AMRPA Magazine February 2017

February 2017 • Vol. 20, No. 2

FINDING ORDER IN CHAOS

Pursuing positive change to advance patient care

Volume 20, Number 2

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 AMRPA Submits Comment Letter to CMS on Medicare Denials for the Use of Group and Concurrent Rehabilitation Therapy.............................. 6 House and Senate 1st Session 115th Congressional Calendar....................... 9 Report on the Technical Expert Panel on PAC Quality Measures................. 10 OIG Slams Rehabilitation Hospitals for Unsuitable Patients as Follow-Up to Prior Study............................................................... 14 CMS Transmittals of Interest for Medical Rehabilitation Providers............... 16 AMRPA Responds to MedPAC’s Chairman Draft Recommendation of Five Percent Reduction for IRFs................................................................... 17

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

Commonwealth Report Examines High-Need Patient Experiences; Focuses on Improving Outcomes and Lowering Costs of Care ................... 19

Mimi Zhang Policy and Research Associate, AMRPA

Efforts to Reduce Hospital-Acquired Conditions Shows Improvement With 21 Percent Decline, Report Says .................................... 21

Lovelyn Robinson Editorial and Research Assistant, AMRPA

MedPAC Finalizes FY 2018 Payment Recommendations for Post-Acute Care Providers and Updates PAC Payment Prototype Research ................. 23 Latest Research Findings.................................................................................. 25

AMRPA Magazine, Volume 20, Number 2.

Published monthly by the American Medical Rehabilitation Providers Association.

More Clinicians Have Opportunity To Join New Advanced APMs............... 26

Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content Š2017

by American Medical Rehabilitation Providers Association. All rights reserved. Materials may not reproduced in any form without written permission.

Design and layout services provided by Kellen Company.

Hospital Value-Based Purchasing Program Results for Fiscal Year 2017....... 28

Quality Indicator Commonly Asked Questions.............................................. 27

MACPAC Releases 2016 Medicaid and CHIP DataBook .............................. 32 RAC News: CMS Awards New RAC Contracts ............................................... 33 Study Examines Costs of Joint Replacements Using Bundled Payment Models ............................................................................... 34

POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th Street, NW, Suite 750, Washington, DC 20045

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AMRPA Magazine February 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

“Our intent is to find ways to partner with the managed care industry to help create better tools to achieve better care decisions for patients with less conflict and disagreement.”

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haos and confusion are likely to reign in healthcare as Congress addresses the “repeal and replace” agenda for the Affordable Care Act. In combination with the flood of recent regulatory releases by the concluding Democratic administration, recently enacted legislation (21st Century Cures Act) and pending legislation (Post-Acute Care Value Based Purchasing Act), we all will have our hands full trying to operate on a day to day basis while we seek to prevent harmful changes from affecting our patients and facilities.

The AMRPA Board, staff and advisors have been working tirelessly on behalf of the field of Medical Rehabilitation to formulate, communicate and execute our agenda for the changes we seek as well as those we hope to prevent. In partnership with other post-acute sectors, consumer organizations and other stakeholders, we are pursuing an agenda of positive change in a fiscally responsible manner to advance our capacity to care for patients who need our services.

In addition, we have started working with a Washington-based consulting firm, Healthsperien, to further address the challenges of dealing with ill-informed decisions by managed care plans that are harming patients. Our intent is to find ways to partner with the managed care industry to help create better tools to achieve better care decisions for patients with less conflict and disagreement. This project has an aggressive time frame and we hope to keep our members informed as we execute the plan.

With data from eRehabData® to provide evidence about our field, a clear and compelling set of principles and policy positions, and the passion of our commitment to our patients, I am confident that with your continuing support, AMRPA will continue successfully to defend and promote our field.

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AMRPA LEGISLATIVE UPDATE

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

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verview On Tuesday, January 3, 2017, Senate Budget Committee Chairman Michael Enzi (R-WY) introduced a Fiscal Year (FY) 2017 Budget Resolution that included reconciliation instructions for repealing the Affordable Care Act (ACA). The bill directs the House Energy and Commerce Committee, the House Ways and Means Committee, the Senate Finance Committee, and the

• • •

• •

The Senate approved the Budget Resolution early in the morning of January 12th by a vote of 51-48.

Senators considered 25 amendments, none of which were adopted. A group of Republican Senators sought to extend the deadline to act on legislation to repeal the ACA from January 27 to March 3, 2017. They withdrew their amendment, however, in recognition

replacement will be completed this year, it is uncertain when the transition to a replacement system would take place. A “repeal and delay” plan could see some parts of the law remain intact for several years. The conservative House Freedom Caucus has called for no longer than a two-year replacement process, the time frame both chambers approved last year in a repeal bill that President Barack Obama vetoed. The Caucus Members also want more information about what a repeal bill and

On January 3, 2017, the 115th Congress convened with Republicans holding a majority in the Senate of at least 52-48.

Fifty-two new House Members were sworn in, resulting in a Republican margin of control of roughly 241 to 194.

On January 20th, Republican Donald Trump was sworn in as the 45th President of the United States.

Nomination hearings for Rep. Tom Price (R-GA), MD to be the Health and Human Services (HHS) Secretary began with a courtesy hearing in front of the Senate Health, Education, Labor and Pensions (HELP) Committee on January 18th and Senate Finance Committee will follow. Rep. Price was expected to receive favorable Senate consideration.

The House and Senate passed a Fiscal Year (FY) 2017 Budget Resolution, step one in the process of repealing Obamacare, through a legislative tool known as “Reconciliation” that requires only a simple majority vote.

On January 12, the Medicare Payment and Advisory Commission (MedPAC) finalized its 5 percent payment reduction recommendation to Congress for inpatient rehabilitation hospitals and units (IRH/Us).

Senate HELP Committee to submit repeal legislation to their respective Budget Committees by January 27.

This legislation is the first step toward consideration of a reconciliation bill that would require only a 51-vote majority in the Senate to pass. Notably, the FY 2017 Budget Resolution establishes a reserve fund that would use any savings from repeal for an ACA replacement.

The Office of Management and Budget estimates the current Budget Resolution would increase the public

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debt from $14.2 trillion in 2016 to $23.7 trillion in 2026.

of the fact that the January 27 deadline in the Budget Resolution is not actually binding. Democrats offered a range of amendments to oppose repeal of the Affordable Care Act, reductions in health care coverage or cuts in funding for Medicare, Medicaid and CHIP, but all were defeated. The House quickly followed with a party-line vote of 227198 on Friday, January 13th.

While House Speaker Paul Ryan (R-WI) believes the legislative work on an ACA

Obamacare replacement would look like before they will agree to support the FY 2017 Budget Resolution.

A number of Republican Senators expressed public support for a swift replacement plan upon repeal. Senate Majority Leader Mitch McConnell (R-KY) has called for a step-by-step replacement approach, which would begin after the law is repealed. Sen. John Cornyn (R-TX) indicated that Republicans are weighing whether

AMRPA Magazine February 2017

some replacement elements could be included in a repeal measure. On January 10, Senate HELP Committee Chairman Lamar Alexander (R-TN) outlined a more detailed “rescue plan” to repeal and replace the ACA, which would give states greater authority.

Senate Democratic Leader Chuck Schumer (D-NY) and his colleagues remain adamantly opposed to ACA repeal. They called for announcing a “day of action” on Sunday, January 15 to “vigorously oppose the Republican plan to end Medicare as we know it and throw our health care system into chaos.” In interviews before his Inauguration, President-Elect Trump called for a swift repeal and replace of the ACA, noting that the replace should not take years, but occur simultaneously to repeal. He also confirmed that his Administration plans to release its own health care plan, once Rep. Price is confirmed as HHS Secretary. His comments have put Congressional Republicans on a much faster track than originally planned to pass a comprehensive ACA replacement plan.

Congressional Committees Organize and Prep for Action Congressional Committees announced their rosters for the 115th Congress.

Senators Bill Cassidy (R-LA) and Claire McCaskill (D-MO) have joined the Senate Finance Committee. Senator Tim Kaine (D-VA) and newly elected Senator Maggie Hassan (D-NH) are now Members of the Senate HELP Committee. Following initial action on the ACA and Budget Reconciliation, the Senate HELP Committee will be focused on reauthorization of the Food and Drug Administration’s user fee acts, and the Senate Finance Committee will likely reconsider the chronic care legislation it unveiled late last year.

On the House side, Rep. Greg Walden (R-OR) is the new full Committee Chair of the House Energy and Commerce Committee, and Rep. Michael Burgess, MD (R-TX) is the new Chairman of the Health Subcommittee. He will lead the Energy and Commerce Committee’s work on repeal and replacement of the ACA and implementation of the new physician payment system under MACRA. Health Subcommittee Vice

Chairman Brett Guthrie (R-KY), who led the Committee’s Medicaid task force, confirmed that reforming Medicaid remains a top priority. Other newly appointed Committee Members include Rep. Buddy Carter (R-GA), Rep. Ryan Costello (R-PA), Rep. Tim Walberg (R-MI), Rep. Mimi Walters (RCA), Rep. Debbie Dingell (D-MI), Rep. Scott Peters (D-CA), and Rep. Raul Ruiz (D-CA).

The House Ways and Means Committee will play a major role in developing ACA repeal and replacement policies, as well as tax reform. The Committee, led by returning Chairman Kevin Brady (R-TX), also is expected to continue its focus on advancing legislation that implements a post-acute care ValueBased Purchasing program. The Ways and Means Committee has a new Ranking Member, Rep. Richard Neal (R-MA), along with the following newly appointed Committee Members: Rep. David Schweikert (R-AZ), Rep. Jackie Walorski (R-IN), Rep. Carlos Curbelo (R-FL), Rep. Brian Higgins (D-NY), Rep. Terri Sewell (D-AL), and Rep. Suzan DelBene (D-WA).

MedPAC Moves Forward with 5 Percent Payment Decrease for IRH/ Us As expected, the Medicare Payment Advisory Commission (MedPAC) finalized a 5 percent payment decrease for inpatient rehabilitation hospitals and units (IRH/Us) during its January 12 public session. Other post-acute care providers received similar recommendations by MedPAC, including a 5 percent payment reduction in 2018, followed by a twoyear rebasing of the payment system in 2019 for home health agencies (HHAs). MedPAC recommends that Congress eliminate the 2018 and 2019 market basket update for skilled nursing facilities (SNFs) and revision of the SNF prospective payment system (PPS). Additionally, MedPAC voted to finalize the recommendation that longterm care hospitals (LTCHs) should not receive an update for its payment rates. The final recommendations will be released formally and published in MedPAC’s March Report to Congress.

Home Health Agency Conditions of Participation Final Rule and Extension of Temporary Moratorium in Targeted States On January 9, CMS released a final rule revising the conditions of participation (CoPs) that home health agencies (HHAs) must meet in order to participate in the Medicare and Medicaid programs. According to CMS, the final rule is meant to “improve the quality of health care services for all home health patients and strengthen patients’ rights,” by implementing a mandatory tracking system that analyzes quality and performance improvements.

Home health agencies will have to meet several new requirements to participate in Medicare and Medicaid, including better care coordination, comprehensive patient assessments and specific qualifications for home health professionals.

On January 6, CMS extended a temporary moratorium on home health agencies in Florida, Texas, Illinois, and Michigan from enrolling in Medicare and Medicaid for six months. CMS maintains that the ban is intended to fight a high level of fraud and abuse in these states. *** As we go to press, preparing for the new Trump Administration and a very active Congress, we urge every AMRPA member to actively reach out to their Members of Congress to educate them about the unique role of rehabilitation hospitals in continuum of care. Please plan today to come to Washington DC March 20-21 to participate in our Spring Executive Forum and lobbying on Capitol Hill – we need you!

Regards, Martha M. Kendrick

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AMRPA SUBMITS COMMENT LETTER TO CMS ON MEDICARE DENIALS FOR THE USE OF GROUP AND CONCURRENT REHABILITATION THERAPY Editor’s Note: On December 23, 2016, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Centers for Medicare and Medicaid Services regarding Medicare Administrative Contractors’ (MACs) denial of inpatient rehabilitation hospital or unit (IRF) claims. The complete letter is provided below and is available on our website www.amrpa.org.

VIA ELECTRONIC MAIL

as intense as one-on-one therapy and offers valuable benefits to certain patients that one-on-one therapy cannot provide.

CMS has stated the opinion that one-on-one therapy is the standard of care expected in an IRF, but the guidance—as discussed more fully below—is so ambiguous that it cannot serve as a bright line rule for the MACs to deny payment where group or concurrent therapy have been included in a patient’s plan of care. Nevertheless, one MAC, Novitas, has used the following rationale to deny payment to IRFs:

December 23, 2016 The Honorable Andy Slavitt Acting Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services 200 Independence Avenue, SW Washington, DC 20201 RE: Medicare Denials for the Use of Group and Concurrent Rehabilitation Therapy Dear Administrator Slavitt: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we write to request that you direct Medicare Administrative Contractors (MACs) to refrain from denying inpatient rehabilitation hospital or unit (IRF) claims when therapy is provided to patients in a group or concurrent setting. These MACs are misapplying the current standards set by the Centers for Medicare and Medicaid Services (CMS) for intensive rehabilitation therapy services.

AMRPA members provide rehabilitation services across the spectrum of health care settings including IRFs, hospital outpatient departments, and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, and skilled nursing facilities (SNFs). AMRPA members help patients maximize their health, functional skills, and independence, so they can participate in society by returning to home, work, or an active retirement. As part of furnishing care in the IRF setting, AMRPA members provide intensive rehabilitation therapy programs that consist of physical and occupational therapy, as well as speech language pathology and prosthetic/orthotic services.

These services are generally provided in an individualized manner, one-on-one between the patient and the therapist. Sometimes, however, a patient’s need or level of function warrants providing rehabilitation therapy in a group setting or concurrently with therapy provided by the therapist to other patients at the same time. In fact, group and concurrent therapy can be just 6

Per Centers for Medicare & Medicaid Services (CMS), the standard for therapy is for individual therapy with group and concurrent therapy to be used as an adjunct. The beneficiary is to receive three hours per day five days per week, or fifteen hours per week of intensive individual therapy. The group and concurrent therapy is to be used in addition to the individual therapy to increase the effectiveness in treating the condition. The medical record submitted did not support the beneficiary met the CMS requirement for individual therapy during the admission.

Another MAC, First Coast Service Options, has also denied claims when IRFs provide group therapy, stating, “[A] significant portion of therapies was provided in group or concurrent settings. Thus [the patient] did not receive an intensive individual rehabilitation program.”

