AMRPA Magazine June 2017

June 2017 • Vol. 20, No. 6

OPPORTUNITY IN UNCERTAINTY

Volume 20, Number 6

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 Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA Jonathan M. Gold, JD Regulatory and Government Relations Counsel*, AMRPA Mimi Zhang Policy and Research Associate, AMRPA Lovelyn Robinson Editorial and Research Assistant, AMRPA

Letter from the Chair........................................................................................... 3 AMRPA Legislative Update................................................................................. 4 Data Brief Examines Barriers to Health Care for Adults with Multiple Chronic Conditions...................................................................... 7 Conflicting Trends in the ALJ Delay Litigation................................................ 10 CMS Transmittals of Interest for Medical Rehabilitation Providers .............. 12 FY 2018 IRF PPS Proposed Rule Is Notable for What It Includes and What It Does Not....................................................................................... 14 When is Group Therapy Beneficial?................................................................. 19 OIG: CMS Needs to Use Additional Tools to Identify Gaming of Hospital-Reported Quality Data................................................... 21 FY 2018 IRF PPS Proposed Rule’s Quality-Related Provisions and Standardized Patient Assessment Data .......................................................... 23 CMS Issues FY 2018 Proposed Rule Outlining Medicare Payment Policies and Rates for SNFs ............................................................. 28

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

Whitepaper Discusses Need for Hospital Readmission Prevention and Improvement in Transitions of Care ........................................................ 30

AMRPA Magazine, Volume 20, Number 6.

CMS Releases Fiscal Year 2018 IPPS Long-Term Care Hospital Prospective Payment System NPRM ............................................................... 32

AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA).

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AHRQ Impact Case Study: Carolinas Rehabilitation PSO Improves Patient Safety ................................................................................... 34 AMRPA Submits Comments on Healthy Days in the Community Quality Measure ........................................................................... 35 AMRPA Submits Comments to CMS on Medicare Advantage Program; Urges Movement Toward Patient-Centered Care ......................... 37

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2

AMRPA Magazine June 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

“Your membership is critical to our field and benefits medical rehabilitation in multiple ways.”

O

perating a rehabilitation hospital or unit is a complicated responsibility. There are so many people and processes involved that it is a wonder things don’t go awry more frequently than they do.

Any adverse event or inefficiency in the operation can be costly or dangerous. Extreme and consistent diligence is the order of the day to prevent human or economic harm from being incurred.

AMRPA has an important role to play in helping to prevent these adversities. AMRPA, as an association, offers multiple opportunities for clinical and administrative learning and sharing of best practices. Our educational conferences, webinars, networking events, website and publications (both electronic and physical) all represent approaches to helping our member hospitals and units to learn, improve their processes and enhance the care they provide. AMRPA exists to serve and protect the field and the patients cared for by our members. AMRPA is proud of

and takes very seriously our role in supporting the frontline clinical operational and quality needs of our member hospitals, units and outpatient rehabilitation facilities.

While many think of AMRPA as an advocacy and policy organization that focuses on Federal law and regulations, our reach goes far beyond this component, and we are much more than advocacy alone. We are actively involved in much more than Medicare policy; we also address Medicaid, VA, private payers, accreditation agencies, and the many other stakeholders that exist in medical rehabilitation.

So when you think of AMRPA, think of advocacy, operations and education – not just Medicare and defending our field.

Your membership is critical to our field and benefits medical rehabilitation in multiple ways.

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AMRPA LEGISLATIVE UPDATE

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

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n May 4, 2017, the House passed the American Health Care Act (AHCA) by a narrow, 217-213, vote.

AHCA was passed with two recent amendments that helped House Leadership secure enough votes to pass the bill. Moderate Rep. Tom MacArthur (R-NJ) co-authored a compromise amendment with House Freedom Caucus Chair Rep. Mark Meadows (R-NC) that would provide

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regular input, and other informal groups have met to discuss their priorities for health reform. Discussions have initially centered on how to address the ACA’s Medicaid expansion. Moderate Republicans are wary of provisions that would cut Medicaid or reduce coverage for those with pre-existing conditions, as well as the “age tax,” that will allow insurers to charge older consumers five times more than young adults, compared with the 3:1 ratio under the ACA. It

On April 27, 2017, the Centers for Medicare and Medicaid Services (CMS) issued several Fiscal Year (FY) 2018 payment rules for the post-acute sector, including the Inpatient Rehabilitation Facility (IRF) Prospective Payment System Proposed Rule.

On May 4, after numerous fits and starts over the past several weeks, Republicans narrowly passed an amended version of the American Health Care Act (H.R. 1628), by a vote of 217-213, delivering President Trump a political victory that is one step closer to his long-held campaign promise of repealing Obamacare.

On May 5, the President signed into a law a $1.07 trillion omnibus spending bill to fund the government through the end of FY 2017 (September 30, 2017).

On May 18, the House Ways and Means Health Subcommittee will hold a hearing to examine the current status Medicare payment systems, with a specific focus on post-acute care.

states with greater flexibility to opt out of certain consumer protections under the Affordable Care Act’s (ACA), including essential health benefits (EHBs). The amendment also requires states to set up high-risk pools. Additionally, states are no longer compelled to institute the continuous coverage provision that Republicans previously proposed in the original version of AHCA. In order to appease moderates, another amendment from former House Energy and Commerce Committee Chairman Rep. Fred Upton (R-MI) added $8 billion over five years to help people with pre4

existing conditions cover premiums and out-of-pocket costs. Despite concerns about whether $8 billion is sufficient to protect the sickest Americans, the amendment ultimately secured enough Republican votes to pass the bill. Twenty Republicans joined the Democrats to vote against passage of AHCA, providing Republicans with only one vote to spare. Though House Republicans are celebrating their legislative victory, the health care bill is likely to be significantly

changed in the Senate, where politics and complex Budget Reconciliation rules are expected to complicate passage. It is likely that the Senate will write its own health reform bill rather than taking up the House version.

Senate Majority Leader Mitch McConnell (R-KY) has convened small working groups of Republican Committee Chairs and other key Senators to develop a consensus package that will become a substitute amendment for AHCA. However, Leader McConnell insists that all 52 Senate Republicans are providing

remains to be seen whether Senators can craft a proposal that will pass the Senate while remaining acceptable to all the factions of the Republican Conference.

Meanwhile, the Senate parliamentarian cannot review legislation for Byrd Rule issues until the Congressional Budget Office (CBO) releases a score for the House AHCA on May 22. As such, it appears the earliest a bill could come to the Senate floor is June.

CMS Releases FY 2018 IRF Prospective Payment System Proposed Rule On April 27, the Centers for Medicare AMRPA Magazine June 2017

and Medicaid Services (CMS) released its Inpatient Rehabilitation Facility (IRF) Prospective Payment System proposed rule for FY 2018. Comments are due by 5pm on June 26, 2017, and as expected, CMS included a separate Request for Information (RFI) for the public to submit their ideas for regulatory, subregulatory, policy, practice and procedural changes to better accomplish the goals of increased quality of care, lower costs, improved program integrity and a more effective, simple and accessible health system. CMS expresses particular interest in ideas about the screening, assessment and evidence-based treatment for individuals with opioid use disorder and other substance use disorders.

CMS is proposing an estimated $80 million in increased payment to IRFs for FY 2018, applying a 1.0 percent update and a 0.75 percentage point reduction to the market basket, as required by law. CMS proposes updates to the casemix group (CMG) relative weights and average length of stay values for FY 2018.

Total estimated aggregate payments to

IRFs for FY 2018 would not be affected as a result of the proposed CMG relative weight revisions. The Proposed Rule removes the 25 percent penalty for inpatient rehabilitation facility patient assessment instrument (IRF-PAI) late transmissions, and removes the voluntary swallowing status item (Item 27) from the IRF-PAI. CMS proposes to update the outlier threshold amount from $7,984 to $8,565 to maintain estimated outlier payments at approximately 3 percent of total estimated aggregate IRF payments for FY 2018. CMS will continue to maintain the facility-level adjustment factors at current levels. For FY 2018, CMS proposes to maintain the policies and methodologies described in the FY 2017 IRF PPS final rule related to labor market area definitions and the wage index methodology for areas with wage data.

CMS proposes a number of changes to the presumptive methodology diagnosis code list. The proposed rule revises and updates quality measures and reporting requirements under the IRF quality reporting program (QRP). Beginning with the FY 2020 IRF QRP, CMS is proposing:

To remove the current pressure ulcer measure, Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678), from the IRF QRP measure set and to replace it with a modified version of that measure, Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury; and To remove the All-Cause Unplanned Readmission Measure for 30 Days PostDischarge from IRFs (NQF #2502) from the IRF QRP. CMS also proposes refining the presumptive methodology for the 60 Percent Rule as it relates to ICD-10-CM diagnosis codes.

Additionally, CMS released proposed rules for the FY 2018 Skilled Nursing Facility (SNF) Prospective Payment System, along with proposed changes to SNF case-mix methodology, and the FY 2018 Hospice Wage Index and Payment Rate Update. CMS proposes an increase in aggregate payments to SNFs of $390 million, or about 1 percent, in FY 2018. CMS proposes an increase of $180 million, or roughly 1 percent, for hospices in FY 2018. Both proposed 5

regulations also included a separate RFI for regulatory feedback.

care in its mention of reviewing various Medicare payment policies. AMRPA plans to submit a statement for the hearing record.

create a Medicare RPM benefit for certain high-risk patients; allow telehealth and remote patient monitoring (RPM) in global/bundled payments; and allow rural health clinics and federally-qualified health centers to serve as originating and distant sites. The bill would also expand Medicare’s Independence at Home model and MA’s Value-based Insurance Design, and permanently extends Special Needs Plans (SNPs).

Congress Approves Omnibus Spending Bill AMRPA members should be alert to the On May 3, the House voted 309-118 to genuine risk that the Committee will move pass a $1.07 trillion Omnibus spending forward with Value Based Purchasing bill to fund the government through legislation this year, so continued September 30, 2017, the end of Fiscal communication with your Members of Year FY 2017. More Democrats than Congress is critically important.

Republicans voted for the measure, by a margin of 178-131. The Senate passed White House Expected to Release Finance Committee to hold hearing the Fiscal 2017 Appropriations package FY 2018 Budget Proposal on May 23 on CHRONIC Care Act on May 4 by a vote of 79-18, with no The Office of Management and Budget The Senate Finance Committee Democrats opposing the legislation.

(OMB) has notified the Senate and scheduled a hearing for May 16 to President Trump quickly singed the House that the President’s FY 2018 examine the Creating High-Quality bill into law before the week-long Budget will be released on May 23, 2017.

Results and Outcomes Necessary to Continuing Resolution (CR) expired. The The President’s Budget will reportedly Improve Chronic (CHRONIC) Care Act $161 billion Labor-HHS portion of the propose about $800 billion in cuts (S. 870), which was recently reintroduced. package provides $73.5 billion in funding to entitlement programs, including Those testifying before the Committee for the Department of Health and Human Medicaid, over 10 years. Other meansinclude Sens. Brian Schatz (D-HI) and Services (HHS), an increase of $2.8 billion tested health care programs that could be Roger Wicker (R-MS), who helped author over fiscal 2016, which includes a $2 cut include Medicare Part D low-income billion boost for the National Institutes of subsidies, the Children’s Health (NIH) to fund research Health Insurance Program related to precision medicine, (CHIP) and Affordable Care antibiotic resistance, Act premium subsidies. The Alzheimer’s disease, and other As we go to press, it is so important Trump Administration is not areas. The Substance Abuse expected to seek cuts to and Mental Health Services that individual AMRPA members Social Security or Medicare.

Administration (SAMHSA) engage in meeting with your would get $3.6 billion in *** funding, nearly $131 million Members of Congress. Invite them more than what the Obama to visit your hospital.

As we go to press, it is so administration requested.

Your constituent voice is essential important that individual Consistent with the directive in AMRPA members engage in the 21st Century Cures Act, the to our effective advocacy. meeting with your Members Omnibus contains significant of Congress. Invite them funding to combat the opioid to visit your hospital. Your crisis ($650 million). The bill constituent voice is essential to our the bill; Katherine Hayes, Director of provides no discretionary funding for effective advocacy. Thank you in advance Health Policy at the Bipartisan Policy the Affordable Care Act (ACA) and for your efforts.

Center; Lee Schwamm, Director of blocks the risk corridor program and the the Partners Telestroke Center; John Independent Payment Advisory Board’s Lovelace, of UPMC Insurance; and (IPAB) operating budget. The ACA’s costRegards, Stephen Rosenthal, Senior Vice President sharing reduction (CSR) payments are Martha M. Kendrick of Population Health Management not part of the bill; the White House has at Montefiore Health System. This confirmed it will continue the payments. legislation has been the top health care priority for the Senate Finance Committee Ways and Means Hearing to Focus for the past two years. The legislation on PAC aims to increase the use of telehealth On May 11, the House Ways and Means and remote patient monitoring (RPM) Health Subcommittee Chairman Pat services in Medicare, by expanding Tiberi (R-OH) announced that the Medicare’s coverage of telemedicine to Subcommittee will hold a hearing accountable care organizations (ACOs), on Thursday, May 18, to examine the provide for remote treatment of stroke Medicare program, changes needed and dialysis, and allow more flexibility for for Medicare’s payment system, and Medicare Advantage (MA) plans to cover the Medicare extenders. The hearing telemedicine. Notably, the bill would notice specifically called out post-acute 6

AMRPA Magazine June 2017

DATA BRIEF EXAMINES BARRIERS TO HEALTH CARE FOR ADULTS WITH MULTIPLE CHRONIC CONDITIONS

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he Centers for Disease Control and Prevention (CDC)’ National Center for Health Statistics (NCHS) published a Data Brief that examines health care access and utilization among adults with multiple chronic conditions (MCC) compared with those with one or no diagnosed chronic condition. Many health care professionals in inpatient rehabilitation settings are providing these patients with chronic care management.

The data brief “Barriers to Health Care for Adults With Multiple Chronic Conditions: United States, 2012–2015” found that adults with two or more chronic conditions may be more likely than those with one or no chronic conditions to use health care services, but they also experience more barriers to health care.

