AMRPA Magazine November 2017

November 2017 • Vol. 20, No. 11

TELLING YOUR STORIES

Volume 20, Number 11

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

Letter from the Chair........................................................................................... 3 AMRPA Legislative Update................................................................................. 4 President Trump Takes Executive Action Impacting Individual Marketplace ..................................................................... 8 What is New with the eRehabDataÂŽ PAS Tool .............................................. 12 CMMI Solicits Ideas on Its New Direction and Models in Recent Request for Information .................................................... 14 RAND/CMS Move Forward in Implementing IMPACT Act ........................... 16 MedPAC Continues PAC PPS Work, Supports Reforming Post-Acute Care Regulations ........................................................ 19 HHS OIG Finds IRFs Failed to Properly Bill for Services Provided at Acute-Care Hospitals ................................................... 21 AMRPA Submits Comments to CMS on Its Proposed Rule to Rescind the Episode Payment Model and Cardiac Rehabilitation Incentive Payment Program, and Revise the CJR Model ............................................................. 23 New AHRQ Training Program Helps Hospitals and Patients Prevent Falls ....................................................................................... 27 Kaiser Foundation Examines Medicare Advantage Physician Networks ..... 29

AMRPA Magazine, Volume 20, Number 11.

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

AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities.

Medicare Advantage Premiums to Decrease in 2018, CMS Says ................. 31 Medicare Advantage Should Increase Transparency and Reduce Burden, ACP Says ............................................................................... 32 MedStar Health Significantly Reduces Patient Harm Using CANDOR Toolkit.............................................................. 33

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New Survey Finds 20 Percent of U.S. Adults Experienced Medical Errors; Diagnostic and Communication Errors Most Common................................. 35

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Transition to Value-Based Payment Takes Time to be Adopted, Accepted, Survey Finds................................................................... 37

Rising Obesity Levels Underscore Need for Enhanced Transitional Care Models ............................................................... 36

CMS Transmittals of Interest for Medical Rehabilitation Providers ............. 39

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

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AMRPA Magazine November 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

Telling Your Stories

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ne of the primary responsibilities of the AMRPA leadership is to participate in the process of advocacy for our field in Washington (and elsewhere, of course). In my years of serving on the Board (which substantially predates the reincarnation of our prior association as the AMRPA), I have probably made hundreds of visits to Congressional and Administration offices, speaking with federal and state career staff, appointees and elected officials to tell our story and educate them about our field, our concerns, and our patients.

Among the things I have learned is that speaking from the heart as well as the head is important, and that conveying the real stories about our patients and our organizations is an incredibly powerful means of connecting, engaging and informing people who don’t routinely live in our world. We all have stories to tell, and while AMRPA has spent considerable time and effort to collect and analyze data to find evidence to support our contentions (eRehabData®, the Dobson and DaVanzo study, etc.), those data sometimes do not present as compelling an argument as our stories.

Recently, I was visiting Congressional offices with our wonderful staff and advisors, and told some of my own stories about patients I have cared for, and patients we have tried to take care of and fought with insurance companies to do so. On the “Gans Scale

of Convincing People --- the GSCP,” I can tell you that data rank about 4 out of 10, and stories score 8 or 9 out of 10 on winning the attention, empathy and engagement of people. Plus, the younger the person in the story, the higher the impact (latent ageism, perhaps).

I share this observation to encourage each of you to realize and believe that your voice and your stories can and will make a difference. Whether you are educating a discharge planner in a short-term acute care hospital about the reasons a rehab hospital is the more appropriate option for a patient, advocating for capital dollars in your hospital or health system’s budget, or informing your congressional delegation, your stories are at least as important as your knowledge of data, evidence and the details of the regulations we deal with day in and day out.

Each of us knows our stories, and they matter, just as much as the people who own those stories.

Continuing to speak up and out for our patients and organizations is the role of AMRPA, to be sure, but it is also your own personal responsibility. AMRPA is here to support and help you, and we truly cannot do it without you. Together we will protect and preserve our field for future generations of patients who will benefit from our care.

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AMRPA LEGISLATIVE UPDATE

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

Last Ditch Effort to Repeal and Replace the ACA Fails, Market Stabilization Negotiations Continue

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epublicans’ latest effort to pass repeal-and-replace legislation came up short in September, with Leadership cancelling a planned vote on the GrahamCassidy proposal after three GOP Senators— Rand Paul (R-KY), John McCain (R-AZ) and Susan Collins (R-ME)—announced their opposition to the bill. The measure would have provided block grants to states to cover health care costs, rolled back the Affordable Care Act’s (ACA) Medicaid expansion,

• • • • • •

Meanwhile, Senate HELP Committee Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) resumed market stabilization talks, which

with most funds directed as grants to states; and direct the Health and Human Services (HHS) Secretary to write regulations on interstate health insurance compacts. It likely will be very difficult for even a narrow bill to pass both Senate and House chambers, however. House Speaker Paul Ryan (R-WI) indicated that the Senate should remain focused on a more substantive repeal and replace of the ACA, and President Trump cautioned against a “bailout” of insurance companies. Chairman Alexander confirmed

Health care repeal and reform continue to spring back to life–another effort surfaced most recently in the form of the Graham-Cassidy bill.