These MACs are misinterpreting and misapplying the standard for intensive rehabilitation therapy services as expressed in current CMS guidance. These MACs improperly deny Medicare coverage for IRF services, which IRFs must then appeal through an administrative appeals process that is hopelessly backlogged.

Therefore, we wish to bring this matter to your attention and request that you halt these denials and direct the MACs to apply the existing guidance properly.

I. Current Guidance CMS has established a standard for an intensive level of rehabilitation services of three hours of therapy a day for five days per week, or a total of 15 hours of therapy over the course of the week.1 CMS has not, however, issued regulations or manual guidance specifically defining the required quantity of different modes of rehabilitation therapy. Instead, CMS has relied upon general statements issued during rulemaking, and in informal question and answer sessions to communicate its expectations about the use of various modes of providing therapy. In the fiscal year (FY) 2010 Inpatient Rehabilitation Facility Prospective Payment System (IRF-PPS) proposed and final rules, CMS briefly discussed the use of individual therapy versus other modes of therapy. In the final rule, CMS acknowledged that group theraAMRPA Magazine February 2017

py may be appropriate: [G]roup therapies may have a role in patient care in an IRF, but that they should be used in IRFs primarily as an adjunct to one-on-one therapy services which should be the standard of care in therapy services provided to IRF patients.

We believe that group therapy should be considered as a supplement to the intensive therapy services generally provided in an IRF.2 This guidance, however, exists only in the preamble and was not codified in any form as part of the regulations governing Medicare coverage of IRF services. Instead, CMS included the following “standard” in its manual guidance: The standard of care for IRF patients is individualized (i.e., one-on-one) therapy. Group therapies serve as an adjunct to individual therapies. In those instances, in which group therapy better meets the patient’s needs on a limited basis, the situation/rationale that justifies group therapy should be specified in the patient’s medical record at the IRF.3 In the preamble to the FY 2010 IRF PPS final rule, CMS stated that it “plan[s] to consider the adoption of specific standards on the use of group therapies at a future date.”4 CMS then held a provider education call on November 12, 2009 to help address any questions about the significant overhaul of the Medicare coverage criteria for IRF care included in that rule. During the call, CMS responded to questions from the audience, including several focusing on the use of group or concurrent therapy. Dr. Susanne Seagrave, the Inpatient Rehabilitation Team Leader in the Division of Institutional Post-Acute Care, specifically stated that CMS had “not established specific standards for a group or concurrent therapy in IRFs yet, so this will not be a reason for denial.”5 Sheila Lambowitz, Director of the Division of Institutional Post-Acute Care, elaborated on this issue further, stating: In general, what we have been saying is that, we expect that the therapy is going to be individualized. We do understand for certain kinds of conditions and certain patients that group therapy is appropriate. And when we see that documented, we would accept that as certainly an appropriate method of treatment. But again, it has to be appropriate to those patient needs. So that should help you a little, and will get a formal response to you as fast as we can.6 The formal response was published by CMS as part of a series of follow-up documents in question-and-answer format on its website.7 As part of the fourth question-and-answer follow-up, Question 36 specifically answered a question about the necessary percentage of one-on-one therapy: Answer: We expect the preponderance of therapy a patient receives at the IRF to be individualized, one-on-one therapy.

IRF patients require an intensive and complex level of therapy services designed specifically to their individual needs.

We believe that individualized, one-on-one therapy most appropriately meets the specialized needs of IRF patients.

We have not yet established a required percentage of one-

on-one individualized therapy in the IRF setting because we are seeking more information on the amount of one-on-one versus group therapies that are most beneficial to patients.

The specific benefit to the IRF patient of any group therapy that is provided must be well-documented in the IRF medical record.8 Since 2009, CMS held one additional “follow-up” session on May 31, 2012. During that call, CMS presented slides that simply restated the position that group therapy is an adjunct to individual therapy, which CMS views as the standard of care.9 CMS currently requires IRFs to report the mode of therapy provided, presumably so that it can assess the prevalence of individual versus group/ concurrent therapy and formulate a policy. CMS has provided no further clarification or specific rules regarding the percentage or proportion of therapy to be provided in IRFs via any specific mode of therapy.

II. MAC’s Use of Group Therapy as a Reason for Denial The MACs’ surging use of group therapy as a justification for denying claims is very inappropriate because CMS has expressly stated that the use of group therapy would not constitute a reason for denial, and CMS has not issued guidance precluding its use. The MACs appear to deny claims that incorporate any group therapy, regardless of how small a proportion of the total therapy is provided in a group setting. For example, one MAC denied coverage of an IRF stay when only 18% of the physical therapy, 14% of the occupational therapy, and 27% of the speech therapy was provided to the patient in a group setting. Moreover, this patient received more than three hours of therapy per day, which resulted in only 6.1% of the total therapy in a group setting. A mere 6.1% is plainly nowhere near a “preponderance” of therapy.

Furthermore, MACs frequently conflate group and concurrent therapy, which serve very different purposes. As explained below, group therapy can be used to motivate patients and/or to permit them to practice interpersonal skills. Concurrent therapy permits a patient to practice skills independently while a therapist intermittently works with another patient nearby. MACs fail to distinguish between the two or to acknowledge the benefits to patients of one or both of these modalities.

CMS has not promulgated a standard for the amount of permissible group or concurrent therapy. However, CMS continues to express a standard for individual therapy provided in IRFs, namely, that individual therapy must constitute a “preponderance” of the therapy provided in an IRH/U. The generally accepted definition of “preponderance” is a “majority,” i.e., greater than 50%.10 This definition compels the conclusion that a patient satisfies the intensity of therapy requirement as long as group therapy constitutes a minority (up to 49%) of the total therapy. Despite CMS’s clear statement that group therapy is permitted when the IRF documents its need and benefit, MACs routinely disregard any documented justification for group therapy in the medical record.

III. Justifications for the Continued Use of Group and Concurrent Therapy These MACs are not only disregarding CMS guidance—they 7

also deprive patients of valuable clinical benefits from group and concurrent therapy. There are numerous clinical factors that are considered in determining what type of therapy an IRF patient receives based on the patient’s overall evaluation and subsequent plan of care. Many IRF patients are still at a fragile functional and medical stage in their recovery upon admission. The use, types, and organization of therapy services is dependent upon each patient’s needs and ability to tolerate therapy. As a patient’s medical status and motor and cognitive function improves, the type and nature of therapy provided may change. As required under Medicare coverage criteria, an interdisciplinary team periodically assesses and reevaluates IRF patients to permit this type of adjustment in a patient’s plan of care.

The type and mode of therapy services that the therapy team orders for an individual patient is based on the patient’s diagnosis, medical status, comorbidities, complications, precautions, current functional status, goals, and contraindications. For example, oneon-one therapy may be the only reasonable mode of therapy at a certain stage in a patient’s recovery, with the addition of group therapy becoming appropriate at a later time, based on a reassessment of the patient. Group and concurrent therapy can be invaluable tools in providing a flexible and adaptable therapy program based on the patient’s needs. Group therapy is often the first place a patient can learn to adapt and interact with others with a new (temporary or permanent) impairment. This need for non-individual therapy can be particularly true of patients requiring speech language pathology services, such as those with aphasia, where a group setting allows patients to practice and focus on functional speech and cognitive-communication skills. Without the group setting and the complexity such a setting creates, these skills could not be developed adequately.11 AMRPA disagrees with CMS’s implication that group therapy is not as “intensive” as one-on-one therapy. For participants in group therapy, the intensity of therapy may not be any different than observed in a one-on-one session, and may, in some instances, be more intensive. For example, a patient with speech deficits will experience greater intensity of speech therapy by carrying out a conversation during with more than a single person. The patients are still asked to participate at their maximum level, be it repetitive resistance exercises, motor planning during activities of daily living training, or listening, processing and speaking in a dynamic group setting. In addition, group therapy can often motivate patients to work harder at therapy. Patients frequently compete with each other and provide emotional and/or peer support for one another.

The comradery, coaching, and competition are added benefits of group therapy.12 CMS should focus on benefits, results, and patient outcomes, not on the manner in which therapy is delivered.

IV. Conclusion CMS has stated that providing group or concurrent therapy “will not be a reason for denial.” CMS has also acknowledged that group and concurrent therapy can be valuable contributions to the intensive rehabilitation program provided in an inpatient rehabilitation hospital or unit. Although CMS has expressed reservations about group therapy as the bulk or majority of therapy services, it has never forbidden the use of group or concurrent therapy for meeting the IRF intensity of therapy requirement. In 8

the absence of a clear standard, established by CMS with the opportunity for comment from stakeholders, MACs should not deny payment for IRF claims because group or concurrent therapy is included in a patient’s plan of care. Consequently, we request that you instruct the MACs to cease denying Medicare claims for IRF services when group or concurrent therapy is prescribed as a component of a patient’s plan of care.

If you have any questions regarding our concerns, please contact Carolyn Zollar, J.D., Executive Vice President for Government Relations and Policy Development (czollar@amrpa.org / 202-2231920), or Peter Thomas, J.D., Washington Counsel (Peter.Thomas@ ppsv.com / 202-466-6550).

Sincerely,

Bruce M. Gans, MD Chair, AMRPA Board of Directors Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation National Medical Director for Rehabilitation, Select Medical Cc:

Melanie Combs-Dyer George Mills Shantanu Agrawal Jeanette Kranacs Suzanne Seagrave

1 42 C.F.R. § 412.622(a)(3)(ii); Medicare Benefit Policy Manual, CMS Pub. No. 100-02, Ch. 1, § 110.2.2.

2 74 Fed. Reg. 39,762, 39,796 (Aug. 7, 2009).

3 Medicare Benefit Policy Manual (MBPM), CMS Pub. 100-2, ch. 1, § 110.2.2.

4 74 Fed. Reg. at 39,797.

5 See page 37 of transcript, available at http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/InpatientRehabFacPPS/Downloads/IRF_call_12122009.zip (emphasis added).

6 See id.

7 Documents (Series 1 through Series 4) available at https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Coverage.html.

8 Id. See also Series 2, questions 1 and 2.

9 See Presentation Material for May 31, 2012 Call, Slide 34, available at https://www. cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/Coverage.html.

10 See Miriam-Webster, https://www.merriam-webster.com/dictionary/preponderance.

11 Mackenzie E. Fama et al., Group Therapy as a Social Context for Aphasia Recovery: A Pilot, Observational Study in an Acute Rehabilitation Hospital, 23 Topics in Stroke Rehab. 4, 276 (2016).

12 Kelli D. Allen et al., Group Versus Individual Physical Therapy for Veterans With Knee Osteoarthritis: Randomized Clinical Trial, Physical Therapy, Vol. 96, No. 5, Pages 597609 (May 2016); Amy V. Wainwright, PT, MScPT et al., The Group Experience: Remodeling Outpatient Physiotherapy after Knee Replacement, Physiotherapy Canada 2015, Vol. 67, No. 4, pages 350 – 356; Caroline I. E. Renner et al., Group Therapy Task Training versus Individual Task Training During Inpatient Stroke Rehabilitation: A Randomized Controlled Trial, Clinical Rehabilitation, July 2016; 30(7): 637-648.

AMRPA Magazine February 2017

HOUSE AND SENATE 1ST SESSION 115TH CONGRESSIONAL CALENDAR: DAYS FOR STATE AND DISTRICT WORK PERIODS

Date

Note

House

Senate

January 16

Martin Luther King Jr.

X

X

February 20 - 24

Presidents’ Day

X

X

March 16-17

-

April 10 – April 21

Spring Holiday

X

X

X

May 29 – Jun 2

Memorial Day

X

X

July 3- July 7

Independence Day

X

X

July 31

Summer

X

X

September 18-22

Labor Day

X

September 21- 22

-

October 9

Columbus Day (Oct. 9)

October 10-13

Columbus Day Recess

October 16-20

Columbus Day Recess

X X

X X

X

November 10

Veteran’s Day

X

X

November 20-24

Thanksgiving Day (Nov. 23)

X

X

December 18-29

-

X

X

X = State/District Working Period

Leadership Forum and Congressional Fly-In Medical Directors Symposium Rehab Administrators Workshop: How to Manage a Successful Rehab Unit

MARCH 20-22, 2017 · WASHINGTON, DC 9

REPORT ON THE TECHNICAL EXPERT PANEL ON PAC QUALITY MEASURES

By Peter W. Thomas, Counsel, AMRPA Consumer and Clinical Affairs Committee and Denials Management Committee, Principal, Powers Pyles Sutter & Verville, PC

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n January 5th and 6th, I participated in a Technical Expert Panel (TEP) to analyze and discuss data elements across four settings of post-acute care (PAC) as required by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). The four settings are Long Term Acute Care Hospitals (LTACHs), Inpatient Rehabilitation Hospitals and Units (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs).

This was the second TEP on this topic, the first of which was held in April 2016, which I also attended. The IMPACT Act requires the Centers for Medicare and Medicaid Services (CMS) to develop, implement, and maintain standardized patient assessment data elements for PAC settings to facilitate care coordination and improve Medicare beneficiary outcomes. The IMPACT Act defines categories of standardized patient assessment data elements including functional status, cognitive function, special services, treatments and interventions, medical conditions and co-morbidities, impairments, and other categories.

Note: functional status measures are not part of this TEP’s responsibilities.

The RAND Corporation is CMS’s principal contractor on this project. RAND has been tasked with development and testing of standardized PAC assessment data elements that can meet the requirements of the IMPACT Act and contribute to care planning, quality measurement, cost estimation, better care transitions, and interoperable data exchange. RAND’s leadership team for the project is as follows:

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• Maria Edelen, PhD (RAND Health), Project Director; • Barbara Gage, PhD, (George Washington University), Project Co-Director; • Deborah Saliba, MD, MPH (RAND Health), Clinical Content Expert; and, • Susan Paddock, PhD (RAND Health), Lead Statistician.

The TEP itself was comprised of 16 individuals, mostly the same individuals who attended the first TEP, representing all four settings of postacute care. There were several TEP participants who understood inpatient rehabilitation hospital care.

The work being performed by RAND has three phases: • Phase I: (September 2015 through April 2016): Information gathering including literature reviews, technical expert panels, focus groups, and stakeholder engagement.

