AMRPA Magazine July 2017 by AMRPA

July 2017 â&#x20AC;˘ Vol. 20, No. 7

STRETCHED THIN

How constant demand, a raging healthcare debate and limited resources are a burden for rehabilitation facilities

Volume 20, Number 7

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 Study Examines Outcomes in Freestanding Rehabilitation Hospitals Versus Hospital-Based Units.............................................................. 9 The Better Care Reconciliation Act of 2017 vs. The American Health Care Act......................................................................... 11 Repeal of Medicare Outpatient Therapy Caps Once Again in the Hands of Congress ........................................................... 16 CMS Transmittals of Interest for Medical Rehabilitation Providers .............. 18

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

RAND/CMS Seek Comments on Additional IMPACT Act Potential Standardized Data Assessment Items............................................. 20

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

Audit To-Do List................................................................................................. 23

Mimi Zhang Policy and Research Associate, AMRPA Lovelyn Robinson Editorial and Research Assistant, AMRPA

AHRQ Study Shows 54 Percent Drop in Infections Among Nursing Home Patients ...................................................................... 25 AMRPA Submits Comments on PROMIS Depression Items ......................... 26

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

Brief Examines Medicaid Spending for Seniors and Persons with Disabilities .............................................................. 28

AMRPA Magazine, Volume 20, Number 7.

GAO Examines Health Status of Beneficiaries who Disenroll from Medicare Advantage Plans ..................................................................... 30

AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA). AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Individuals who are employees of member institutions may subscribe to the magazine for $100 annually. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th Street, NW, Washington, DC 20045 USA. Make checks payable to AMRPA. ADVERTISING RATES: Full page = $1500; Half page = $1000; Third page = $750. Ads may be B&W or full color. Contact Ryan Foster, rfoster@kellencompany.com for additional specs and acceptable submission format. Advertising Contact: Rachel Koresky, AMRPA, 529 14th Street, NW, Washington, DC 20045 USA, Phone: +1-202591-2469, Email: rkoresky@amrpa.org 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 ÂŠ2017 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. POSTMASTER: Send address changes to Kellen Company, Attn: AMRPA Magazine Circulation 529 14th Street, NW, Suite 750, Washington, DC 20045

AMRPA Magazine July 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

Is anyone not busy these days in healthcare?

jokingly tell folks that I spend half my time in New Jersey at Kessler, half in Los Angeles at our new California Rehabilitation Institute, and the third half in Washington, DC (68 square miles surrounded by reality). No, I’m not looking for sympathy, but I am pointing out that the business of medical rehabilitation is critically dependent on what happens in Washington, and if you can’t spend much of your time there yourself advocating for us, you need AMRPA and our volunteer leaders to do just that. AMRPA has wonderful staff, management and advisors who do a great job of identifying issues, advising on courses of action, managing our committees and task forces, and preparing position papers, comment letters, and advisories for the membership, but there is no substitute on Capitol Hill for the voice of working experts and local voting constituents.

Rich Kathrins and I recently were visiting the office of a key member of Congress, educating them about the challenges we all face with managed care denials across the country. The response was: “I need to hear from our local providers that this is a problem for us, too.” Of course, we immediately put that office into contact with local constituent members to reinforce the message. So if/when we reach out to you, you’ll know it is important work that AMRPA is doing on your behalf to preserve and protect our ability to give patients access to the care you all provide day after day in your facilities and offices. Since it is not realistic to think that you can all pop into DC every few weeks, think of your dues payments for AMRPA membership as a work avoidance strategy…we do the visits so you won’t have to (nearly as often)!

AMRPA LEGISLATIVE UPDATE

By Martha M. Kendrick, Esquire, Partner, Akin Gump Strauss Hauer & Feld LLP Overview of Affordable Care Act Repeal/ Replace Senate Efforts

fter more than a month of negotiations, Senate Republicans finally released a legislative draft that attempts to reform policies put in place by the Affordable Care Act (ACA) through a fast-tracked procedure known as Budget Reconciliation. The Senate’s version of the House-passed American Health Care Act (AHCA),

• • • • •

the perceived secrecy with which the Senate legislation was crafted. Virtually immediately, Senators Ted Cruz (R-TX), Ron Johnson (R-WI), Mike Lee (R-UT) and Rand Paul (R-KY) released a joint statement expressing concerns with the draft and confirming they are not ready to vote in support of the bill, and moderate Senator Dean Heller (R-NV) released an early statement conveying he could not

As the July 4th recess nears, Senators grapple with how to pass its version of the Obamacare repeal and replace legislation. Although Trump’s first Budget Proposal as President lacks any major Medicare proposals, HHS Secretary Price is forced to defend major funding cuts to Medicaid and medical research to lawmakers. As part of a series of “round three” bills, the House moves forward on legislation that amends AHCA and aims to improve health care options for Americans. The Senate Finance Committee’s unanimously approved the bipartisan CHRONIC Care Act (S. 870) and the bill moves to an eventual Senate floor vote. MedPAC finalized its recommendations to Congress for a unified prospective payment system (PPS) for post-acute care (PAC) services.

renamed the “Better Care Reconciliation Act of 2017” (BCRA), was released to Senators and the public on June 22, after weeks of closed-door discussions. There are a number of notable changes from the House-passed American Health Care Act (AHCA), including a slower phase-out of the enhanced federal Medicaid funding for expansion enrollees, retention of the Affordable Care Act’s (ACA’s) existing premium subsidy framework and delayed effective dates for repeal of certain ACA taxes. While the Senate bill does not

expressly give states the flexibility to waive essential health benefits (EHBs) as the AHCA does, it does ease the process for obtaining the ACA’s Section 1332 state innovation waivers, under which states can already waive EHBs, actuarial values, and other requirements. It also omits the AHCA’s flexibility for states to opt out of ACA’s community risk-rating, which would essentially allow insurers to

underwrite coverage based on health status and preexisting conditions. It temporarily funds the controversial cost-sharing subsidies through 2019, but then repeals them. The bill creates a stabilization fund to help states strengthen their individual health insurance markets, as well as a $62 billion long-term state innovation fund to assist costly, low-income individuals purchase health insurance. The bill comes after weeks of criticism from Members of both parties over

support the bill as introduced. Several other moderate Senators are expected to follow suit in seeking changes. Under Reconciliation, Republicans only need a simple majority of fifty-one votes to pass the bill in the Senate (Vice President Pence would serve as the tie-breaking vote) and can only afford two GOP defections. If Republican leaders are able to secure the necessary support among their own party and bring the BCRA to the floor for a vote, Reconciliation rules allow for twenty hours of debate followed by a marathon

AMRPA Magazine July 2017

voting session on amendments known as a “vote-a-rama.” A vote-a-rama can last long hours before a vote on final passage is held. On June 26, the Congressional Budget Office (CBO) released its cost estimate of the Senate bill, projecting that the legislation would increase the number of uninsured by 22 million in 2026 relative to the number under current law. This is slightly fewer than the number of uninsured estimated for the AHCA. CBO also estimates that the current version of the BCRA would reduce federal deficits by $321 billion over 10 years, $202 billion more than estimated net savings for the House bill. The coverage losses outlined in the CBO analysis could complicate passage of the bill in the Senate. Indeed, moderate Senator Bill Cassidy (R-LA) was quick to remark that the score made him more concerned about the legislation. If the Senate successfully passes the Better Care Reconciliation Act, the

Chamber will need to resolve the differences with the House version. The House has the option of amending the Senate version of the bill and sending it back to the Senate. However, if the House returns the Reconciliation bill to the Senate, it is subject to another twenty hours of debate and a vote-arama. Therefore, as a practical matter, if the Senate sends an amended Reconciliation bill back to the lower chamber, the House will either accept the Senate’s version or send the bill to a Conference Committee to resolve differences. If Senate Republican Leaders are unable to find the immediate votes to pass the bill, action on the legislation could slip into July. Further, if the Senate bill does not sit well with conservatives in the House, their version may be unable to move through the House. Consequently, this may require a Conference Committee or substantial delay in final floor consideration and passage. President Trump has increased pressure

on the Senate to move forward, and he, along with HHS Secretary Tom Price and the Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma, all expressed support for the Senate version. The President tweeted “I am very supportive of the Senate #HealthcareBill. Look forward to making it really special! Remember, ObamaCare is dead.” Trump Administration Keeps Insurance Companies in Limbo On May 22, the White House filed a motion in federal court for another 90-day delay in the House lawsuit over the ACA’s cost-sharing reduction (CSR) payments. Lawyers for the Justice Department and the House asked for the delay as they “continue to discuss measures that would obviate the need for judicial determination of this appeal, including potential legislative action.” The next status report is due on August 20, 2017, meaning insurance companies will likely face continued uncertainty regarding the CSRs for the next several months at least.

Congressional Budget Office Releases Estimate of American Health Care Act On May 25, the Congressional Budget Office (CBO) released its cost estimate for H.R. 1628, the American Health Care Act (AHCA), as passed by the House. CBO estimates that in 2018, 14 million more people would be uninsured in contrast with current law. By 2026, CBO estimates that figure would rise to 23 million. CBO projects the legislation would reduce federal deficits by $119 billion over ten years. CBO anticipates that insurance markets would continue to remain stable in most of the country. However, the report estimates that about one-sixth of the U.S. population resides in areas in which the nongroup market would start to become unstable in 2020, as a result of states waiving requirements for essential health benefits (EHBs) and community rating. MedPAC Recommends PAC PPS in June Report to Congress On June 9, the Medicare Payment Advisory Commission (MedPAC) released its June 2017 Report to Congress.

The first chapter of the report looks at implementing a unified payment system for post-acute care (PAC). MedPAC recommends that Medicare implement a prospective payment system (PPS) for post-acute care beginning in 2021, with a three-year transition. The Commission has long-championed the idea of a PAC PPS due to their concerns over the wide range of Medicare payments for similar patients within the different PAC settings. Notably, the report states that “Medicare payments exceed providers’ cost by 14 percent across the PAC settings.” MedPAC’s proposed design would include the following components: •

A common unit of service;

•

A common method of risk adjustment that relies on administrative data on patient characteristics and incorporates functional status as these data become available;

•

Two payment models to reflect differences in benefits across settings;

•

Adjustment of payments for home health stays to prevent considerable overpayment;

•

A high-cost outlier policy to protect providers from incurring large losses and help ensure beneficiary access to care;

•

A short-stay outlier policy to prevent large overpayments for unusually short stays; and

•

Uniform application of any payment adjusters across all providers.