HHS Secretary Price submits resignation after intense scrutiny over using government funds for private air travel; Alex Azar is the likely Trump Administration nominee for HHS Secretary.

Work begins in earnest on a FY 2018 Budget Resolution that Republicans seek to use as a vehicle for tax reform.

Committees of jurisdiction begin marking up a reauthorization of the Children’s Health Insurance Program (CHIP), a “must-pass” priority before year end.

The Senate HELP Committee concluded hearings on market stabilization, and despite a brief delay for a focus on the Graham-Cassidy bill, negotiations continue with the hope of producing bipartisan market stabilization legislation.

Rep. Kristi Noem (R-SD) introduced legislation to delay implementation of the controversial Home Health Grouper Model in order to capture the savings to use as an “offset” to pay for other health care legislation.

zeroed out penalties for the individual and employer mandates, and terminated cost-sharing reduction payments starting in 2020. The Reconciliation instructions for an ACA repeal included in the FY 2017 Budget Resolution expired on September 30, and, at present, Republicans intend to use the FY 2018 Budget Resolution for tax reform through Reconciliation. While some members of Congress would like to 4

include FY 2018 Reconciliation instructions for both tax reform and an ACA repealand-replace, President Trump has indicated that repeal efforts will pick up again in 2018 after tax reform. Republicans could include corresponding Reconciliation instructions in an early FY 2019 Budget next year.

were put on hold amid the debate over the Graham-Cassidy bill. A bipartisan agreement was announced on October 17, and included policies that would provide states with flexibility to create more choices in individual market (improvements to Section 1332 waivers); allow for a “Copper Plan” (catastrophic coverage); fund the cost sharing reduction (CSR) subsidies through 2019; restore funding for outreach and enrollment,

he plans to continue working with the Trump Administration to improve the bill.

Congress is now focusing on the Children’s Health Insurance Program (CHIP) and the Medicare extenders. Renewed funding for CHIP expired on September 30, although most states have sufficient carryover funds set aside to last through the end of the calendar year.

AMRPA Magazine November 2017

Trump Signs Executive Order on Insurance Markets and Eliminated CSR Payments On October 12, 2017, President Trump signed an Executive Order intended “to promote healthcare choice and competition across the United States.” Executive Order 13813 aims to improve health care choice by focusing reforms in three specific areas of the insurance market: association health plans (AHPs), short-term limited duration insurance (STLDI), and health reimbursement arrangements (HRAs). President Trump’s proposal would: Direct federal agencies to expand access to AHPs; allow individuals to purchase insurance plans across state lines; and extend the amount of time that individuals can have short-term plans for. He also filed notice in federal court announcing that the HHS is immediately halting costsharing reduction (CSR) payments to insurers.

These payments offset the cost to insurers of reducing deductibles and copayments for individuals with incomes from 100 to 250 percent of the federal poverty level (FPL).

The Administration stated that it could not legally continue the payments, based on an October 11 legal opinion from the Attorney General, which found that funding for the payments had not been appropriated.

Therapy Caps and other Medicare Extenders Not Yet Addressed by Congress House and Senate Committees have not

yet advanced most of the expiring Medicare extenders, such as the therapy cap exceptions process, the Medicare ambulance add-on payment, the Medicare Dependent Hospital program and the low-volume hospital adjustment, among others. The Committees of jurisdiction expect to do so in the coming weeks, though it is unclear whether extender provisions will be packaged with the CHIP reauthorization or another moving health care vehicle. Some of these Medicare extenders expired on September 30, and based on prior precedent, extension of these payments may have a retroactive effect.

Therapy caps expire on December 31, 2017; a coalition of stakeholders has been working in a bipartisan manner with Congressional staff of the Senate Finance Committee, the House Ways and Means Committee and the Energy and Commerce Committee to develop policy that permanently addresses the exceptions process. AMRPA has participated in these discussions and is developing comments that focus on an exceptions process that ensures timely access to needed therapy for Medicare beneficiaries while placing minimal administrative burdens on providers. Although a permanent repeal is the high priority for AMRPA and the therapy caps coalition, it may be unattainable due to the expected high “score” it would receive and lack of consensus about options to pay for it. AMRPA and other groups are lobbying Congress to extend the exemptions process at a minimum.