Multiple Chronic Conditions (MCCs) The selected 10 multiple chronic conditions included whether an adult had ever been diagnosed by a doctor or other health care professional with: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Hypertension Cancer Stroke Coronary heart disease Diabetes Arthritis (including rheumatoid arthritis, gout, lupus, and fibromyalgia) Hepatitis A current diagnosis of asthma A diagnosis of weak or failing kidneys in the past 12 months A diagnosis of chronic obstructive pulmonary disease (COPD) (indicated by having ever been diagnosed with COPD or emphysema or having been diagnosed with chronic bronchitis in the past 12 months)

Findings In 2015, the percentage of adults who had seen or talked to a health care professional in the past 12 months increased as the number of diagnosed chronic conditions increased.

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For adults aged 18–64, 73.1 percent of those without a chronic condition had seen or talked to a health care professional in the past 12 months.

However, among those with two or more chronic conditions this percentage increased to 95.4 percent.

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The percentage of adults aged 65 and over who had seen or talked to a health care professional in the past 12 months was lowest among those without a chronic condition (80.7 percent) and highest among those with two or more chronic conditions (98.3 percent).

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In 2015, the percentage of adults who delayed or did not obtain needed medical care due to cost in the past 12 months increased as the number of diagnosed chronic conditions increased.

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65 and over who delayed needed medical care due to a non-cost reason in the past 12 months was lowest among those without a chronic condition (3.4 percent) and highest among those with two or more chronic conditions (11.4 percent).

Among adults with the same number of diagnosed chronic conditions, those aged 18–64 were less likely than adults aged 65 and over to have seen or talked to a health care professional in the past 12 months.

The percentage of adults aged 18– 64 who delayed or did not obtain needed medical care due to cost in the past 12 months was lowest among those without a chronic condition (8.5 percent) and highest among those with two or more chronic conditions (16.9 percent).

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Among adults with the same number of diagnosed chronic conditions, those aged 18–64 were more likely than those aged 65 and over to have delayed needed medical care for a non-cost reason in the past 12 months.

For 2012–2015, the percentage of adults with two or more chronic conditions who delayed or did not obtain needed medical care for any reason decreased for adults aged 18–64, but the percentage increased for adults aged 65 and over.

decreased, from 16.5 percent in 2012 to 11.7 percent in 2015.

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There was an increasing trend in the percentage of adults aged 18–64 with two or more chronic conditions who delayed needed medical care due only to a non-cost reason in the past 12 months, from 12.4 percent in 2012 to 14.6 percent in 2015.

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Among adults aged 65 and over with two or more chronic conditions, there was no significant change in the percentage who delayed or did not obtain needed medical care in the past 12 months due only to cost or only for a non-cost reason.

Summary The report compared national estimates of health care access and utilization among adults diagnosed with two or • Among adults aged 65 and over, more of 10 selected chronic conditions those with two or more chronic and adults diagnosed with one or none conditions were more likely to have of the selected conditions. delayed or not obtained Regardless of the number of needed medical care diagnosed chronic conditions, due to cost in the past adults aged 18–64 were less 12 months (5.2 percent) Adults with two or more chronic likely to use health services in compared with adults conditions may be more likely the past 12 months, compared without a chronic with those aged 65 and over, condition (2.7 percent) than those with one or no chronic they were more likely to and those with one conditions to use health care services, and delay or not obtain needed chronic condition (2.9 but they also experience more medical care due to cost and percent). non-cost related reasons. In barriers to health care.

• Among adults with summary, the researchers found the same number of that adults with two or more diagnosed chronic chronic conditions may be more conditions, the likely than those with one or no chronic • There was a decreasing trend in the percentage of adults who delayed or conditions to use health care services, percentage of adults aged 18–64 did not obtain needed medical care but they also experience more barriers with two or more chronic conditions due to cost in the past 12 months to health care. who delayed or did not obtain was higher among those aged 18–64 needed medical care for any reason compared with those aged 65 and in the past 12 months, from 34.3 over. percent in 2012 to 31.4 percent in 2015.

In 2015, the percentage of adults who • There was an increasing trend in delayed needed medical care for a the percentage of adults aged 65 non-cost reason in the past 12 months and over with two or more chronic increased as the number of diagnosed conditions who delayed or did not chronic conditions increased. obtain needed medical care for any • For adults aged 18–64, 7.9 percent reason in the past 12 months, from of those without a chronic condition 13.5 percent in 2012 to 15.0 percent delayed needed medical care due in 2015. to a non-cost reason in the past 12 • The percentage of adults aged months compared with 19.7 percent 18–64 with two or more chronic of those with two or more chronic conditions who delayed or did not conditions. obtain needed medical care due • The percentage of adults aged only to cost in the past 12 months 8

AMRPA Magazine June 2017

15TH ANNUAL AMRPA EDUCATIONAL CONFERENCE & EXPO

OCTOBER 23-25, 2017 • SWISSÔTEL

REGISTRATION IS NOW OPEN! Register by June 30 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.

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.

9

CONFLICTING TRENDS IN THE ALJ DELAY LITIGATION

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his month has seen two important developments in litigation challenging the extensive delay in Medicare administrative law judge (ALJ) decisions.

Two separate cases are pending: one in the District of Columbia Circuit Court of Appeals and the other in the Ninth Circuit Court of Appeals in California.

Oral arguments were held in both cases in May. The Ninth Circuit did not indicate how it will rule, although there were several positive signs for providers during the oral argument. In the AHA case, the government has appealed a district court order to clear the ALJ backlog by the end of 2020. The judges in the AHA case seemed to favor the government’s argument that it cannot clear the backlog without additional funds from Congress. It seems possible that the court will modify the district court order or remand to the district court for further factfinding on what actions the Department of Health and Human Services (HHS) can take to reduce the backlog.

AMPRA’s sister organization, the Fund for Access to Inpatient Rehabilitation (FAIR Fund) has played an active supporting role in the AHA case by filing three “friend of the court” briefs. AHA has sued on behalf of all of its member hospitals, including inpatient rehabilitation hospitals (IRH/Us). Casa Colina is itself an inpatient rehabilitation hospital in southern California and is a leading AMRPA member.

History and Status of the Cases Both cases concern the extensive backlog in ALJ appeals. The Medicare statute requires that ALJs issue decisions in 90 days. HHS has failed to meet this deadline 10

for several years. Decisions issued in 2017 took 1,041.5 days on average to decide, more than 2.5 years past the deadline. Currently, there is a backlog of approximately 700,000 appeals at the HHS Office of Medicare Hearings and Appeals (OMHA). In both cases, the hospitals have requested a “writ of mandamus.”

A writ of mandamus is a court order requiring a government official to comply with a clear duty. Here, the duty is to decide ALJ appeals in 90 days. There are typically two stages to a mandamus case. First, a plaintiff must show that the court has jurisdiction by establishing the following: 1) that the plaintiff has a clear right to relief; 2) that the government official has a clear duty to act; and 3) that the plaintiff has no adequate alternative remedy. Once jurisdiction is established, however, a court usually must then weigh equitable factors for and against issuing the mandamus order.

AHA filed suit against HHS in 2014. In December 2014, the court dismissed AHA’s suit. AHA appealed to the D.C. Circuit Court of Appeals, where the FAIR Fund filed an amicus curiae (friend of the court) brief in support of AHA. The D.C. Circuit reversed the district court and held that AHA satisfied the core jurisdictional requirements. The court held that hospitals have a clear right to ALJ decisions in 90 days; the Secretary has a clear duty to decide ALJ appeals in 90 days; and hospitals have no adequate alternative remedy other than mandamus. Citing the FAIR Fund’s brief, the D.C. Circuit noted that the ALJ backlog is having a real impact on human health and welfare because some providers are admitting fewer cases that are likely to be

targeted by Recovery Audit Contractors (RACs). The D.C. Circuit sent the case back (i.e., “remanded”) to the district court, however, to determine whether Congress and the Secretary are making “significant progress” toward solving the ALJ backlog.

The D.C. District Court determined that the factors in favor of a writ of mandamus

ABOUT THE AUTHORS

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

Ronald S. Connelly Principal, the Powers Firm AMRPA Magazine June 2017

outweighed the factors against. The court mentioned the real impact on health and human welfare from the ALJ delay. The court discussed the statistics presented by the FAIR Fund showing that IRFs have at least $135 million tied up in the backlog.

Because IRFs win as many as 80 percent of their appeals – 87 percent when the value of the claims are used to calculate the percentages – it follows that most of these funds rightfully belong to the IRFs that provided care to Medicare beneficiaries.

On December 5, 2016, the district court granted a writ of mandamus and ordered HHS to clear the backlog by 30 percent per year and to completely eliminate it by the end of 2020. In early February, HHS appealed to the D.C. Circuit Court.

testimony if they escalate to the Medicare Appeals Council. Judge Owens asked the HHS attorney if mandamus would be appropriate if the backlog were 100 years, indicating that he is searching for the point at which mandamus would be appropriate rather than questioning whether it is appropriate at all.

Judge Kozinski was concerned, however, that issuing the writ of mandamus would permit Casa Colina to jump to the front of the ALJ queue, which might be unfair to other hospitals that would be pushed further down the line. Casa Colina argued that a mandamus order should push HHS to take real steps to clear the ALJ backlog, which would benefit all appellants, not just Casa Colina.

Henderson and Robert Wilkins. Judge Garland was very skeptical that the district court had correctly weighed the equities in favor of issuing the mandamus order. He also suggested that the district court judge should have held a fact-finding hearing to determine what measures HHS can take to clear the backlog and how long that would reasonably take.

Counsel for AHA countered that HHS can do more to settle meritorious claims and cited appeal statistics in the FAIR Fund’s brief as an example of a provider type that has a high success rate and, thus, many meritorious claims.

Both Judges Garland and Wilkins were concerned that it may not be possible for HHS to clear the backlog in four years.

Casa Colina’s case, in contrast, is at the Judge Garland also accepted HHS’s Indeed, Casa Colina stated repeatedly in court of appeals for the first time. Casa argument that mass settlements are the its briefs that its goal was to prompt HHS Colina filed suit in 2015 in the U.S. District only way it can clear the backlog without to solve the ALJ problem and not to obtain Court for the Central District of California, additional funds from Congress. He was an advantage over other hospitals. Casa after AHA had lost in the D.C. District concerned that these mass settlements Court. As an active participant in AMRPA would result in payment of and a leader of the FAIR Fund, improper or even fraudulent Casa Colina was concerned claims. Judge Garland also that the ALJ backlog impacts suggested that the district IRH/Us more acutely than The ALJ backlog has now been court should have considered many other provider types. In a serious problem for providers the escalation option when late 2015, the District Court for seven years. An appeal filed today weighing the equities, which dismissed the suit. Although presumably would factor against the court believed that Casa could take eight to 10 years hospitals.

Colina had “likely satisfied” to complete. the jurisdictional requirements Conclusion of a clear right to relief and The ALJ backlog has now been the agency’s clear duty to act, a serious problem for providers for seven Colina also pointed to a prior Ninth Circuit the court believed that a mandamus order years. An appeal filed today could take decision (Biodiversity Legal Foundation v. would unfairly permit Casa Colina to “jump eight to 10 years to complete. HHS claims Badgley) stating that courts should strictly the queue.” Casa Colina appealed to the that it cannot solve the problem without enforce clear statutory deadlines and Ninth Circuit. additional funding from Congress, but should not consider equitable factors such Congress shows no signs of increasing as the “line jumping” issue. Judge Kozinski The May Oral Arguments the resources of OMHA in order to hire did not seem comfortable constraining The Casa Colina oral argument was held in more ALJs. The only way that the ALJ the court’s authority in this way, but if the Pasadena, California on May 8, 2017. The backlog is likely to be cleared is if a federal panel decides that Casa Colina has met the case was argued by Ronald Connelly of the court forces HHS to do it. A mandamus three jurisdictional requirements, the court Powers law firm, which also serves as the order would prompt HHS to think more will have to distinguish Biodiversity Legal FAIR Fund’s counsel. The three-judge panel creatively and perhaps enter into good Foundation in order to consider the lineconsisted of Judges Alex Kozinski, John faith settlement negotiations with groups jumping issue.

Owens and Benjamin Settle. The Ninth of providers, including IRH/Us. Thus, Circuit judges did not clearly indicate how the IRH/U community should hope that The AHA case was argued on May 15, they will rule. There were several comments either the D.C. Circuit or the Ninth Circuit 2017, one week after Casa Colina’s oral by the judges, however, that are positive supports health care providers by requiring argument. The D.C. Circuit assigned a for Casa Colina’s case. Judge Kozinski, in HHS to comply with law by clearing the new three-judge panel to the AHA case. particular, seemed to view the ALJ deadline ALJ backlog so that HHS can once again The new panel seemed to view the case as mandatory. He referred to the deadline decide ALJ appeals in 90 days. differently than the prior D.C. Circuit panel. as a “clear statutory command” and stated The AHA case was heard by Judges Merick that it “looks like a clear entitlement.”

Garland (the judge who was nominated to Judge Settle was concerned that hospitals the Supreme Court last year), Karen Lecraft would lose the ability to present witness 11

CMS TRANSMITTALS OF INTEREST FOR MEDICAL REHABILITATION PROVIDERS

June 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

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

2017-05-05

Analysis for Common Working File (CWF) to Medicare Beneficiary Database (MBD) Extract File Changes for Detailed Skilled Nursing Facility Data to Support HIPAA Eligibility Transaction System (HETS) 1002

2017-10-02

2017-05-05

Modification to Two Fiscal Intermediary Shared System (FISS) Edits Created Through Change Request (CR) 9681

2017-08-07

2017-05-05

Outlier Limitation on Outpatient Prospective Payment System (OPPS) Community Mental Health Centers (CMHC) Services

N/A

2017-05-05

April Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

2017-04-03

2017-04-28

July Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

N/A

2017-04-28

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

2017-05-30

2017-04-28

Implementing the remittance advice messaging for the 20-hour weekly minimum for Partial Hospitalization Program services.