MedPAC also recommends lowering aggregate payment across PAC settings by 5 percent, and beginning alignment of regulatory requirement for PAC providers. Further, MedPAC recommends the periodic revision and rebasing of payment, if needed. An additional chapter of the report (Chapter 9) examines hospital use by long-stay nursing facility (NF) residents. MedPAC expresses concern over the high rates of hospital use by these patients, which may be an indicator of

AMRPA Magazine July 2017

a lack of care coordination between the NF and physician, or poor quality of care.

cuts in Medicaid in the coming decade. In particular, Democrats took issue with the $610 billion cuts to Medicaid that is included in the Trump proposal as well as the $880 billion in reductions over the same period included in the AHCA. Democrats surmised that this would lead to a $1.4 billion cut to Medicaid over the next decade. Secretary Price pushed back on the claims that the Administration and Congressional Republicans were pushing for $1.4 trillion in Medicaid cuts. He asserted that the Budget assumes the federal government would establish a per capita cap or block grant model for Medicaid that will result in savings of over $610 billion over ten years. The future of the cost-sharing reduction (CSR) payments, insurance market stability, and the opioid crisis were topics that Members also delved into at the hearing.

On June 7, 2017, the House Ways and Means Committee Health Subcommittee held a hearing titled, “Promoting Integrated and Coordinated Care for Medicare Beneficiaries.” The hearing primarily focused on Special Needs Plans (SNPs), and the Program of AllInclusive Care for the Elderly (PACE), but Medicare Advantage was also a topic of discussion. Dr. Mark Fendrick, Executive Director of the University of Michigan’s Center for Value-Based Insurance Design, testified that moving Medicare Advantage from a volume-driven to a value-based model requires a change in how we engage consumers seeking care. To that end, a bipartisan effort is needed to allow Advantage plans across the country to incorporate Value-Based Insurance Design (VBID). A clinically nuanced cost-sharing approach, he added, will encourage the use of highvalue services and providers while discouraging the use of low-value care.

HHS Secretary Defends FY 2018 Budget Proposal On May 23, President Trump released a Fiscal Year (FY) 2018 Budget that includes $3.6 trillion in spending reductions and seeks to balance the federal Budget by 2027. The proposal, which includes a repeal of the ACA and more than $600 billion in cuts to Medicaid and the Children’s Health Insurance Program (CHIP), projects health care savings of $866 billion over a decade. The Budget proposes no significant cuts to Medicare; however, it does repeal the Independent Payment Advisory Board (IPAB) and provides $1.3 billion to implement Medicare appeals reforms. Additionally, the Administration notes that it wants to work with Congress to develop a legislative proposal on 340B drug discount program integrity, while making sure that benefits from the “Round Three” Health Reform program are targeted to Vehicles Pass House help the right patients. Both On May 24, the House Ways and Democrats and Republicans Invite members of Congress now Means Committee advanced have expressed concerns “phase three” legislation as about the President’s to visit your hospital during part of its broader ACA repealBudget’s steep cuts to the August recess! Your constituent and-replace effort. On May 24, medical research and other voice is essential to our the Committee approved H.R. domestic programs and, 2581, introduced by Rep. Lou not surprisingly, leaders effective advocacy. Barletta (R-PA) to require the of the Congressional Social Security Administration Appropriations Committees and Homeland Security to have indicated they will verify an individual’s eligibility for Ways and Means Committee develop their own proposals for FY 2018 health insurance exchange premium tax Holds Hearing on MedPAC funding. credits; H.R. 2372, introduced by Rep. Recommendations and Medicare Sam Johnson (R-TX) to allow veterans to Advantage On June 8, 2017, Department of Health receive subsidies if they are not enrolled On May 18, the House Ways and Means and Human Services (HHS) Secretary in coverage through the Department Committee Health Subcommittee held Tom Price appeared before two key of Veterans Affairs (VA); and H.R. 2579, a hearing on the Medicare program, Congressional Committees to discuss introduced by Rep. Pat Tiberi (R-OH) payment systems, and the Medicare President Trump’s FY 2018 Budget request to authorize subsidies for individuals extenders. Mark Miller, executive director for health-related funding. Members of receiving coverage under COBRA. of the Medicare Payment Advisory the Senate Finance and House Ways Commission (MedPAC), testified before and Means Committees delved into a On June 13, the House began the Committee on the Commission’s wide range of issues connected to the consideration of the bills and passed March 2017 Report to Congress. Several President’s Proposed FY 2018 Budget. H.R. 2581, the Verify First Act, mostly Republicans pushed back against Both hearings struck similar tones with along party lines by a vote of 238-184. MedPAC’s recommendations, with Rep. Republicans and Democrats on both The remaining bills are expected to be Peter Roskam (R-IL) stating that the Committees pressing Secretary Price taken up by the House shortly. Commission’s recommended 5-percent on a wide array of issues related to not cut to IRF payments is “difficult to only the President’s Budget proposal, CHRONIC Care Act Advances After fathom.” Democrats, meanwhile, used but also the House-passed AHCA. Senate Committee Vote the hearing to criticize the American The Budget and AHCA’s treatment of On May 18, the Senate Finance Health Care Act (AHCA) and to press for Medicaid was a chief topic of discussion Committee voted 26-0 to advance the action on drug prices. at both hearings. Democrats expressed CHRONIC Care Act (S. 870), legislation their continued opposition to proposed 7

that aims to improve Medicare’s payment policies for patients with chronic conditions. The bill would: extend the Independence at Home demonstration; expand telehealth services for stroke and dialysis patients; permanently authorize Special Needs Plans (SNPs); expand the Value-Based Insurance Design (VBID) model; and provide for prospective beneficiary assignment for Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). In its current form, the bill is expected to be budget-neutral, as most of its costs will be offset using money from the Medicare Improvement Fund. The legislation now advances to the full Senate, but it is unclear when the bill will receive floor consideration. CMS Releases Proposed MACRA Regulation for Program Year Two On June 20, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule providing CY 2018 updates to the Quality Payment Program, as established under the Medicare Access and CHIP Reauthorization Act (MACRA). The proposed rule includes a number of changes intended to increase flexibility and reduce burdens for doctors and clinicians, including the continued “pickyour-pace” option that allows physicians to report on minimal amounts of quality data without being subject to a penalty. CMS also proposes a new reporting option that creates a “virtual group”

bringing together solo practitioners with other clinicians to combine their patient care information in order to meet MACRA group requirements. Comments are due on August 21, 2017. Two New Members Appointed to MedPAC On May 24, the Government Accountability Office (GAO) on May 24 announced the appointment of two new members to the Medicare Payment Advisory Commission (MedPAC). David Grabowski, PhD, a professor in the Department of Health Care Policy at Harvard Medical School, and Dana Gelb Safran, ScD, Chief Performance Measurement and Improvement Officer and Senior Vice President, Enterprise Analytics, at Blue Cross Blue Shield of Massachusetts, received appointments to the Commission. Their terms expire in April 2020. CMS Issues Further Mandatory Demonstration Delays On May 18, CMS issued a notice that further delayed the start of the cardiac care and episode payment models (EPMs) from October 1, 2017 to January 1, 2018. CMS also delayed aspects of the Comprehensive Care for Joint Replacement (CJR) model until January 1, 2018. CMS’ Home Health Pre-Claim Review demonstration has been put on hold as of April 1, 2017. According to an updated FAQ document released last

month, CMS is considering structural improvements to the demonstration in response to stakeholder feedback. This series of delays effectively postpones last year’s final rule, which would expand CJR to SHFFT (hip fracture)/EPMs, as well as make other changes to the model, such as who can be a collaborator in the CJR model. That said, the delay does not impact the original CJR program, which is ongoing. It still remains to be seen whether the Administration will move to make the program voluntary and make other substantive changes at some point. *** As we go to press, it is so important that individual AMRPA members engage in meeting with your Members of Congress. Value Based Purchasing legislation continued to loom as a genuine threat and it is critically important that you meet with your Members, and develop strong relationships. Invite them now to visit your hospital during the August recess! Your constituent voice is essential to our effective advocacy. Thank you in advance for your efforts. Regards, Martha M. Kendrick

AMRPA Magazine July 2017

STUDY EXAMINES OUTCOMES IN FREESTANDING REHABILITATION HOSPITALS VERSUS HOSPITAL-BASED UNITS

Postacute Discharge Following published (HSR).

recent research study examined patient outcomes in freestanding rehabilitation hospitals and hospital-based units. The study “Effects of AcuteContinuity on Community and 30-Day Rehospitalization Inpatient Rehabilitation” was in Health Services Research

The authors sought to examine the effects of hospital-level acute–postacute continuity on probability of community discharge and 30-day rehospitalization following inpatient rehabilitation. The researchers used national Medicare enrollment, claims and assessment data to study 541,097 patients discharged from 1,156 inpatient rehabilitation hospitals and units (IRH/Us) in 2010 and 2011. The researchers calculated hospital-level continuity as the percentages of an IRF’s patients admitted from each contributing acute care hospital. Patients were categorized into three groups:

1. Low continuity (<26 percent from same hospital that discharged the patient) 2. Medium continuity (26–75 percent from same hospital) 3. High continuity (>75 percent from same hospital) The multivariable models included an interaction term to examine the potential moderating effects of hospital type (freestanding hospital vs. hospital-based rehabilitation unit) on the relationships between hospital-level continuity and two outcomes: community discharge and 30day rehospitalization. Conclusions The study found that Medicare beneficiaries in hospital-based rehabilitation units were more likely to be referred from a highcontributing hospital compared to those in freestanding rehabilitation hospitals. However, the association between higher acute–postacute continuity and desirable outcomes is significantly better in freestanding rehabilitation hospitals than in hospital-based units. Both observed

referral patterns and continuity-related benefits differed markedly by provider type. According to the authors, these findings provide a starting point for health systems establishing or strengthening acute–postacute relationships to improve patient outcomes in this new era of shared accountability and public quality reporting programs. The study was funded by Funded by the National Institutes of Health (Grant Number: NIH: P2C HD065702, R01 HD069443) and the National Institute on Disability, Independent Living, and Rehabilitation Research. (Grant Number: NIDILRR: 90IF0071). For the abstract Effects of Acute-Postacute Continuity on Community Discharge and 30-Day Rehospitalization Following Inpatient Rehabilitation, please see http:// onlinelibrary.wiley.com/doi/10.1111/14756773.12678/abstract

AMRPA PAC MARKET ANALYSIS REPORTS Market Analysis of Medicare Post-Acute Care (PAC) Referral Patterns, Episode Spending, Performance Measures and Impact of Medicare Bundled Payment Models Using Medicare claims data, Dobson DaVanzo & Associates will deliver inpatient rehabilitation providers with general market-level analysis on their facilityâ&#x20AC;&#x2122;s episode spending and key performance metrics which can be benchmarked against state and national inpatient rehabilitation providers. Also, Dobson DaVanzo & Associates can help facilityâ&#x20AC;&#x2122;s understand how the Bundled Payment for Care Improvement (BPCI) initiative and the Comprehensive Care for Joint Replacement Payment Model (CJR) are impacting the markets.