CHIP Reauthorization Consideration Begins, Committees Approve IPAB Repeal and Telestroke Bills On October 4, 2017, the Senate Finance Committee held an Executive Session to reauthorize the Children’s Health Insurance Program (CHIP). The bill would extend CHIP funding for five years and phase out the 23-percentage-point bump in the federal matching rate for the program that was included in the ACA. Senators filed unrelated amendments that included repeal of the Independent Payment Advisory Board (IPAB) and repeal of the Medicare outpatient rehabilitation therapy caps. Long-time champion of repealing the therapy caps, Sen. Cardin (D-MD), author of the amendment spoke strongly in support of repealing the caps, and stated that caps longer make sense and restricted patient access. Senators refrained from requesting votes on any of the proposed amendments, and the clean, unamended CHIP reauthorization bill, without any offsets, was approved by voice vote with bipartisan support.

Later that same day, the House Energy and Commerce Committee held its mark-up of CHIP reauthorization legislation, similar to the Senate’s version, and also considered other health care bills. The House version was passed on a 28-23 vote over the objections of Democrats, who oppose the offsets identified in the measure. The House bill would be paid for through increased means5

testing for higher-income seniors, changes to Medicaid third-party liability policies and tightening Medicaid asset rules with regard to lottery winnings.

On October 10, Chairman Greg Walden (ROR) released a statement on current CHIP negotiations. He explained that, “If [the Committee is] unable to reach a deal by the end of this week, I would expect the House to take up the Committee marked bill immediately following the district work period.” Republicans and Democrats still cannot agree on how to pay for the CHIP reauthorization, but Chairman Walden is hopeful that the additional time will allow for a bipartisan agreement on offsets.

On October 4, the Committee also approved by voice vote H.R. 1148, the Furthering Access to Stroke Telemedicine (FAST) Act of 2017, which would expand access to telehealtheligible stroke services in Medicare. The Committee did not take up H.R. 849, which would repeal the IPAB because the House Ways and Means Committee had already reported the bill earlier in the day.

Bill to Delay Home Health Grouper Model Introduced On October 6, Rep. Kristi Noem (R-SD) introduced legislation, H.R. 3992, “to delay application of, transition to, and limit savings for” the Home Health Groupings Model (HHGM) proposed under the FY 2018 Home Health Prospective Payment System Rule.

The controversial, non-budget neutral policy has alarmed the home health industry with its intention to reduce Medicare payments by almost $1 billion annually. AMRPA submitted comments expressing concerns about the CMS proposed rule.

Senate Passes CHRONIC Care Act On September 26, the Senate passed the CHRONIC Care Act (S. 870) by voice vote. The legislation, which the Senate Finance Committee approved in May, would permanently reauthorize Medicare Advantage Special Needs Plans (SNPs), expand certain telehealth services, and extend the Independence at Home demonstration. It remains unclear whether the House will take up the Senate bill, craft its own package, or possibly move selective provisions of the Senate legislation. As noted above, the Energy and Commerce Committee recently approved the FAST Act of 2017 (H.R. 1148), which is part of the CHRONIC Care Act. 6

Secretary Price Resigns Amid Use of Private Jet Use HHS Secretary Tom Price submitted his resignation on September 29, amid criticism of his use of private jets for government business.

Don Wright, a respected career official, the current Deputy Assistant Secretary for Health and director of the Office of Disease Prevention and Health Promotion, served as acting secretary for less than two weeks. President Trump announced on October 11, that Eric Hargan will serve as acting HHS Secretary.

Hargan recently received Senate confirmation as Deputy Secretary by a vote of 57-38.

Speculation about Secretary Price’s replacement originally centered on Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma, Food and Drug Administration (FDA) Administrator Scott Gottlieb, Veteran’s Affairs Secretary David Shulkin and former Louisiana Gov. Bobby Jindal (R). However as we go to press, Alex Azar is reportedly the leading candidate for Secretary Price’s replacement.

He served as Deputy Secretary and General Counsel at the Department during the George W. Bush Administration and later oversaw U.S. operations for Eli Lilly, a pharmaceutical company.

HHS is seeking feedback on the draft and will be accepting comments through October 27, 2017.

Medicare Advantage, Part D Premiums Not Expected to Rise On September 29, CMS announced that premiums for Medicare Advantage and Medicare Part D are expected to decrease in 2018. The average monthly premium for a basic Part D plan is projected to decrease by $1.20 to $33.50. The average monthly premium for Medicare Advantage is expected to decrease by $1.91 to $30 in 2018.

Comments are due by November 20, 2017.

AMRPA is planning to respond to the RFI.

HHS Releases Draft Strategic Plan for FY 2018-2022 On September 27, HHS released its draft Strategic Plan for Fiscal Years 2018-2022. The draft includes five strategic goals: •

Strategic Goal 1: Reform, Strengthen and Modernize the Nation’s Health Care System

•

Strategic Goal 2: Protect the Health of Americans Where They Live, Learn, Work and Play

•

Strategic Goal 3: Strengthen the Economic and Social Well-Being of Americans Across the Lifespan

•

Strategic Goal 4: Foster Sound, Sustained Advances in the Sciences

•

Strategic Goal 5: Promote Effective and Efficient Management and Stewardship

CMMI Seeking Information on Testing New Models On September 20, the CMS Innovation Center (CMMI) issued an informal Request for Information (RFI) seeking feedback on the future direction of the Innovation Center and how to promote patient-centered care and test market-driven reforms. The Innovation Center is interested in testing models in the following eight focus areas: 1.