2017-10-02

2017-04-28

Implementation of Section 1557 for Medicare Redetermination Notices (MRNs) by Adding a Notice and Tagline Sheet

2017-10-02

2017-04-28

Shared System Enhancement 2015: Identify Inactive Medicare Demonstration Projects within the Fiscal Intermediary Shared System (Analysis Only)

2017-10-02

2017-04-28

Analysis and Design Working Sessions for the Development of a Pre-Payment Common Additional Documentation Request (ADR) Letter

2017-10-02

2017-04-28

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

N/A

2017-04-21

QIO Manual Chapter 16 – “Healthcare Quality Improvement Program”

2017-04-21

2017-04-19

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

2017-07-03

2017-04-14

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) Edits, Version 23.2, Effective July 1, 2017

2017-07-03

R1843OTN R1844OTN R1705OTN R3768CP R3760CP R1831OTN R1833OTN R1839OTN R1837OTN R1834OTN R3764CP R30QIO R3750CP R3748CP

Implementation Date

Updated as of May 15, 2017

12

AMRPA Magazine June 2017

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FY 2018 IRF PPS PROPOSED RULE IS NOTABLE FOR WHAT IT INCLUDES AND WHAT IT DOES NOT

T

he Centers for Medicare and Medicaid Services (CMS) published the Inpatient Rehabilitation Facilities Prospective Payment System (IRF PPS) federal fiscal year (FY) 2018 proposed rule at the end of April, in keeping with its annual schedule, and published it in the May 3, 2017 Federal Register. The proposed FY 2018 rules for the acute care prospective payment system (IPPS), long-term care hospitals (LTCH) PPS and the skilled nursing facilities (SNF). PPS were all issued within the same two weeks. CMS also issued an advanced notice of proposed rulemaking (ANPRM) regarding changing the SNF payment system. Please see related articles in this issue. As is required by law, the rule addresses the statutorily required changes to the payment system discussed below. It also includes anticipated changes to the inpatient rehabilitation facilities quality reporting program (IRF QRP), which is discussed in another article in this issue.

As expressed during his campaign and since he took office, President Trump seeks to reduce the number of regulations, reduce government oversight and reduce the burdens imposed by regulations and statutes on businesses and the public.

For inpatient rehabilitation hospitals and 14

units (IRH/Us), this desire may translate to reducing many of the Medicare regulations IRH/Us face and, which adversely affect patients and increase costs. This proposed rule includes one (possibly two) proposals that appear to stem directly from this goal. It includes a Request for Information (RFI) titled, “Request for Information on CMS Flexibilities and Efficiencies.” In the RFI, CMS states that it is committed to transforming the health care delivery system, including the Medicare program, by putting additional focus on patient centered care. To do so, it seeks to work with providers, physicians and patients to reduce burdens to improve quality, decrease costs and make sure providers, patients and physicians are “making the best health care choices possible.” The Agency is inviting ideas for changes with respect to regulatory, sub-regulatory, policy, practice and procedures changes – the whole gamut of how the government issues its policies and practices. It states that ideas can include payment system redesign, elimination or streamlining of reporting, monitoring and documentation requirements, data sharing and other ideas. In other words, it is the perfect opportunity to propose any ideas and wishes that have percolated for years. Get rid of the 60 percent rule! Implement the Continuing Care Hospital! Provide some

ABOUT THE AUTHORS

Carolyn C. Zollar, J.D Executive Vice President for Policy Development and Government Relations

Jonathan Gold J.D. Regulatory and Government Relations Counsel* AMRPA Magazine June 2017

flexibility under the “three-hour rule”!

AMRPA has a workgroup brainstorming on this unprecedented opportunity. This proposal will, we believe, be just one opportunity to put forward numerous ideas that may move to a new payment system, simplify reporting requirements and otherwise try to reduce the current burden. As we know, IRH/Us have a plethora of regulations applicable to them which are not necessarily applicable to other providers.

The second proposal in this vein is a request for comments on the classification criterion known as the “60 percent rule.” It is but one of several classification criterion that CMS uses to distinguish IRH/Us from acute care hospitals as required by the statute. CMS stated that it is seeking comment on the 60 percent rule, including but not limited to the list of the infamous 13 conditions. It states it is doing so to assist it in generating ideas and information for analyzing refinements and updates to the criteria used to classify providers. It cites two early reports on the classification criteria, which include recommendations on the 60 percent rule. They are, “ More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities” from the Government Accountability Office (GAO, June 16, 2005) and “Analysis of the Classification Criteria for Inpatient Rehabilitation Facilities,” which was a Report to Congress done by the Research Triangle Institute International (RTI, September 2009). Again, this is an unprecedented and probably welcome request. However, if you take a skeptical view of the opportunity, the result could go in many directions – from deleting the criterion to further refining and narrowing the 13 conditions, thereby further jeopardizing patient accessibility and requiring providers to have to even more carefully manage patients.

Third, as part of the IRF Quality Reporting Program (IRF QRP) proposals, CMS introduces the Improving Medicare PostAcute Care Transformation (IMPACT) Act requirement to collect standard patient assessment data. The Act requires the agency to collect data in certain designated domains starting October 1, 2018 (FY 2019) or January 1, 2019 (CY 2019). These elements will be collected by all four post-acute care providers as

required under the Act: IRH/Us, LTCHs and SNFs in FY 2019 and home health agencies (HHAs) by CY 2019. The data collected from these data elements and others yet to follow – plus the existing quality measures – will be used by the Secretary of the Department of Health and Human Services (HHS) in drafting a proposed report of a prototype for a post-acute care payment system at least two years after the data starts to be collected. Hence, they may be viewed as the potential bricks or basis for a payment system and it is critical that the elements are well vetted and sensitive enough to distinguish among the various patient groups and characteristics.

CMS published a report in August 2016 seeking comments on the standardized patient assessment items and AMRPA filed comments at that time. A separate article in this issue describes them and other IRF QRP proposals in greater detail.

Two CMS projects are not reflected in this rule. First, last summer CMS called for comments on the tier comorbidities attached to the IRF PPS. It stated it was seeking to reevaluate them. AMRPA filed comments. However, the results of that project were not included in this proposed rule. Second, CMS has been collecting data on individual, co-treatment; concurrent treatment and group therapy since October 1, 2015. However, CMS has yet to propose any policy changes based on that data. Stay tuned on both points!

Proposed Payment Updates Facility Level Adjustments For the last several years, CMS has put a freeze on adjustments to the facility-level

factors for IRFs. In FY 2018, CMS will again continue to hold the adjustment factors at the FY 2014 levels. The adjustment levels include a Low-Income Pool (LIP) factor of .3177; a rural adjustment of 14.9 percent, and a teaching adjustment factor of 1.0163.

Labor and Wage-Related Share Statutory guidance specifies that the Secretary is to determine a labor-related share of rehabilitation facilities’ costs.

The labor-related share is determined by identifying the national average proportion of total costs that are related to, influenced by, or vary with the local labor market.

CMS proposes using a labor-related share of 70.7 percent for the IRF PPS in FY 2018.

CMS employs the same methodology to calculate the FY 2018 labor-related share as it has to calculate previous fiscal years’ IRF PPS labor-related share. See Table 1, IRF Labor-Related Share.

Statutory guidance also requires the Secretary to adjust the proportion of rehabilitation facilities’ costs attributable to wages and wage-related costs by a factor reflecting the relative hospital wage level in the geographic area of the rehabilitation facility compared with the national average wage level for those facilities. For FY 2018, CMS proposes to mostly maintain the policies and methodologies described in the FY 2017 IRF PPS final rule related to market area definitions and the wage index methodology for areas with wage data. In 2016, CMS implemented the new OMB statistical area delineations for the IRF PPS wage index. For the FY 2016 wage index, CMS implemented a one-year transition with a blended wage index for all providers and a three-year phase-out (in 2016, 2017,

Table 1. IRF Labor-Related Share

1 2

FY 2018 Proposed LaborRelated Share 1

FY 2017 Final Labor-Related Share 2

Wages and Salaries

47.7

47.7

Employee Benefits

11.3

11.3

Professional Fees: Labor-related

3.4

3.5

Administrative and Facilities Support Services

0.8

0.8

Installation, Maintenance, and Repair Services

1.9

1.9

All other: Labor-related Services

1.8

1.8

Subtotal

66.9

67.0

Labor-related portion of capital (46%)

3.8

3.9

Total Labor-related Share

70.7

70.9

Based on the 2012 based IRF Market Basket, IHS Global Insight, Inc. 1st quarter 2017 forecast Federal Register (81 FR 52073)

15

and 2018) of the rural adjustment for 19 rural IRFs that will become urban and that experience a loss in payments due to changes from the new CBSA delineations.

FY 2018 is the third and final year of that transition, which means there will be no phase-out adjustment for impacted IRFs. For FY 2018, CMS is proposing to rely on a 2015 bulletin from OMB titled OMB Bulletin No. 15–01, which updates the delineations used for the first time in 2016.

This Bulletin was not used in the FY 2017 update. This bulletin will impact IRF laborrelated shares for providers in Garfield County, OK, the County of Bedford City, VA, and the City of Macon, GA. Since CMS estimates that only one facility will see an impact, and it will be minor, they are not proposing a transition period for this change.

Standard Rate Conversion Factor CMS is proposing a standard rate conversion factor for FY 2018 of $15,835.

This rate is an increase from the standard payment rate conversion factor for FY 2017, which was $15,708. This amount is the result of a 1 percent rehabilitationspecific market basket and productivity adjustment, budget neutrality factors for the wage index and labor related share of 1.0007 percent, and budget neutrality factor for the revised CMG relative weights of 0.9974 percent. In previous rules, CMS has proposed changes to the market-basket update (which switched to an IRF-specific basket in FY 2017), as well as the productivity adjustment which are used to arrive at the Standard Payment Conversion Factor. This year, CMS states that section 411(b) of Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 requires the combined factors to sum to 1 percent. Since the update to these two factors are statutorily mandated, the proposed update is a de facto final update.

CMS does state that the FY 2018 basket update would have been 1.55 percent if not for MACRA. It reaches this number by estimating a 2.7 percent IRF marketbasket update, and subtracting a 0.4 percentage 2018 productivity adjustment and a 0.75 percentage point reduction, as required by the ACA. Table 2 breaks down the calculation of the Standard Payment Conversion Factor.

Outlier Payments The Secretary has the statutory authority to make payments in addition to the standard rates for cases incurring extraordinarily high costs. A case qualifies for an outlier payment if the estimated cost of the case exceeds the adjusted outlier threshold, and then CMS makes an outlier payment for the case equal to 80 percent of the difference between the estimated cost of the case and the outlier threshold. CMS proposes to update the outlier threshold amount from $7,984 for FY 2017 to $8,656 for FY 2018 to account for the increases in IRF PPS payments and estimated costs, and to maintain estimated outlier payments at approximately 3 percent of total estimated aggregate IRF payments for FY 2018.

CMS also proposes changing the national cost-to-charge ratio ceiling for FY 2018 to 1.28, with the ceiling for rural IRFs being 0.516 and 0.416 for urban IRFs. CMS states they will apply the national urban and rural cost-to-charge ratio in the following situations: •

New IRFs that have not yet submitted their first Medicare cost report.

•

IRFs whose overall CCR is in excess of the national CCR ceiling for FY 2018

•

IRFs for which accurate data to calculate an overall CCR are not available.

Table 2. Calculations to Determine the Proposed FY 2018 Standard Payment Conversion Factor Explanation for Adjustment Standard Payment Conversion Factor for FY 2017

$15,708

Market Basket Increase Factor for FY 2018 (1.0 percent) as required by section 1886(j)(3)(C)(iii) of the Act

x 1.0100

Budget Neutrality Factor for the Wage Index and Labor-Related Share

x 1.0007

Budget Neutrality Factor for the Revisions to the CMG Relative Weights

x 0.9974

Proposed FY 2018 Standard Payment Conversion Factor 16

Calculations

= $15, 835

CMG Weights and Average Length of Stay In the FY 2018 proposed rule, CMS proposes to update the Case Mix Group (CMG) weights. As required by statute, CMS uses the most recent available data to update the CMG weights and the average lengths of stay (ALOS). Hence, CMS proposes to use the FY 2016 IRF claims and the FY 2015 IRF cost report data. Presently, only a small proportion of the FY 2016 IRF cost report data is available. However, the vast majority of FY 2016 IRF claims data is available.

CMS proposes to apply the FY 2016 IRF claims data and FY 2015 IRF cost report data using the same methodologies that it has used to update CMG relative weights and average length of stay values each fiscal year since it implemented an update to the methodology. This updated methodology uses more detailed CCR data from the cost reports of IRF sub-provider units of primary acute care hospitals, instead of CCR data from the associated primary care hospitals, to calculate IRFs’ average costs per case. It is unclear as to how CMS plans to use the CCR to calculate CMG weights. A full table of the proposed updated CMG weights can be found on page 20697 in the Federal Register.

CMS notes that because it proposes to implement the CMG relative weight revisions in a budget-neutral manner, total estimated aggregate payments to IRFs for FY 2018 would not be affected as a result of the proposed CMG relative weight revisions. However, the proposed revisions would affect the distribution of payments within CMGs and tiers. CMS states that 99.3 percent of CMG cases and tiers would experience less than a 5 percent change (whether an increase or decrease). The largest increase is for CMG 0603 (neurological), and largest decrease is for CMG 0506 (spinal cord).

As mentioned before, on page 20697 of the Federal Register, CMS presents the proposed CMGs, the comorbidity tiers, the corresponding relative weights and the ALOS values for each CMG and tier for FY 2018. The ALOS CMG is used to determine when an IRF discharge meets the definition of a short-stay transfer, which results in a per diem case level adjustment.

As it did last year, CMS states that the AMRPA Magazine June 2017

ALOS values for FY 2018, compared with the FY 2017 values, are small and do not show any particular trends in IRF length of stay patterns. CMS did not publish its methodology for calculating the ALOS, as it did for some other methodologies.

IRF Classification Criteria Currently, 60 percent of an IRF’s patients must fall in to one of 13 categories. As discussed below, CMS uses different ICD-10-CM codes and record reviews to determine compliance with the review.

CMS has issued a request for comments on one of the criteria used to classify IRFs. More specifically, CMS said it would like to hear from stakeholders on the 60 percent rule, including but not limited to, the list of conditions in used for determining compliance with the 60 percent rule.

compliance criteria. It will however continue to retain exclusion of “IGC Brian Dysfunction-0002.22Traumatic, Closed Injury, S06.9X9A—Unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter.”

2. Hip Fractures under IGC 0008.11 and IGC 0008.12 Remove some of these codes from the excluded list and will thereby allow them to be Included in the presumptive methodology calculation.