PAC MARKET ANALYSIS PRICING AMRPA Members Non-Members First hospital cost

$4,950

$7,300

Each additional hospital cost

$2,500

$4,500

For questions about the AMRPA PAC Market Analysis Reports or to submit a completed subscription agreement, please contact Mimi Zhang, AMRPA Policy and Research Associate, at mzhang@amrpa.org. For more information, visit www.amrpa.org/Resources-Communication/AMRPA-PAC-Market-Analysis-Reports

THE BETTER CARE RECONCILIATION ACT OF 2017 VS. THE AMERICAN HEALTH CARE ACT SUMMARY OF KEY DIFFERENCES

n June 22, 2017, Senate Republicans released a discussion draft of their proposal to repeal and replace the Affordable Care Act (ACA), titled the “Better Care Reconciliation Act of 2017” (BCRA). The proposal retains a number of provisions from the House passed American Health Care Act (AHCA). Beyond the title change, there are notable differences in the Senate’s bill, including a slower phase-out schedule for the Medicaid expansion, retention of the ACA’s premium subsidy structure, somewhat reduced State waiver flexibility, and delayed implementations of effective dates for certain ACA tax provisions. The Congressional Budget Office is expected to release its cost estimate for the BCRA shortly. Senate Majority Leader Mitch McConnell aims to get a floor vote before the July 4th recess, but early resistance from conservative Senators Ted Cruz (R-TX), Rand Paul (R-KY), Mike Lee (R-UT), and Ron Johnson (R-WI) threatens the BCRA’s passage. Several Senators who expressed concerns during the drafting process have yet to publicly comment on the discussion draft. Changes and floor amendments to the discussion draft are expected. Like the AHCA, the BCRA would not repeal ACA in its entirety — partially due to conscious policy decisions, but also because of procedural limits within Senate Budget Reconciliation rules. For instance, both the AHCA and the BCRA would maintain some of the “popular” insurance market reforms in Title I of ACA, such as: rules requiring issuers to offer dependent coverage until age 26; prohibitions on annual and lifetime limits; and prohibition of discrimination based on race, nationality, disability, or sex. Further, neither bill proposes changes to any Medicare provisions from Title III of ACA, such as those implementing quality

and valuebased provider payment reforms (many of which are budget neutral), the Center for Medicare and Medicaid Innovation, and provider rate cuts (repeal of which would add to the deficit outside of the ten-year budget window, in violation of procedural rules).

would have an average actuarial value of 58%. •

Health Savings Accounts (HSAs) – The BCRA would maintain three HSA expansion provisions from the AHCA, including: (1) increasing contribution limits from the current $3,400 for individuals and $6,750 for families in 2017 to the out-of-pocket maximum amounts (currently $6,550 for an individual and $13,100 for a family); (2) allowing both spouses to make catch-up contributions to the same HSA; and (3) allowing individuals up to 60 days to establish an HSA upon enrolling in HSAeligible coverage to be reimbursed from their account for medical expenses. These changes would be effective in January 2018.

•

Continuous coverage incentive – The AHCA replaced the ACA’s individual mandate with a continuous coverage incentive that resulted in a penalty for individuals who did not maintain continuous insurance coverage. The BCRA repeals the individual mandate, but also eliminates any penalties for failing to purchase health insurance. This is an area where the draft may be modified before it reaches a final version.

•

Cost sharing subsidies – Unlike the AHCA, the BCRA extends costsharing subsidy payments, which reduce premiums and deductibles for low-income individuals, until December 31, 2019.

•

State innovation waivers – The BCRA seeks to provide states with better and more efficient access to the ACA’s Section 1332 state innovation waivers by eliminating the requirement that waivers be codified in state law. Section 1332 waivers include waivers of ACA requirements like essential health benefits, actuarial values, and

The BCRA’s reforms fall into three broad categories described below. Coverage and Affordability in the Individual and Small Group Market While the BCRA’s market-based provisions mirror many of those in the AHCA, they also include several significant changes. For instance, the BCRA maintains the AHCA’s increase in the maximum premium variation based on age from 3:1 to 5:1 in 2019, with the option for states to provide for other age rating requirements. Like the AHCA, the BCRA also would repeal the ACA’s individual and employer mandates. Notably, however, the BCRA does not include the AHCA waivers that would allow states to engage in health status underwriting for individuals who do not maintain continuous coverage. Below is a brief summary of the differences between the House and Senate bills. •

Tax credits – The AHCA created a system of age based tax credits. The BCRA instead relies on the existing ACA system of federal tax credits. However, the BCRA’s credits are based on age, income, and geographic location. Eligibility for the subsidies is scaled back to include households with incomes under 350% of the federal poverty level (FPL), and like the ACA, the subsidies are tied to a benchmark plan. However, the BCRA benchmark provides much less coverage — under the ACA, the benchmark plan was based on an actuarial value (average percentage of annual health expenses covered) of 70% while the BCRA benchmark plan

exchange requirements. The BCRA would allow states to waive these provides if the state describes how it would “provide for alternative means of, and requirements for, increasing access to comprehensive coverage, reducing average premiums, and increasing enrollment,” a lower standard than under the ACA.

for bronze, silver, gold, and platinum plans) after December 31, 2019. •

The BCRA also appropriates $2 billion for 2017 through 2019 to allow states to submit waiver applications and to use the long-term stability fund to carry out innovation waiver plans. The BCRA allows for an expedited approval process if the Secretary determines it is necessary and requires all waivers to be approved, unless they will increase the federal deficit. Waivers are granted for an eight year period, unless a state requests a shorter period, with automatic renewals upon application. Finally, the BCRA provides that 1332 waivers approved prior to enactment will be governed under the ACA parameters. •

•

Preexisting conditions – The ACA’s prohibition on charging higher premiums or denying coverage based on existing medical conditions seems to remain intact under the BCRA. However, this does not guarantee that someone will not be denied coverage for a preexisting condition. The discussion draft grants states more flexibility with respect to other insurance rules, such as the establishment of basic benefits packages and minimum payments insurers must make toward medical bills. To the extent that states modify essential health benefits under a waiver, this could weaken preexisting condition protections if certain benefits are not included. However, the Senate does not maintain the AHCA provision which allowed states to request a waiver to engage in health status underwriting for individuals who did not maintain continuous coverage. Actuarial value standards – Unlike the AHCA, the BCRA does not address the ACA’s actuarial value standards. The AHCA would have repealed these standards (which establish mandatory actuarial values

Small business health plans – The BCRA would amend the Employee Retirement Income Security Act of 1974 (ERISA) to allow for the creation of small business health plans, which means, “a fully insured group health plan, offered by a health insurance issuer in the large group market” whose sponsor meets specified requirements. The BCRA would require the Secretary to establish a certification process no later than 6 Year

The second fund, aimed at ensuring long-term stability, would appropriate $62 billion from 2019 to 2026. Funding would be front-loaded and allocated as follows:

Long-Term Fund Appropriation

Total Appropriation (including Short-Term Fund)

2018

$15,000,000,000

2019

$8,000,000,000

$23,000,000,000

2020

$14,000,000,000

$24,000,000,000

2021

$14,000,000,000

$24,000,000,000

2022

$6,000,000,000

2023

$6,000,000,000

2024

$5,000,000,000

2025

$5,000,000,000

2026

$4,000,000,000

months after the date of enactment. •

Opioid funding – The BCRA appropriates $2 billion in 2018 for the Secretary to distribute grants to states to support substance use disorder treatment and recovery support services. This is different than the AHCA, which earmarked $15 billion over 10 years for mental health, substance abuse, and maternity care.

•

Prevention and Public Health Fund – Like the AHCA, the BCRA would end the ACA’s $1 billion in funding for the Prevention and Public Health Fund, but one year earlier than the AHCA in October 1, 2017 (FY 2018).

•

issuers to address coverage and access disruption and respond to urgent health care needs” with no state matching requirement. Insurers would be required to apply for the short-term stability fund, with applications for 2018 due within 35 days of the BCRA’s enactment.