2.

3.

4.

5.

6.

7.

8.

Increased participation in Advanced Alternative Payment Models (APMs); Consumer-Directed Care and MarketBased Innovation Models; Physician Specialty Models; Prescription Drug Models; Medicare Advantage (MA) Innovation Models; State-Based and Local Innovation, including Medicaid-focused Models; Mental and Behavioral Health Models; and Program Integrity.

*** As you can see, the pace of legislative activity over this past month has been intense. We expect the legislative activity to continue to intensify even more as several “must pass” bills still need to reach the President’s desk by the end of the year. As members look for last-minute offsets, we cannot stop worrying that there may be a late Ways and Means Committee push to add its post-acute care Value-Based Purchasing proposal on one of the moving legislative vehicles as a potential pay-for, so we must continue to be vigilant.

Therefore, we urge you to reach out to your members of Congress and let them know your concerns and the impact such policies will have on patients who need and depend on rehabilitative care. AMRPA also remains diligent in advocating for full repeal of the arbitrary therapy caps. Your support in sending similar messages to your lawmakers will make a difference as we move into an uncertain, fast-moving legislative period!

Martha M. Kendrick

AMRPA Magazine November 2017

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PRESIDENT TRUMP TAKES EXECUTIVE ACTION IMPACTING INDIVIDUAL MARKETPLACE

ASSOCIATION HEALTH PLANS, ENDING COST-SHARING REDUCTION PAYMENTS LATEST IN EXECUTIVE ACTION UNDERMINING AFFORDABLE CARE ACT

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rustrated with the lack of action in Congress to repeal and replace the Affordable Care Act (ACA), on October 12 President Trump signed an executive order directing the Secretary of Labor to consider proposing regulations or revising guidance within 60 days, consistent with law, to allow more employers to form Association Health Plans (AHPs). AHPs allow groups of small business owners or trade groups to purchase health insurance outside of the ACA’s individual market, thereby skirting federal ACA insurance regulations. Also on October 12, the President announced the Administration would no longer pay Cost-Sharing Reduction (CSR) subsidies to insurance plans, sparking widespread concern as to the future viability of the individual insurance market. These developments follow a long list of executive actions on the ACA that many believe indicates that the Trump Administration is systematically trying to repeal the law without the need to rely on Congress.

Executive Order on Association Health Plans AHPs have been controversial for years.

Proponents believe they offer more affordable coverage options for those who do not need protections against pre-existing conditions and other insurance mandates. Opponents believe AHPs “cherry pick” the healthiest groups of patients and segregate them from the broader insurance pool, thereby weakening the risk pool of the ACA’s individual marketplace. The least healthy patients would likely remain in the ACA, driving up premiums up for those remaining, potentially causing a “death spiral” of the program.

Operating outside the legal framework of the ACA, AHPs will be allowed to provide plans that do not comply with

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the ACA’s 10 essential health benefits, including rehabilitative and habilitative services and devices. They will also not be governed by the ACA’s laws regarding non-discrimination and preexisting conditions, community rating and lifetime or annual caps in benefits.

Additionally, the executive order directs the Secretaries of the Departments of the Treasury, Labor, and Health and Human Services (the Secretaries), within 60 days from the executive order, to consider expanding coverage through low cost, short-term, limited duration insurance (STLDI) plans sold outside the marketplace. The executive order also directs the Secretaries to consider allowing such insurance to cover longer periods and be renewed by the consumer. In an October 2016 rule issued by the Obama Administration, the duration of such plans must be less than three months. The previous rule stated that the duration of such plans must be less than 12 months.

The executive order also directs the Secretaries, within 120 days of the executive order, to increase the usability of Health Reimbursement Arrangements (HRAs) to expand employers’ ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with non-group coverage. HRAs allow employers to use pre-tax dollars to reimburse employees for healthcare expenses, including deductibles and copayments.

Cost-Sharing Reduction Payments With respect to its discontinuance of CSR payments, the Trump Administration announced that it is not within the bounds of executive power to continue making those payments to insurance plans, which rely heavily on them to stabilize the individual market.

In a statement, the Justice Department stated that the agencies that would normally pay the cost-sharing reduction payments “have decided not to spend money to fund those payments,” and issued a legal opinion on October 11 to the Departments of the Treasury and Health and Human Services stating that the permanent appropriation for “refunding internal revenue collections” under 31 U.S.C. § 1324 was not available to fund the CSR payments authorized by the ACA.