It is proposing to remove the diagnosis code exclusion for a fracture of “unspecified part of neck of femur” but is retaining the exclusion of the code pertaining to “fracture of unspecified part of neck of femur of unspecified femur.” CMS believes

Ribs and Sternum Fracture It also proposes to remove ICD-10CM diagnosis code T07—Unspecified multiple injuries from the presumptive methodology list and replace it with codes from the three major multiple trauma lists (in the specified code combinations), as described above.

Any patient who suffered multiple trauma and subsequently required admission into an IRF would have experienced an extensive medical examination to identify the scope of his or her injuries in the acute care setting.

CMS believes that after a review of the acute care medical record, these injuries would be known to both the IRF pre-admission personnel and the admitting IRF physician, and would be able to be coded from the medical record in the most specific manner possible in the IRF setting.

Proposed Refinements to the Presumptive Compliance Methodology The contractors CMS deploys to determine compliance with 4. Unspecified Codes the 60 percent rule use two CMS also proposes to continue The Agency is inviting ideas for stages of review: presumptive to remove what it believes are changes with respect to regulatory, compliance and medical imprecise codes in that they may sub-regulatory, policy, practice and record review. In the first stage, “inappropriately” categorize an presumptive compliance, an “overly broad segment” of the procedures changes – the whole IRF submits the ICD codes of patients as having conditions gamut of how the government issues required for inclusion under the patients it has treated, and an estimate is created of the the presumptive methodology. its policies and practices. percentage of patients who fell For example, CMS proposes in to one of the 13 categories. to remove the diagnosis code From time to time, CMS T22.559S—Corrosion of first updates the list of ICD codes that count degree of unspecified shoulder, that the documentation should state towards presumptive compliance. Shortly sequela. However, it proposes that which femur – right, left, or bilateral is after the FY 2015 final rule was published T22.551S—Corrosion of the first affected. with the list of ICD-10-CM codes that degree of right shoulder, sequela and would be considered as included in the T22.552S—Corrosion of first degree of 3. Major Multiple Trauma (MMT) Codes presumptive compliance methodology, left shoulder, sequela remain on the CMS proposes to count IRF PAIs that AMRPA members reported codes Presumptive List. contain two or more of the ICD-10-CM previously covered under presumptive codes from the three major multiple 5. Arthritis Codes compliance in the ICD-9-CMs not included trauma lists in the specified code In the FY 2014 IRF PPS final rule, CMS as presumptively compliant in the ICD-10combinations that are included. finalized the removal of ICD-9-CM CM codes. CMS informed AMRPA it was diagnosis codes for arthritis conditions conducting a comprehensive review of CMS states that in order for patients with from the ICD-9-CM Codes That Meet the lists. This proposed rule appears to multiple fractures to qualify as meeting Presumptive Compliance Criteria address some of the errors made in the the 60 percent rule requirement for IRFs list because the inclusion of patients transition to ICD-10-CM. under the presumptive methodology, with these medical conditions in the the following codes could be used if Specifically, CMS proposes to: presumptive compliance calculation combined as described above: of the IRF’s compliance percentage • List A: Major Multiple Trauma— 1. Traumatic Brain Injury was conditioned on those patients Lower Extremity Fracture Remove some of the traumatic brain meeting the described severity and • List B: Major Multiple Trauma— injury codes listed as exclusions on prior treatment requirements. CMS Upper Extremity Fracture the IGC list thereby allowing them felt the ICD-9-CM diagnosis codes to count toward the presumptive that reflected these arthritis and • List C: Major Multiple Trauma— 17

arthropathy conditions did not provide any information about the severity of the condition or whether the prior treatment requirements were met.

The FY 2014 IRF PPS final rule stated that additional information beyond the presence of the code is necessary to determine if the medical record would support inclusion of people with arthritis and arthropathy conditions in the 13 conditions in the presumptive compliance methodology. Even though CMS removed arthritis diagnosis codes from the ICD-9-CM Codes That Meet Presumptive Compliance Criteria list prior to the ICD-9-CM to ICD-10-CM conversion process, some ICD-10CM arthritis codes are listed due to the straight translation. However, in analyzing the ICD-10-CM diagnosis codes CMS proposes to remove 15 ICD-10-CM diagnosis codes related to “rheumatoid polyneuropathy with rheumatoid arthritis.”

6. Proposed Removal of ICD-10CM Code G72.89 – Other Specified Myopathies Through its monitoring of IRFs’ use of the ICD-10-CM codes that currently count toward an IRF’s compliance percentage under the presumptive compliance method, CMS believes there is an inconsistent use of one ICD-10-CM code (G72.89 – Other Specified Myopathies). It included this ICD-10-CM code on the presumptive compliance code list based on our understanding that it is intended to represent a relatively narrow set of specified myopathies that are confirmed by the results of specific medical testing and identified as such in the patients’ medical records.

However, CMS reviewed certain IRFs’ disproportionately higher use of the code and found that some IRFs are using it more broadly, including to represent patients with generalized weakness who do not meet the requirements in the 60 percent rule.

Therefore, “to avoid the improper inclusion of cases that do not meet the requirements in the 60 percent rule” under presumptive compliance, it is proposing to remove G72.89 – Other Specified Myopathies from

18

the presumptive compliance list.

However patients with other specified myopathies that can be verified through a review of the patient’s medical record would continue to count toward the compliance percentage using the medical review method.

Proposed Subregulatory Process for Certain Updates to the Presumptive Methodology Diagnosis Code Lists CMS is proposing to establish a formal process of making non-substantive changes to the list of ICD-10-CM codes used in the presumptive compliance methodology for the 60 percent rule. CMS proposes a subregulatory process whereby the qualifying codes would be updated by applying all relevant changes to the lists of codes by synchronizing the codes with the most current ICD-10 medical code data set as updated ICD-10 Coordination and Maintenance Committee each year.

CMS says that these non-substantive changes that would be implemented at the subregulatory level would be limited to those specific changes that are necessary to maintain the same conditions on the presumptive compliance list due to changes in the most current ICD-10 medical code data set.

CMS proposes that each year’s updated lists of ICD-10-CM codes for presumptive compliance methodology will be available on the IRF PPS website prior to the effective date, but does not provide a more specific deadline for posting of the updated qualifying codes. CMS also emphasizes that they will not use the subregulatory process to make policy judgements about the codes included on the presumptive compliance list, but will only mirror changes made to the ICD-10CM codes.

apply for a waiver from the penalty. CMS proposes this change become effective for all discharges beginning on or after October 1, 2017.

Also in the proposed rule, CMS says it proposes to remove voluntary item 27: Swallowing status, from the IRF PAI. In the FY 2016 IRF PPS final rule, CMS revised the IRF PAI to include new items that assess functional status and the risk factor items.

Section K Swallowing/Nutritional Status, was added to the IRF PAI as a risk adjustor for the functional outcome measures.

CMS concludes that voluntary item 27 is duplicative of Section K, and adds unnecessary burden to provider reporting.

CMS proposes this change become effective for all discharges beginning on or after October 1, 2017.

CMS also proposes to use the information recorded for Item 25A-Height and Item 26A-Weight on the IRF PAI in to determine if a patient’s BMI is greater than 50 and to use that data to determine and presumptively count lower extremity single joint replacement cases toward an IRF’s compliance percentage. Items 25A-Height and 26A-Weight were added to the IRF PAI in the 2014 IRF PPS Final Rule. There is no suggested start date from CMS in the proposed rule.

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

IRF PAI Updates CMS is proposing to remove the 25 percent payment penalty that results from a late transmission of the IRF Patient Assessment Instrument (IRF PAI). CMS reasons that their change in 2012, which tied provider payment to a timely submission of both the IRF claim and an IRF PAI, already incentivized a timely submission of IRF PAIs. Therefore, the 25 percent payment penalty is redundant, and also creates and extra burden on providers who need to

AMRPA Magazine June 2017

WHEN IS GROUP THERAPY BENEFICIAL?

By Lisa Werner, MBA, MS, CCC-SLP

I

n 2010, CMS introduced documentation guidelines in an effort to better define medical necessity.

The guidelines included a statement indicating that the majority of therapy minutes should be spent in individual care. The industry wondered what that meant. Since then, we have been waiting for more information about how the use of various modes of therapy would be viewed. In 2015, we began to submit data to CMS on the minutes and mode of therapy delivered per discipline in the first two weeks of the patient’s rehabilitation stay.

CMS has yet to publish any information learned from the data collection.

two patients at the same time who are engaged in different activities. From a coding perspective, it is important to capture the treatment of two patients by one therapist with the group therapy CPT code regardless of whether that is delivered as group or concurrent therapy.

While CMS has offered no specific regulation around the use of modes of therapy and desired thresholds for each, at the AMRPA Spring Executive Forum, Lawrence Wilson, Deputy Director in the Center for Medicare at CMS, said that his team believes there is value in offering group therapy. As long as the group benefits the patient and offers value that helps them meet their established goals, group therapy is appropriate.

time devoted to recreation and social adjustment, patients only get these interactions during therapy time in the gym. When appropriate, group therapy can offer some of the same added benefits while the patient is working on therapeutic tasks. You can probably tell that I believe in group therapy when it is used appropriately.

Appropriate groups are those that provide skills enrichment such as lower extremity exercise group, gait group, dysphagia group, or cooking group. If you also believe in the benefit of group therapy, then be sure that your utilization and documentation reflect appropriate use. I recommend establishing a standardized charter for your group therapy offerings. The charter should Individual therapy is therapy that is identify the mission of the provided by one therapist group, goals for each session, to one patient. We record and tasks to be included. the time a patient spends in Then create a documentation individual therapy using CPT As long as the group benefits the template that includes the codes that represent each mission, goals, and tasks fifteen minute increment of patient and offers value that helps to ensure that they are time. Co-treatment means them meet their established goals, documented with each session that two therapists from in order to fully support the group therapy is appropriate. different therapy disciplines use of group therapy. For each are treating one patient session, the note should be together, with each therapist individualized to include an assessment working on different activities to help of the patient’s performance.

During my years of working in rehab, the patient meet specific but different many things have changed. The most goals. For billing purposes, each Do not include education groups, such obvious to me is the social benefit therapist captures their billable time as home safety, current events, stroke garnered from the program. In the years using individual CPT codes, such as prevention, and discharge planning, in when patients went to communal dining therapeutic activity or gait training. the therapy time. Education classes are spaces and recreation therapy programs, not considered therapeutic. Only include they socialized with others. The time The CPT code for group therapy is 97150. groups that directly support progress allowed them to share experiences and Group therapy is defined as one therapist toward the patient’s established goals. provide moral support for one another. working with two to six patients at one Education classes are essential to a safe It also may have sparked a bit of healthy time who are performing the same or and timely discharge, but they are not competition among patients when they similar activities. Concurrent treatment is always within the scope of therapy time. discussed accomplishments and next a new term for rehabilitation providers. It steps. Now, with private rooms and less means that a single therapist is treating

19

It is also important to note that Medicare Administrative Contractors (MACs) have been viewing group time differently than Mr. Wilson. They frequently deny claims and state as a reason that the patient did not need or did not receive an intensive therapy program. When the patient received at least 3 hours of therapy 5 times per week, it appears that the denials are related to use of group therapy minutes as part of the required

3 hours. These denials are not based on a published regulation and should be challenged.

Be sure that you are doing your part up front by documenting sound reasons to use group therapy, including an assessment of how the patient benefited from the activity. I spoke recently to a group of therapists at a facility that uses very little group therapy but had lower

than desired discharge FIM scores.

Someone said it seemed impossible that others used more groups and had better outcomes. It is not only possible, but probable, that some group therapy can be motivational and beneficial. Just be sure that it is presented in a manner that allows auditors to see the benefit too.

JOIN TODAY!

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

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AMRPA Magazine June 2017

OIG: CMS NEEDS TO USE ADDITIONAL TOOLS TO IDENTIFY GAMING OF HOSPITAL-REPORTED QUALITY DATA

T

he Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) recently published a report examining the Centers for Medicare and Medicaid Services (CMS) use of quality data reported by acute care hospitals. The report “CMS Validated Hospital Inpatient Quality Reporting Program Data, But Should Use Additional Tools to Identify Gaming” was released in April.

Beginning in federal fiscal year (FY) 2005, CMS requires Medicare inpatient acute care hospitals to report quality data or be subject to a payment reduction under the Hospital Inpatient Quality Reporting (IQR) Program. Inpatient rehabilitation hospitals and units (IRH/Us) similarly report data under the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) and also incur a payment penalty for noncompliance. However, OIG’s review at this time was limited to the quality data reported by acute care hospitals.

The OIG sought to determine the extent to which: •

CMS validated hospital-reported inpatient quality data in accordance with regulatory requirements

•

CMS’ approach to validation is likely to identify gaming (i.e., “hospitals’ manipulating data to improve their scores”)

•

Assess the outcomes of CMS’s validation

the number of hospitals selected for validation

•

why CMS selected them

•

the outcome of the validation

OIG’s Findings: •

•

OIG recommended that CMS make better use of analytics to ensure the integrity of hospital-reported quality data and the resulting payment adjustments by:

•

•

Increasing the number of hospitals in its targeted validation sample

•

•

Analyzing data to identify outliers and determine those that warrant further review, and then add them to the sample.

•

Identifying hospitals with abnormal percentages of patients having infections present on admission as this might help identify hospitals engaging in overculturing patients, one of the concerns highlighted in CMS and CDC’s Joint Reminder.

•

CMS

For payment year 2016 CMS met its regulatory requirement by validating sufficient IQR data, which are used to adjust payments on the basis of quality Almost 99 percent of hospitals that CMS reviewed passed validation, and CMS took action against the six hospitals that failed, including reducing their Medicare payments.

CMS and CDC offer training to hospitals to help improve the accuracy of quality data that hospitals report.

However, OIG states that CMS’s approach to selecting hospitals for validation for payment year 2016 made it less likely to identify gaming of quality reporting.

CMS did not include any hospitals in its targeted sample on the basis of their having aberrant data patterns.

However OIG states that it is important for CMS to ensure that hospitals are accurately reporting their quality data as hospitals have much at stake with their reporting of quality data, as do Medicare and its beneficiaries.

CMS’s approach to selecting hospitals for validation for payment year 2016 made it “less likely to identify gaming of quality reporting.”

