk. For 2018, CMS states the patient threshold will be 25 percent of payments or 20 percent of patients. CMS has proposed to freeze the nominal risk standard at eight percent for at least the next two years. CMS is also retaining the alternate nominal standard that an Advanced APM entity must risk three percent of expected Medicare expenditures for CY 2018. Further, CMS is proposing to significantly lower revenue risk requirements for

*Admitted Only in Illinois. Supervision by Carolyn C. Zollar, J.D., a member of the D.C. Bar

CMS DELAYS NEW REQUIREMENTS FOR HOME HEALTH AGENCIES BY 6 MONTHS The Centers for Medicare and Medicaid Services (CMS) delayed the effective date for its final rule implementing significant changes to requirements for home health agencies (HHAs) participating in Medicare and Medicaid programs from July 13 of this year to January 13, 2018. Industry stakeholders told CMS that they needed more time to comply with the new rules. The delay allows agencies to have more time to prepare for the changes. The new home health care conditions of participation (CoP) include changes for the agencies, including Quality Assurance Performance Improvement (QAPI); projects for performance improvement will be phased in more slowly than other QAPI requirements. For the July 10 Federal Register announcement please see https://www.gpo.gov/fdsys/pkg/FR-2017-07-10/pdf/2017-14347.pdf

AMRPA Magazine August 2017

MEDICARE ADVANTAGE ENROLLEES COULD SIGNIFICANTLY REDUCE MEDICAL COSTS BY SWITCHING PLANS, AHRQ STUDY FINDS

eniors enrolled in Medicare Advantage (MA) insurance plans could save 19 percent annually on health care spending by switching to a lower-cost MA alternative offered in their area, according to a study funded by the Agency for Healthcare Research and Quality (AHRQ).

enrolled in the same plan for different periods of time? •

Compared with lower-cost options available to beneficiaries, what is the dollar value of the foregone savings – if any – from remaining in the same plan over time?

Methods Using linked administrative enrollment and plan data, the authors compared the costs of the MA plans that beneficiaries chose with the costs of other plans available to them. The study showed predicted values adjusted for age, gender, race/ethnicity, disability, individual health risk, presence of

The study excluded beneficiaries who were not enrolled in both Part A and B of Medicare in January of each year, did not choose an MA plan with Part D coverage (MA-PD plans), were enrolled in a Special Needs Plan (SNP) or an employer plan, or were enrolled in Medicaid or the Part D Low-Income Subsidy program. From each beneficiary’s set of MA plan choices, the researchers excluded SNPs, plans that were not an MA-PD, and employer-sponsored plans. The final sample included 93,519 beneficiaries in 2013.

Medicare Advantage plans are offered by private insurers as alternatives to traditional Medicare, and the option to choose a private health insurance plan has existed for Medicare beneficiaries Findings and Conclusions for several decades. In 2016, more than The study authors found that for each 17 million beneficiaries (31 percent) year that enrollees remained in their were enrolled in MA plans —up from 6.8 Medicare Advantage plans, million a decade earlier— premiums and out-of-pocket and beneficiaries had an costs increased by roughly average of 19 plan choices in $50. Beneficiaries who that year. When choosing a MA beneficiaries could reduce remained in their plans for six plan, beneficiaries often face or more years were most at risk a tradeoff between premiums their exposure to health care of spending higher amounts, versus expected out-ofspending by switching to plans with paying $786 more each year pocket (OOPC) medical lower premiums, although there than they would have in the costs which have important lowest-cost plan available to consequences given the may well be rational reasons for them. The study concluded by lower incomes and higher paying costs in excess of those stating that MA beneficiaries average medical spending could reduce their exposure of Medicare beneficiaries of the lowest-cost plan. to healthcare spending by compared with the broader switching to plans with lower U.S. population. premiums, although there may well be rational reasons for paying The study compared how premiums and mental health diagnoses, health plan costs in excess of those of the lowestexpected OOPCs vary with beneficiaries’ quality, relative size of the plan’s provider cost plan. length enrollment in their plans, and network and the number of years also sought to address the following continuously enrolled in the same plan. According to the report, the amount of questions: money “left on the table” increases with The study results were derived from length of enrollment in a plan, suggesting a 2-percent random sample of the • Compared with other plans that beneficiaries may not be “actively Medicare Beneficiary Summary File available to beneficiaries, how much and regularly comparing plans, and thus, enrollment databases for 2013, although are beneficiaries currently spending are subject to a certain amount of inertia historical data on beneficiary plan on premiums and cost sharing? in their plan selections”. One potential selections from as early as 2006 was used • How do plan costs compare for consequence is a diminished incentive to measure tenure in MA plans. beneficiaries who have been for insurers to compete for enrollees

by reducing premiums and tailoring benefits to consumer preferences. The report also pointed out that although several previous studies have investigated decision making in the MA market, few have looked specifically at what beneficiaries pay for coverage and how that compares with other options. Study Limitations The authors were not able draw firm conclusions regarding the appropriateness of beneficiariesâ&#x20AC;&#x2122; choices because there may be unobserved components of beneficiary demand for plans. Furthermore, the absence

of MA claims data prevented direct comparisons of what beneficiaries would have actually spent on cost sharing had they chosen differently. Since healthcare needs differ greatly, some beneficiaries may have chosen plans that reduced their own exposure to medical costs (e.g., richer coverage for anticipated stays in skilled nursing facilities (SNFs), even though they appeared to pay more for premiums or OOPC.

for-service (FFS) plans exited the market around that time. Some beneficiaries in the sample may have been exposed to this policy change and chose new plans.

The study also notes that due to regulations issued by the Centers for Medicare and Medicaid Services (CMS) requiring plans to develop provider networks as of 2011, many private fee-

For the abstract please see http://www. ajmc.com/journals/issue/2017/2017vol23-n6/How-Do-Medicare-AdvantageBeneficiary-Payments-Vary-With-Tenure

Authors Paul D. Jacobs, PhD, and Eamon Molloy, PhD, How Do Medicare Advantage Beneficiary Payments Vary With Tenure, The American Journal of Managed CareÂŽ Vol. 23, No. 6, June 2017.

AMRPA Magazine August 2017

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AMRPA Magazine August 2017