Stability funds – Unlike the AHCA’s “Patient and State Stability Fund,” the BCRA would create two funds geared towards stabilizing insurance markets. First, the short-term stability fund would appropriate $50 billion over four years ($15 billion annually in 2018 and 2019 and $10 billion annually for 2021 and 2022) to the Centers for Medicare and Medicaid Services (CMS) to “fund arrangements with health insurance

Beginning in 2022, states would be required to match funding, initially at a 7% rate and increasing to 35% in 2026. The long-term fund dollars could be used to provide financial assistance to high-risk individuals, make payments to health care providers, or to reduce cost-sharing. States would be required to complete a one-time application that is subject to automatic renewal. However, the entire short-term stability fund ($50 billion) and $15 billion of the long-term fund must be used to stabilize premiums and insurance markets. Medicaid Expansion and Federal Participation The BCRA proposes many of the Medicaid changes included in the AHCA, such as the sunset of the essential health benefits requirements for Medicaid plans effective January 1, 2020. The BCRA also retains the conversion of Medicaid to a per capita cap system with optional block grants for certain populations, as well as the AHCA’s optional work requirement. Key differences between the BCRA and the House-passed bill are: •

Presumptive eligibility – Like the AHCA, the BCRA would allow state Medicaid plans to conduct AMRPA Magazine July 2017

eligibility determinations every 6 months and provides a 5% increase in the federal medical assistance percentage (FMAP) for states that elect this option. However, the BCRA gives states more flexibility by allowing them to make eligibility redeterminations after fewer months. •

•

Medicaid expansion freeze – The AHCA would freeze Medicaid expansion after March 1, 2017, by eliminating the state option to expand and receive enhanced FMAP payments. By contrast, the BCRA would not freeze Medicaid expansion, allowing states to enroll and cover individuals up to 133 percent FPL through December 31, 2017. States that had not expanded their programs as of March 1, 2017 could opt to do so, but would receive their regular matching rate to cover new enrollees.

enrollee categories established by the AHCA: (1) elderly; (2) blind and disabled; (3) children; (4) expansion enrollees; and (5) other non-elderly, nondisabled, non-expansion adults. However, the BCRA includes several key differences: • Medically complex children would be carved out from the cap. • The baseline for the cap would no longer be based on state FY 2016 spending trended forward by the medical consumer price index (CPI-M) to 2019 in each enrollee category. Instead, the BCRA cap baseline is a period of 8 consecutive quarters between 2014 and the second quarter of 2017 selected by the state. • The growth factor for the cap is altered. Under the BCRA, from FY

2020. Similar to the AHCA, states would be subject to minimum requirements, but they also would retain the ability to set eligibility and minimum benefits, and general funding will remain the same. The key difference is that, under the BCRA, before the Secretary of HHS may approve a block grant proposal, it must be made public for a 30 day notice-and-comment period. Medicaid managed care waivers – Unlike the AHCA, the BCRA permits states that have grandfathered managed care waivers to continue to implement the managed care delivery system that is subject to the waiver without reapplying to the Secretary, as long as the waiver’s terms and conditions are not modified. A managed care waiver is deemed “grandfathered” if the provisions of the waiver or demonstration project under Section 1115 of the ACA were approved as of January 1, 2017, and have been renewed by not the Secretary no less than one time. •

Phase-out of FMAP – Unlike the AHCA, the BCRA would provide Like the AHCA, the BCRA would a prolonged phaseout repeal ACA in its entirety — of enhanced federal partially due to conscious policy Medicaid funding for states. Under the AHCA, decisions, but also because of states that have already procedural limits within Senate expanded could keep the enhanced match Budget Reconciliation rules. for expansion enrollees until December 31, 2019, but after that would receive an enhanced FMAP 2020 to FY 2024, the per capita • only for individuals enrolled as cap would increase annually by of December 31, 2019, who do the CPI-M for expansion adults, not become disenrolled for more children and other adult enrollee than a month (“grandfathered categories. The cap would grow expansion enrollees”). The BCRA annually by medical inflation plus maintains the enhanced FMAP for one percent. Then, beginning the Medicaid expansion population in FY 2025, the per capita cap until December 31, 2020, after which would grow more slowly for enhanced funding would be phased all enrollee categories at the down from 85% to 75% over three general consumer price index years (2021-2023). No enhanced rate. The BCRA would impose funding would be available to states deeper Medicaid cuts than the after December 31, 2023. AHCA because it utilizes a slower • annual growth rate for payments Per capita cap – Like the AHCA, made to states. the BCRA would convert federal funding for Medicaid to a per capita • Optional block grant, “Medicaid cap model, unless a state chooses Flexibility Program” – Similar to to receive block grant funding for the AHCA, the BCRA would give children and non-expansion adult each state the option to receive enrollees, beginning in FY 2020. The block grant funding for its “other • BCRA also would maintain the five adult” and children populations in

• Home and community based service waivers – The BCRA directs the Secretary to implement procedures to encourage states to adopt or extend waivers to make home and community-based services available. Medicaid DSH allotments – The AHCA would repeal the Medicaid disproportionate share hospital (DSH) payments for non-expansion states in 2018 and for expansion states in 2020. The BCRA instead would exempt non-expansion states from scheduled reductions in DSH payments from FY 2021 through 2024, and provide an increase in DSH payments for non-expansion states in FY 2020 based on each state’s Medicaid enrollment. Provider tax – The BCRA reduces permissible Medicaid provider taxes from 6% under the ACA in 0.2% increments beginning in 2021 to ultimately reduce the tax to 5% in FY 2025. There was no such similar provision in the AHCA. State performance bonus payments 13

– Unlike the AHCA, the BCRA would provide an $8 billion pool for bonus payments to state Medicaid and CHIP programs for FY 2023 through 2026. The Secretary could use these funds to increase federal matching rates for states that have lower than expected expenses under the per capita cap allotment, report applicable quality measures, and have a plan to use the additional funds on quality improvement. •

Optional

assistance

for

certain

inpatient psychiatric services – The BCRA would provide optional state Medicaid coverage of inpatient psychiatric services for individuals between the ages of 21 and 65. The coverage would not exceed 30 days in any month or 90 days in any calendar year. To receive the assistance, a state must maintain its number of licensed psychiatric beds as of the date of the BCRA’s enactment, and maintain current levels of funding for inpatient services and outpatient psychiatric

House Bill AHCA

services. The BCRA also provides a lower match for such services (50%) furnished on order after October 1, 2018. Revenue and Tax Provisions Generally, the BCRA’s tax provisions are similar to those included in the AHCA. However, the BCRA does make several changes, such as delaying the repeal of the Additional Medicare Tax. Below is a chart of key differences between the tax provisions in the House and Senate legislation.

Senate Bill BCRA

Cadillac Tax

Delays effective date to January 1, 2026.

Health Insurance Tax

Repeals tax, effective after December 31, 2016.

Medical Device Tax

Repeals tax, effective after December 31, 2016.

Repeals tax, effective after December 31, 2017.

Medicare Hospital Insurance Surtax

Repeals tax, effective after December 31, 2022.

Repeals tax increase, effective after December 31, 2022.

Pharmaceutical Manufacturer Tax Repeals tax, effective after December 31, 2016.

Repeals tax, effective after December 31, 2017.

Deductions for Expenses Allocable to Medicare Part D

Reinstates deduction, effective after December 31, 2016.

Medical Expense Deduction

Decrease AGI threshold, effective in 2017.

Flexible Spending Accounts (FSA)

Repeals contribution limits, effective after December 31, 2016.

Repeals contribution limits, effective after December 31, 2017.

Health Savings Accounts (HSA)

Returns to pre-ACA rate, effective after December 31, 2016.

Decreases to 10 percent, effective after December 31, 2016.

Increases yearly contribution limit, effective December 31, 2016.

Increases yearly contribution limit, effective after December 31, 2017.

Repeals exclusion for over-thecounter drugs, effective after December 31, 2016.

Health Insurance CEO Deduction

Repeals tax, effective after December 31, 2016.

Tanning Tax

Repeals tax, effective after June 30, 2017.

Repeals tax, effective after September 30, 2017.

OTC Tax

Repeals tax, effective after December 31, 2016.

AMRPA Magazine July 2017

15TH ANNUAL AMRPA EDUCATIONAL CONFERENCE & EXPO

OCTOBER 23-25, 2017 • SWISSÔTEL

EARLY BIRD REGISTRATION EXTENDED! Register by July 31 and save $100 on your registration fees. www.amrpa.org

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

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

Learn from other rehab professionals' experiences with issues impacting the post-acute care industry. Questions? Please contact Rachel Koresky, AMRPA Member Services Coordinator, at rkoresky@amrpa.org. To discuss exhibit and sponsorship opportunities, contact Samantha Schwarz at sschwarz@amrpa.org or 202-207-1132. 15

REPEAL OF MEDICARE OUTPATIENT THERAPY CAPS ONCE AGAIN IN THE HANDS OF CONGRESS

he perennial problem of the Medicare outpatient therapy caps once again needs to be addressed before Congress adjourns at the end of this calendar year. If no action is taken, the caps will go into effect for the first time since their inception (with the exception of a brief three-month period more than a decade ago). The legislation to repeal the current therapy caps and exceptions process, the Medicare Access to Rehabilitation Services Act of 2017 (H.R. 807/S. 253), was introduced in both the House and the Senate on February 1, 2017. The bipartisan House bill was introduced by Rep. Paulsen (R-MN) and Rep. Kind (D-WI) and has 158 co-sponsors. The bipartisan Senate bill was introduced by Sen. Cardin (D-MD) and Sen. Collins (R-ME) and has 26 co-sponsors. Both bills simply repeal outright the Medicare therapy caps. But all parties agree that such a bill would do nothing to limit utilization of therapy services and would cost too much to pass. Therefore, while supporters are rallying around the repeal bills, stakeholders are working on an amendment that would lift the caps while limiting the benefit in some manner that will reduce the cost of the bill. Known as the Cardin Amendment in the 114th Congress, this alternative language relied heavily on prior authorization of therapy services for “aberrant” billers. But this approach was controversial with many consumer and provider stakeholders, including AMRPA. This year’s alternative language, known as the Cardin Amendment 2.0, makes several revisions that are favorable to rehabilitation providers and beneficiaries. If passed, it would extend the therapy cap and current exceptions process until December 31, 2018. Beginning January 1, 2019, the therapy cap and exceptions process would be replaced with a targeted medical review process (pre- and 16

post-payment review) for aberrant billers. However, there is some concern that this approach will not produce enough savings in the eyes of the Congressional Budget Office (CBO). This concern is prompting additional proposals that may eventually take the form of a new Cardin Amendment “3.0”. History of the Medicare Outpatient Therapy Caps and Exceptions Process In 1997, as a result of the Balanced Budget Act, Congress capped the benefit for Medicare outpatient rehabilitation services (excluding hospital outpatient services until recently, when the caps were applied to these settings as well). The purpose of this policy was to address alleged overutilization of the benefit, limit Medicare spending in order to balance the federal budget, and improve the solvency of the Medicare Trust Fund. Congress established one cap of $1,500 for physical therapy and speech language pathology services combined, and another $1,500 cap for occupational therapy services. Congress later delayed implementation of these caps on multiple occasions by placing a moratorium on their enforcement until 2006. The Deficit Reduction Act of 2005 (DRA) implemented the caps but coupled them with a new “exceptions process” to ensure beneficiary access to vital rehabilitation services for those whose treatment needs exceeded the therapy caps. The therapy caps and exceptions process has been extended numerous times to the present day. By all accounts, the exceptions process is working well and achieving its intended purpose of permitting Medicare beneficiaries to receive the amount of therapy needed, but fiscally, the exceptions process is not sustainable over the long term. In 2017, annual inflation adjustments have brought the therapy cap limits to $1,980 for each cap. Outpatient therapy “thresholds” of $3,700 per episode were also established to further limit alleged overutilization.