ABOUT THE AUTHORS

Peter W. Thomas Counsel to the AMRPA Denials Management Committee and the Consumer and Clinical Affairs Committee

Steve Postal Director, Health Policy, Powers Pyles Sutter & Verville, PC AMRPA Magazine November 2017

to them to waive, defer, grant In a federal lawsuit brought a few years exemptions from, or delay the ago against the Obama Administration implementation of any provision or by the House of Representatives, requirement of the Act that would House v. Price, the House claimed the impose a fiscal burden on any Obama Administration overstepped State or a cost, fee, tax, penalty, or into legislative powers by allocating regulatory burden on individuals, CSR payments without a formal families, healthcare providers, authorization to do so. While the health insurers, patients, recipients House won this case in the lower court of healthcare services, purchasers last year, the case, appealed by the of health insurance, or makers Obama Administration, was put in of medical devices, products, or abeyance in January through a motion medications.” [Emphasis added.] filed by the Trump Administration. Both parties are required to submit status reports every three months, starting Internal Revenue Service Weakens May 22 of this year. On August 1, a Individual Mandate (February 2017) federal appeals court in Washington On February 15, the Internal Revenue issued a ruling that permitted 17 states Service (IRS) issued a statement to join the Administration’s appeal, reversing the plan under the Obama effectively allowing them to defend Administration to strengthen the the CSR payments against the House’s individual mandate. The IRS had lawsuit. CSR payments are seen as a critical funding source to compensate health plans that cannot otherwise collect deductibles and These developments follow copayments from low income enrollees. President a long list of executive actions Trump has repeatedly on the ACA that many believe threatened to stop making these payments. indicates that the Trump

for this final rule to provide needed flexibility to issuers to help attract healthy consumers to enroll in health insurance coverage, improve the risk pool and bring stability and certainty to the individual and small group markets.

The final rule included changes to: •

The special enrollment periods;

•

The annual open enrollment period;

•

Guaranteed availability;

•

Network adequacy rules;

•

Essential community providers; and

•

Actuarial value requirements.

CMS issued this final rule in an attempt to preserve high participation in the individual and small group markets but critics noted that many of the provisions lessened ACA burdens on insurers and increased them on individuals seeking coverage. It remains to be seen what role this final rule will play in the context of future executive action targeting the ACA.

President Trump Issues Executive Order Directing Secretaries to Consider Amending Regulations to Administration is systematically I. Trump Administration Conscience-based Objections trying to repeal the law Action on Repealing the to the Preventative-Care Affordable Care Act to Mandate (May 2017) without the need Date On May 4, President Trump to rely on Congress. issued an executive order This executive order follows directing the Secretaries to several steps already taken consider issuing amended by the Trump Administration regulations, consistent with applicable to achieve its stated purpose in rolling planned to refuse to accept tax returns law, to address conscience-based back the ACA. These previous steps are that did not disclose the filer’s health objections to the preventive-care summarized below. insurance status. Based on the executive mandate. This was widely interpreted order issued on January 20 to reduce as initial authority for federal agencies President Issues Executive Order the financial burden caused by the ACA, to implement regulations that would on the Affordable Care Act (January the IRS decided not to refuse to accept permit restrictions in coverage of 2017) these tax returns. Accordingly, the IRS contraceptives and related health care On January 20, President Trump issued will continue to accept filings that are services. an executive order consisting of a silent on this issue. This is expected directive to all federal agencies which to have the effect of weakening the IRS Relaxes Reporting Requirements states, in relevant part: individual mandate and, in turn, the for Catastrophic Plans (August 2017) health insurance marketplaces.

On August 3, the Internal Revenue “To the maximum extent permitted Service (IRS) released Notice 2017-41 by law, the Secretary of Health and CMS issues Market Stabilization Final informing payors that for 2017, as well Human Services (Secretary) and Rule (April 2017) as for 2015 and 2016, they may, but are On April 18, the Centers for Medicare the heads of all other executive not required to, report 2017 coverage and Medicaid Services (CMS) published departments and agencies (agencies) under a catastrophic plan enrolled in a final rule in the Federal Register titled with authorities and responsibilities through an Exchange. Further, Notice Patient Protection and Affordable Care under the Act shall exercise all 2017-41 stated that payors reporting Act; Market Stabilization. CMS intended authority and discretion available 9

coverage under a catastrophic plan are not subject to information reporting penalties under §§ 6721 and 6722 of the Internal Revenue Code with respect to returns and statements voluntarily filed and furnished under this notice. The individual mandate of the ACA requires minimum essential coverage. Under the ACA, payors and employers are required to file 1095-B or 1095-C forms with the IRS, and to provide these forms to individuals they cover, documenting this coverage.