• Phase II: (August 2016 through June 2017): Pilot Testing in two phases: o Alpha I testing which has already occurred and was conducted between August and October of 2016 in eight facilities (two of each PAC setting in the Greater Hartford, Connecticut area). Alpha I data elements tested included: • Cognition executive function items; • Care preferences; • Medication reconciliation; • Bladder and bowel continence; • Additional vision and hearing items; and, • Pain interview assessment.

o Alpha II testing which will take place in Spring 2017 in three cities: Denver, Colorado (four facilities); Houston, Texas (four facilities); and Chicago, Illinois (eight facilities).

• Phase III: (Begins Fall of 2017): National Beta Testing.

Alpha I testing included cognitive interviews with facility staff, training of facility personnel performing the assessments, collection of data (about 120 assessments between admission and discharge, or approximately 15 assessments per PAC setting), and debrief interviews with facility staff.

Some of the data elements were easily understood and highly scored by staff, while other data elements required significant revision or even replacement with alternative data elements.

For instance, the pain data elements showed high reliability and took only 3.6 minutes on average to complete.

Therefore, the pain data elements will go straight to Beta testing. On the other hand, the medication reconciliation data elements were confusing, took a long time to administer (15.6 to 20.8 minutes to complete), and were not considered sufficiently reliable.

Alternative medication reconciliation assessment data elements are, therefore, being considered in preparation for Alpha II testing.

The purpose of the second TEP was to consider the findings of Alpha I testing and to solicit feedback in preparation for a second feasibility field test, i.e., Alpha II testing. The TEP’s objectives were to solicit stakeholder input on adAMRPA Magazine February 2017

ditional promising data elements that require feasibility testing, and need further development and consensus building.

The data elements for Alpha II testing are currently in the process of being finalized and will include: • Data elements from Alpha I that have been modified based on pilot testing; • New items to assess cognitive status and care preferences; • Additional self-report items from the PROMIS (patient reported outcomes measure set); and, • Observational assessments of depressed mood, pain, and cognitive status for individuals who are unable to communicate.

The testing protocol will mirror Alpha I testing including cognitive testing, a goal of conducting 120 observational assessments (between admission and discharge), staff training, and debriefing interviews. Results from Alpha I and Alpha II testing will be used to modify and select a subset of data elements to move forward with a national Beta test.

Providers will be randomly selected to participate in this test and data from this Beta test will provide setting-specific reliability and validity data to RAND and CMS to factor into the final data elements to be selected. The Beta test is scheduled to begin in the fall of 2017.

Overall Comments by the TEP In general, the materials compiled

by RAND were well organized and understandable. RAND staff and CMS officials seemed genuinely interested in stakeholder input in order to further refine data elements and then test them for reliability, validity, feasibility of use, utility for case mix (i.e., can the data element improve systems or be used for payment models), and, ultimately, the ability of the data element to lead to improvements in the quality of care.

At numerous times, virtually all TEP members agreed that the multiple data elements being discussed cumulatively created a significant burden on both patients and the providers responsible for administering the assessments at each level of post-acute care. The goal, as it was often stated throughout the two-day meeting, is to identify those data elements that will

most efficiently identify key factors that will drive improvements in care across all four PAC settings. The RAND and CMS teams seemed to clearly understand the importance of limiting the burden of data collection on PAC patients and providers, but whether the final set of data elements that are implemented under the IMPACT Act meet this standard may differ depending on one’s perspective.

Summary Comments of TEP Deliberations Cognitive Status: The TEP spent significant time debating alternative data elements to assess patients’ cognitive status and level of executive function. A number of data tools were discussed that sought providers’ responses to questions about individual patients such as memory, attention, problem solving, planning, organizing, and judgment. Some data collection tools divided these questions into simple problems and complex problems. Other data tools discussed the frequency at which the patient had difficulty solving problems. Still other data tools focused on memory and attention. Most TEP members favorably commented on the inclusion of data elements to measure executive function.

The TEP considered a wide range of cognitive data assessments including a “menu” test where a patient is asked to plan his or her menu for the day but must limit the selections to a certain number of total calories and total ounces of liquid. Another test involved a pill box where patients are asked to arrange all of their medications in the box for a week’s timeframe. This received particularly positive reaction because the test was both a performance-based test (as opposed to observational) and the task itself was highly relevant to the ability to return home after discharge. There were a number of “brief screeners,” which are single questions that are designed to indicate the need to pursue additional cognitive follow-up. There were separate questions to address auditory comprehension, abstract reasoning, verbal computation, thought organization, and convergent thinking.

These brief screeners were generally highly regarded by the TEP members.

Other cognitive tests focused on a

fall-related impulsive behavior scale, an overall behavior scale, and patient reported outcome measures (i.e., PROMIS) on both cognition and anxiety.

The discussion highlighted pros and cons of each of these data collection tools from different perspectives across the PAC continuum. Portions of these measure sets were also discussed to limit the burden on providers of administering these tools and the burden on patients of answering the questions. RAND and CMS will now factor these discussions into their additional planning.

Behavioral Signs and Symptoms: The data tool for this discussion asked questions about the existence of behavioral signs or symptoms that impacted the health, safety, or care provided to the patient or others. A separate data element focused on the presence and frequency of the rejection of care. The TEP members offered mixed reactions to the measurement tools presented but noted the importance of assessing behavioral factors that impact patients and others. The inquiry on rejection of care received particularly favorable responses from the TEP. Assessment of Patients who are Noncommunicative: The TEP considered separate data elements on cognition, mood, and pain for patients who are unable to communicate. This is a staff assessment of mental status based on observation. It received significant discussion and, for patients who cannot otherwise communicate, the measure set was viewed generally favorably with several mentions of concern about provider burden in completing the assessments themselves.

Medication Reconciliation: Alpha I testing of the medication reconciliation data elements revealed several problems including confusion in administration and extensive time spent gathering data to answer the data elements. Thus, the TEP devoted a significant amount of time to discussing alternative methods of performing medication reconciliation in each of the PAC settings. The data elements being considered are heavily process-oriented and encompass a wide range of questions to ensure that available lists of medications are compiled for each patient, indications are obtained 11

and assessed, and then medications are reconciled. The emphasis is clearly on high-risk discrepancies (i.e., medications in the following categories): • • • • • • •

anti-coagulants; anti-platelets; anti-diabetics (for example, insulin); opioids; anti-psychotics; anti-microbials; and, other medications listed in the Beers Criteria for patients 65 years of age or older.

Once reconciled, the data elements probe to ensure that new instructions for medications have been fully communicated to the patient, the patient’s family, throughout the PAC setting, and back to primary care providers, pharmacies, and other relevant providers.

There was strong support for the inclusion of data elements that address medication reconciliation. Comments from the TEP indicated that despite the time-consuming nature of medication reconciliation that is performed well, it is critically important to patient health, safety, and quality at each level of post-acute care. This exercise appeared very burdensome on providers, but the clinicians on the TEP insisted that this was among the most effective ways to improve quality of care in the PAC beneficiary population, especially in the elderly and chronic illness population.

Care Preferences: The care preferences data elements focused on two main areas, whether there were decision aides in the medical records, such as advance directives, and whether the care preferences of the patient undergoing treatment were being identified and respected. On the former point, the data elements focused on the existence of advance directives, Do Not Resuscitate (DNR) orders, Do Not Intubate (DNI) orders, and Do Not Hospitalize (DNH) orders being present in the medical record. The data element also asked about the existence of health care “proxies,” who are persons designated to make decisions if the patient is incapacitated. While the TEP members generally recognized the importance of this line of inquiry, many were more interested in data elements that focused

12

on patients who were fully capable of expressing their own care preferences.

A number of these data elements involved questions that asked patients about tradeoffs between quality and quality of life. For instance, “The most important thing to me is living as long as I can, no matter what my quality of life is.” Other data elements addressed tradeoffs between future and present health status. For instance, “I am willing to have side effects right now if it means I could have a better quality of life in the future.” These types of questions are designed to help providers determine care preferences of individual patients.

There were many different versions of these data elements considered by the TEP. Many TEP members agreed with the importance of this line of data collection but warned of excessive provider and patient burden considering the length of the data elements we examined.

The care preferences discussion also stimulated a discussion about the meaning of “quality of life” and how one may change their view of quality of life over the course of one’s treatment, or one’s lifetime. I stressed the importance of ensuring that all data elements used to assess care preferences do not presume what quality of life means for people with disabilities and that concept appeared to be widely supported.

Special Services, Treatments, and Interventions: This set of data elements recognizes that PAC patients have a variety of medical conditions that require specialized services and complex clinical care. Documenting each PAC patient’s special services is important for a variety of reasons, including care planning, clinical decision support, and ensuring care coordination. It also helps providers determine resource use. The goal of this data element is to efficiently assess key special services and treatments with enough detail to capture the complexity of the patient’s clinical picture and to minimize additional time burden for providers.

After initial discussions in the first TEP, and consideration of public comments, the final list of special services and treatments is as follows, subject to additional Beta testing:

Cancer Treatment: • IV Chemotherapy; and, • Radiation.

Respiratory Treatments: • Invasive Mechanical Ventilator (weaning or non-weaning); • CIPAP/CPAP; • Oxygen (Intermittent or Continuous); • Suctioning; and, • Tracheostomy Care.

Nutritional Approaches: • Total Parenteral Nutrition (TPN); and, • Enteral Nutrition.

Other: • Hemodialysis; • Vasoactive Medications; and, • Central Line Management.

The TEP generally agreed with this list of special services and treatments. There was support for adding peritoneal dialysis to the list. In addition, the TEP discussed adding oral cancer medications to the list but it quickly became clear that it would complicate the data element and would require more than a simple box to check. The TEP generally viewed the data element as easy to complete—by simply checking a box for all conditions that apply to each patient—while denoting important information that each PAC setting should know.

Health-Related Quality of Life Profile Score: The final set of data elements considered by the TEP involved the creation of a composite score for each patient’s health-related quality of life (HRQOL).

This is a measure of the degree to which a medical condition or its treatment affects an individual’s life.

It takes into account multiple aspects of a patient’s well-being, including physical and occupational function, psychological state, social interaction, and perception of symptoms. RAND and CMS believe that assessing a patient’s HRQOL is important because it helps clinicians better monitor symptoms and treatment effectiveness, facilitates physician-patient communication and patient engagement, and predicts mortality and hospitalization.

RAND believes this is most effectively assessed through patient reported outcomes (PROs).

AMRPA Magazine February 2017

RAND proposes to customize a HRQOL for the PAC patient population by using a subset of the Patient-Reported Outcomes Measurement Information System (PROMIS) measures developed

by National Institutes of Health. These measures have been validated and provide reliable measures related to physical, mental, and social well-being.

To assess the overall HRQOL of PAC patients, RAND proposes to include items from eight of the major PROMIS domains, including: • • • • • • • •

Depression; Anxiety; Physical Function; Pain Interference; Pain Intensity; Fatigue; Sleep Disturbance; and, Ability to Participate in Social Roles and Activities.

Since this is developmental work, RAND is seeking input from a wide range of stakeholders to identify specific data elements in each of these categories.

A subset of items will be selected and undergo cognitive interviewing prior to Beta testing. Results from Beta testing will be analyzed to identify a small subset of items (1 to 3 items per domain) for potential standardization. Given the fact that there are 130 items in the PROMIS Physical Function item bank, 95 items in the PROMIS Fatigue item bank, and similar numbers of items in other domains, the selection of a small number of sentinel items to create a reliable composite quality of life measure for PAC patients is a difficult task.

stressed the importance of identifying reliable data elements that will form the basis of the composite measures. Most TEP members agreed that the PROMIS measure set was a good starting point for this work. RAND cautioned that its work on this composite measure was still in the formative stages.

It is not clear whether there will be another meeting of this particular Technical Expert Panel. As already noted, the next steps include Alpha II testing and then a national Beta test of these and related measures. Again, the functional status measures under the IMPACT Act are not part of this TEP’s responsibilities. CMS has other contractors working on those measurement tools.

The TEP members offered mixed reviews of this proposal, with several TEP members warning about the potential lack of reliability of composite measures. Others

CHICAGO

15TH ANNUAL AMRPA EDUCATIONAL CONFERENCE & EXPO

OCTOBER 23-25, 2017 • SWISSÔTEL

SAVE THE DATE 13

OIG SLAMS REHABILITATION HOSPITALS FOR UNSUITABLE PATIENTS AS FOLLOW-UP TO PRIOR STUDY

By Carolyn C. Zollar, MA, JD, Executive Vice President of Government Relations and Policy Development, AMRPA

T

he Department of Health and Human Services’ (DHHS) Office of the Inspector General (OIG) put coal in every rehabilitation provider’s stocking in late December when it issued its latest study of freestanding rehabilitation hospitals, titled “Case Review of Inpatient Rehabilitation Hospitals Not Suited for Intensive Therapy.” This is a follow-up to the OIG’s study “Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries” issued last summer. The OIG said it did this review because in the initial study, “physician reviewers found a small number of hospital stays in which the patients appeared to be unsuited for intensive therapy”. The data used in this study were however very limited, this second review was conducted by two out of the three original physicians.

The data analyzed was taken from a March 2012 sample of patients admitted to freestanding rehabilitation hospitals.

In the original study, 426 stays were reviewed. The three physician reviewers identified 39 stays in which the patients were unable to actively participate in and benefit significantly from intensive therapy. They identified the factors that contributed to the patients’ inability to participate; they defined a stay as three days and an extended stay as lasting longer than three days. It appears they define a three-day stay as the maximum time appropriate for patients who are unable to participate, as opposed to the appropriate overall rehabilitation length of stay (LOS). Under the Inpatient Rehabilitation Facility Prospective Payment System (IRF14

PPS) three days is the short stay case mix group (CMG) for cases that were inappropriately admitted.

However, the OIG concluded that most of the patients (32 of 39) in question remained in the rehabilitation hospitals for “extended periods of time”. The average length of stay (ALOS) in the inpatient rehabilitation hospitals for these 32 patients was 15 days, with a range from five days to 24 days. According to the OIG, patients who were not suited for therapy had certain physical limitations and lacked endurance fell into four categories: • Pre-existing physical limitations For 30 of the 39 stays, physical limitations restricted the patients’ ability to participate in therapy. These physical limitations included pre-existing functional disabilities, limited mobility, and inability to carry out activities of daily living (ADLs). Patients with physical limitations also had comorbidities such as cerebral palsy, degenerative joint disease, and morbid obesity.

• Lack of endurance - For 27 of the 39 stays, inadequate physical endurance limited the patients’ ability to participate in intensive therapy.