Once a beneficiary exceeds this threshold, Medicare contractors are permitted to perform targeted claims reviews (i.e., audits) of providers who submit these claims. For years, annual extensions of the therapy caps and exceptions process rode along with the annual legislation to fix the Medicare Sustainable Growth Rate (SGR) formula for physician payment, which was a compelling political issue that Congress was always expected to pass, and did. Now that the physician fee schedule fix has been permanently resolved in the Medicare Access and CHIP

ABOUT THE AUTHORS

Peter W. Thomas Principal, counsel to the AMRPA Consumer and Clinical Affairs Committee

Steve Postal Director, Health Policy, Powers Law Firm AMRPA Magazine July 2017

Reauthorization Act of 2015 (MACRA), therapy cap stakeholders must find another legislative vehicle on which to ride. MACRA extended the therapy caps exceptions process through December 31, 2017. If Congress passes no further legislation, the full caps will be imposed beginning in January 2018. Therefore, a fix to the therapy caps will have to be enacted this year, presumably along with a long list of other Medicare policies that will also need to be extended, commonly referred to as “Medicare extenders.”

The Proposed Cardin Amendment 2.0 The proposed Cardin Amendment 2.0 addresses many of the concerns raised by consumer and provider organizations, including AMRPA, with the first Cardin Amendment. Both amendments would permanently repeal the therapy caps and set in statute a $3,700 “threshold” of services starting in 2019 (adjusted for inflation annually using the Medicare Economic Index (MEI)) over which therapy claims would be subject to additional scrutiny. Notably, Cardin 2.0:

This revised language is intended to protect against therapy practices being targeted for medical review when they simply serve a disproportionate number of patients with brain injury, spinal cord injury, stroke, or other high users of care. On balance, it is an improvement over the original Cardin Amendment. However, with the Medicare appeals process hopelessly backlogged, there may be providers under this approach whose error rates would be much lower if they received timely Administrative Law Judge hearings and decisions. In addition, this approach may not authorize CMS to perform reviews it is not already authorized to perform, in which case, the CBO would not likely score the bill as a major saver. Finally, the Cardin Amendment 2.0 would prohibit Recovery Audit Contractors (RACs) from performing medical review on therapy providers who exceed the thresholds. This is because RACs are financially incentivized through a contingency fee payment scheme that lends itself to potential abuse.

As already stated, the current exceptions • Does not include prior authorization, process provides an effective solution for which in turn reduces the likelihood beneficiaries in need of therapy services of delays in patient access to care. that exceed the caps. An extensive list Treatment delayed often translates of condition codes determines which into treatment denied when it comes patients can receive therapy beyond to rehabilitation. In its place, Cardin the cap, as long as the services can be 2.0 would impose pre-payment documented as medically necessary. The and post-payment claims review on fact that the exceptions process is currently aberrant billers. effective provides a fall-back strategy of simply further extending the exceptions process, if enactment of the Cardin Amendment 2.0 is not possible politically. While this would not solve the problem If no action is taken, the caps permanently, it would advance will go into effect for the first time the issue for another year since their inception (with the or two, a strategy that has demonstrated results for the exception of a brief three-month past 20 years since the caps period more than a decade ago). were first implemented. The Original Cardin Amendment The original Cardin Amendment relied on prior authorization of claims submitted by “aberrant” billers, i.e., therapy providers that provide a disproportionate amount of services. AMRPA and other stakeholders had three major concerns with this proposal: •

The fact that prior authorization would be applied to therapy services for the first time, setting a precedent;

•

The fear that prior authorization would result in potential delays in patient treatment; and,

•

The concern that “aberrant” billers might misidentify for prior authorization specialty therapy practices that focus on high users of therapy services (i.e., patients with spinal cord injuries, brain injuries, stroke, etc.).

•

Modifies how the original Cardin Amendment defined “aberrant” billers. In determining which providers are considered aberrant billers, CMS will consider case mix of the therapy provider and compare therapy providers: o Whose pattern of billing is aberrant compared to peers or otherwise has questionable billing practices (in the case of post-payment review); and o For which there is consistently high utilization and aberrant billing patterns, and the provider has previously been the subject of targeted review and continues to have a persistent high error rate (in the case of pre-payment medical review).

Conclusion Despite fairly positive reactions to Cardin 2.0 from the beneficiary and provider community, concern among Congressional staff centers on the potential lack of savings Cardin 2.0 might achieve. An outright repeal of the therapy caps would cost between $16 to $20 billion over ten years. The first Cardin Amendment (which included prior authorization) would have cost $11 billion. While still a major line item, the reduced cost of this provision engendered significant support on both sides of the political aisle. Congressional staff have been signaling that a third alternative may be needed, one that combines targeted medical review after the thresholds have been exceeded with more limited prior authorization of providers whose error rates persist. This would likely save more money than Cardin 2.0 but it would also reintroduce the concept of prior authorization in the provision of Medicare outpatient therapy services. Expect accelerated action as Congress grapples with the end-of-the-year deadline to resolve this issue.

CMS TRANSMITTALS OF INTEREST FOR MEDICAL REHABILITATION PROVIDERS

July 2017

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

Issue Date

Subject

Implementation Date

R287FM

2017-06-09

Removal of Contractor Requirement to Submit Opt Out Data into the Contractor Reporting of Operational and Workload Data (CROWD) System (Form 8)

2017-07-11

R286FM

2017-06-09

Medicare Financial Management Manual Chapter 4, Section 20 Demand Letter Updates

2017-07-03

R169SOMA

2017-06-09

New to State Operations Manual (SOM) Appendix Z, Emergency Preparedness for All Provider and Certified Supplier Types

2017-06-09

R235BP

2017-06-09

Removal of Contractor Requirement to Submit Opt Out Data into the Contractor Reporting of Operational and Workload Data (CROWD) System (Form 8)

2017-07-11

R3792CP

2017-06-09

July 2017 Update of the Ambulatory Surgical Center (ASC) Payment System

2017-07-03

R721PI

2017-06-09

Elimination of Routine Reviews Including Documentation Compliance Reviews and Instituting Three Medical Reviews

2017-07-11

R3788CP

2017-06-02

July 2017 Update of the Ambulatory Surgical Center (ASC) Payment System

2017-07-03

R285FM

2017-06-02

Pub. 100-6, Chapter 3 and 4 Revisions

2017-07-01

R105GI

2017-06-02

Update to General Information, Eligibility, and Entitlement, Chapter 7 Contract Administrative Requirements, Section 40 â&#x20AC;&#x201C; Shared System Maintainer Responsibilities for Systems Releases

2017-07-03

R3782CP

2017-05-26

Claim Status Category and Claim Status Codes Update

2017-10-02

R3781CP

2017-05-26

Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE)

2017-10-02

R3780CP

2017-05-26

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

2017-10-02

R722PI

2017-05-26

Clarifying Date and Timing Requirements for Certain Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS)

2017-06-27

R1854OTN

2017-05-26

ICD-10 Coding Revisions to National Coverage Determinations (NCDs)

N/A

R196NCD

2017-05-26

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

2017-06-27

R3783CP

2017-05-26

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

2017-07-03

R3784CP

2017-05-26

Instructions for Downloading the Medicare ZIP Code File for October Files

2017-10-02

R3786CP

2017-05-26

Common Edits and Enhancements Modules (CEM) Code Set Update

2017-10-02

R3787CP

2017-05-26

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

2017-06-27

R104GI

2017-05-26

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

2017-10-02

R3778CP

2017-05-24

Screening for the Human Immunodeficiency Virus (HIV) Infection

2017-10-02

AMRPA Magazine July 2017

R3779CP

2017-05-24

Instructions to Process Services Not Authorized by the Veterans Administration (VA) in a Non-VA Facility Reported With Value Code (VC) 42

2017-04-03

R718PI

2017-05-19

Reviewing for Adverse Legal Actions (ALA)

2017-06-20

R174DEMO

2017-05-19

Payment of G9678 (Oncology Care Model Monthly Enhanced Oncology Services) Claims for Beneficiaries Receiving Care in an Inpatient Setting

2017-10-02

R3776CP

2017-05-19

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/ Biological Code Changes - July 2017 Update

2017-07-03

R173DEMO

2017-05-19

Medicare Care Choices Model - Per Beneficiary per Month Payment (PBPM) Implementation (eligibility updates and clarification)

2017-10-02

R3777CP

2017-05-19

July 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.2

2017-07-03

R1851OTN

2017-05-17

Shared System Enhancement 2015: Identify Inactive Medicare Demonstration Projects Within the Common Working File (CWF)

N/A

R1852OTN

2017-05-17

Update FISS Editing to Include All Three Patient Reason for Visit Code Fields

2017-10-02

R1850OTN

2017-05-16

Common Working File (CWF) to Archive Inactive Part B Consistency Edits

2017-05-16

R716PI

2017-05-12

Clarifying Medical Review of Hospital Claims for Part A Payment

2017-06-13

R1847OTN

2017-05-12

Common Working File (CWF) to reject CWF Provider Queries containing Health Insurance Claim Numbers (HICNs) starting with '9'