CCIIO Clarifies Abortion Coverage by Qualified Health Plans (October 2017) On October 6, the Center for Consumer Information and Insurance Oversight (CCIIO) released a bulletin addressing coverage of abortion by qualified health plans (QHPs) sold through the exchanges. CCIIO’s bulletin reminds QHP issuers that they are obligated under Section 1303 of the ACA to: 1) provide notice to enrollees if non-Hyde abortions are covered by their QHP; 2) determine the amount of, and collect from enrollees, a separate payment that equals the cost, determined on an average actuarial basis, for covering nonHyde abortion services, and that such payment must be at least $1 per enrollee per month; and 3) segregate funds for non-Hyde abortion services collected from enrollees into a separate allocation account that is to be used exclusively to pay for non-Hyde abortions. The Hyde Amendment, incorporated in the ACA, prohibits spending federal funds for abortion services unless the pregnancy is a result of rape or incest, or would endanger the woman’s life. These exceptions to the Hyde Amendment are called “non-Hyde abortions.”

DOT, DOL and HHS Issue Interim Final Rule Softening Preventative-Care Mandate (October 2017)

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On October 13, the Secretaries published two interim final rules to expand exemptions based on “religious beliefs or moral convictions” of certain entities and individuals whose health plans are subject to a mandate of contraceptive coverage through guidance issued pursuant to the ACA. This is likely to have the effect of less access to insurance-covered birth control.

Kaiser Reports Steep Reduction in Funding to Navigators (October 2017) According to a Kaiser Family Foundation survey released on October 11, HHS awarded approximately $37 million to nearly 100 navigator organizations across the country in 2017, compared with approximately $60 million they received annually in prior enrollment seasons.

The same survey stated that almost 90 percent of navigators expect to lay off staff, and more than 80 percent said they would cut back enrollment efforts. Navigators assist individuals with questions as they negotiate the complexities of identifying, selecting, and enrolling in ACA insurance.

II. Future Administrative Action to Repeal the Affordable Care Act President Trump is expected to follow up on these executive actions with more administrative steps that, the Administration believes, will expand competition and reduce health insurance prices. The October 12 executive order also calls for the Secretaries, in consultation with the Federal Trade Commission, to provide a report to the President within 180 days, and every two years thereafter, on how states and the federal government can facilitate the purchase of insurance across state lines

and the development and operation of a healthcare system that provides highquality care at affordable prices.

There are other regulatory steps the Trump Administration has been rumored to be considering. For instance, it could use its administrative authority to change significant parts of the ACA, such as essential health benefits (EHBs).

The ACA required health insurance plans to cover 10 categories of EHBs, including rehabilitative and habilitative services and devices. But the Obama Administration’s regulations gave states the ability to designate a benchmark plan on which each state’s specific EHB standards are based. The Trump Administration could engage in a new rule-making procedure governing state benchmark plans, essentially allowing states to relax their standards and weakening EHB and other insurance requirements.

Conclusion In issuing his statement regarding CSR payments, President Trump accompanied his message with an invitation to Democrats to begin discussions on resolving the legality of these payments through the legislative process. Many speculate that some of his administration’s regulatory efforts are also designed to stimulate a broader repeal and replace legislative effort. However, on the same day of this announcement, the President made it clear that he does not support bipartisan efforts led by Senators Alexander (R-TN) and Murray (D-WA) to stabilize the ACA marketplaces. We will continue to keep AMRPA informed as these important developments continue to occur.

AMRPA Magazine November 2017

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WHAT IS NEW WITH THE eREHABDATA® PAS TOOL

By Lisa Werner, MBA, MS, CCC-SLP

S

ince the IRF-PPS Final Rule of • Combination of necessary treatments all relevant medical necessity information (one of which must be physical 2010 entered our lives, we have is compiled. Using that information, you therapy or occupational therapy). become aware of the technical can craft statements of medical necessity that justify patient rehabilitation stays. components required within our • Expected frequency and duration of documentation. Included in this IRF treatment.

Also available in our software is a notes rule were several areas of the pre-admission • Anticipated discharge destination. box in the Close Medical Supervision screening (PAS) that required updating. These section, which is an ideal location to state updates made it clear that the PAS must • Anticipated post-discharge cases for admission. This section is used to include documentation that proves that treatments. draw conclusions from previously reported patients require and receive appropriate • Other information relevant to patient information on the patient history and therapy regimens necessary in an inpatient care needs. review of systems screen. Liaisons should rehabilitation unit or hospital stay. It must use the information gathered during also verify that patients are expected In our current era of payment denials, I treatment in an acute care setting to to make measurable improvements of urge everyone to thoroughly review their decide which conditions will require care practical value to their functional capacities and management during or impairment adaptations, rehabilitation. Compiling a show that patients’ conditions list of conditions that require are stable enough for them to ongoing care is the most actively participate in intensive We understand that it is essential sensible first step towards rehabilitation programs, show not only to analyze the data from streamlining this process. patient willingness to participate This list should include in the rehabilitation programs screened and admitted patients, but comorbidities, which help to provided by a coordinated from screened and denied patients underscore the necessity of interdisciplinary team in an as well. To help better facilitate certain types of care. It can also inpatient setting, and include serve as the starting point for a list of items that elucidate your denial tracking, we’ve made a post-admission assessments. patient appropriateness for few small changes and added two While coding from the PAS tool rehabilitation stays. A list of isn’t an acceptable practice, items that help determine additional reasons for denial to the it’s a good base of information patient appropriateness is list of choices. for noting previously treated included below: conditions (especially those • Patient’s prior level of occurring immediately before function (prior to the event admission) and how they may affect a pre-admission screenings and verify that or condition that led to the patient’s patient’s rehabilitation stay. each of the aforementioned items are need for intensive rehabilitation included and completed. In addition to therapy).