• Unresolved health problems - For 21 of the 39 stays, unresolved health problems limited the patients’ ability to participate in therapy. Medical records for these patients described problems such as inadequate recovery from a prior illness or surgery; uncontrolled pain; debilitation from cancer; and pressure ulcers. For example, one patient had not adequately recovered from numerous cardiac issues (including arrhythmia,

mitral insufficiency, and congestive heart failure) to fully participate in therapy at the time of admission to an inpatient rehabilitation hospital.

In another instance, a patient had uncontrolled pain from a chronic pain disorder (reflex sympathetic dystrophy syndrome), compounded by experimental chemotherapy to treat metastatic colon cancer.

• Altered mental status - For 18 of the 39 stays, altered mental status limited the patients’ ability to participate in therapy. Medical records for the patients in this category described cognitive problems such as delirium and dementia. For example, one patient was difficult to rouse and was unable to remain alert during therapy due to significant delirium. Another patient had severe dementia and was unable to follow commands during therapy.

The OIG found that some of the patients (seven of 39) who were unsuited for intensive therapy were in very poor condition and died within weeks of being admitted to an inpatient rehabilitation hospital. All seven patients were unable to participate in therapy and were kept in inpatient rehabilitation hospitals for longer than three days. One of the patients was recovering from a stroke and had multiple comorbidities, including complications of paralysis of one side of the body, pneumonia, and a Stage II pressure ulcer. Upon arrival at the inpatient rehabilitation hospital, the patient was too lethargic to provide a history and was unable to follow commands. Despite being unable to participate in therapy, the patient spent 11 days at the inpatient rehabilitation hospital before being discharged to hospice, dying there 8 days AMRPA Magazine February 2017

later. In another case, a patient was admitted to an inpatient rehabilitation hospital while undergoing palliative chemotherapy for advanced metastatic cancer. The patient was significantly fatigued and sedated from narcotics given for pain. The patient was discharged after 13 days in the inpatient rehabilitation hospital and died four days later.

The OIG concluded that the Center for Medicare and Medicaid Services (CMS) should consider providing additional technical assistance to ensure that Medicare patients are placed in the most appropriate setting for post-acute care, and that inpatient rehabilitation hospitals do not admit patients who are unable to participate in and benefit from intensive therapy.

their endurance “making them better candidates for an alternative setting such as a Skilled Nursing Facility (SNF).” The report makes such comparisons to SNFs at least twice. The report states that different types of post-acute care providers treat patients with similar conditions. It also states that Medicare pays 40 to 50 percent more for patients recovering from strokes and hip replacements in hospital-based units and inpatient rehabilitation hospitals than it does for those in SNFs. In FY 2012, SNFs received an average reimbursement of $12,000 per admission, compared to $17,000 for inpatient rehabilitation hospitals”. The data was taken from the March 2014 Medicare Payment Advisory Commission (MedPAC) Report to Congress and OIG’s own calculations for the original report issued in the summer of 2016.

Furthermore, and quite chilling, is that the OIG is conducting a national audit to assess the proportion of inpatient rehabilitation stays that do not comply with all Medicare coverage and documentation criteria, including both rehabilitation hospitals and units. The report alludes to the fact that the intensive therapy given to many rehabilitation patients is beyond

What is worrisome for the rehabilitation community is the failure to look at the larger picture and the lack of familiarity and understanding of rehabilitation. The sample of cases -39- is approximately 9 percent of the 426 cases. The data used in the study were very limited; in looking at eRehabData®, the short stay cases to which the report alludes were only 1.08 percent of

cases in CY 2012; deaths were 0.18 percent.

For example, Medicare allows patients who are not able to tolerate three hours of therapy, five days a week but otherwise fit other admission criteria, to receive 15 hours of therapy of over seven days. There is no mention of whether this was applied to any of the patients not tolerating or benefiting from the three hours of therapy. When the initial study was published AMRPA welcomed any studies that shine a light on opportunities to improve health care delivery. AMRPA has focused on quality and safety for many years, through a wide range of initiatives and programs. In reviewing these OIG studies, it is also important to note that significant changes have occurred in rehabilitation hospitals to advance quality, prevent hospital readmissions, reduce medical errors, and improve safety since the limited study period in 2012, including the implementation of a Medicare Inpatient Rehabilitation Facility Quality Reporting Program (IRF- QRP) revised Joint Commission standards, and other quality and operational initiatives generally designed to instill a culture of safety.

JOIN TODAY!

EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE AMRPA: Working Together To Preserve Access To Medical Rehabilitation Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org

15

CMS TRANSMITTALS OF INTEREST FOR MEDICAL REHABILITATION PROVIDERS

February 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 # R3692CP R166DEMO R1774OTN R280FM R1767OTN R165DEMO R3689CP

Issue Date

Subject

Implementation Date

2017-01-13

April 2017 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

2017-04-03

2017-01-13

Affordable Care Act Bundled Payments for Care Improvement Initiative - Recurring File Updates Models 2 and 4 April 2017 Updates

2017-04-03

2017-01-12

Shared System Enhancement 2014 – Identification of Fiscal Intermediary Standard System (FISS) Obsolete Reports - Analysis Only

N/A

2017-01-11

Notice of New Interest Rate for Medicare Overpayments and Underpayments -2nd Qtr Notification for FY 2017

2017-01-19

2017-01-06

Health Insurance Portability and Accountability Act (HIPAA) Electronic Data Interchange (EDI) Front End Updates for July 2017

2017-07-03

2017-01-06

Shared System Enhancement 2015: Archive/Remove Inactive Medicare Demonstration Projects - Common Working File Analysis Only

2017-07-01

2017-01-05

2017 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List

2017-01-24

Revised Centers for Medicare & Medicaid Services (CMS) 855S Application – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

SE17004 R693PI R3684CP R1765OTN R232BP R3685CP R691PI R473P122 R3678CP R1763OTN

2016-12-30

Clarification of Appeal Rights for Denials Stemming from Statutory Requirements

2017-01-31

2016-12-22

2017 Durable Medical Equipment Prosthetics, Orthotics, and Supplies Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List

2017-01-24

2016-12-22

SSNRI: MAC-Only Analysis and Planning for the Social Security Number Removal Initiative (SSNRI) Project

2017-02-24

2016-12-22

January 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)

2017-01-03

2016-12-22

January 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)

2017-01-03

2016-12-16

Contacting Non-Responders and Documentation Requests

2017-01-19

2016-12-16

Provider Reimbursement Manual - Part 1, Chapter 22, Determination of Cost of Services to Beneficiaries

N/A

2016-12-16

Prolonged Services Without Direct Face-to-Face Patient Contact Separately Payable Under the Physician Fee Schedule (Manual Update)

2017-01-03

2016-12-16

Shared Savings Program (SSP) Accountable Care Organization (ACO) Qualifying Stay Edits

2017-01-03

2016-12-14

Revisions to State Operations Manual (SOM) Appendix W - Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) and Swing-Beds in CAHs

2016-12-16

2017 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder

2017-01-03

R165SOMA R3675CP

2016-12-13

Updated as of January 13, 2017

16

AMRPA Magazine February 2017

AMRPA RESPONDS TO MEDPAC’S CHAIRMAN DRAFT RECOMMENDATION OF FIVE PERCENT REDUCTION FOR IRFS Editor’s Note: On January 12, 2017, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Medicare Payment Advisory Commission (MedPAC) urging the rejection of MedPAC’s Chairman draft recommendation of a five percent reduction in Medicare payments for inpatient rehabilitation hospitals and units (IRFs). The letter outlines the grossly negative impact that these recommendations may have on inpatient rehabilitation providers and the patients they serve. The complete letter is below and will be available on our website at www.amrpa.org.

In addition, this February issue of the magazine also includes a summary article on MedPAC’s January 12 public meeting to vote on fiscal year (FY) 2018 Medicare payment recommendations for inclusion in its March 2017 Report to Congress.

January 12, 2017 Francis J. Crosson, MD, Chairman Medicare Payment Advisory Commission 425 Eye Street, NW Suite 701 Washington, DC 20001 Re: American Medical Rehabilitation Providers Association’s Comments on Chairman’s Draft Recommendation for Inpatient Rehabilitation Facilities Dear Chairman Crosson and MedPAC Commissioners: This letter is submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) to provide our comments on the Chairman’s draft recommendation relating to Medicare payments for inpatient rehabilitation hospitals and units (IRFs) and specifically to urge its rejection.

AMRPA is the national voluntary trade association representing more than 500 freestanding rehabilitation hospitals, rehabilitation units of general hospitals, and outpatient rehabilitation service providers. Our members provide medical rehabilitation services in a vast array of health care settings working with patients to maximize their health, functional skills, independence, and participation in society so they are able to live as independently as possible by returning home, returning to work or, in many instances, pursuing an active retirement.

On average Medicare Part A payments represent more than 60 percent of IRFs’ revenues.1 The Commission’s findings indicate that Medicare margins among inpatient rehabilitation providers remain adequate.

Scratching below the surface, however, the aggregate margin is not indicative of the range of margins among IRFs. In actuality, MedPAC’s analysis reveals that most IRFs do not have sig-

nificant margins. The vast majority of IRFs are hospital-based rehabilitation units (78 percent) with aggregate margins of 2 percent. A substantial majority of IRFs are also nonprofit (57 percent) with aggregate margins of 3.6 percent.

The Chairman’s draft recommendation of a 5 percent reduction to the IRF Prospective Payment System (IRF PPS) base rate runs the risk of severe adverse effects for a number of providers and their patients. A cut of this magnitude would result in sharply negative average margins for many segments of the IRF sector, including hospital-based units, which represent four out of every five IRFs. Based on MedPAC’s data, this suggests that half of those units would have margins of less than negative 3 percent per case. This lack of profitability is not sustainable and would likely lead to rehabilitation unit closures as well as further market consolidation, thereby compromising patients’ access to care.

In addition to the Medicare data relied on by the Commission, the IRF PPS 2017 rate setting files reveal additional pertinent findings about the adequacy of Medicare payments to IRFs. Our analysis found that in FY 2015: • 473 IRFs, or 42 percent of IRFs with available data, had negative Medicare margins (below 0 percent); • 50 percent of IRFs had margins below 5.0 percent; • 58 percent of rural IRFs had margins below 5.0 percent; • 65 percent of IRFs had margins below 13.9 percent, MedPAC’s aggregate Medicare margin for all IRFs in FY 2015; and • The median margin for all IRFs was 4.9 percent.2 In analyzing payment versus cost as a definition of margins, it is clear that a 5 percent payment cut would have dramatic consequences for the majority of IRFs. Given that the median margin for IRFs is 4.9 percent, an aggregate 5 percent cut to the payment system is unduly harmful to more vulnerable providers due to the wide variations in margins at the individual provider level.

The root causes of variability in Medicare margins among IRFs are not well understood. Surely, economies of scale and other cost efficiencies contribute to the disparity given the lower margins of units, which typically have fewer patients and lower occupancy rates. Nonprofit IRFs tend to have narrower margins irrespective of size, which MedPAC staff has inferred for several years is attributable to relatively less focus on cost control. There may also be poorly understood links between cost ratios and staffing, patient mix, and the use of different therapy modalities. Based on the literature we have seen, we do not believe there is evidence that differentials in patient coding (i.e., upcoding) meaningfully contributes to the variability. Still, 17

AMRPA shares MedPAC’s desire to better understand the factors underlying the significant variation in Medicare margins. While we appreciate the Commission’s concerns, we know that a 5 percent reduction is not the solution and, to the contrary, is likely to further exacerbate underlying financial disparities and hence potentially patient access.

Additionally, AMRPA does not believe that expanding the outlier pool is the solution to margin variability or otherwise adequate to offset the tremendous harm that a 5 percent reduction would inflict. We note CMS has determined that the current level of outlier payments at 3 percent is most appropriate. There may be multiple reasons for outlier cases: complex patents known at admission, patients who developed unforeseen costly problems, higher cost structures and other factors. All of these factors suggest that expanding the outlier pool would not be an appropriate response to the intended objective of adequately compensating for the treatment of highly complex patients and avoiding financial disincentives to care for them. As we have previously cautioned, outlier payments are not a general policy that should be used to arbitrarily redistribute funds within the IRF sector, nor could they be reliably employed in this way.

As MedPAC is aware, the outlier payment policy is a budgetneutral program, such that increasing total outlier payments would further decrease the PPS base rate in addition to the reduction the Commission is considering. Moreover, given the prospective nature of the outlier payment methodology, outlier payments have consistently resulted in a net loss that has taken money out of the IRF PPS system in recent years. This is certainly the case for individual IRFs that, despite their high costs, have fewer than average outlier cases. For these reasons, expanding the amount of the outlier pool further risks reducing reimbursement for those IRFs that can ill-afford it. While AMRPA is more than willing to discuss with CMS and MedPAC potential ways to improve the effectiveness of the outlier pool policy in its own right, we simply do not feel this is a viable approach to mitigate the harm of an excessive payment reduction.

It is apparent to AMRPA from the discussion at recent MedPAC meetings that most Commissioners recognize the important and unique role of inpatient rehabilitation providers in the post-acute continuum of care. A number of important observations were offered during the December meeting, including concerns about the blunt impact of using the market basket update to address Medicare margins, which range from ample to inadequate.

Therefore, AMRPA is disappointed that the Commissioners would consider supporting a recommendation that is likely to jeopardize the financial wellbeing and viability of so many providers in the inpatient rehabilitation sector. MedPAC’s prior recommendation regarding medical review is another option.

isn’t room for improvement in both IRF quality and Medicare payment policies, AMRPA believes the focus should be on sound reforms to modernize the program and link it to quality rather than the blunt instrument of an across-the-board cut that has no nexus to improving quality. For example, we believe that there are a range of alternative payment models, such as the Continuing Care Hospital (CCH) model required by law, that have the potential to both enhance quality and efficiency, and thereby reduce cost. In addition, AMRPA would be happy to meet with MedPAC staff to discuss and understand the true scope of Medicare margins, the apparent variability therein and ways by which to examine potential contributing factors.

AMRPA Recommendation: For all of the foregoing reasons, we recommend that the Commissioners reject the Chairman’s draft recommendation and not propose a 5 percent reduction to IRF payments.

Once again, AMRPA appreciates the opportunity to provide the Commissioners with our comments on the important work you do. We welcome the opportunity to provide additional input throughout the process and to clarify any comments in this letter. If you have questions, please do not hesitate to contact Carolyn Zollar, AMRPA’s Executive Vice President of Government Relations and Policy Development at (202) 223-1920 or czollar@ amrpa.org, or Martha Kendrick, AMRPA’s Washington Counsel at (202) 887-4215 or mkendrick@akingump.com.