Methods OIG analyzed CMS validation data for payment year 2016 to determine: •

OIG conducted interviews with five stakeholder experts about hospital quality data and any concerns they had about the data or CMS’ validation. It also conducted interviews with CMS and the Centers for Disease Control and Prevention (CDC) staff regarding quality assurance activities, as well as any analyses they conduct on the quality data. OIG also reviewed training materials that CMS and CDC offered to hospitals on how to report their quality data.

CMS concurred with recommendation.

OIG’s

For the complete report please see https://www.oig.hhs.gov/ oei/reports/oei-01-15-00320.asp

Conclusion OIG concluded that through its validation of hospital IQR data, CMS has made progress to ensure that Medicare’s payment adjustments linked to measures of quality are based on accurate data.

21

R

E

G

I

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T

E

R

N

O

W !

5th ANNUAL

National Summit on Safety and Quality for Rehabilitation Hospitals

July 17 – 18, 2017

RITZ CARLTON PENTAGON CITY

Bringing to light the latest clinical breakthroughs and research in safety and quality

Continuing education hours for physicians, nurses, physical therapists, occupational therapists, and speech language pathologists will be offered pending state approval. Further details can be found at safetyqualitysummit.org.

ARLINGTON, VA

LISTEN to leading experts SHARE best practices & strategies LEARN to meet the challenges at your hospital

Featured Speakers

Sam Fleming - Fleming-AOD

Thomas A. Demetrio, Esq. - Corboy & Demetrio

Shantanu Agrawal, MD - National Quality Forum

Chris MacDonell, FACRM - CARF Richard Riggs, MD - California Rehabilitation Institute and Cedars-Sinai Health System

Alison Cernich, PhD - NCMRR, NICHD Bruce Gans, MD - Kessler Institute for Rehabilitation

For more information, or to register, visit safetyqualitysummit.org

SPONSORED BY:

IN COLLABORATION WITH:

Inpatient Rehabilitation Division of Select Medical

22

AMRPA Magazine June 2017

FY 2018 IRF PPS PROPOSED RULE’S QUALITY-RELATED PROVISIONS AND STANDARDIZED PATIENT ASSESSMENT DATA

By Mimi Zhang, Policy and Research Associate, AMRPA

O

n April 27, the Centers for Medicare and Medicaid Services (CMS) issued its proposed annual update for the Inpatient Rehabilitation Facilities Prospective Payment System (IRF PPS) for fiscal year (FY) 2018. The proposed rule covered numerous changes to the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP), most notably the addition of standardized patient assessment data items. The new assessment items would be reported via the IRF Patient Assessment Instrument (IRF PAI) beginning October 2018.

In recent years, the IRF QRP has significantly expanded the set of quality measures that inpatient rehabilitation hospitals and units (IRH/Us) must report in order to receive a full annual payment update (APU). Although this year’s rule does not carry a spate of new quality measures, by no means has CMS lessened providers’ data reporting requirements as it continues to carry out its statutory mandates pursuant to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. In addition to implementing cross-setting quality measures for post-acute care (PAC) providers, the Act also requires that IRH/ Us, SNFs, and LTCHs report standardized patient assessment data at admission and discharge by October 2018 (FY 2019) (home health agencies (HHAs) begin in January 2019).

Proposed Changes to Currently Adopted Measures Replacing the Pressure Ulcer Measure CMS proposes to replace the current pressure ulcer measure, “Percent of

Residents or Patients with Pressure Ulcers that are New or Worsened (Short Stay) (NQF #0678)” with a modified pressure ulcer measure titled “Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury.” The modified measure will begin data collection October 1, 2018 for the FY 2020 QRP performance year. CMS proposes that the modified measure would satisfy the IMPACT Act data reporting domain of “skin integrity and changes in skin integrity.” IRH/Us would be required to report these data on admission and discharge for patients discharged from October 1, 2018 through December 1, 2018 for the FY 2020 QRP year. Starting in CY 2019, IRFs would submit data for the full calendar year (CY).

Measure Changes The modified measure would include new or worsened unstageable pressure ulcers, including deep tissue injuries (DTIs), in the measure numerator. Hence, this measure would report the percent of patient stays with reports of Stage 2-4 pressure ulcers, or unstageable pressure ulcers due to slough/eschar, non-removable dressing/device, or deep tissue injury, that were not present or were at a lesser stage on admission. The modified measure would be calculated from IRF PAI item M0300--Current Number of Unhealed Pressure Ulcers/ Injuries at Each Stage (at admission and discharge) instead of item M0800-Worsening in the Pressure Ulcer Status Since Admission. Item M0800 would be removed from the version of the IRF PAI effective 10/1/2018 (IRF PAI version 2.0). The measure terminology is also changed to “pressure ulcers/injuries” to align with recommendations from

Highlights: •

•

CMS proposes to remove the all-cause readmissions measure and modify the pressure ulcer measure Adds six pages of new patient assessment data items to IRF PAI version 2.0 effective October 2018

the National Pressure Ulcer Advisory Panel (NPUAP). In conjunction with the proposed rule, CMS issued a report that details technical specifications for the proposed standardized patient assessment data and other QRP changes included in the proposed rule. The report is Proposed Specifications for IRF QRP Quality Measures and Standardized Data Elements Effective 10/1/2018 and is available on CMS’ IRF QRP website.

According to CMS, the inclusion of unstageable pressure ulcers and DTIs in the numerator of this measure will increase measure scores (note: lower is “better”). CMS estimates that provider scores will increase more than twofold on average. Under the current measure, the mean score for all IRH/ Us is 0.64 percent, and the 25th and 75th percentiles are 0 percent and 0.95 percent, respectively (timeframe: Quarter 4 2016). In the proposed measure during the same timeframe, the mean score is 1.46 percent, and the 25th and 75th percentiles are 0 percent and 2.27 percent, respectively.

The measure would be risk-adjusted for the following patient characteristics: 23

•

Functional Mobility Admission Performance;

•

Bowel Continence;

•

Peripheral Vascular Disease / Peripheral Arterial Disease or Diabetes Mellitus; and

•

in November 2016. AMRPA supported the draft modifications at that time and recommended that M0800 be removed if it no longer has utility, which CMS does propose to do.

Low Body Mass Index.

CMS first released these specification changes in draft form for public comment

Removal of All-Cause Unplanned Readmission Measure CMS proposes to remove the All-Cause Unplanned Readmission Measure for 30 Days

Quality Measures Currently Adopted for the IRF QRP Short name

Measure name and data source IRF PAI

Post-Discharge from IRFs (NQF #2502) from the IRF QRP beginning with the FY 2019 IRF QRP. At that time, the measure would also be removed from being publicly reported. Two readmissions measures were introduced in the FY 2017 IRF PPS final rule which would essentially replace All-Cause readmissions: the Potentially Preventable Readmissions (PPR) 30-Day Post-Discharge measure, and the Potentially Preventable Within Stay Readmission measure. AMRPA and other stakeholders have commented to CMS that having three readmissions measures is duplicative, and unnecessarily confusing and burdensome for providers to track and improve performance.

Pressure Ulcers

Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678) Proposed for replacement beginning 10/1/2018

Patient Influenza Vaccine

Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680)

All other current IRF QRP measures, as seen in the table below, would be retained.

Application of Falls

Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)*

Potential Future Changes and Measures

Application of Functional Assessment

Application of Percent of LTCH Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)*

Change in Self-Care

IRF Functional Outcome Measure: Change in SelfCare Score for Medical Rehabilitation Patients (NQF #2633)

Change in Mobility

IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

Discharge Self-Care Score

IRF Functional Outcome Measure: Discharge SelfCare Score for Medical Rehabilitation Patients (NQF #2635)

Discharge in Mobility

IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

DRR

Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC IRF QRP*

CAUTI

National Healthcare Safety Network (NHSN) CatheterAssociated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138)

MRSA

NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)

CDI

NHSN Facility-wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)

HCP Influenza Vaccine

Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431)

NHSN

Claims-based All-Cause Readmissions

All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from IRFs (NQF #2502) Proposed for removal beginning 10/1/2018

MSPB

Medicare Spending per Beneficiary (MSPB)—PAC IRF QRP*

DTC

Discharge to Community—PAC IRF QRP*

Potentially Preventable Readmissions (PPR) 30 day

Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP*

PPR Within Stay

Potentially Preventable Within Stay Readmission Measure for IRFs.*

* Not currently endorsed by the National Quality Forum (NQF) for IRH/Us. 24

Experience of Care and Patient-Reported Pain CMS is developing an IRH/U experience of care survey and survey-based measures will be developed from this survey. The survey explores experience of care across five main areas: (1) beginning stay at the IRH/U; (2) interactions with staff; (3) experience during the stay; (4) preparing for leaving; and (5) overall IRH/U rating. CMS is also considering a measure focused on pain, Application of Percent of Residents Who Self-Report Moderate to Severe Pain (Short Stay) (NQF #0676), that relies on the collection of patient-reported pain data in a future rulemaking. However, the pain measure was designed for nursing homes and CMS did not provide literature in this proposed rule indicating that it had been tested in IRFs. The proposed rule did not discuss start dates for these measures.

Modifications to the Discharge to Community Measure Last year, CMS finalized the Discharge to Community-Post Acute Care for the IRF QRP and other PAC providers. The measure is claims-based and assesses successful discharge to the community including no unplanned rehospitalizations or death in the 31 days following IRH/U discharge. In response to AMRPA and other stakeholders’ feedback, CMS is considering “possible modifications” to exclude baseline nursing facility AMRPA Magazine June 2017

residents from the measure and seeks additional comment. At the time of the measure’s development, CMS stated that it did not have a way to tease out baseline nursing home residents based on Medicare FFS data and hence their included in the measure population.

Risk Adjustment for Social Risk Factors CMS does not propose in this rule to risk-adjust quality measures for social risk factors, also known as socioeconomic or sociodemographic status (SES/SDS) factors. Nonetheless, it does seek public comment on the issue in light of recent work from the NQF, National Academy of Sciences, Engineering, and Medicine, and the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) on measuring and accounting for social risk factors in Medicare’s quality reporting and value-based purchasing programs. Examples of social risk factors include dual eligibility/ low-income subsidy, race and ethnicity, and geographic area of residence. Any changes would be proposed through future rulemaking.

Input Sought on Including Non-Medicare Patients CMS is seeking feedback on whether it should require quality reporting of assessment-based measures for all IRH/U patients, regardless of payer. The Agency states it has received input suggesting that it expand quality measures to include all patients regardless of payer status. It acknowledges that this would create additional provider burden.

Transfer of Information CMS is developing two IMPACT Actrequired measures to assess PAC providers’ Transfer of Information.

However, it does have any proposals related to the measures in this rule. CMS states it intends to specify these measures

by October 1, 2018 and propose them for adoption in the FY 2021 IRF QRP, with data collection beginning “on or about” October 1, 2019. The measures are 1) Transfer of Information at Post-Acute Care Admission, Start or Resumption of Care from other Providers/Settings, and (2) Transfer of Information at Post-Acute Care Discharge, and End of Care to other Providers/Settings. The IMPACT Act domain is “accurately communicating the existence of and providing for the

transfer of health information and care preferences.”

Proposed Changes to Public Reporting CMS proposes to add six (6) measures to public reporting beginning in CY 2018: •

Application of Percent of LongTerm Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631) (assessment-based);

•

Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674) (assessment-based);

•

Medicare Spending Per BeneficiaryPAC IRF QRP (claims-based);

•

Discharge to Community-PAC IRF QRP (claims-based);

•

Potentially Preventable 30-Day PostDischarge Readmission Measure for IRF QRP (claims-based); and

•

Potentially Preventable Within Stay Readmission Measure for IRFs (claims-based).

CMS proposes to remove the All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge (NQF #2502) from public reporting by October 2018. CMS

also proposes to replace the pressure ulcer measure with the modified version proposed in this rule. For the assessment-based measures, CMS proposes to display data based on four rolling quarters of data and would initially use discharges from CY 2017. For the claims-based measures, CMS proposes to transition the public reporting annual cycle from calendar year to fiscal year to make these measures data public available by October 2018. Thus, it is proposing to publicly report four claimsbased measures beginning CY 2018, and the underlying claims data would be from FYs 2016 and 2017.

To ensure statistical reliability of the reported provider scores, CMS proposes that IRH/Us which do not meet a minimum number of discharges during a performance period would not have their measure scores reported. The thresholds are 20 cases for the assessment-based measures; 20 cases for the MSPB measure; and 25 cases for all other claims-based measures.

The table below lists the currently adopted and proposed quality measures that are or will be publicly reported on the IRF Compare website.

Previously Finalized and Proposed Measures for CY 2018 Public Display and Confidential Provider Feedback Reports Previously Finalized Measures and Data Source Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #678) Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (NQF #0680)

IRF PAI

National Healthcare Safety Network Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138) NHSN Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus Bacteremia Outcome Measure (NQF #1716)

NHSN

NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection Outcome Measure (NQF #1717) Influenza Vaccination Coverage Among Healthcare Personnel (NQF #0431) Proposed Measures and Data Source Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)

IRF PAI

Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF# 0674) Medicare Spending Per Beneficiary-PAC IRF QRP Discharge to Community-PAC IRF QRP Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP

Claimsbased

Potentially Preventable Within Stay Readmission Measure for IRFs 25

Standardized Patient Assessment Data and Collection Much of the proposed rule’s QRP content is dedicated to standardized patient assessment data and how it will be collected and integrated into the QRP. The IMPACT Act requires that PAC providers report standardized patient assessment data at admission and discharge in the following categories: •

•

•

•

•

•

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 the need for ventilator use, dialysis, chemotherapy, central line placement and total parenteral nutrition; Medical conditions and comorbidities such as diabetes, congestive heart failure and pressure ulcers; Impairments, such as incontinence and an impaired ability to hear, see or swallow; and Other categories deemed necessary and appropriate.

IRF PAI Items Beginning October 2018 Timeline CMS proposes to add 24 items to the IRF PAI on admission and discharge in order to meet the IMPACT Act’s data collection requirements. IRH/Us would begin reporting on October 1, 2018, and the data collected from OctoberDecember 2018 would be used for the FY 2020 IRF QRP year. In other words, providers’ reporting in Q4 2018 will be used to determine their QRP compliance for the FY 2020 APU. Past measures have followed a similar reporting timeframe when introduced into the QRP. Following the initial reporting year for the FY 2020 IRF QRP, subsequent performance years would be based on a full calendar year of such data reporting.