Remember that the conclusions we draw these individual items, auditors will also • Expected level of improvement. when considering a patient’s need for close look for clear, solid justifications for the medical supervision can also serve as the necessity of each rehabilitation stay. In • Expected length of time needed to basis for establishing the medical necessity essence, the information that we report reach the pre-determined level of of an inpatient rehabilitation stay. When to auditors must clearly and emphatically improvement. compiling these lists, make sure that they demonstrate that medical necessity exists • Evaluation of patient risks for clinical are thorough and customized specifically and that a rehabilitation stay is justified complications. to serve your facility. Avoid crafting according to the rules laid out by CMS. In • Conditions that caused the need for common statements for multiple patients our PAS tool, the Justification tab is where and focus on individualized statements rehabilitation.

12

AMRPA Magazine November 2017

that reflect the specific, personal ongoing needs noted during the liaison’s acute care records reviews. For clarity of reasoning, keep in mind that the ultimate goal of this process is to notate conditions that will require management once the patient has been admitted to rehab, rather than restating the conditions treated in an acute care setting. It is possible that some of the conditions treated in acute care will have already been resolved, and thus will not help you to justify the medical necessity of a patient’s stay.

Most recently, we have added features to the eRehabData PAS tool based on user requests. We’ve created and implemented a customizable evaluator list that allows you to configure a custom list of evaluator names on the Justification tab. We’ve also implemented signature shortcuts to

make the process of signing the final preadmission screening more user friendly.

Now, signatures only require a quick button click to assign them to specific documents. You can assign time zones to your signatures as well.

We’ve also made a few clinical changes.

The patient diet section has been slightly altered and a “notes” box has been added to both the gastrointestinal and vaccination sections in an effort to help capture your comments.

We understand that it is essential not only to analyze the data from screened and admitted patients, but from screened and denied patients as well. To help better facilitate your denial tracking, we’ve made a few small changes and added two

additional reasons for denial to the list of choices.

In conclusion, make especially sure that your pre-admission screenings are thoroughly completed with no blanks (with special attention paid to the Justification tab). The Justification tab was designed to provide a succinct compilation of all CMS-required elements, meaning that all items present on that tab should be addressed and reviewed. As pre and postpayment denials continue to ramp up, an effective way to avoid unnecessary and unwanted denials is to make sure that your pre-admission screenings are technically sound and provide ample individualized information to justify each patient’s rehabilitation admission.

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.

13

CMMI SOLICITS IDEAS ON ITS NEW DIRECTION AND MODELS IN RECENT REQUEST FOR INFORMATION

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

T

he Centers for Medicare and Medicaid Innovation (CMMI) recently issued an informal Request for Information (RFI) to stakeholders as part of an announcement regarding its new direction. CMMI said it is seeking feedback on a “new direction to promote patient-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce cost and improve outcomes.” It further stated that “CMS is setting a new direction for the Innovation Center.” It will evaluate how models consistent with the new direction can complement what it is learning from the existing initiatives such as the Bundled Payment for Care Improvement (BPCI).

CMMI stated it is particularly interested in testing models in the following areas: 1. Increased Participation in Advanced Alternative Payment Models (APMs); 2. Consumer-Directed Care and MarketBased Innovation Models; 3. Physician Specialty Models; 4. Prescription Drug Models; 5. Medicare Advantage (MA) Innovation Models; 6. State-Based and Local Innovation, including Medicaid-Focused Models; 7. Mental and Behavior Health Models; and 8. Program Integrity.

Comments were due by November 20 and AMRPA submitted a letter.

As part of this redirection, CMS recently issued a proposed rule to cancel and rescind the Episode Payment Models (EPMs) and Cardiac Incentive 14

payment model (CR), and to modify the Comprehensive Care for Joint Replacement (CJR) mandatory bundling program. All of these programs were established by the prior Administration.