Sincerely,

Bruce M. Gans, MD Chair, AMRPA Board of Directors Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation National Medical Director for Rehabilitation, Select Medical cc:

Mark Miller, Ph.D., Executive Director

MEDPAC, REPORT TO CONGRESS 240 (Mar. 2015).

This data is derived from AMPRA’s analysis of CMS Final Rule Inpatient Rehabilitation Facility Prospective Payment System rate setting files for FY 2017

1 2

As the data in MedPAC’s report consistently make clear, IRFs are not part of the problem of unsustainable Medicare spending or even the growth in post-acute care. The total number of discharges as a function of the Medicare population has remained flat for many years and is lower than a decade ago.

At the same time that patient cases and spending have held steady, the quality of inpatient rehabilitation care has continually improved. While these trends are not meant to suggest that there 18

AMRPA Magazine February 2017

COMMONWEALTH REPORT EXAMINES HIGH-NEED PATIENT EXPERIENCES; FOCUSES ON IMPROVING OUTCOMES AND LOWERING COSTS OF CARE

A

study “How High-Need Patients Experience Health Care in the United States” published by the Commonwealth Fund found that many patients with high needs —those having two or more major chronic conditions such as diabetes or heart failure—also have unmet social needs that may worsen their medical conditions and that the health care system is failing to meet the complex needs of these patients.

These patients are being treated in many inpatient rehabilitation hospitals and units (IRH/Us), and continuing to shed light on their needs will lead to better informed choices for patients and providers.

Patients with complex needs are a diverse group, including older adults, people with major complex chronic conditions, and younger people with disabilities. Since many are older than 65, experts say addressing this issue will become more urgent as America’s population ages. Researchers have estimated that although these patients represent just 5 percent of the population, they account for 50 percent of U.S. health care spending.

Study Methods The study sampled 3,009 U.S. adults, including 1,805 high-need adults and 1,204 other adults without high needs, to investigate how the challenges faced by this patient population affect their experiences with the health care system and where there might be opportunities for improvement.

This article highlights findings from the study.

Findings • Many High-Need Patients Report Social Isolation and Other Unmet Social Needs The study found that this group is more likely to report experiencing emotional distress that was difficult to cope with on their own in the past two years than the general population. Approximately four of 10 (37 percent) high-need respondents reported often feeling socially isolated, including lacking companionship, feeling left out, or feeling lonely or isolated from others, compared with 15 percent of other adults. Almost two-thirds (62 percent) of high-need respondents report stress or worry about material hardships, such as being unable to pay for housing, utilities, or meals, compared to only one-third of other adults (32 percent). In addition, six of 10 (59 percent) high-need adults report being somewhat or very concerned about being a burden to family or friends.

• Nearly Half of High-Need Patients Delay Care and Report Access Problems More than two-fifths (44 percent) reported delaying care in the past year because of an access problem such as lack of transportation to the doctor’s office, limited office hours, or an inability to get an appointment quickly enough. Nearly one-quarter (22 percent) of highneed respondents specifically reported a lack of transportation as a reason for delaying care, compared with only 4 percent of other adults.

Three of 10 (29 percent) high-need respondents reported delaying care specifically as a result of not being able to get an appointment soon enough with their regular provider.

Study Finds: •

Examining the unique challenges and needs of high-need patients helps to identify and develop innovative interventions to meet their needs.

In particular, high-need respondents report difficulty in being able to get after-hours medical care on weekends, evenings, or holidays. Only one-third (35 percent) of high-need respondents reported that it was somewhat or very easy to get medical care after-hours without going to the emergency room, compared with more than half (53 percent) of other adults.

• Less Than Half of High-Need Adults Receive Assistance in Managing Conditions High-need patients are somewhat less likely than others to report receiving care that is accessible, efficient, and high quality. They are also unlikely to have convenient and timely access to key services or supports that can help them manage their conditions outside hospitals or ED. 1. Half of high-need respondents reported experiencing emotional distress that they found difficult to cope with alone. Of these, fewer than four of 10 (39 percent) could get counseling as soon as they wanted.

2. Of the 53 percent of high-need respondents who reported seeing multiple doctors or using multiple health care services in the past year, less than half (43 percent) reported having an informed and up-to-date care coordinator.

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3. Of the 57 percent of high-need respondents who have trouble with activities of daily living, fewer than four of 10 (38 percent) usually or always have someone to help them.

Among respondents who received help, about three-quarters said it came from family members or relatives.

• Good Patient–Provider Communication Is Critical for High-Need Population More high-need patients (60 percent) than other adults (52 percent) have doctors or providers who fully engage in patient-centered communication.

However, high-need adults are less likely to report that their providers specifically involve them in treatment decisions (82 percent of high-need adults versus 90 percent of others) or listen carefully to them (85 percent of high-need adults versus 91 percent of others).

• With Good Access and Communication, High-Need Patients Are Less Likely to Delay Care and Visit the ED For high-need patients, having accessible after-hours care, being able to get a same-day answer to a medical question, and having a good relationship with their regular health care provider through patient-centered communication are associated with lower rates of nonurgent ED visits for conditions that could have been handled by a regular doctor if one had been available.

Additionally, having accessible afterhours care is associated with less frequent total ED use (both urgent and non-urgent) among high-need patients In addition, for high-need adults, having good communication with their regular provider and good access to care are associated with lower rates of delaying care because of the following reasons: not having transportation, the office not being open when the patient could get there, and not being able to get an appointment soon enough. Being able to access care and information in a timely manner are also associated with decreased emotional distress among high-need adults.

The report concluded by stating that examining the unique challenges and needs of high-need patients helps 20

to identify and develop innovative interventions to meet their needs. The report recommended three ways to do so: 1. Understanding patients’ social and behavioral needs in addition to their medical conditions For health systems, payers, and programs to improve outcomes for high-need adults, providers must consider multiple factors— individuals may have multiple chronic diseases, functional limitations, behavioral health conditions, and material hardships.

To help people who most need resources, the interventions must be more comprehensive and creative than just a standard set of doctor visits.

Health care providers should build relationships and collaborate with social service agencies, communitybased organizations, and behavioral health providers to deliver better outcomes and avoid high-cost care for this population.

2. Ensuring patients obtain much-needed assistance to manage their health Although high-need adults report they are more likely to have—and enjoy good communication with—a regular doctor or place of care, these patients do not receive the services and supports they need. In particular, high-need patients report limited access to known effective supports and services, such as transportation services, emotional counseling, assistance in managing functional limitations, and care coordinators.

Of patients who have high needs and functional limitations, as well as financial stress, those who had an informed care coordinator or had patient-centered communication with their provider were less likely to use the ED for a non-urgent condition.

3. Improving outcomes while potentially lowering costs of care The researchers suggest two key strategies for improving patient care while potentially curbing costs — increasing patient-centered communication and enabling easier access to appropriate care and information, both of which would support patients in managing their conditions. Having timely access to

care—by phone, or in person after hours—and good provider–patient communication could potentially reduce non-urgent ED visits and help patients avoid delays in needed care.

Increasing the health care system’s responsiveness to patients in this way could help avoid unnecessary care that leads to higher health care costs.

Previous studies by The Commonwealth Fund that have examined this population’s demographics and their high use of health care services are available at http://www. commonwealthfund.org/topics/currentissues/high-need-high-cost-patients.

New Online Resource On December 9, five national health care foundations—the John A. Hartford Foundation, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation, The SCAN Foundation, and The Commonwealth Fund—launched a new online resource “The Playbook: Better Care for People with Complex Needs” to help improve care for patients with complex medical and social needs.

The Playbook was developed by experts at the Institute for Healthcare Improvement in order to compile and share promising approaches and offers insights about patients with complex needs, examples of successful approaches to care, guidance on making the business case for these models, and opportunities for policy and payment reform. The Playbook website is available at http://www. bettercareplaybook.org/ Study Authors: Jamie Ryan, Melinda K. Abrams, Michelle M. Doty, Tanya Shah, Eric C. Schneider, MD For the complete report please see: How High-Need Patients Experience Health Care in the United States: Findings from the 2016 Commonwealth Fund Survey of High-Need Patients, The Commonwealth Fund, December 2016.

AMRPA Magazine February 2017

EFFORTS TO REDUCE HOSPITALACQUIRED CONDITIONS SHOWS IMPROVEMENT WITH 21 PERCENT DECLINE, REPORT SAYS

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atest research from the Agency for Healthcare Research and Quality (AHRQ) shows that nearly 125,000 fewer patients died in hospitals as a result of hospital-acquired conditions (HACs), and that approximately $28 billion in health care costs were saved from 2010 to 2015 due to the reductions in HACs. The report is entitled: “National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer.”

Hospital acquired conditions include adverse drug events, catheterassociated urinary tract infections (CAUTIs), central line associated bloodstream infections (CLABI), pressure ulcers (PUs) and surgical site infections (SCIs), among others.

Many inpatient rehabilitation hospitals and units (IRH/Us) treat patients with these conditions and are subject to penalties under the Inpatient Rehabilitation Facility-Quality Reporting Program (IRF-QRP).

The preliminary estimates for 2015: • The 2015 national HAC incidence rate is nearly 21 percent lower than in 2010, resulting in 980,000 fewer incidents of harm occurred in 2015 than would have occurred if the rate of HACs had remained steady at the 2010 level.

• Approximately 3.1 million fewer incidents of harm occurred in 2011, 2012, 2013, 2014, and 2015 (compared with 2010). About 42 percent of this reduction is from adverse drug events, 23 percent from pressure ulcers, and 15 percent from CAUTIs. These HACs constituted about 34

percent, 27 percent, and 8 percent, respectively, of the HACs measured in the 2010 baseline rate.

• Approximately 37,000 fewer patients died in hospitals in 2015 as a result of the decline in HACs compared with the number of deaths related to HACs that would have occurred if the rate of HACs had remained steady at the 2010 level.

• The decline in HACs resulted in estimated cost savings of approximately $8.3 billion in 2015.

Estimated cumulative savings for 2011, 2012, 2013, 2014, and 2015 are approximately $28.2 billion.

The report states that these data indicate that hospitals have made substantial progress in improving safety.

While the reasons for this progress are not comprehensively understood, possible contributing causes include: • Financial incentives created by the Centers for Medicare & Medicaid Services (CMS) and other payers’ payment policies; • Public reporting of hospital-level results; • Technical assistance offered to hospitals by the Quality Improvement Organization (QIO) program; and • Technical assistance and catalytic efforts of the U.S. Department of Health and Human Services (HHS) Partnership for Patients (PfP) initiative.

Many other public and private initiatives to improve health care quality and patient safety have also been implemented since 2010, such as the widespread use of electronic health records (EHRs).

More Work Remains Despite this progress, AHRQ states

Report Highlights: •

•

•

Hospital-acquired conditions declined by 21 percent since 2010.

Nearly 125,000 fewer patients died in the hospital as a result of the reduction in HACs. Approximately $28 billion in health care costs were saved from 2010 to 2015.

that much work remains to be done and public and private partners are continuing to work to improve patient safety. The data through 2015 indicate that it is possible to make substantial progress in reducing virtually all types of HACs simultaneously. CMS and HHS leaders have termed this objective as achieving “Safety Across the Board” and believe it should be a national goal.

AHRQ has developed a variety of methods, tools, and resources to help hospitals and other providers prevent HACs, and has expanded its efforts to extend the success that acute care hospitals have achieved to all health care settings. As part of this initiative, AHRQ is targeting current challenges such as diagnostic error and antibiotic resistance and developing and disseminating evidence-based practices that will sustain national progress in making health care safer.

For the complete report please see: National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/ quality-patient-safety/pfp/2015-interim.html 21

• Fighting Restrictive Medicare Policies • Challenging Aggressive Contractors • Ensuring Access and Quality of Life for Seniors

We Are the Fund for Access to Inpatient Rehabilitation, a Common Legal Defense Fund Composed of America’s Top Inpatient Rehabilitation Hospitals and Units.

AMRPA Magazine February 2017 For22more information, please contact Deb Curington at dcurington@firminc.com or at (217) 753-1190

MEDPAC FINALIZES FY 2018 PAYMENT RECOMMENDATIONS FOR POST-ACUTE CARE PROVIDERS AND UPDATES PAC PAYMENT PROTOTYPE RESEARCH

By Mimi Zhang, Policy and Research Associate

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n January 12, the Medicare Payment Advisory Commission (MedPAC) held public meetings to vote on fiscal year (FY) 2018 Medicare payment recommendations for inclusion in its March 2017 Report to Congress. As expected, the Commission finalized its draft recommendation to reduce inpatient rehabilitation facility prospective payment system (IRF- PPS) payments by 5 percent for FY 2018. There were no additional IRF recommendations.

In advance of the meeting, AMRPA submitted a letter to MedPAC to provide comments on the recommendation and specifically to urge its rejection. The letter is reprinted in this edition of the AMRPA magazine.

The Commissioners held an expedited vote for all the PAC payment updates and did not hold question-and-answer periods following the staff presentations for those sessions. MedPAC staff also updated the Commission on their continuing work on a post-acute care prospective payment system (PAC PPS) as mandated by the Improving Post-Acute Care Transformation (IMPACT) Act of 2014.

This article covers the following sessions: I. Inpatient rehabilitation facility PPS recommendations (expedited review); II. Payment updates for other PAC providers (expedited reviews); and III. Updates on developing a unified PAC PPS.

pitals and units (IRH/Us) treated 381,000 fee-for-service (FFS) beneficiaries with an estimated Medicare spending of $7.4 billion. Discharges grew by 1.7 percent after remaining stable for several years. Access to capital remained adequate for many facilities, with hospital-based units having access through their parent institutions.

The 2015 Medicare aggregate margin for all IRH/Us was 13.9 percent and the marginal profit (stated to represent a provider’s incentive to admit one additional beneficiary) was 30.7 percent. MedPAC notes that IRH/U margins increased by 1.5 percent in 2015 and is predicted to grow, though at a slower pace. The 2017 aggregate margin is projected to be 14.3 percent.

According to MedPAC staff, payments to IRH/Us now “substantially exceed” the costs of caring for beneficiaries. Between 2009 and 2015, the cumulative growth in cost per case was 8.3 percent while the cumulative growth in payment per case was 14.2 percent based on their analysis.