Burden CMS estimates that the additional IRF PAI proposed in this rule detailed

26

below will add 14.4 minutes to a patient assessment (7.2 minutes each to admission and discharge). However, CMS also believes that the total burden of the new data elements ($5,244 per IRH/U annually or $5,963,253 for all providers annually) will be off-set by the proposed removal of some pressure ulcer items and the voluntary Swallowing Status item. Therefore, the Agency estimates that the annual net cost from the rule’s proposed changes is $2,989 per IRH/U or $3,399,023 for all providers. AMRPA will be addressing burden in its comment letter to CMS. Assessment Items The new IRF PAI items would further standardize the patient assessment instruments used in PAC settings, as many of the items are currently on the LTCH Care Data Set (LCDS), the SNF Minimum Data Set (MDS), or the HHA OASIS. Almost all of the items would reported on admission and discharge, with the exception of the Brief Interview of Mental Status (BIMS), Hearing, and Vision items. The IRF PAI version 2.0 effective October 1, 2018, reflects these changes. CMS has made the IRF PAI v.

2.0 and a change table available here: https://tinyurl.com/CMSIRFPAI. The proposed patient assessment items are listed below according to the IMPACT Act domain they would satisfy: •

Functional Status No new items are proposed.

Rather, the data reported for the Application of Percent of LongTerm Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631) would be used to fulfill the functional status data domain.

•

Cognitive Status

Function

and

Mental

o Brief Interview for Mental Status (BIMS): Already reported on the IRF PAI so no changes are proposed. o Short Confusion Assessment Method (CAM): New item added to IRF PAI Section C o Behavioral Signs and Symptoms:

New Section E—Behavioral Symptoms created for these items. o Patient Health Questionnaire (PHQ-2): New Section D--Mood created for the PHQ-2 items.

•

Special Services, Treatments, and Impairments New items added in Section O for the following items: o Cancer Treatment: Chemotherapy (IV, Oral, Other) o Cancer Treatment: Radiation o Respiratory Treatment: Oxygen Therapy (Continuous, Intermittent) o Respiratory Treatment: Suctioning (Scheduled, As needed) o Respiratory Treatment: Tracheostomy Care o Respiratory Treatment: Noninvasive mechanical ventilation (BiPAP, CPAP) o Respiratory Treatment: Invasive mechanical ventilator o Other Treatment: Intravenous (IV) Medications o Other Treatment: Transfusions o Other Treatment: Dialysis (Hemodialysis, Peritoneal dialysis) o Other Treatment: IV Access (Peripheral IV, Midline, Central line, Other) o Nutritional Approach: Parenteral/ IV Feeding o Nutritional Approach: Feeding Tube o Nutritional Approach: Mechanically Altered Diet o Nutritional Approach: Therapeutic Diet o Impairments: Hearing (admission only) o Impairments: Vision (admission only)

Data Completion Threshold and QRP Penalty CMS proposes to fold the new assessment data under the QRP’s reporting requirement and extend the QRP completion threshold (95 percent) to

AMRPA Magazine June 2017

include standardized patient assessment data. According to CMS, its data suggests that the majority of IRFs are currently in compliance with or exceed this threshold, and thus the Agency feels it is feasible to also apply the threshold to standardized patient assessment data.

Providers that do not meet the reporting threshold are deemed noncompliant and are subject to a two percentage APU reduction.

Applying Other QRP Policies CMS also proposes to extend other current IRF QRP policies applicable

to quality measures to the reporting of standardized patient assessment data. These include the exceptions and extensions policies, the retention policy, and the process of using sub-regulatory means (as opposed to formal rulemaking) for any non-substantive changes in data reporting requirements. Finally, CMS also proposes to apply its current reporting schedule for quality data to the reporting of standardized patient assessment data. That is, IRFs must report data on measures for discharges during the 12-month CY, except in the first program year for which a measure is

adopted. For the first year of a measure’s implementation in the QRP, IRFs are only required to report data on discharges on discharges in Quarter 4 of the applicable calendar year. *** For more information on the IRF QRP, please see CMS’ webpage at https:// tinyurl.com/cmsIRFQRP.

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.

27

CMS ISSUES FY 2018 PROPOSED RULE OUTLINING MEDICARE PAYMENT POLICIES AND RATES FOR SNFS

By Lovelyn M. Robinson, Research and Editorial Assistant

T

he Centers for Medicare & Medicaid Services (CMS) issued its annual fiscal year (FY) 2018 proposed rule updating Medicare payment policies and rates under the Skilled Nursing Facility Prospective Payment System (SNF PPS), the SNF Quality Reporting Program (SNF QRP) and the SNF Value-Based Purchasing (SNF VBP) Program in the May 4, 2017 Federal Register. This article covers some of the major provisions in the proposed rule.

Policy Provisions The proposed rule outlines provisions which include a net market basket increase of 1 percent under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), or an additional $390 million, in aggregate payments than were made in 2017. CMS is clarifying definitions and provisions related to investigation of complaints and team composition and to align regulatory provisions for investigation of complaints with the statutory requirements found in the Act. The rule addresses several parts of the SNF VBP program, set to begin in FY 2019, such as updated performance standards, a proposed logistical exchange function for SNF performance and incentive payments, and details on publishing SNF performance to the public. For example, for the SNF VBP, CMS proposed limiting the program to one readmission measure per year and reducing the total amount of Medicare payments to a SNF by 2 percent to fund the value-based incentive payments.

Changes to SNF PPS Payment Rates CMS projects that aggregate payments to SNFs will increase in FY 2018 by $390 million, or 1.0 percent, from payments in FY 2017. This estimated increase is attributed to a 1.0 percent market basket increase required under MACRA.

28

CMS is proposing to replace the current pressure ulcer measure with an updated version and to adopt the four new measures below that address functional status for FY 2020: SNF Quality Reporting Program (SNF QRP) SNFs that fail to submit the required quality data to CMS will be subject to a 2 percentage point reduction to the otherwise applicable annual market basket percentage update with respect to that fiscal year CMS is proposing to begin publicly reporting six new measures by fall 2018.

Beginning in FY 2019, SNFs must also report standardized patient assessment data (SPAD). For FY 2020, SNFs must begin reporting standardized patient assessment data under five specific patient assessment categories:

Highlights: •

•

Aggregate payments to SNFs will increase by $390 million in FY 2018.

CMS will begin publically reporting six new measures for display by fall 2018.

1. functional status 2. cognitive function 3. special services, treatments and interventions 4. medical conditions and co-morbidities 5. impairments For more information please SNF QRP: https://www.cms.gov/Medicare/ Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/ SNF-Quality-Reporting-ProgramMeasures-and-Technical-Information.html.

Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633) Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

Four New Measures

Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635) Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

AMRPA Magazine June 2017

Scoring and operational policies for (FY 2019) include: The Program is limited to one readmission measure for each year and requires the Secretary to reduce the total amount of Medicare payments to SNFs in a fiscal year by 2 percent reduction to fund the valuebased incentive payments for that fiscal year.

The total amount of valuebased incentive payments that can be made to SNFs in a fiscal year is statutorily limited to between 50 percent and 70 percent of the total amount of the reduction to SNF Medicare payments for that fiscal year.

SNF Value-Based Purchasing Program (SNF VBP) The SNF VBP Program has adopted scoring and operational policies for its first year (FY 2019) and has specified measures and program features as required by statute.

The SNF VBP proposed policies in the FY 2018 proposed rule also include performance and baseline periods for the FY 2020 Program year, updated values for performance standards for FY 2020, additional details for the Review and Correction process for SNFs’ performance information to be made public on Nursing Home Compare, and revising the previously-adopted rounding policy for SNF performance scores. Public comments on these proposals will be accepted through June 26, 2017.

For more information please see SNF VBP: https://www.cms.gov/Medicare/ Quality-Initiatives-Patient-AssessmentInstruments/Value-Based-Programs/ Other-VBPs/SNF-VBP.html

The Program must pay SNFs ranked in the lowest 40 percent less than the amount they would otherwise be paid in the absence of the SNF VBP.

Advance Notice of Proposed Rulemaking (ANPRM) CMS also released an Advance Notice of Proposed Rulemaking (ANPRM) which solicits comment on potential revisions to the SNF payment system, based on research conducted under the SNF Payment Models Research project.

CMS is particularly seeking comments on the possibility of replacing the SNF PPS’ existing case-mix classification model, the Resource Utilization Groups, Version 4 (RUG-IV), with a new model, the Resident Classification System, Version I (RCS-I). CMS also released a Technical Report on the development of RCS-I, which is available at https://www.cms. gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/therapyresearch.html.

Request for Information (RFI) In addition to the proposed rule, CMS released a Request for Information (RFI) for feedback on the Medicare Program.

CMS is soliciting ideas for regulatory, subregulatory, policy, practice and procedural changes to promote the availability of high value and efficiently-provided care

for its beneficiaries. Ideas could include recommendations regarding: •

payment system re-design

•

elimination or streamlining of reporting

•

monitoring and documentation requirements

•

operational flexibility

•

feedback mechanisms and data sharing that would enhance patient care

•

supporting doctor-patient relationship in care delivery

•

facilitating patient-centered care

They could also include recommendations regarding: •

when and how CMS issues regulations and policies

•

how CMS can simplify rules and policies for Medicare beneficiaries, clinicians, providers and suppliers

CMS states that it will not respond to RFI comment submissions in the final rule, but will consider input in developing future regulatory proposals or future subregulatory guidance.

The RFI was published in the May 4, 2017 Federal Register and CMS will accept comments until June 26, 2017.

For more information on the SNF PPS please see: http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/SNFPPS/index. html

29

WHITEPAPER DISCUSSES NEED FOR HOSPITAL READMISSION PREVENTION AND IMPROVEMENT IN TRANSITIONS OF CARE

M

CG Health, part of the Hearst Health network, released a whitepaper “Preventing Hospital Readmissions and Improving Transitions of Care” that examines the problem of readmissions with a discussion on underlying causes and the need to focus on transitions of care.

•

There has been continued discussion about readmissions due to the significant cost to the healthcare system and impact on patients’ quality of life. The report states that patients often return to the hospital within 30 days of discharge for the following reasons: Unavoidable readmissions

Avoidable readmissions

Caused by an event unrelated to the initial hospitalization.

Example: A patient who was initially admitted with a hip fracture and then readmitted 2 weeks later due to injuries sustained in a car accident experienced an unavoidable readmission.

Refer to situations that could have been prevented if an intervention was performed (or was performed better) during the discharge process from the hospital.

Example: If the same patient with a hip fracture was overmedicated with pain medications, unsteady on her feet, and fell while at home, that was likely an avoidable readmission.

Underlying Causes of Readmissions According to the author preventing a readmission to the hospital requires an understanding of the root causes of the readmission as the discharge process from the hospital is quite complex, and there are many steps that may be missed or handled 30

exist within a provider organization (eg, specialists not talking to one another about treatment decisions or the plan for follow-up), between care facilities (eg, the next levelof-care not receiving all of the pertinent information regarding the hospitalization), and between every person involved with the patient’s care (eg, physicians, nurses, social workers, case managers).

poorly. Medical studies have concluded that several common elements can drive inappropriate readmissions such as:

•

Lack of patient readiness for discharge. A lack of patient readiness refers to situations in which patients are discharged too early from the hospital, such as when the patient is not yet medically stable, when the patient or caregiver cannot or is not ready to manage the care needed by the patient, or when there is a mismatch between the provider’s and patient’s goals for ongoing care and discharge. Unfortunately, patients and their families often do not feel empowered to speak up to express their concerns about the discharge plan, and even if they do, their concerns may not be heard or validated by the team caring for the patient.

Lack of communication between stakeholders.

Communication issues can also contribute to a lack of patient readiness discharge, such as cases in which patients and caregivers are not notified or educated about their discharge. But communication problems are often more pervasive. Communication problems may occur at any point during the transitions process and can happen during any point along the entire care continuum.

Communication problems can

•

Provider overreaction. A premature reaction by the provider can also lead to readmission. A patient may be able to be safely managed in the outpatient arena or at a lower level of care instead of being referred to the hospital, but may be admitted due to provider inexperience, convenience, or even frustration.

Examples of these sorts of inappropriate readmissions include when skilled nursing facility (SNF) staff do not attempt to stabilize a patient but automatically sends him to emergency room (ER) or when an emergency department (ED) provider opts for admission despite the patient being an appropriate candidate for observation care.

Unfortunately, readmissions happen.

However, the readmissions themselves are not the problem; they are the outcome of an underlying failure in the patient’s care transitions, the author noted.

FY 2012 Rule

FY 2015 Rule

FY 2016 Rule

FY 2017 Rule

CMS started the program with three diagnoses: 1. acute myocardial infarction, 2. heart failure, and 3. pneumonia.

CMS expanded the program to include: 1. acute exacerbations of COPD and elective total hip and total knee arthroplasties

CMS updated the definition of pneumonia to include: 1. aspiration 2. pneumonia and 3. sepsis

The program is set to include coronary artery bypass graft (CABG).

AMRPA Magazine June 2017

Payors have been active in addressing the issues associated with readmissions.

For decades, commercial payors have provided case management services to focus on ensuring that a patient’s care occurred at the right level of care, at the right time, and that avoidable complications were addressed/prevented.

within 30 days for designated diagnoses, if the hospital’s number of readmissions exceed a national average for that set condition.

readmission rates. The challenge is knowing which interventions and tools will provide the most value and ensuring that allocated resources are fully utilized. The evidence suggests that there is not a single intervention, or even a set of interventions, that will prevent every avoidable readmission, but there are benefits to implementing care transition programs that provide There is not a single intervention, a comprehensive, structured discharge plan. This enhanced or even a set of interventions, discharge planning deploys that will prevent every avoidable strong communication pathways, patient-centric planning and readmission, but there are benefits education, and promotes followto implementing care transition up monitoring and support.

Hospital Readmissions Reduction Program (HRRP) In 2015 the Centers for Medicare & Medicaid Services (CMS) enacted several programs directed at preventing readmissions through the Hospital Readmissions Reduction a Program (HRRP).

These government initiatives have motivated hospitals to focus on improving care transitions and preventing avoidable readmissions by tying reimbursement levels to readmission rates. The most notable initiative is the HRRP, which incentivizes hospitals to prevent avoidable readmissions. The “incentive” consists of a decreased payment to a hospital for a readmission

programs that provide comprehensive, structured discharge plan.