2017-10-02

R1849OTN

2017-05-12

Implementation of Modifier CG for Type of Bill 72x

2017-10-02

R3772CP

2017-05-12

Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July CY 2017 Update

2017-07-03

R1846OTN

2017-05-12

MCS Implementation of the Restructured Clinical Lab Fee Schedule

N/A

R3771CP

2017-05-12

New Waived Tests

2017-07-03

R714PI

2017-05-12

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

N/A

R715PI

2017-05-11

Update to Pub. 100-08, Chapter 15

2017-06-13

R1845OTN

2017-05-10

New Common Working File (CWF) Medicare Secondary Payer (MSP) Type for Liability Medicare Set-Aside Arrangements (LMSAs) and No-Fault Medicare Set-Aside Arrangements (NFMSAs)

N/A

R1840OTN

2017-05-05

Update FISS Editing to Include All Three Patient Reason for Visit Code Fields

N/A

R1841OTN

2017-05-05

Medicare Fee-for-Service Recovery Audit Contractor (RAC) Data Centers

2017-06-06

Updated as of June 15, 2017

RAND/CMS SEEK COMMENTS ON ADDITIONAL IMPACT ACT POTENTIAL STANDARDIZED DATA ASSESSMENT ITEMS By Carolyn C. Zollar, MA, JD, Executive Vice President of Government Relations and Policy Development, AMRPA

he Centers for Medicare and Medicaid Services (CMS) via its contractor the RAND Corporation (RAND) is asking post-acute care (PAC) providers to comment on a second set of potential standard patient assessment data (SPAD) pursuant to the requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). The report is titled “Development and Maintenance of PostAcute Care Cross-Setting Standardized Patient Assessment Data: Data Element Specifications for Public Comment 2, April 2017.” The IMPACT Act requires submission of standardized data on specified assessment domains and specified quality measurement domains. It states that the: “data be standardized and interoperable so as to allow for the exchange of such data among such post-acute care providers and other providers and the use by such providers of such data that has been exchanged, including by using common standards and definitions in order to provide access to longitudinal information for such providers to facilitate coordinated care and improved Medicare beneficiary outcomes….” The Act focuses on cross-setting data collection, outcome comparison and interoperable data exchange, while seeking to improve care coordination, “fostering seamless transitions, improving person-centered outcomes and goals, and providing for reliable information that may support providers in making appropriate

discharge placements.” According to RAND, standardized assessment data elements across PAC settings will subsequently support the priorities of the CMS Quality Strategy, which is built from the three broad aims of the National Quality Strategy:

3. •

•

Better Care: Improve the overall quality of care by making healthcare more patient-centered, reliable, accessible and safe Healthy People, Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher-quality care Affordable Care: Reduce the cost of quality healthcare for individuals, families, employers and government

The May issue of the AMRPA magazine discussed the next steps in implementing the IMPACT Act with respect to collecting SPAD. As a part of the project, last September RAND sought comments on an initial set of data elements, most of which were included in the Continuity Assessment Record and Evaluation (CARE) tool developed as part of the Post-Acute Care Payment Reform Demonstration project. (PAC PRD). AMRPA commented at that time. In this second comment solicitation CMS/ RAND again sought comments on the development and use of standardized data elements to meet the Act’s domains, which are as follows: 1. Functional status, such as mobility and self-care at admission to a PAC

provider and before discharge from a PAC provider Cognitive function, such as ability to express ideas and to understand and mental status, such as depression and dementia Special services, treatments and interventions, such as need for ventilator use, dialysis, chemotherapy, central line placement, and total parenteral nutrition Medical conditions and co-morbidities, such as diabetes, congestive heart failure and pressure ulcers Impairments, such as incontinence and an impaired ability to hear, see or swallow Other categories deemed necessary and appropriate by the Secretary

This Round 2 proposes 42 data items, which are drawn from various sources: •

• •

CMS research projects, such as the Post-Acute Care Payment Reform Demonstration (PAC PRD) and Developing Outpatient Therapy Payment Alternatives (DOPTA) Current PAC patient assessment instruments (PAIs), primarily the MDS Other sources such as the National Institute of Health (NIH) PROMIS data bank

In addition to general comments, CMS was specifically interested in feedback regarding the following as it was in the first round: •

Potential for improving quality, which includes consideration of the data element’s ability to improve care transitions through meaningful exchange of data between providers; AMRPA Magazine July 2017

•

improve person-centered care and care planning; be used for quality comparisons; and support clinical decision-making and care coordination Validity, which includes consideration of the data element’s proven or likely inter-rater reliability (i.e., consensus in ratings by two or more assessors) and validity (i.e., whether it captures the patient attribute being assessed) Feasibility for use in PAC, which includes consideration of the data element’s potential to be standardized and made interoperable across settings, clinical appropriateness and relevance to the work flow across settings Utility for describing case mix, which includes whether the data element could be used with different payment models and whether it measures differences in patient severity levels related to resource needs

Each domain section in the report includes the following: • •

The rationale for assessing each domain Descriptions of the assessment data elements in each section, including the following: o Current use of the data elements, including descriptions of whether it is already used in existing PAC assessment instruments o Performance of the data element, such as inter-rater and cross-setting reliability estimates o Proposed modifications to the data element, if applicable o Details on how data elements are administered and coded

The specific domains and data elements upon which RAND sought comments are as follows:

1. Cognitive Functional and Mental Status — Data elements • Items from the Developing Outpatient Therapy Payment Alternative (DOTPA) CARE tool. • Complex sentence repetition • Staff assessment of mental status • Behavioral sign and symptoms • PROMIS Anxiety Items • PHQ9-OV • PASS medication management 2. Medical Conditions: Continence- Data elements • Bladder – Device Use • Bladder – Incontinence • Bladder – Incontinence Interview • Bowel – Device Use • Bowel – Incontinence • Bowel – Incontinence Interview 3. Medical Conditions: Pain- Data elements • Pain frequency • Pain severity • Pain effect on sleep • Pain interference – therapy activities • Pain interference–other activities • Pain relief • Observational assessment of pain or distress 4. Impairments of Hearing and Vision – Data elements • Glasses/corrective lenses • Hearing aids 5. Medication Reconciliation – Data elements • Medication Reconciliation – Completion • Medication Reconciliation – Use of Medications in Specific Classes • Medication Reconciliation – Indication • Medication Reconciliation – Discrepancies

• Medication Reconciliation – Discrepancies Addressed with Patient/Resident/Caregiver Involvement • Medication Reconciliation – Discrepancies Communicated to Physician • Medication Reconciliation – Recommended Actions Taken • Medication Reconciliation – List Communicated to Patient/ Resident/Caregiver/Care Team 6. Care Preferences – Data elements • Advanced care directive — health care agent • Physician orders • Goals of care • Preference for involvement of family / friends in care decisions • Preferences for involvement in decision making 7. Patient – Reported Outcomes Measurement Information System (PROMIS ®) – Data elements • Sleep elements • Fatigue • Ability to participate in social roles and activities • Global health One serious question, however, is whether CMS intends to propose that all of these data elements and those as yet to be tested in the upcoming Beta field tests be added to the inpatient rehabilitation facility patient assessment instrument (IRF PAI). The FY 2018 inpatient rehabilitation rehabilitation facility prospective payment system (IRF PPS) proposed rule would add at least 17 items to the IRF PAI effective October 1, 2018, thereby expanding it to 24 pages. Apparently, RAND and CMS do intend to eliminate some items before the data elements from this solicitation and the field beta tests are included.

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

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

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

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

Powers Pyles Sutter &Verville PC 22Powers

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

CHRISTINA HUGHES Christina.Hughes@PowersLaw.com 202-349-4248

@PowersPylesSutterAndVervillePC

@PowersLawFirm

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

AUDIT TO-DO LIST By Lisa Werner, MBA, MS, CCC-SLP

edicare audits are occurring throughout the country. I have been in contact with a large number of providers about activity by the Recovery Audit Contractors (RAC), Supplemental Medical Review Contractors (SMRC), and Medicare Administrative Contractors (MAC). Chances are good that you are either a victim of pre-payment or postpayment reviews or you are expecting to be at any minute. If you are waiting for your first Additional Documentation Request, this article is for you. Below you will find a checklist of things to do when a request for information comes to your facility.

a. Pre-admission screen that was approved within the CMS required 48-hours prior to admission b. History and physical, and postadmission physician evaluation completed within 24-hours of the patientâ&#x20AC;&#x2122;s admission c. Orders to admit the patient to rehab on the day of admission d. Consult reports physicians

from

other

e. Physical medicine and rehabilitation physician progress notes for each visit completed at least three times per week at a minimum. These three visits should be in addition to the H&P

beginning within 36-hours of midnight of the day of admission. k. Documentation of appropriate variances for missed time or additional orders if the patient is best served with 15 hours of therapy across seven days per week l. Evidence of weekly team conference attended by all clinical staff m. Case management documentation that describes the discharge plan and progress toward meeting the plan n. Authenticated IRF-PAI filed in the chart

o. Any additional documentation 1. Discuss with your team the process that supports medical necessity for alerting appropriate such as FIM scoring sheet, lab staff when a document and x-ray results, MARs, etc comes in. The ADR 5. Once the record is copied request will likely be Chances are good that you are and arranged in the correct sent to you in a letter. either a victim of pre-payment or order, number the pages and Determine who in your create a table of contents for facility receives Medicare post-payment reviews or you are the record. Be sure to crosscorrespondence and expecting to be at any minute. reference all documents in the make sure they know the list of required documents from letter is time sensitive the additional documentation and to whom they should request letter to the names of pass it along. for the first week of the stay documents in your record. Provide 2. Quickly pull the records in f. Additional medical progress explanation if things have different question and download or copy notes titles. For example, if you include the charts. Forward the copies g. Overall plan of care completed your overall plan of care in your team to the rehabilitation director or by the end of the fourth conference documentation, make staff designated to coordinate rehabilitation day note of that in the table of contents. chart submissions. The designated h. Nursing assessments, plans of 6. Scan the record and send the person should review each chart for care, and daily treatment notes electronic record to the RAC or completeness. MAC, or send the hard copy. i. Therapy assessments, plans of 3. Review the record to ensure that care, and daily treatment notes 7. Remember that you usually are told all requested items are present. you have 30 days to respond to Assemble the chart in the order that j. Evidence of intensive therapy audits. makes sense for the reviewer. services totaling at least three4. Audit for the presence of:

hours per day, five times per week

8. Submit the records using a method 23

that allows package tracking. Follow-up to be sure the packages are received by the requester. 9. Create a tracking log of all records requested, the date submitted, the date a decision is returned, and the results. You may want to include additional information such as amount in dispute, dates of service, attending physician, and CMG/ HIPPS code. 10. For denied claims that you are appealing, include a copy of the appropriate CMS form used to request the appeal.