The staff also reminded Commissioners that they have recommended zero payment updates for the IRF PPS every year since 2008. CMS, however, is required to update payments by adjusted market based increase.

•

•

“Spending will decrease relative to current law by between $250 million and 750 million in 2018 and between $1 billion and $5 billion over 5 years.

No adverse impact is anticipated for beneficiaries’ access to care or out-

of-pocket spending.

There may be increased financial pressure on some providers, but the effect should be eased by an accompanying expansion in the outlier pool (as recommended last year).”

MedPAC did not discuss any perceived issues with IRF coding practices or patient admissions, which were focused on in January 2016.

II. Other Medicare Payment Updates MedPAC also voted on payment recommendations for Medicare payment systems for FY 2018. Like the IRF PPS recommendation, the Commissioners quickly provided unanimous consent for the following recommendations: •

Long-term care hospitals (LTCHs): The Congress should eliminate the update to the payment rates under the LTCH PPS for FY 2018.

Implications: o “Spending will decrease relative to the current law (a statutory payment update) by between $50 million and $250 million in 2018 and less than $1 billion over five years. o This is not expected to affect providers’ willingness and ability to care for Medicare beneficiaries. No adverse impact on beneficiaries is expected.”

The Commissioners unanimously voted in favor of a 5 percent reduction for the IRF PPS for FY 2018. MedPAC staff noted the following implications of this cut:

I. IRF PPS Recommendations and Issues State of the Field In 2015, 1,180 inpatient rehabilitation hos-

•

•

Skilled nursing facilities (SNFs): The Congress should eliminate the market basket update for 2018 and 2019 and direct the Secretary to revise the prospective payment system for SNFs. In 2020, the Secretary 23

should report to the Congress on the impacts of the reformed PPS and make any additional adjustments to payments needed to more closely align payments and costs.

Implications: o “Spending will decrease relative to current law by between $750 million and $2 billion in FY 2018; between $5 billion and $10 billion over 5 years. o Beneficiaries will not experience any adverse impact and will increase access for medically complex beneficiaries. o Providers will continue to treat beneficiaries.

The impact on individual providers will vary based on the mix of cases and current practice patterns. The disparities in Medicare margins across providers will be reduced.”

•

Home health agencies (HHAs): The Congress should reduce home health payments by 5 percent in 2018 and implement a two-year rebasing of the payment system beginning in 2019. The Congress should direct the Secretary to revise the PPS to eliminate the use of the number of therapy visits as a factor in payment determinations, concurrent with rebasing.

Implications: o “Spending will decrease relative to current law by $750 million to $2 billion in 2018 and more than $10 billion over five years. o Payments would be lower for all providers relative to current law.

Lower payments should not affect providers’ willingness to deliver aggregate home health care.

Elimination of therapy thresholds would redistribute payments among providers.”

•

Physicians and professional health services: The Congress should increase payments rates for physicians and other health professional services by the amount specified in current law for calendar year (CY) 2018. This recommendation is current law, and so it has no effect on federal program spending.

III. Developing a Unified PAC PPS 24

As mandated by the IMPACT Act, MedPAC is to design a prototype unified PAC PPS based on patient characteristics rather than the site of care. MedPAC issued the first of two mandated reports in June 2016. In the report, MedPAC concluded that their prototype PAC PPS model was feasible, could satisfactorily predict costs when applied to 2013 Medicare administrative data, and could be implemented sooner than the IMPACT Act’s current timetable. At this meeting, the staff noted that based on the Act’s current timeline, it is unlikely a PAC PPS would be proposed before 2024 and then before implementation some time later.

MedPAC staff applied the PAC PPS prototype to projected 2017 Medicare costs and payments to test the model’s cost-estimation accuracy¬¬.

According to the staff, doing so confirmed that the model accurately predicted the average cost for most of the approximately 30 patient condition groups used in the analysis.

Furthermore, MedPAC staff noted that the “equity of payments” across groups increased under a PAC PPS. For all patient groups, payments remain well above the cost of care, even for groups with decreased payments. However, the estimated level of payments is high at 14 percent above costs. The need for a transition period to the PAC PPS was also evaluated as part of the analysis. MedPAC offered an example of a transition payment system that would blend settingspecific PPS and PAC PPS rates over three years. While a transition period would delay redistribution of payment “equity,” MedPAC staff noted that it would afford providers time to adjust their costs and practices and would also dampen the changes in average payments in the early years of a PAC PPS. According to MedPAC, additional research is necessary to evaluate the relationships between payments and relative profitability. For example, preliminary data suggest that medically intensive conditions such as severe wounds or ventilator-dependency would experience an 8-10 percent increase in payments under a PAC PPS, whereas

orthopedic medical stays and types of neurological conditions would sustain a 6-8 percent payment decrease relative to current rates. The redistribution between different stays would dampen incentive to selectively admit patients. Providers that would have large payment increases under a unified PPS have below-average profitability currently. In summary, a provider’s relative profitability under a PAC PPS would be inversely related to their current profitability, as illustrated below:

Because provider practice patterns and costs may change in response to payment changes, according to the staff, refinements to the PAC PPS would be needed periodically. This could include revising the case-mix groups (CMGs) and their relative weights or rebasing payments if the costs of care change.

MedPAC notes that the Secretary will need authority to refine and rebase payments, and that the implementation of a PAC PPS does not need to be budget neutral.

Next Steps AMRPA will continue to monitor MedPAC’s progress in developing a prototype PAC PPS, as well as other IMPACT Act initiatives that the Centers for Medicare and Medicaid Services (CMS) is undertaking. The Commission is expected to release its 2017 Report to Congress on Medicare Payment in March and release a separate report on the unified PAC PPS report in June 2017. The next MedPAC public meeting will be March 2-3, 2017 in Washington DC. Meeting presentation materials and transcripts can be found at http://medpac.gov/-public-meetings-.

AMRPA Magazine February 2017

LATEST RESEARCH FINDINGS DEMENTIA RATES ARE DECLINING, STUDY FINDS

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ccording to a study, “A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012” published in the January 2017 issue of the JAMA Internal Medicine, dementia prevalence among Americans age 65 and older decreased significantly between 2000 and 2012.

The results are from the Health and Retirement Study (HRS) which found that dementia prevalence decreased from 11.6 percent in 2000 to 8.8 percent in 2012 - a decrease of about 24 percent.

The HRS, launched in 1992 and funded by the National Institute on Aging (NIA) is a longitudinal study that follows more than 22,000 individuals 50 and older collecting data every two years, from pre-retirement to advanced age.

The study consisted of interviews with

participants, who were asked detailed questions about their health, economic status, social factors, cognitive ability, and life circumstances. The researchers analyzed responses from approximately 10,500 HRS participants aged 65 or older in 2000 and 2012 and found that more years of education were associated with the decline in prevalence, but could not completely explain it. The average number of years of education increased from 11.8 to 12.7 between the cohorts.

The decrease in dementia prevalence was noted for both men and women in the study, despite an increase between 2000 and 2012 in cardiovascular risk factors such as high blood pressure, diabetes, and obesity.

to grow. Study findings suggest that rates of dementia can improve, but more research will be needed to identify all of the social, behavioral, and medical factors that directly influence the development of and reduced risk for Alzheimer’s and other dementias.

The authors note that monitoring the incidence and prevalence of dementia is important as the number of older adults, who are most at risk, continues

For the study abstract, please see: http:// jamanetwork.com/journals/jamainternalmedicine/article-abstract/2587084

The researchers concluded that the study is part of a growing body of evidence that alternative payment models (APMs) for Medicare can be better for patients while also reducing health care costs.

For the announcement please see: https://www.nia.nih.gov/newsroom/announcements/2016/12/national-studyreports-decreased-dementia-prevalence

MEDICARE ADVANTAGE PATIENTS HAVE BETTER OUTCOMES IN TREATING COMMON PROCEDURES

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University of Southern California (USC)-led study has found that Medicare Advantage (MA) results in greater savings, more efficient quality care and better patient outcomes for knee replacement and other common procedures than the traditional fee-for-service (FFS) Medicare programs.

The study “Less Intense Postacute Care, Better Outcomes For Enrollees In Medicare Advantage Than Those In Fee-For-Service” was published in the January 2017 issue of Health Affairs.

Traditional Medicare programs for seniors 65 and older pay fees to providers each time a patient receives care in a new

setting such as inpatient rehabilitation facilities (IRFs), home health agencies (HHAs) or skilled nursing facility (SNFs).

However, in Medicare Advantage, private participating insurers are given a premium from Medicare that caps the money available to cover patient care costs. Hospitals and facilities that manage to maintain lower costs than the fixed amounts keep the savings.

The researchers tracked hospital discharges for traditional Medicare and MA beneficiaries who had undergone surgery for knee or hip replacement, stroke or heart failure from January 2011 to June 2013. The data included 968,936 cases (episodes) of joint replacement,

481,074 stroke and 762,228 heart failure, and 25 to 27 percent of all the episodes involved MA patients.

The researchers accounted for comorbidities such as: • • • • •

diabetes obesity depression hypertension chronic lung disease

Researchers examined demographic differences in the patient population such as socioeconomic status.

In addressing concerns about a selection 25

bias, the researchers said there was no evidence that one group of beneficiaries was sicker than the other. There also was no evidence that Medicare Advantage patients’ health was compromised by lower usage of IRF or SNFs. Medicare Advantage patients overall were less likely than traditional Medicare patients to stay in IRFs post-surgery: • Joint replacement: 3.7 percent versus 11 percent • Stroke: 17 percent versus 25 percent • Heart failure recovery: (less than 1 percent versus 3 percent) In all cases, Medicare Advantage patients were about as likely as traditional fee-forservice Medicare patients to end up in SNFs after surgery; however, their lengths of stay (LOS) were shorter: • Joint replacement: 20 days versus 24 days • Stroke: 36 days versus 41 days

• Heart failure: 28 days versus 30 days • Hospital readmission rates within 90 days of surgery were: • Joint replacement: 10 percent for Medicare Advantage versus 12 percent for traditional • Stroke: 22 percent versus 24 percent • Heart failure: 36 percent versus 39 percent They compared the post-discharge results for both groups of beneficiaries and found several striking differences in outcomes for patients enrolled in traditional Medicare and those in MA. 1. Patients in MA plans were less likely than the traditional Medicare enrollees to be placed in nursing homes and IRFs after hospitalization.

2. MA beneficiaries who were placed in IRFs had shorter stays on average than traditional Medicare beneficiaries, and patients had lower rates of hospital readmission.

The researchers estimate that Medicare could have realized a 16-percent savings had the traditional Medicare patients been given the same cost-effective care and experienced the same positive results as MA patients.

The researchers conducted the comparison as policymakers have proposed changing Medicare to a “premium support” system - shifting traditional Medicare programs toward a bundled payment model.

For the announcement, please see: http:// news.usc.edu/114860/privatized-versionof-medicare-saves-more-money-than-traditional-fee-for-service/.

For the study abstract please see: http:// content.healthaffairs.org/content/36/1/91. abstract

MORE CLINICIANS HAVE OPPORTUNITY TO JOIN NEW ADVANCED APMS

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he Centers for Medicare and Medicaid Services (CMS) has opened applications for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program in new rounds of two CMS Innovation Center models for the 2018 performance year: • The Comprehensive Primary Care Plus (CPC+) model; and • The Next Generation Accountable Care Organization (ACO) model.

Under the Quality Payment Program, clinicians may earn a 5 percent incentive payment through sufficient participation in the following Advanced APMs for the 2017 performance year: • Comprehensive ESRD Care Model (Large Dialysis Organization (LDO) arrangement) • Comprehensive ESRD Care Model (non-LDO two-sided risk arrangement) • CPC+ • Medicare Shared Savings Program - Track 2 • Medicare Shared Savings Program - Track 3 • Next Generation ACO Model

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• Oncology Care Model (two-sided risk arrangement) CMS anticipates that clinicians may also earn the incentive payment through sufficient participation in the following new and existing models in 2018: • Medicare ACO Track 1+ Model • New voluntary bundled payment model • Comprehensive Care for Joint Replacement Payment Model (Certified Electronic Health Record Technology (CEHRT) track) • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT track) CMS states that lists will continue to change and grow as more models are proposed and developed in partnership with the clinician community and with input from the PhysicianFocused Payment Model Technical Advisory Committee.

For more information about CPC+, please visit: https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus/ For more information about Next Generation ACO Model, please visit: https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/

AMRPA Magazine February 2017

QUALITY INDICATOR COMMONLY ASKED QUESTIONS

By Lisa Werner, MBA, MS, SLP

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e now have a full quarter with the new IRF-PAI under our belt. None of you are happy about this, from what I have heard, but you survived. At eRehabData®, we have been fielding questions about a number of issues, and in this article I will address some of the commonly asked questions.

of a patient who is unable to complete the stairs assessments now, but climbed stairs at home prior to this hospitalization, 9 is not the appropriate code to use to indicate that stairs were not tested. One exception to this rule is car transfers. If you are unable to assess a car transfer because you do not have a car simulator and are unable to use another car, CMS provided guidance to use a 9 in that case.

percent of your discharges. I know that many of you are trying to avoid the use of dashes, but be aware that some cases may require it. If you did not complete a required assessment and information on the patient’s level of function is not found in the record, you will be unable to complete the assessment. It is incorrect to provide a score if the documentation does not support the score.

The area that appears to trouble people the most is how to code cases for patients who arrived and left on the same day without being fully assessed. The items on the Cognition tab in eRehabData® must be completed upon admission, but it is not possible to select code 88 to reflect an inability to test items due to medical illness. It is important that staff know to complete the Brief Interview of Mental Status (BIMS) as close to the time of admission as possible. If the patient is unable to complete that assessment because they are found to be inappropriate for inpatient rehab, consider defaulting to the Staff Assessment for Mental Status instead. This information may be obtained from other sections of the record, which staff, hopefully, had the opportunity to document. Note that in eRehabData®, when answering “No” to question C0100 about whether the BIMS should be conducted, you must then skip directly to the C0900 questions. You do not answer C0600, which asks whether or not the Staff Assessment for Mental Status should be conducted.

On the topic of car simulators, the rule is to code the car transfer when a true car simulator or car is used. If you modify the environment to be like getting into or out of a car, this does not count as an assessment of a car transfer.