Conclusion Provider organizations are incentivized to reduce readmission rates and are doing so through programs that improve care transitions. There are many different interventions and tools that organizations can deploy as they try to impact their

Author Angela Askren, RN, MSN, CMC, MCG Health For the whitepaper “Preventing Hospital Readmissions and Improving Transitions of Care” please see https:// pages.questexweb.com/rs/294-MQF-056/ images/MCG-Hospital-ReadmissionPrevention.pdf

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CMS RELEASES FISCAL YEAR 2018 IPPS LONG-TERM CARE HOSPITAL PROSPECTIVE PAYMENT SYSTEM NPRM

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

O

are subject to a quality reporting program been phasing in, and due to statutory n Friday, April 14, the (QRP), in which they must submit certain requirements, CMS has been enforcing Centers for Medicare metrics to CMS in a timely manner or face the policy at a 50 percent threshold for and Medicaid Services a 2 percent annual payment reduction. In most facilities. CMS says it is reexamining (CMS) released its notice the proposed rule, CMS is proposing to the policy in light of the new site-neutral of proposed rulemaking replace the currently required pressure payment policies for LTCHs, which may (NPRM) for the Inpatient Prospective ulcer measure, Percent of Residents or make the 25 percent rule unnecessary.

Payment System (IPPS) and Long-Term Patients with Pressure Ulcers That Are New They further state that they will review Care Hospital Prospective Payment or Worsened (Short Stay) (NQF #0678), public comments on the proposal, and if it System (LTCH PPS) for Fiscal Year (FY) 2018. with a modified version of that measure decides not to implement the moratorium, CMS proposes to update the LTCH PPS called Changes in Skin Integrity Postthen it will enforce the threshold at 50 standard payment rate by 1 percent, which Acute Care: Pressure Ulcer/Injury. CMS is percent for FY 2018. was mandated by the Medicare Access proposing the same replacement in the and CHIP Reauthorization Act of 2015 Inpatient Rehabilitation Facility (IRF) QRP There are a number of steps CMS took in (MACRA). Despite the 1-percent update, and the Skilled Nursing Facility (SNF) the proposed rule to comply with the 21st CMS estimates that overall LTCH PPS QRP this year, hence continuing its efforts Century Cures Act, including extending payments would decrease by 3.75 percent, to standardize quality measures across an exemption to a moratorium on adding or $173 million in FY 2018. CMS states that post-acute care settings. The proposed a significant cause of this decrease is the rule also adds two measures phase in of the dual payment related to ventilator care called rate system which requires that Compliance with Spontaneous Medicare pay “site-neutral” Breathing Trial (SBT) by Day 2 rates, based on what Medicare Despite the 1-percent update, of the LTCH Stay and Ventilator pays for similar cases in acute CMS estimates that overall Liberation Rate. CMS further care hospitals, unless the LTCH proposes to remove the Allcase meets certain criteria. This LTCH PPS payments would Cause Unplanned Readmission transition began in FY 2016 and decrease by 3.75 percent, Measure for 30 Days Postwas mandated by The Pathway or $173 million in FY 2018.

Discharge (NQF #2502) from for SGR Reform Act of 2013.

LTCHs, which it has also proposed for the IRF QRP. CMS also proposes a Finally, CMS is also proposing moratorium on enforcement to begin publicly reporting six new additional beds to LTCHs for facilities of the 25 percent rule. This rule aims to measures to display on the LTCH Compare that qualify, and excluding Medicare ensure LTCHs operate independently of website by fall 2018 and one new measure Advantage (MA) and site-neutral patients acute care hospitals by requiring that no to display on the LTCH Compare website from calculating a facility’s average length more than 25 percent of their patients are by fall 2020. of stay (ALOS). CMS also proposes an referred from any one facility. If an LTCH increase in the fixed-loss amount for exceeds the applicable threshold during a Patient Assessment Data Reporting high cost outlier cases to $30,081 and a cost reporting period (CRP), payment for As a result of The Improving Medicare fixed-loss amount under the site-neutral the discharge that puts the LTCH over its Post-Acute Care Transformation Act of payment rate of $26,713. threshold, and all discharges subsequent 2014 (IMPACT Act), LTCHs and other postto that discharge in the cost reporting acute care settings must begin reporting Quality Reporting Program period from the referring hospital are standardized patient assessment data Similar to other types of providers, LTCHs adjusted downward. As the policy has 32

AMRPA Magazine June 2017

(SPAD). For FY 2019, CMS proposes that the data LTCHs report under the proposed modified pressure ulcer measure will satisfy some of these requirements. For FY 2020, CMS is proposing that LTCHs begin reporting standardized patient assessment data on October 1, 2018 with respect to five specified patient assessment categories required by law that include: 1. Functional status; 2. Cognitive function; 3. Special services, treatments and interventions; 4. Medical conditions and comorbidities; and 5. Impairments These changes will align the assessment items on the LTCH Care Data Set (LCDS)

with the MDS 3.0 in SNFs and the IRF Patient Assessment Instrument (IRF PAI) so that standardized patient data is collected across post-acute care (PAC) settings.

Hospital-Within-Hospital Rules CMS has proposed to revise its hospitalwithin-hospital (HWH) regulations in the proposed rule, which are the rules that govern the control and operation of LTCHs co-located with another type of facility. The proposal would make separateness and control requirements of the HWH rules apply only to IPPS-excluded HWHs that are co-located with an acute-care hospital.

CMS says the change to make the HWH rules no longer apply to LTCHs hospitals co-located with facilities other than acute care hospitals is because many of the patient shifting concerns that were the

impetus for the original HWH rules have been mitigated by more recent policies such as the creation of the Inpatient Rehabilitation Facility PPS and Inpatient Psychiatric PPS.

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

FY 2018 MEDICARE PROSPECTIVE PAYMENT SYSTEMS RULES STATUS *These dates reflect the dates of publication in the 2017 Federal Registers* Proposed Rule Hospital Inpatient PPS

Correction Notice

Final Rule

April 28, 2017

Hospital Outpatient PPS Inpatient Rehabilitation Facilities PPS

May 3, 2017

Home Health Agencies PPS Long Term Care Hospitals PPS

April 28, 2017

MS-LTC- DRG PPS

May 4, 2017

Skilled Nursing Facilities Psychiatric Hospitals PPS Medicare Physician Fee Schedule Source: CMS Prospective Payment Systems - General Information website http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/index.html

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AHRQ IMPACT CASE STUDY: CAROLINAS REHABILITATION PSO IMPROVES PATIENT SAFETY

T

Unassisted Falls

he Agency for Healthcare Research and Quality (AHRQ) featured a case study focused on Carolinas Rehabilitation Patient Safety Organization (PSO), which serves 34 freestanding inpatient rehabilitation hospitals units (IRH/Us). According to the latest research, Carolinas is facilitating the improvement of quality and patient safety across 19 states with improvements particularly noted in the prevention of falls and hospitalacquired pressure ulcers.

Carolinas Rehabilitation is the first AHRQlisted PSO specifically targeted for inpatient rehabilitation settings to help improve patient care. For example, the PSO recognized that quality and safety metrics for acute and post-acute settings did not take into account the unique characteristics of inpatient rehabilitation – a critical setting in the post-acute continuum of care.

acquired pressure ulcer rates.

Overall improvement has reported from 2010 to 2015:

Impact Case Study Identifier: also

been

•

Rates of restraint use dropped 40.6 percent

•

Hospital-acquired venous thromboembolism rates fell 25.9 percent

2017-05 AHRQ Product(s): Patient Safety Organization (PSO) Topics(s): Blood Clots, HealthcareAssociated Infections (HAIs), Long-Term Care, Outcomes, Patient Safety, Pressure Ulcers, Health Care Quality Geographic Location: National Implementer: Carolinas Rehabilitation Patient Safety Organization (PSO) Date: 04/14/2017

To help facilities reduce harm and improve the quality of care, the PSO used the AHRQ PSO Web site to create a database that tracks quality and safety events in the rehabilitation To search All Impact Case From 2010 to 2015, the reported setting. The PSO also shared Studies please see https:// rate of unassisted falls per 1,000 tools from AHRQ’s Preventing www.ahrq.gov/policymakers/ Falls in Hospitals guide with patient days improved by 18.9 case-studies/index.html its facilities on universal fall percent. In 2010, the reported rate precautions (including the For the announcement was 5.39 unassisted falls per 1,000 scheduled rounding protocols), please see https://www. standardized assessment of a h r q . g o v / p o l i c ymakers/ patient days, and in 2015 the rate fall risk factors, care planning case-studies/201705. dropped to 4.37 and interventions addressing html? utm_so urc e=3 &ut m_ risk factors within the overall m e d i u m = e n & u t m _ patient care plan, and post-fall term=&utm_content=4&utm_ procedures (including a clinical review and campaign=ahrq_ics_2017 • Catheter-related urinary tract root cause analysis). infections (CAUTI) rates were Alan Zaph, P.T., Coordinator of the PSO, noted that the most significant improvement reported has been in the rates of unassisted falls and hospital-

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reduced 70 percent •

Urinary catheter use fell 41.7 percent

AMRPA Magazine June 2017

AMRPA SUBMITS COMMENTS ON HEALTHY DAYS IN THE COMMUNITY QUALITY MEASURE Editor’s Note: On April 21, 2017, the American Medical Rehabilitation Providers Association (AMRPA) submitted recommendations to Mathematica Policy Research and the Centers for Medicare and Medicaid Services (CMS) in response to the Call for Public Comment on the Healthy Days in the Community quality measure under development. The complete letter is provided below and is on the www.amrpa.org website.

outlined in the MIF.

April 21, 2017

To our knowledge, Healthy Days in the Community measure does not duplicate an existing NQF-endorsed measure. However, it may potentially be confused with similarly named measures that are currently used in population health research. The Centers for Disease Control and Prevention (CDC) health-related quality of life (HRQOL) “Healthy Days” measures use patient reported outcome (PRO) survey questions to assess a patient’s overall health and the impact on their quality of life. The HRQOL measures are used widely in population health studies and the questions pertain to general self-rated health and recent days of physical health, mental health, and activity limitation. The proposed Healthy Days in the Community is materially different from the HRQOL Healthy Days measures because it is derived from administrative claimsbased, not PRO, data.

Mathematica Policy Research 1100 First St NE, 12th Floor Washington, DC 20002

To Mathematica and the Centers for Medicare and Medicaid Services (CMS): The American Medical Rehabilitation Providers Association (AMRPA) submits this letter in response to the Call for Public Comment on the Healthy Days in the Community quality measure under development for CMS programs serving Medicare-Medicaid (“dual-eligible”) enrollees and Medicaid-only enrollees. AMRPA appreciates this opportunity to provide feedback on this measure and CMS’ willingness to extend the deadline for public comments.

AMRPA is the national trade association representing more than 500 inpatient rehabilitation hospitals and units (referred

by Medicare as inpatient rehabilitation facilities (IRFs)), hospital outpatient departments (HOPDs), comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, long-term care hospitals (LTCHs), and skilled nursing facilities (SNFs). AMRPA members provide post-acute care and rehabilitation services across multiple health care settings to help patients maximize their health, functional skills, independence, and participation in society so they can return to home, work, or an active retirement. Many of the patients our members treat are dual-eligible or Medicaid beneficiaries. Hence, we are keenly interested in the appropriate development of the Healthy Days in the Community measure so it best reflects the needs of these vulnerable patient populations.

The Healthy Days in the Community measure assesses the number of days a dual-eligible beneficiary is alive, residing in the community and does not require acute care services in the hospital or emergency department (ED), post-acute care in a facility or home health setting, or other non-acute care in an institutional facility setting. This measure seeks to provide a quality metric indicating “good health” by measuring days in which beneficiaries did not interact with the health care system due to suboptimal health. AMRPA has reviewed the Measure Justification Form (MJF) and Measure Information Form (MIF) accompanying the measure.

We offer the following comments in response to the questions

General Questions 1. Do the measures duplicate comparable measures that have already been validated and widely used, are now under development, or will be submitted for consensus- based entity (NQF) endorsement?

Because Healthy Days in the Community does not rely on patient feedback, it also presupposes what “healthy” is, i.e., any day not spent in health care settings. However, that is a deficient definition of healthy when viewed from a patient-centric perspective. For instance, a beneficiary who lives at home and has multiple chronic conditions may not consider themselves “healthy,” despite the fact that they are living at home. In other words, absence of medical intervention does not equate to health. Though this measure may be the most readily available surrogate for health status and general well-being, it is not the same as truly healthy days. We recommend that Mathematica and CMS change the name of this proposed measure to simply “Days in the Community.”

2. Is the candidate measure useful for measuring important domains of quality for the dual eligible population?

AMRPA does not support the use of this proposed measure as a quality measure. The measure would not assess whether care was delivered in a timely, patient-centered, and safe manner, and hence does not pass the litmus test of a valuable quality measure.

Furthermore, Healthy Days in the Community does not measure a beneficiary’s level of function, health status, or other quality outcomes that are important to patients. These outcomes are assessed in the CDC’s Healthy Days measures.

In our view, measuring the incidence rate of health care encounters over 365 days only measures resource utilization, not quality of care.

“Healthy” Days in the Community could be useful as a resource use measure (if it is modified as we recommend below), but not

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as a quality measure. We were not able to fully discern from the MFJ and MIF CMS’ ultimate intent and purpose for this measure.

As such, we seek to strongly impress upon CMS that its use for this measure must be reasonable and would not inadvertently incentivize or create access barriers to necessary levels of care.

Measure Specification Questions 1. How should mortality be handled in the measure – exclude individuals who die during the measurement year or count mortality against the count of healthy days in the community?

Mortality is an indicator of patient outcome and should be included in the measure.

2. Should utilization of home health care, emergency departments, or urgent care be counted against the count of healthy days in the community (e.g., a day utilizing home health care would not count as a day in the community)?

Utilization of home health care, emergency departments, and urgent care should be counted in this measure only for resource use purposes, as we recommend. However, patient encounters with these settings should not be discouraged in any way. For instance, some innovative care delivery models use home health to better and more proactively manage chronic illnesses to keep patients out of the acute care hospital.

for IRFs when deciding upon the most appropriate discharge destination for a patient. For example, even if a patient has met the goals of an IRF admission (e.g., regained household level ambulatory function and is able to walk on level surfaces at discharge), if he or she lives alone in a third floor walkup without handicap access, a discharge directly to home may not be safe.