Once the records are submitted, watch for a reply or instructions for the next level of appeal, but please do not hold your breath. This part of the process will take up to 60 days. Again, be vigilant in looking for a response from CMS because it is vitally important that you move to the successive steps quickly in order to maintain your ability to appeal the claim and to delay recoupment. The above checklist can be used at each level of documentation submission. In addition to the chart submission, an appeal letter should accompany the appeal along with the appropriate CMS form. Ideally you would have an appeals team consisting of various members of your

treatment team. This team would review the charts to offer suggestions for items to include in your appeal letter. An additional suggestion that I can offer for preparing for audits is to do a trial run, like a fire drill. Beginning with creating a fake request letter, go through each step according to this checklist to be sure you understand where opportunities for improvement exist. Lastly, reach out to others who have experience with reviews to gain insight into potential pitfalls and lessons learned in order to create a smooth process in your facility.

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EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE AMRPA: Working Together To Preserve Access To Medical Rehabilitation Maggie Ramirez · VP ofTogether Membership Services · 347-573-3732 · mramirez@amrpa.org AMRPA: Working to Preserve Access to Medical Rehabilitation Rachel Koresky, AMRPA Member Services Coordinator | 202-591-2469 | rkoresky@amrpa.org

AMRPA Magazine July 2017

AHRQ STUDY SHOWS 54 PERCENT DROP IN INFECTIONS AMONG NURSING HOME PATIENTS

ccording to a research study published by the Agency for Healthcare Research and Quality (AHRQ), rates of catheter-associated urinary tract infections (CAUTIs) dropped by 54 percent across more than 400 long-term care (LTC) facilities that participated in a patient safety project funded by AHRQ. The study was published in JAMA Internal Medicine. The project adapted Comprehensive Unit-based Program (CUSP) for use in long-term care facilities. CUSP is designed to promote improvement in leadership, teamwork, communication and safety culture to facilitate consistent use of evidencebased practices for infection prevention.

AHRQ’s Safety

project, CAUTI rates dropped from about 6.4 to 3.3 per 1,000 catheter days. Threequarters of the facilities showed a CAUTI rate reduction of at least 40 percent, indicating that this approach could benefit a majority of long-term care facilities.

and other leaders in all long-term care facilities prevent CAUTIs. The resource is based on the experiences of facilities that participated in the project. It includes checklists and other tools and educational materials to guide facilities that seek to apply infection-reduction programs.

The researchers also found that orders for urine cultures – tests to find germs in the urine – decreased by 15 percent during the study period. Best practices encouraged in the project included avoiding urine cultures for most patients without symptoms.

“We continue to see the power of AHRQ tools to help front-line staff tackle safety problems, now in nursing homes as well as hospitals,” said Jeffrey Brady, MD, MPH, director of AHRQ’s Center for Quality Improvement and Patient Safety. “This means that some of the most vulnerable members of society – those who reside in long-term care facilities and nursing homes example of – are less likely to be harmed as into practice a result of infections.”

“This project is an translating research using innovative implementation strategies and by empowering frontline teams.”

CAUTI is a healthcareassociated infection (HAI) that is common in long-term care facilities, where up to 10 percent of residents have urinary catheters. CAUTI can sometimes lead to severe illness and hospitalization and generates significant expenses for antibiotics and hospitalizations. The infections are generally treatable with antibiotics, but long-term or repeated use of antibiotics can increase the risk of other infections as well as lead to development of antibiotic resistance. Program Analysis Data from nursing homes in 38 states were included in the new analysis. During the

“This project is an example of translating research into practice using innovative implementation strategies Lona Mody, MD, University of Michigan, VA Ann Arbor Healthcare System and by empowering front-line teams,” said Lona Mody, M.D., of the University of Michigan and VA Ann Arbor Healthcare System, lead The study of CAUTI-prevention strategies author of the study. was part of a multiyear national implementation project. The reductions The study states that previous efforts by took place during rolling 12-month AHRQ to implement CUSP and other periods from 2014 to 2016 in participating safety programs in hospitals have led community-based nursing homes. The to significant reductions in CAUTIs and contract was led by the Health Research & bloodstream infections associated with Educational Trust of the American Hospital central line catheters. Association and a team of partners. For more information about AHRQ’s work AHRQ released a Toolkit to Reduce to prevent HAIs, visit www.ahrq.gov/hais. CAUTIs and Other HAIs in Long-Term Care Facilities to assist doctors, nurses 25

AMRPA SUBMITS COMMENTS ON PROMIS DEPRESSION ITEMS Editor’s Note: On June 9, 2017, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the RAND Corporation in response to a call for stakeholder input on PROMIS depression assessment items being considered for post-acute care settings pursuant to the IMPACT Act’s requirements for crosssetting standardized patient assessment data. The complete letter is provided below and is available on the www.amrpa.org website. June 9, 2017 Wenjing Huang, PhD RAND Corporation 1776 Main Street Santa Monica, CA 90407 Dear Dr. Huang: These comments are submitted on behalf of the American Medical Rehabilitation Providers Association (AMRPA) with respect to the above captioned Request for Stakeholder Input. We welcome the opportunity to offer feedback on the development of standardized assessment items pursuant to the requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. AMRPA supports the principles and objectives of the Act and remains committed to working with the Centers for Medicare and Medicaid Services (CMS) and its contractor, the RAND Corporation, to achieve them. AMRPA is the national trade association whose members provide rehabilitation services across the spectrum of health care settings including inpatient rehabilitation hospitals and units (IRFs), hospital outpatient departments (HOPDs), and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, long-term care hospitals (LTCHs), and skilled nursing facilities (SNFs). AMRPA members help patients maximize their health, functional skills, independence, and participation in society so they can return to home, work, or an active retirement. With our Quality Committee and member clinicians, AMRPA has reviewed the list of 28 Patient-Reported Outcome Measurement Information System (PROMIS) depression items that RAND proposes for consideration for post-acute care (PAC) settings. We offer the following comments. I. PROMIS and Inpatient Rehabilitation There is a lack of strong scientific literature that the PROMIS item bank has been satisfactorily or sufficiently validated in inpatient institutional and non-community settings, and even less so for institutional PAC settings such as IRFs, LTCHs, and SNFs. The PROMIS items were designed and intended for the outpatient setting and since they have not been tested in PAC settings, it would not be psychometrically sound to extrapolate the items’ suitability 26

for PAC based on their use in outpatient settings. We do not support using PROMIS data items for the purposes of meeting the IMPACT Act’s data collection requirements, and we perceive there is a risk of negative unintended consequences for doing so. Furthermore, the use of patient-reported outcome measures (PROMs) in IRFs remains an ongoing area of research. AMRPA encourages CMS and its contractors to reference these findings, when published, to identify vetted PROMs, patient-reported data items, and application methods that are suitable for PAC settings. II. Depression Screening in Inpatient Rehabilitation While AMRPA appreciates the desirability of using standardized measures and data items across settings, we urge CMS and RAND to develop sensible approaches to do so and resist subjecting our patients to inappropriate questions that distract clinicians from meaningful work and could create misleading comparisons. We do not support the premise that using the PROMIS scale as a common depression screening tool for all PAC patients is aligned with the intended objectives of the IMPACT Act. The vast majority of IRF patients are admitted from short-stay acute care hospitals after a severe illness or catastrophic event in their lives (e.g. stroke, spinal cord injury, brain injury, multiple trauma). They have very commonly experienced a sudden and dramatic decline in function within the few days prior to the IRF admission. Hence, asking them screening questions that start with the stem “Within the last seven days have you...” is highly unlikely to yield meaningful insight into chronic depression. To paint a picture of an IRF patient, imagine someone who, five days ago, was working full time and playing competitive tennis but now find themselves with severe hemiplegia as the result of a stroke. Needless to say, the PROMIS screening questions become – at a minimum – insensitive, and are fruitless from a clinical perspective. According to our physician members, the most operant psychological response observed in IRF patients is denial or adjustment disorder/stress response syndrome, a group of symptoms such as stress, feeling sad or hopeless, and physical symptoms that can occur after one undergoes a stressful life event. It would be faulty to administer a tool such as PROMIS that was designed to identify chronic depression in outpatient settings. As requested, we reviewed and scored the depression items’ suitability for PAC and offer the following feedback on specific items: •

Items such as “I withdrew from other people” or “I had trouble feeling close to people” may lead to false positives because patients’ impairments can contribute to a sense of isolation, i.e. not being able to get out of one’s bed or room by oneself.

•

“I have trouble making decisions” is unsuitable because IRF patients may have been under the influence of medications in the acute care hospital in the days preceding their IRF admission.