I have noticed over the past quarter of auditing that our “choice” to assign section GG items to the therapists to ensure completion has resulted in an IRF-PAI that may reflect different levels of assistance between the FIM and quality indicator items. While this should be expected because of the way scores are derived, I have concerns over vast differences. If we are trying to obtain and report the patient’s level before therapeutic intervention, then the nurses input in areas such as transfers and toileting would do a better job communicating baseline performance than even the therapists might. Now that we have a quarter of data collection under our belt, I challenge you to consider adding some of the mobility items to the nurse’s admission assessment, if you have not done so already. I think it is our best interest to send data to CMS that truly reflects our burden of care at baseline as I believe this is one of the best indicators of what makes the inpatient rehabilitation level of care unique.

For the Function items, I have seen misuse of the code 9-Not applicable in many records. Remember that the use of 9 indicates that the patient did not complete the activity prior to admission and is not expected to complete the activity following discharge. In the case

Also remember to complete the ambulation and stairs assessments consecutively. First test one step, then four steps, and finally 12 steps. Because each assessment includes going up and down, they should be tested individually.

Please do not forget to factor in the amount of assistance required with compression stockings when assigning a code for the footwear item. This differs from FIM assessments so it should be reviewed with therapy staff. The same is true for upper body orthotics like a TLSO brace. Consider the amount of help required to apply the brace in the upper body dressing item.

When a patient discharges emergently, CMS noted that they consider it an incomplete stay. You can code the mobility items with code 88 if they were not assessed during the discharge window.

Remember that the use of dashes may result in a 2 percent payment penalty for an entire year if your number of assessments with incomplete QRP data exceeds 5

We created a new thread in the eRehabData® Users Forum entitled “IRF-PAI V1.4” to enable you to share questions and answers with each other.

Take a moment to reflect on the expertise of others in the industry or share your experiences that may be helpful to others.

We are all in this together.

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HOSPITAL VALUE-BASED PURCHASING PROGRAM RESULTS FOR FISCAL YEAR 2017

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n December 20, 2016, the Centers for Medicare and Medicaid Services (CMS), Center for Medicare and Medicaid Innovation (CMMI) issued a final rule to implement a new mandatory bundled payment model for cardiac care. The rule also expands the Comprehensive Care for Joint Replacement (CJR) model, which is currently in its first performance year, to include surgical hip and femur fracture treatments as (SHFFT), and also establishes a cardiac rehabilitation incentive program.

The new bundled payment models, referred to as Episode Payment Models (EPMs), will be implemented in select geographic areas. For the cardiac models, acute care hospitals within 98 select geographic areas are required to participate in a retrospective, twosided-risk bundled payment model for acute myocardial infarction (AMI) or coronary artery bypass graft (CABG) procedures. The SHFFT model will be implemented in the 67 markets where the CJR Model is currently underway.

The EPMs will start on July 1, 2017 and go through December 2021.

However, it remains to be seen how Medicare’s mandatory payment models will play out under the incoming administration. While not surprising to many, the final rule was unexpected to some, given that Representative Tom Price (R-GA), President Trump’s nominee for Secretary of the U.S. Health and Human Services Department and an orthopedic surgeon, has been critical of mandatory models implemented under CMMI’s authority.

In a September 29, 2016 letter to CMS officials co-signed by 178 members of the House, Rep. Price asked the agency to limit the size and scope of CMMI demonstrations, stating that “these mandatory models overhaul major payment systems, commandeer clinical decision making and dramatically alter the delivery of care.” Rep. Price has also introduced legislation that delays

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and suspends implementation of CJR. Certainly one of the interesting developments to anticipate is whether the Trump Administration will seek to freeze or reverse these eleventh hour final Obama Administration initiatives as an early priority.

The potential impact of the proposed bundled payment models on inpatient rehabilitation hospitals and units (IRH/ Us) is quite significant. According to eRehabData®, cardiac patients accounted for approximately 6.5 percent of all Medicare IRH/U discharges and lower extremity fractures represented approximately 11 percent of all Medicare IRH/U discharges in 2016.

I. Bundled Payment Episodes Under the EPMs, the acute care hospital in which a Medicare fee-forservice (FFS) beneficiary is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment is accountable for the cost and quality of care provided during the inpatient stay and for 90 days after discharge.

Specifically, participant hospitals would be paid a fixed target price for each care episode, with hospitals that deliver higher-quality care receiving a higher target price. In contrast to lower-extremity joint replacement (LEJR) episodes in the current CJR model, which are mostly elective and during which hospital readmissions are rare, the EPM episodes have very different patterns of care. Beneficiaries undergoing these procedures commonly have chronic conditions that contribute to the initiation of the episodes and need both planned and unplanned care throughout the EPM episode following discharge from the initial hospitalization. Furthermore, beneficiaries in the AMI and CABG models generally have chronic cardiovascular disease, which likely contributed to the acute events or procedures that initiate the episodes.

A. Heart Attacks (Acute Myocardial Infarctions)

Highlights •

•

•

A new mandatory bundled payment program would hold acute care hospitals in 98 markets financially accountable for the quality of care associated with heart attacks and bypass surgery for 90-days post-discharge.

CMS will also expand the CJR program to include surgical treatments for hip and femur fractures other than joint replacement.

The rule establishes a cardiac rehabilitation incentive payment model to encourage the use of cardiac rehabilitation services.

ABOUT THE AUTHORS

Mimi Zhang Policy and Research Associate

Carolyn Zollar, J.D. Executive Vice President for Government Relations and Policy Development AMRPA Magazine February 2017

AMI model episodes are initiated by claims for AMI MS-DRGs 280282, or claims for percutaneous coronary intervention (PCI) MS-DRGs 246-251 with an AMI International Classification of Diseases (ICD)-Clinical Modification (CM) diagnosis code in the principal or secondary diagnosis code position. Based on analysis of historical episodes beginning in calendar year (CY) 2012-2014, CMS found that there were, on average, 168,000 AMI episodes that began with hospitalizations and extended 90-days post-hospital discharge, i.e. episodes which would have fit the proposed AMI episode care model. Total annual Medicare spending (CY 2012-2014) for these historical episodes was $4.1 billion. About half the average AMI model historical episode spending was for the initial hospitalization, with the majority of post-discharge due to hospital readmissions and relatively less spending on skilled nursing services, Part B professional services, and hospital outpatient services.

B. Bypass Grafts CABG model episodes are initiated by claims for CABG MS-DRGs 231236. Between CY 2012-2014, there were approximately 48,000 CABG care episodes, representing total annual Medicare spending of $2.3 billion between CY 2012-2014. CMS found that for historical CABG episodes, about three-quarters of episode spending was for the initial hospitalization, with the remaining episode spending relatively evenly divided between Part B professional services and hospital readmissions, and a lesser percentage on SNF services. Similar to AMI episodes, post-acute care (PAC) use was relatively uncommon in CABG model historical episodes.

However, hospital readmissions during CABG model historical episodes were relatively common.

C. Hip and Femur Fractures The CJR model is expanded to include SHFFT episodes initiated by procedure claims resulting from hip and femur fractures, except major joint, MS-DRGs 480-482. The CJR model currently underway begin with admission to acute care hospitals for LEJR procedures assigned to MS-

DRG 469 (Major joint replacement or reattachment of lower extremity with major complications or comorbidities) or MS-DRG 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities), including total and partial hip replacement in the setting of hip fracture.

Based on analysis of historical episodes beginning in CY 20122014, CMS found that there would have been approximately 109,000 qualifying SHFFT historical episodes.

Medicare expenditures associated with these episodes total $4.7 billion.

In the proposed rule, CMS noted that the SHFFT model historical episodes also were accompanied by substantial spending for hospital readmissions, and PAC utilization in these episodes also was high.

Acute care hospitals in BPCI Models 2 and 4 for the hip and femur procedures (except major joint) or for all three of the BPCI cardiac episodes (AMI, PCI, and CABG) are exempt from participating in the EPMs. II. Episode Pricing and Timeline CMS will set target prices every year for the models based on historical data on total costs related to the episode of care for FFS beneficiaries admitted for heart attacks, bypass surgery, or SHFFT, beginning with the hospitalization and extending 90 days following discharge.

Target prices will be adjusted based on

on whether the heart attack patient was treated with surgery or medical management.

At the end of a model performance year, actual spending for the episode (total expenditures for related services under Medicare Parts A and B) would be compared to the target price that reflects episode quality for the responsible hospital. Hospitals that achieve the target price while meeting or exceeding quality standards would be paid the savings achieved. Hospitals with costs exceeding the quality-adjusted target price would be required to repay CMS. Target prices would be based on a blend of hospitalspecific data and regional historical data: •

•

•

July 1, 2017 – December 31, 2018 (performance years 1 and 2): Twothirds participant-specific data and one-third regional data; 2019 (performance year 3): One-third participant-specific data and twothirds regional data; and 2020 – 2021 (performance years 4 and 5): Only regional data.

As in the CJR model, hospitals’ risk would phased-in over the five years of the model, with no downside losses (repayment to CMS) required in the first year. The table below summarizes the performance years of the EPM program. Please see Table 12 in the final rule, “Table 12—Final StopLoss Thresholds and Discount Percentage Ranges for Medicare Repayments by Performance Year,” for the thresholds applicable to providers’ rates of potential downside risk and upside gain.

Performance Year (PY) and Calendar Year (CY)

Episodes Included in Performance Year

PY 1 / Quarters 3 and 4 of CY 2017

Episodes that begin on or after July 1, 2017 and end on or before Dec. 31, 2017

PY 2 / CY 2018

Episodes that end from Jan. 1, 2018 through Dec. 31, 2018

PY 3 / CY 2019

Episodes that end from Jan. 1, 2019 through Dec. 31, 2019

PY 4 / CY 2020

Episodes that end from Jan. 1, 2020 through Dec. 31, 2020

PY 5 / CY 2021

Episodes that end from Jan. 1, 2021 through Dec. 31, 2021

the complexity of treating a heart attack or providing bypass surgery. For example, CMS will adjust prices upwards for heart attack patients who need to be transferred to a different hospital during their care to reflect the most resource-intensive cardiac care provided during the hospitalization.

Target prices would also differ depending

III. Participants in the Models The AMI and CABG models will be implemented in 98 geographic areas, defined by metropolitan statistical areas (MSAs). MSAs are counties associated with a core urban area that has a population of at least 50,000. Non-MSA counties (no urban core area or urban core area of less 29

than 50,000 population) are excluded from the EPMs. Eligible MSAs must have had at least 75 AMI Model eligible cases among other criteria. Because the SHFFT model builds upon the existing CJR program, the SHFFT model would be tested in the 67 CJR MSAs in which the CJR model is current underway. Approximately 1,120 hospitals will participate in the AMI and CABG models and 860 hospitals in the SHFFT Model. A list of the selected MSAs and a list of selected hospitals can be found on the CMS EPM website at https:// innovation.cms.gov/initiatives/epm.

Rural counties are excluded from the models. In addition, CMS will limit the financial risk for the remaining rural hospitals that are located in participating MSAs, such as sole community hospitals, Medicare-dependent hospitals, and rural referral centers.

IV. Quality Measurement and Pay-forPerformance Under the EPMs, only hospitals that meet quality standards would be paid the savings from providing care for less than the quality-adjusted target price. Similar to the CJR model, CMS adopts a payfor-performance methodology for EPMs that relies upon a composite quality score to assign respective EPM participants to four quality categories. These quality categories will determine an EPM hospital’s eligibility for a reconciliation payment as well as the effective discount percentage at reconciliation. Points for quality performance and improvement (as applicable) will be awarded for each episode measure and then summed to develop a composite quality score that will determine the EPM participant’s quality category for the episode.

Hospitals will be assessed based on the following quality metrics: AM Model: • Hospital 30-Day, All-Cause, RiskStandardized Mortality Rate Following Acute Myocardial Infarction (AMI) Hospitalization (NQF #0230) • Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey (NQF #0166)

30

•

Voluntary Hybrid Hospital 30Day, All-Cause, Risk-Standardized Mortality eMeasure (NQF #2473) data submission

CABG Model: • Hospital 30-Day, All-Cause, RiskStandardized Mortality Rate Following Coronary Artery Bypass Graft (CABG) Surgery (NQF #2558) • HCAHPS Survey (NQF #0166) • Voluntary data submission for the Society of Thoracic Surgeons (STS) consensus-based outcomes composite measure.

SHFFT Model (same measures as in the CJR model): • Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550) • HCAHPS Survey (#0166) • Voluntary Total Hip Arthroplasty (THA)/Total Knee Arthroplasty (TKA) Patient-Reported Outcome (PRO) and Limited Risk Variable data submission V. Waivers CMS adopted its proposal to waive the home health “incident-to” requirement for the AMI, CABG and SHFFT EPMs. This waiver, also active in CJR, allows a beneficiary who does not qualify for home health services under standard Medicare requirements to receive post-discharge visits in his/her home any time during their EPM episode. For the AMI program only, CMS adopted its proposal to waive the skilled nursing facility (SNF) 3-Day rule requirement only on the condition that the SNF has been rated three stars or higher on the Five Star Rating Program for seven of the last 12 months. This requirement would also parallel CJR. CMS is also waving certain geographic site requirements for telehealth services.

CMS did not issue any waivers of fraud and abuse authorities in the final rule. CMS states that waivers of certain fraud and abuse laws for purposes of testing these models would be issued by CMS and the HHS Office of the Inspector General (OIG). These notices are published on the CMS and OIG websites.

VI. Alternative Payment Models under MACRA The final rule also establishes new pathways for physicians who participate in bundled payment models to qualify for financial rewards through the proposed Quality Payment Program, implemented under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. MACRA introduced financial incentives for physicians participating in Advanced Alternative Payment Models (APMs) that align incentives for highquality, cost-effective care. For the new EPMs, clinicians may potentially earn the incentive payment beginning in performance year 2019 or potentially as early as performance year 2018 if they collaborate with participant hospitals that choose the Advanced APM path. For the CJR model, clinicians may potentially earn the incentive payment beginning in performance year 2017. The EPM rule also creates opportunities in the new Medicare ACO Track 1+ so that, under that model, clinicians may potentially earn the incentive payment beginning in performance year 2018.

VII. Cardiac Rehabilitation Incentive Program The final rule also includes the cardiac rehabilitation (CR) incentive payment model as proposed. In promoting incentives for CR, CMS notes that CR program are very successful but enormously underutilized.