For similar reasons, CMS should take into account the geographic availability of providers in a given market and adjust for its effect on observed utilization rates. Having a high number of Days in the Community does not necessarily mean that beneficiaries are healthier by virtue of having fewer encounters with health care settings. For example in a rural market, it could actually mean that there is diminished access to certain care settings.

Conclusion AMRPA appreciates the opportunity to comment on the Healthy Days in the Community quality measure and CMS’ willingness to extend the deadline for public comments. If you have any questions regarding our recommendations, please contact Carolyn Zollar, J.D., Executive Vice President for Government Relations and Policy Development (czollar@amrpa.org), or Mimi Zhang, Policy and Research Associate (mzhang@amrpa.org) at 202-223-1920.

Sincerely,

3. Should beneficiaries residing in long-term care (LTC) facilities (e.g., custodial nursing facility or intermediate care facility) be excluded from the measure denominator?

LTC beneficiaries and their utilization of health care settings should not be overlooked, but including them in this measure with beneficiaries who reside at home would not produce an “apples to apples” comparison. We suggest that CMS consider these beneficiary populations to be two distinct cohorts and stratify the measure so that it could be applied separately to beneficiaries residing at home as one cohort and beneficiaries residing in LTC as another.

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 Suzanne Kauserud, FACHE, MBA, PT Chair, AMRPA Quality Committee Vice President/Administrator, Carolinas Rehabilitation-Charlotte Carolinas HealthCare System

4. Additional comments on risk adjustment In addition to the proposed adjustment for clinical conditions, we recommend that CMS also incorporate risk adjustment for socioeconomic and sociodemographic (SES/SDS) factors and the geographic availability of health care providers in a given market.

This is especially critical if the measure would be used to compare plans in order to mitigate the risk of plans cherry-picking against patients who have high resource needs, or otherwise restricting patients’ access.

SES/SDS factors play a strong role in the longitudinal health outcomes for all patients, and especially for post-acute care patients. Many post-acute care patients who live alone without the oversight or assistance of family or another community caregiver have a higher risk of readmission, as well as poorer outcomes regarding quality and resource use metrics. The presence and willingness of family or community supports are critical drivers

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AMRPA Magazine June 2017

AMRPA SUBMITS COMMENTS TO CMS ON MEDICARE ADVANTAGE PROGRAM; URGES MOVEMENT TOWARD PATIENTCENTERED CARE Editor’s Note: On April 24, 2017 the American Medical Rehabilitation Providers Association (AMRPA) submitted recommendations to the Centers for Medicare and Medicaid Services (CMS) in response to Medicare Advantage, Part C and Part D Final Call Letter Request for Information: 2017 Transformation Ideas. The letter addresses solutions to enhance enrollee access to, and receipt of, rehabilitation services, particularly in inpatient hospitals and units (IRH/Us), under the Medicare Advantage program. The complete letter is provided below and is on the www.amrpa.org website.

April 24, 2017 Seema Verma Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244

Dear Administrator Verma: On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we submit this letter in response to the Request for Information (RFI) included as Attachment 1 to the Announcement of Medicare Advantage and Part D Payment Policies and Final Call Letter for Calendar Year (CY) 2018. AMRPA applauds the Centers for Medicare and Medicaid Services (CMS) for including this RFI to examine transformational solutions to longstanding challenges in the Medicare Advantage (MA) program.

We believe this degree of proactive stakeholder engagement will pay dividends in making the program more flexible, accountable, transparent, and ultimately more responsive to MA enrollees’ individualized needs.

AMRPA members provide rehabilitation services across the spectrum of health care settings including inpatient rehabilitation hospitals and units (referred to by Medicare as inpatient rehabilitation facilities, or IRFs), hospital outpatient departments, comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, and skilled nursing facilities (SNFs). As part of furnishing care in the IRF setting, AMRPA members provide intensive, comprehensive, hospital-based, rehabilitation therapy programs coupled with medical management of the patient.

Specific services include physical and occupational therapy, speech language pathology, and prosthetic/orthotic services, to name a few. As you know, IRFs are part of a continuum of care that is delivered to patients after an acute hospital care episode,

known as post-acute care, which is often integral to restoring patients’ physical and mental health for life in the community.

AMRPA members help patients maximize their health, functional skills, and independence, so they can participate in society by returning to home, work, or an active retirement.

Given AMRPA’s area of focus on medical rehabilitative care, our letter primarily addresses transformative solutions to enhance enrollee access to, and receipt of, rehabilitation services, particularly in the IRF setting, under the Medicare Advantage program.

Individualizing Care and Empowering Enrollees As you know, the RFI seeks innovative approaches for providing Medicare benefits to enrollees and empowering them as individuals. More specifically, it seeks ways to provide more choices to Medicare beneficiaries and to empower direct patient involvement in their own care. These are goals that AMRPA strongly supports, and we have many ideas for advancing them, both in the MA program and the Medicare program more broadly.

In many ways, post-acute care is a microcosm for the larger issue of patient-driven health care as patients being discharged from an acute care hospital and their caregivers are faced with different options, widely variable information, and expected to make what is often a very impactful decision about their long-term health and wellbeing. Although the Medicare coverage criteria are clearly defined, MA plans do not appear to adhere to these in the same fashion as in Medicare fee-for-service. AMRPA believes that within those regulatory confines the decisions of patients, their caregivers, and their health care providers should be honored with as limited additional interference as possible. As Dr. Price testified before the Senate Finance Committee, his “main goals” as Secretary are to ensure “that we have a system that… provides choices to patients so that they’re the ones selecting who’s treating them, when, where and the like.”

Access Challenges As AMRPA commented in response to the draft call letter, within the MA program there are significant—often insurmountable— administrative hurdles to getting patients the post-acute care they need. In that comment letter, we provide detailed information regarding the challenges that MA enrollees face accessing medical rehabilitation on a daily basis. We will refrain from restating the same information here, but we remain concerned that many MA plans continue to deny medically necessary inpatient rehabilitation care at alarming rates and are circumventing mandatory Medicare regulations in the process.

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Instead of following Medicare IRF coverage criteria, many MA plans improperly apply private, proprietary decision tools, such as Milliman and InterQual guidelines, to make coverage decisions that override shared patient and clinician decision-making, both prospectively and retrospectively. The effect of this practice is to divert many of all enrollees who qualify for inpatient hospital rehabilitation to less appropriate lower-acuity settings, such as nursing homes and homecare, inevitably decreasing patients’ prospects for full recovery.

Based on reports from our members, the rates of pre-authorization denials and retroactive claims denials have steadily risen as MA plans increasingly rely on these proprietary guidelines, defer to medical or clinical staff who lack rehabilitation expertise, and erect other administrative barriers that make appealing initial denials untenable for patients, their caregivers, and the acute care hospitals forced to extend their stays until discharge plans are arranged. More and more, AMRPA members report that MA plans inform their enrollees that IRF care is not covered under their plan.

Several years of Medicare data have demonstrated that this issue is a worsening phenomenon. In its March 2016 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) found that in 2014, MA enrollees were admitted to IRFs at approximately onethird the rate of Medicare fee-for-service beneficiaries.

Once again, these proprietary guidelines do not govern Medicare coverage but are nevertheless being used to deny patients access to medically necessary and clinically appropriate medical rehabilitation services. It should come as no surprise then that independent researchers recently found that MA plan benefits are not designed to adequately meet enrollees’ post-acute and long-term care needs, and that post-acute provider networks and cost-sharing restrict access to needed care. The study’s authors identified these practices as driving a unidirectional flow of highercost enrollees from MA back to traditional fee-for-service. For these reasons, AMRPA renews our request for CMS to remedy this situation by instructing MA plans to apply the existing Medicare coverage rules governing IRFs. Transformational Regulatory Reform As this Administration embarks on the commendable, and critical, exercise of re-evaluating the extensive regulatory burdens on all industries, but particularly on Medicare-participating providers who desperately want to turn more of their resources and attention back to treating patients, it will be imperative to think about costs holistically. Providers, payors, and an array of entities in between— from managed care to integrated provider organizations—do not operate in silos but in a complex ecosystem where they function as one another’s counterparts. Therefore, in some instances, reducing administrative burdens on one entity can redistribute those costs to others. As an example, relaxation of enrollees’ appeals protections would reduce burdens on managed care companies while making life more difficult for patients and more costly for the providers seeking to furnish them medically necessary care.

In other instances, reducing regulatory burdens will have positive externalities that flow to other actors in the health care system.

One area where tremendous resources are wasted, and where all sides would benefit from regulatory simplification, is medical

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reviews—especially pre-authorization and the disagreements that invariably ensues. Nowhere is this more pronounced than in the context of hospital discharges as there are multiple referral options for post-acute care and the placement criteria are highly patient-specific. In this context, acute care providers are engaged in triangulated discussions with post-acute care providers and payors, post-acute care providers are competing with one another, and in many instances, providers end up fighting with managed care companies to approve access—while patients remain stuck in the middle.

An important and obvious remedial step for CMS is to encourage simplification of managed care review processes and foster greater transparency around coverage criteria. For example, clear direction from CMS about the preeminence of Medicare coverage regulations vis-à-vis proprietary guidelines would reduce administrative costs on both MA plans and providers. The entire system today is designed around conflict, and all sides have built up infrastructure to dispute referral and placement decisions ranging from line staff to medical reviewers to appeals specialists. As Dr. Price lamented during his nomination hearing, while practicing as a physician he “realized there were more people in the office behind the door where [he] saw patients in the front clinic area trying to fight with insurance and regulators and government than there were in the front of the door actually caring and treating patients.”

This dynamic is understandable given the way MA plans are incentivized to constrain short-term spending rather than looking at longer-term costs and health outcomes. But the consequence is that everyone loses from a system like this—managed care companies waste scarce resources defending denials; post-acute care providers like IRFs lose clinically appropriate patients, and the Medicare program ultimately bears much of these costs. Not to mention the untold harm to patients who are denied medically appropriate rehabilitative care. For example, after comprehensive and independent analysis, the American Stroke Association and American Heart Association emphatically recommend that stroke patients should receive their immediate post-acute care in the IRF setting. There is evidence, however, that many MA enrollees who suffer strokes are denied access to inpatient rehabilitation and are redirected to nursing homes for their post-acute care. In a recent survey of our membership, AMRPA found that patients with a primary diagnosis of stroke constituted 30 percent of cases denied pre-admission approval by MA plans.

Admittedly, the root cause of many access challenges that MA plan enrollees face derives not from overregulation, but from insufficient beneficiary protections and a general lack of government oversight. So while deregulation is not the only answer, greater regulatory clarity can go a long way to simplifying participation in the Medicare program, both for plans and for providers.

While clarity in coverage policy would be an important first step to alleviating a great deal of administrative burdens, an even more transformative approach would be to begin to shift away from payor-provider competition and towards collaboration. Rather than the current win-lose frame, managed care organizations and health care providers must find ways to work collaboratively on

AMRPA Magazine June 2017

behalf of patients and efficiently as good stewards of the Medicare Trust Fund’s scarce resources. This collaboration can range from joint operating agreements to alternative payment models (APMs) that do not fixate on site of service decisions. Some of that work needs to be developed on the private side, but CMS could do much more to realign incentives to foster such collaboration. This includes pursuing existing APMs and disseminating additional request for proposals, as well as more basic incentives within the MA program to allow for cooperative agreements. CMS should invest in demonstrations and innovative model testing to ascertain whether such collaborative payor-provider initiatives could improve quality of care and patient outcomes. The Medicare program must afford post-acute care providers greater flexibility to structure their services in a way that does not force MA plans to have to pick and choose between alternative sites of service for their enrollees, but to allow placement to proceed on a continuum that is responsive to the patient’s needs. Ultimately, these types of changes produce systems of care that are designed around the patient rather than the provider or the benefit.

Beyond the scope of the MA program, the Continuing Care Hospital (CCH) model is a creative solution to the problem of wrangling over site of post-acute care service. In brief, the CCH moves from a provider-oriented payment system to a patient-centered one in which the silos established by the disparate Medicare payment systems based on care setting are eliminated and different levels of post-acute care are consolidated into a single enterprise with a unified payment and quality measurement system. In addition to simplicity for patients, and substantially diminished administrative costs to deliver complex medical rehabilitation, the CCH would also result in cost-savings for the Medicare program. It is also a model that CMS’ Innovation Center is under a legal obligation to pursue and yet has continually refused to move forward.

program for years. We look forward not just to working with the agency on big solutions, but to convening diverse stakeholders to work collaboratively on these issues.

If you have any questions regarding our concerns, please contact Carolyn Zollar at (202) 223-1920 or czollar@amrpa.org, or Martha Kendrick at (202) 887-4215 or mkendrick@akingump.com. Thank you again for the opportunity to provide comments on the RFI. Sincerely,

Bruce M. Gans, MD Chair, AMRPA Board of Directors Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation National Medical Director for Rehabilitation, Select Medical cc: Amy Larrick, Director of Medicare Drug Benefit and C and D Data Group Cheri Rice, Director of Medicare Plan Payment Group Vikki Ahern, Director of Medicare Parts C and D Oversight and Enforcement Group

In the face of administrative inaction, the rehabilitation hospital community is pioneering novel delivery and payment models for private sector payors and seeking partners to test and adopt these approaches. For example, AMRPA is leading a collaborative initiative to develop and test an integrated post-acute network, which coordinates care across the post-acute care continuum to ensure patients are treated in the right setting at the right time.

By simplifying the labyrinth of conventional referral and placement decisions, the model forges a shared mission between plans and providers to help patients rehabilitate. There are preliminary signs of movement in the managed care space, but while this private uptake is slowly progressing, CMS can do much more to be a force for innovation in many of the ways described above. * * * AMRPA presents these comments to constructively suggest moving the MA program in a clear direction toward patientcentered care. We have ideas for how many of these reforms can be implemented under CMS’ existing authorities and we look forward to following up with more concrete steps that can be taken to achieve the transformative objectives of programmatic accountability, transparency, and patient-centeredness. We strongly encourage the Administration to continue to solicit creative approaches to problems that have plagued the Medicare

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AMRPA Magazine June 2017