AMRPA Magazine July 2017

The items “I felt sad” and “I felt depressed” received stronger support for PAC suitability from our members. However, these topics are also addressed in the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9, which CMS is already proposing to implement across PAC settings. The PHQ-2 and PHQ-9 have been tested in PAC and are also used for a subset of rehabilitation patients, such as in the Traumatic Brain Injury (TBI) Model Systems. They are also more appropriate and administratively suitable across settings since the PHQ-2 is a gateway trigger that goes into the PHQ-9 if needed. Our members report that this process is effective at determining if a psychological screen is necessary for a particular patient. The PROMIS depression scale, on the other hand, would be significantly more burdensome for all PAC patients to complete just to screen for depression. III. Impact on Care Delivery AMRPA remains concerned with the direction of PRO data collection as it is not clear how data on patients’ depressive symptoms will improve the efficiency and quality of the care they receive in PAC. As CMS and its contractors continue to develop standardized crosssetting assessment items for PAC pursuant to the IMPACT Act, we strongly urge CMS to prioritize and consider in concert both the administrative burden to providers of collecting PRO data and the data’s clinical effectiveness and utility. Conclusion AMRPA appreciates the opportunity to provide input on the

development of cross-setting PAC standardized patient assessment data items. We seek to ensure these elements achieve the data collection objectives of the IMPACT Act while being minimally burdensome for PAC providers. If you have any questions, please contact Carolyn Zollar, JD, Executive Vice President for Government Relations and Policy Development (czollar@amrpa.org) and Mimi Zhang, Policy and Research Associate (mzhang@amrpa.org) at 202223-1920. Sincerely,

Suzanne Kauserud, FACHE, MBA, PT Chair, AMRPA Quality Committee Administrator, Carolinas Rehabilitation – Charlotte Vice President, Continuing Care Division of Carolinas HealthCare System

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

THINK ABOUT IT…

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

BRIEF EXAMINES MEDICAID SPENDING FOR SENIORS AND PERSONS WITH DISABILITIES By Lovelyn M. Robinson, Research and Editorial Assistant, AMRPA

new Issue Brief, “State Variation in Medicaid Per Enrollee Spending for Seniors and People with Disabilities,” from the Kaiser Family Foundation examined the variation in Medicaid spending per enrollee for seniors, nonelderly adults with disabilities and children with disabilities, compared with other populations, as well as variation in spending for these populations among states.

spending that is roughly three times greater than their share of program enrollment (2 percent vs. 7 percent, and 12 percent vs. 36 percent), while the share of program spending devoted to seniors is more than double their share of enrollment (9 percent vs. 21 percent). The discrepancies were due to the greater health and long-term care needs of these populations, thus resulting in more intensive service use, compared with adults and children who enroll in the program based solely on their low incomes.

compared to other children ($2,399) and more than three times higher for nonelderly adults with disabilities ($9,922) compared with other nonelderly adults ($3,234). Again, these differences were due to seniors and persons with disabilities’ greater use of long-term care services compared with those without disabilities. •

Per-enrollee spending for seniors and persons with disabilities varied substantially by state.

According to the brief, Medicaid spending and enrollment are affected by Per-enrollee spending for children federal and state policy choices, as well as with disabilities ranges from $6,945 economic factors. Medicaid coverage of in Tennessee to $53,557 in New • Medicaid spending per enrollee is acute and long-term care (LTC) for more Hampshire. Seventeen states spend substantially higher for seniors and than 6 million low-income seniors and 10 less than $15,000 per enrollee for million nonelderly persons with disabilities children with disabilities, while accounts for nearly two-thirds six states spend $25,000 or more. of overall Medicaid spending, although such enrollees Per enrollee spending for represent less than a quarter nonelderly adults with disabilities Medicaid spending for seniors and of persons on Medicaid. ranges from $9,903 in Alabama persons with disabilities varied Medicaid’s spending on to $37,132 in New York. Ten seniors and persons with states spend less than $15,000 substantially by state. disabilities also depends on per enrollee for nonelderly state decisions about whom adults with disabilities while to cover and which services seven states spend $25,000 or persons with disabilities, compared to pay for, which is a big reason why more. with those without disabilities. Medicaid spending per enrollee for these Per-enrollee spending for seniors populations varies greatly from state to Per-enrollee spending for children ranges from $10,518 in North Carolina state. with disabilities totaled $16,802 in FY to $32,199 in Wyoming. Eleven states 2011, nearly seven times higher than spend less than $15,000 per enrollee Some of the key findings discussed are for other children ($2,463). for seniors, while another 11 states provided below: spend $25,000 or more. Per-enrollee spending for nonelderly adults with disabilities is more than Key Findings This variation in per enrollee spending five times higher ($16,613), and per• Seniors and persons with disabilities by state is due to state choices about enrollee spending for seniors is four together account for 23 percent of eligibility and services. Because most age times higher ($13,249), than per Medicaid enrollment but 64 percent and disability-related Medicaid services, enrollee spending for other adults of program spending as of FY 2011. such as community-based long-term care, ($3,247). are provided at state option, states could Children with disabilities and Medicaid acute care spending per potentially cut back on them if faced with nonelderly adults with disabilities enrollee is nearly six times higher for federal Medicaid funding reductions over each account for a share of program children with disabilities ($13,591) time. 28

AMRPA Magazine July 2017

AHCA’s Proposed Caps on Medicaid Spending The American Health Care Act (AHCA) proposes to change federal Medicaid financing to a per-capita capped allotment beginning in FY 2020, and repealing this Medicaid expansion would result in an estimated $839 billion reduction in federal Medicaid spending from 2017 to 2026, according to the Congressional Budget Office (CBO). The CBO decreased its initial estimate of $880 billion less in federal Medicaid spending over the 10-

year period, which amounts to a reduction of roughly 25 percent by 2026.

new treatments for seniors and persons with disabilities.

The brief noted that a per-capita cap could lock in historical state differences in the scope of coverage and spending for seniors and persons with disabilities. However, tying Medicaid spending levels to a base year under a per capita cap also does not account for future spending increases due to new drug therapies or other medical advances yet to be developed, which could offer important

For the complete report “State Variation in Medicaid Per Enrollee Spending for Seniors and Persons with Disabilities,” MaryBeth Musumeci and Katherine Young, Kaiser Family Foundation, May 01, 2017, please see http://www.kff.org/medicaid/ issue-brief/state-variation-in-medicaidper-enrollee-spending-for-seniors-andpersons-with-disabilities/

CHICAGO

15TH ANNUAL AMRPA EDUCATIONAL CONFERENCE & EXPO

OCTOBER 23-25, 2017 • SWISSÔTEL

GAO EXAMINES HEALTH STATUS OF BENEFICIARIES WHO DISENROLL FROM MEDICARE ADVANTAGE PLANS By Jonathan M. Gold, JD, Regulatory and Government Relations Counsel*, AMRPA

he Government Accountability Office (GAO) has recommended that the Centers for Medicare and Medicaid Services (CMS) review the health status of beneficiaries who disenroll from Medicare Advantage (MA) plans as part of their oversight of the MA program.

plans had what the GAO termed to be health-biased disenrollment, which it described as beneficiaries in poor health being substantially more likely to leave their plans than those in better health. More specifically, plans were considered to have health-biased disenrollment if the likelihood that poor health beneficiaries disenrolled was more than 27 percent greater than that of beneficiaries in better health.

the former had lower overall enrollment, were more likely to be HMOs and had more beneficiaries in Special Needs Plans (SNPs).

GAO also analyzed CMSâ&#x20AC;&#x2122;s Disenrollment Reasons Survey, which beneficiaries may participate in when changing plans. Twenty-seven percent of surveyed disenrollees from plans with health-biased The recommendations are the result of disenrollment reported difficulty getting a study conducted by GAO to examine needed care. In contrast, 16 percent health-biased disenrollment and reasons of surveyed disenrollees from plans GAO took a closer look at the 35 plans given by beneficiaries when they disenroll without health-biased disenrollment with health-biased disenrollment and from MA plans. cited difficulty getting care. Forty-one identified a number of characteristics. percent of beneficiaries who left the GAO found that of the 126 high To perform this analysis, GAO looked at plans with health-biased disenrollment CMS enrollment and disenrollment data said they left because their for 2014, which is the most preferred doctor or hospital recent year of data available. was not covered by their plan, GAO identified 252 plans that compared with 25 percent had at least 100 disenrollees GAO found that of the 126 high of surveyed disenrollees in poor health and 100 from plans that did not have disenrollees in better health. disenrollment plans, the 35 with health-biased disenrollment. GAO also had beneficiary health-biased disenrollment For overall cost, the trend feedback available for generally had lower was reversed, with 28 analysis. Beneficiaries whose percent of disenrollees from projected spending was overall quality ratings. plans without health-biased twice as much as the average disenrollment identifying Medicare beneficiary were problems with costs as a categorized as poor health, reason for leaving, compared with 18 disenrollment plans, the 35 with healthand the remaining beneficiaries with percent of disenrollees from plans with biased disenrollment generally had lower projected spending below that amount health-biased disenrollment. overall quality ratings through Medicareâ&#x20AC;&#x2122;s were considered healthy. five-star rating system than plans without In concluding its report, GAO expressed health-biased disenrollment. Only 36 Of the 252 plans, GAO found a median concern that CMS does not identify percent of the plans with health-biased disenrollment rate of 10.6 percent, patterns of disenrollment by beneficiary disenrollment had above-median overall which represents the percentage of health status in its routine oversight of star ratings, compared with 49 percent of beneficiaries that did not reenroll for MA plans. It advised that because this those high disenrollment plans without the subsequent year or left the plan data is not used, CMS may fail to identify health-biased disenrollment. GAO also during the course of the year. When problems in MA plan performance and found that when comparing the 35 plans GAO analyzed the plans with higher thus poses a risk to beneficiaries. GAO with health-biased disenrollment with disenrollment rate (above the median of noted that MA plans are prohibited from the other 91 high-disenrollment plans, 10.6 percent), it found that 35 of those 30

AMRPA Magazine July 2017

limiting or conditioning their coverage or provision of benefits based on health status and must ensure adequate access to covered services for all beneficiaries.

program. It noted that CMS does use the disenrollment survey in its star rating program, but that it will look for ways to incorporate it into oversight of MA plans.

17-393: Published: Apr 28, 2017. Publicly Released: May 30, 2017. Please see http://www.gao.gov/products/GAO-17393.

CMS responded to the GAO report by saying that it agrees with GAO’s recommendation that it incorporate this data into its oversight of the MA

For the complete report “Medicare Advantage - CMS Should Use Data on Disenrollment and Beneficiary Health Status to Strengthen Oversight,” GAO-

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

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AMRPA Magazine July 2017