In the proposed rule, CMS pointed to medical literature which indicates that CR and intensive cardiac rehabilitation (ICR) services are capable of achieving significant improvements in longterm patient outcomes. The same and additional literature also makes it clear that these services are unfortunately underutilized, estimating that only about 35 percent of AMI patients receive CR or ICR. Recent studies showed a similar pattern for Medicare beneficiaries. In the final rule CMS states, “This pattern is virtually unchanged over the past two decades, despite clinical practice guidelines for CR that were published in 1995 and subsequently endorsed by a number of professional associations and CMS.” Generally speaking, Medicare Part B covers CR/ICR services for beneficiaries

AMRPA Magazine February 2017

who are referred by their physician after an AMI, CABG, or other cardiac events. To test strategies to encourage CR participants to refer beneficiaries following an AMI or CABG for important CR/ICR services, monitoring for beneficiary adherence to the treatment plan, and coordinating care, CMS established a two-level CR incentive payment for the use of any CR/ ICR services which would increase once a beneficiary meets or exceeds the CR/ ICR service utilization benchmark. CMS wants to encourage timely referral of beneficiaries that have had an AMI or a CABG to CR/ICR programs as it would promote better adherence to CR/ICR service protocols, an expectation that is supported by data showing that patients who are referred early to CR were more likely to enroll.

The CR program is limited to a maximum of two one-hour sessions per day for up to 36 sessions over up to 36 weeks with an option to extend. ICR programs are limited to 72 one-hour sessions, up to six sessions per day, over a period of up to 18 weeks. CR participants would receive an incentive payment of $25 for the first 11 services provided and $175 for subsequent services. The services that would count towards the CR/ICR payments are distinguished by HCPCS codes in Table 56 of the rule. However, CMS made a small change in the services from the proposed rule.

The CR/ICR services which count towards CR incentive payments are identified by the HCPCS codes for CR/ICR services in the CR performance year when those CR/

ICR services are paid under the OPPS or to any supplier reporting place of service code 11 on a PFS claim. CMS believes that this modification to limit CR/ICR services from suppliers to those reporting place of service code 11 on the PFS claim, rather than all CR/ICR services from suppliers, will ensure that it can establish a unique, unduplicated count of CR/ICR services furnished in the hospital outpatient department and in the physician’s office to a CR beneficiary for purposes of the CR incentive payment to CR participants.

The CR incentive payment model will test the effects on quality of care and Medicare expenditures of providing direct financial incentives to hospitals (“CR participants”) for beneficiaries experiencing an AMI or CABG in order to encourage care coordination and greater utilization of medically necessary CR/ICR services for 90 days’ post-hospital discharge where the beneficiary’s overall care is paid under either an EPM or the FFS program.

Under the AMI/CABG EPM, the hospital where the initial hospitalization for AMI or CABG treatment occurs would be financially accountable for the entire AMI or CABG episode. CMS expects that EPM participant hospitals would be highly engaged in care management of beneficiaries for the 90-day postdischarge duration included in the episode and may be able to capitalize on that engagement to encourage greater use of medically appropriate CR/ ICR services if they are also selected for participation in the CR incentive payment model. Therefore, under the CR incentive payment model, CMS will provide a CR

HCPCS Codes for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Services HCPCS Code

Descriptor

93797

Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session).

93798

Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session).

G0422

Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session.

G0423

Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise.

incentive payment to selected hospitals with financial responsibility for AMI or CABG model episodes (hereinafter EPM–CR participants) because they are already engaged in managing the AMI or CABG model beneficiary’s overall care for a period of time following hospital discharge. A list of EPM-CR MSAs and a list of CR providers can be found at https://innovation.cms.gov/initiatives/ epm.

Similarly, CMS will provide CR incentive payments to hospitals under the traditional Medicare FFS program. Hence, CMS will provide a CR incentive payment specifically to selected non-EPM hospitals (hereinafter FFS–CR participants). A list of FFS-CR MSAs and CR providers can also be found at https://innovation. cms.gov/initiatives/epm. Approximately 1,320 hospitals will participate in the CR Incentive Payment Model.

Focusing on the two types of hospitals (FFS and non-EPM) will allow CMS to test the effects of the CR incentive payments, as well as identify potential interactions between the proposed CR incentive payment and the underlying EPM and FFS payment methods. There may be providers and suppliers other than hospitals caring for beneficiaries with AMI or CABG whose care is paid under the Medicare FFS program and that could assume responsibility for encouraging greater utilization of CR/ICR services under the CR incentive payment model.

However, for purposes of comparability with the EPM and non-EPM participating hospitals, CMS believes that hospitals are the appropriate entity to take on care coordination responsibility for increasing the utilization of medically necessary CR/ICR services for those beneficiaries following AMI or CABG who are in the CR incentive payment model but that are not in an EPM. The program would parallel the time period of the EPM models and therefore is proposed to begin July 1, 2017 and run through December 31, 2021.

31

MACPAC RELEASES 2016 MEDICAID AND CHIP DATABOOK

By Lovelyn M. Robinson, Editorial and Research Assistant

T

he Medicaid and CHIP Payment and Access Commission (MACPAC) released its annual update of national and statespecific data for Medicaid and the State Children’s Health Insurance Program (CHIP). The MACStats: Medicaid and CHIP Data Book includes data on enrollment and spending, beneficiaries’ health, service use, and access to care.

Medicaid and CHIP cover more than onequarter of the U.S. population. MACPAC is required to review national and statespecific Medicaid and CHIP data as part of its statutory mandate under the Social Security Act (SSA). Medicaid is approximately 10-15 percent of inpatient rehabilitation providers’ revenues.

The databook is divided into six sections that include: 1. Medicaid and CHIP enrollment and spending compared to other payers; 2. Trends in Medicaid and CHIP enrollment and spending; 3. State-level Medicaid and CHIP enrollment and spending; 4. State-level Medicaid and CHIP eligibility thresholds for children, non-aged and non-disabled adults, as well as persons with disabilities and those aged 65 or older; 5. Measures of beneficiary health, use of services, and access to care; and 6. A technical guide that describes data sources used in MACStats and the methods MACPAC uses to analyze the data.

The report states that, together, Medicaid and CHIP accounted for 16.8 percent of national health expenditures in 2014, Medicare (20.4 percent), and private insurance (32.7 percent). Adults whose primary coverage source was Medicaid or CHIP in 2015 reported having a usual source of care at a similar rate as those with private insurance. Children whose primary source of coverage was Medicaid or CHIP were reported as having well-child checkup rates

32

similar to children with private insurance.

Medicaid spending and enrollment are affected by federal and state policies as well as economic factors. For example, spending and enrollment both grew around the recessions of 2001 and 2007–2009, and slowed as economic conditions subsequently improved. More recently, Medicaid spending in fiscal year (FY) 2014 and beyond grew in part due to expanded eligibility under the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended).

Enrollment In 2015, more than one-quarter of the U.S. population was enrolled in Medicaid or CHIP at some point during the year. The estimated number of people ever enrolled in Medicaid in FY 2015 was 81.0 million and 8.9 million for CHIP. Nearly half (45.9 percent) of all individuals enrolled in Medicaid in 2015 had family incomes below 100 percent of the federal poverty level (FPL). Nearly two-thirds (63.8 percent) of all individuals enrolled in Medicaid had incomes less than 138 percent FPL. People enrolled in Medicaid or CHIP were more likely to be Hispanic or black and were more likely to be in fair or poor health than either privately insured or uninsured individuals.

than average monthly enrollment during July to September 2013. Between July 2014 and July 2015, enrollment grew by an additional 8.2 percent. However, enrollment growth from 2015 to 2016 grew by 0.2 percent. The Medicaid and CHIP program is projected to maintain a 17.7 percent national health expenditures through 2025, and Medicare’s share is projected to increase from 20.2 percent to 22.8 percent.

Spending Total Medicaid spending was $556 billion in fiscal year (FY) 2015, an 11.6 percent increase from the prior year. Total State CHIP spending increased by about 4.7 percent, to $13.7 billion.

In FY 2013, individuals eligible on the basis of disability and those age 65 and older accounted for roughly one-quarter of Medicaid enrollees and two-thirds of program spending. Many of these individuals were users of long-term services and supports (LTSS) and accounted for only 5.9 percent of Medicaid enrollees, but over 41.8 percent of all Medicaid spending. The majority of FY 2013 Medicaid spending for enrollees eligible on the basis of disability and enrollees age 65 and older was for LTSS, while more than half of spending for children and adults eligible on a basis other than disability was for capitation payments to managed care plans.

Medicaid and CHIP together accounted for 16.8 percent of national health expenditures in calendar year (CY) 2014, Medicare accounted for 20.4 percent, and private insurance accounted for 32.7 percent. The federal budget funds devoted to Medicaid and Medicare has grown steadily since the programs were enacted in 1965, but Medicaid continues to account for a smaller share at 9.5 percent in FY 2015 than Medicare at 14.6 percent.

The share of Medicaid benefit spending on capitation payments for managed care reached 43.1 percent of all Medicaid benefit spending in FY 2015, up from 37.5 percent in the prior year.

Growth

For more information please see the MACStats: Medicaid and CHIP Data Book at www. macpac.gov/wp-content/uploads/2016/12/ MACStats_DataBook_Dec2016.pdf

After experiencing high rates of growth in 2014 and 2015, Medicaid and CHIP enrollment grew less than 1 percent in 2016. Enrollment in July 2014 was 17.2 percent higher

Disproportionate share hospital (DSH), upper payment limit, and other types of supplemental payments accounted for almost half of fee-for-service payments to hospitals in FY 2015.

AMRPA Magazine February 2017

RAC News: CMS Awards New RAC Contracts

O

n October 31, 2016, CMS awarded new Medicare fee-for-service (FFS) RAC contracts to the following regions: Region 1 – Performant Recovery, Inc., Region 2 – Cotiviti, LLC, Region 3 – Cotiviti, LLC, Region 4 – HMS Federal Solutions, and Region 5 – Performant Recovery, Inc. Please see the updated MAP below and for more information please see https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/ Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/

Medicare Fee-for-Service RAC Regions

Region 4 HMS Federal Solu<ons

AK

JL

PA

WA

JF

Region 1 Performant Recovery, Inc.

MD

MT

MI

NJ

MI

DE

ND

KY

J8

OR ID

OH

Region 2 Co<vi<, LLC

UT

NE AZ CO

KS

HI

Region 5 (DME/HHH) Performant Recovery, Inc.

IN

MN

NV

JE

VT

SD WY

CA

IN

OK

NM

J6

J15

IL

J5 MO

TX

MA RI CT

WI IA

ME RI

JK

KY

Region 3 Co<vi<, LLC TN

WV

NC

JJ

AR AL

JH

NY

NH

VA

JM

SC GA

MS LA

JN FL

Effec>ve October 31, 2016

33

STUDY EXAMINES COSTS OF JOINT REPLACEMENTS USING BUNDLED PAYMENT MODELS

A

recent change in the way Medicare pays for joint replacements is saving millions of dollars annually and could save billions without impacting patient care, according to a new study published in the Journal of the American Medical Association (JAMA) entitled: “Cost of Joint Replacement Using Bundled Payment Models”. The purpose of the study was to analyze changes in quality, internal hospital costs, and postacute care (PAC) spending for lower extremity joint replacement bundled payment episode hospitalizations and 30 days of PAC. Background The Comprehensive Care for Joint Replacement (CJR) program proposed rule was published by the Centers for Medicare and Medicaid Services (CMS) on July 9, 2015. Under the new program, Medicare agrees to pay hospitals a set fee —a bundled payment — for all care related to hip or knee replacement surgery, from the time of the surgery until 90 days after. Traditionally, hospitals collect payments for many components of care and rehabilitation individually.

In April 2016 Medicare launched the mandatory CJR bundled payment model in 67 urban areas for approximately 800 hospitals following its experience in the voluntary Acute Care Episodes (ACE) and Bundled Payments for Care Improvement (BPCI) demonstration projects. Little information from ACE and BPCI exists to guide hospitals in redesigning care for mandatory joint replacement bundles.

However, the program may have implications for referrals to inpatient rehabilitation hospitals and units (IRH/Us) in these areas.

According to CMS, the hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy 34

recovery and rehabilitation periods. In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for these hip and knee replacement surgeries still vary greatly among providers. The rate of complications such as infections or implant failures after surgery are often than three times higher at some facilities than others, increasing the chances or readmission. The average Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000.

Study Methods The study participants consisted of 3,942 total patients with lower extremity joint replacement at Baptist Health System (BHS) in San Antonio, Texas, which participated in the Acute Care Episodes (ACE) and Bundled Payments for Care Improvement (BPCI) demonstration projects. The outcome measures included average Medicare payments per episode, readmissions, emergency department (ED) visits, prolonged length of stay (LOS), and hospital savings from changes in internal hospital costs and PAC spending. The research is based on Medicare claims data from 2008 through mid-2015.

Between July 2008 and June 2015, average Medicare episode expenditures declined 20.8 percent, from $26 785 to $21 208 (P < .001) for 3,738 episodes of joint replacement without complications.

It declined 13.8 percent from $38 537 to $33 216 (P = .61) for 204 episodes of joint replacement with complications.

Readmissions and emergency department visits declined 1.4 percent (P = .14) and 0.9 percent (P = .98), respectively, while episodes with prolonged LOS decreased 67.0 percent (P < .001). Patient illness severity remained stable. By 2015, 51.2 percent of overall hospital savings were

Highlights •

Researchers estimate that if every hospital used the CJR model, Medicare would save $2 billion annually.

from internal cost reductions and 48.8 percent from PAC spending reductions.

Reductions in implant costs, down on average $1,920.68 (29 percent) per case, contributed the greatest proportion of hospital savings. Average PAC spending declined $2,443.12 (27 percent) per case, largely due to reductions in inpatient rehabilitation facility (IRF) and skilled nursing facility (SNF) spending but only when bundles included financial responsibility for PAC. Findings The study found that hospitals saved an average of 8 percent under the program, and some saved much more. However, the researchers estimate that if every hospital used this model, it would save Medicare $2 billion annually.

The researchers concluded that during a period in which Medicare payments for joint replacement episodes increased by 5 percent, bundled payment for procedures at BHS was associated with substantial hospital savings and reduced Medicare payments. Decreases in PAC spending occurred only when it was included in the bundle.

The study authors were Amol S. Navathe, MD, PhD; Andrea B. Troxel, ScD; Joshua M. Liao, MD; Nan Nan, MS; Jingsan Zhu, MS; Wenjun Zhong, PhD; Ezekiel J. Emanuel, MD, PhD The abstract is available on the JAMA website at http://jamanetwork.com/ journals/jamainternalmedicine/articleabstract/2594805

AMRPA Magazine February 2017

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AMRPA Magazine February 2017