Such proposals are inconsistent with the views of the new administration and recently departed Secretary of the Department of Health and Human Services, Tom Price, MD. CMMI’s current portfolio includes the following:

Highlight: •

CMMI Has a New Direction Under Trump Administration

•

FQHC Advanced Primary Care Practice Demonstration

•

Frontier Community Health Integration Project Demonstration

•

Frontier Extended Stay Clinic Demonstration

•

Graduate Nurse Education Demonstration

•

ACO Investment Model

•

Accountable Health Communities Model

•

Health Care Innovation Awards: Round 1, Round 2

•

Advance Payment ACO Model

•

Health Plan Innovation Initiatives

•

Advanced Primary Care Initiatives

•

•

Beneficiary Engagement and Incentives: DDS & SDM Models

Hispanic Health Services Research Grant Program

•

•

Bundled Payments for Care Improvement Models 1-4

Historically Black Colleges and Universities Research Grant Program

•

•

Cardiac Rehabilitation (CR) Incentive Payment Model

Home Health Value-Based Purchasing (HH VBP) Model

•

•

Community-based Care Transitions Program

Independence at Home Demonstration

•

•

Comprehensive Care for Joint Replacement (CJR) Model

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

•

•

Comprehensive ESRD Care Model

•

Comprehensive Primary Care Initiative

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents: Phase Two

•

Innovation Advisors Program

•

Maryland All-Payer Model

•

Medicaid Emergency Psychiatric Demonstration

•

Medicaid Incentives for the Prevention of Chronic Diseases Model

•

Comprehensive Primary Care Plus + Round 2

•

Episode Payment Models: AMI, CABG, CR, SHFFT

•

Financial Alignment Initiative for Medicare-Medicaid Enrollees

AMRPA Magazine November 2017

•

State Innovation Models Initiatives

•

Strong Start for Mothers and Newborns Initiatives

Nursing Home Value-Based Purchasing Demonstration

•

Transforming Clinical Practice Initiative

•

Oncology Care Model

•

Vermont All-Payer Model

•

Part D Enhanced Medication Therapy Management Model

•

Partnership for Patients

•

Pennsylvania Rural Health Model

•

Physician Group Practice Transition Demonstration

•

Physician Hospital Collaboration Demonstration

•

Pioneer ACO Model

•

Private, For-Profit Demonstration Project for the Program of AllInclusive Care for the Elderly (PACE)

•

Regional Budget Payment Concept

•

Rural Community Hospital Demonstration

•

Specialty Practitioner Payment Model Opportunities

•

Medicaid Innovation Accelerator Program

•

Multi-Payer Advanced Primary Care Practice

•

Medicare Acute Care Episode (ACE) Demonstration

•

Next Generation ACO Model

•

•

Medicare Advantage Value-Based Insurance Design Model

•

Medicare Care Choices Model

•

Medicare Coordinated Care Demonstration

•

Medicare Diabetes Prevention Program

•

Medicare Health Care Quality Demonstration

•

Medicare Hospital Gainsharing Demonstration

•

Medicare Imaging Demonstration

•

Medicare Intravenous Immune Globulin (IVIG) Demonstration

•

Medicare Part B Drugs Payment Model

•

Million Hearts

•

Million Hearts: Cardiovascular Disease Risk Reduction Model

15

RAND/CMS MOVE FORWARD IN IMPLEMENTING IMPACT ACT

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

T

he RAND Corporation and the Centers for Medicare and Medicaid Services (CMS) are holding quarterly Special Open-Door Forums to provide all interested stakeholders with an update on the next steps of the implementation of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. The most recent forum, which took place on September 28, provided context for the recent pull back of some data items in the various post-acute care FY 2018 payment rules and how RAND intends to proceed. The analysis of these data elements, plus data collected from the various quality measures, will be used by the Secretary of the Department of Health and Human Services to develop a prototype of a post-acute care prospective payment system (PAC PPS), as required by the Act. Hence, it is critically important that the elements being developed are chosen carefully. Each must contribute value to providing information about patient characteristics, which are then reflected in the resources used by the patients.

As noted below in the evaluation of candidate elements, they are evaluated for their potential of improving quality, as well as utility in describing case mix, which leads to resource use and construction of a payment methodology.

The Act requires the Secretary to begin collecting standardized patient assessment data by October 1, 2018 (FY 2019). Under the IRF PPS FY 2018 final rule, and other PAC 2018 payment rules, CMS stated that the pressure ulcer measure, NQF #0678 Percent of 16

Residents or Patients with Pressure Ulcers That are New or Worsened, would meet the definition of standardized patient assessment data for medical conditions and comorbidities pursuant to the Act. Additionally, CMS stated that measure NQF #2631 Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function, would meet the function category. The forum also provided further information on why CMS did not finalize all the data elements in the FY 2018 proposed rule pertaining to cognitive function and mental status, special services, treatment and inventions, and impairments. They are: •

To be responsive to stakeholders’ concerns of too much, too soon;

•

To allow providers the ability to recover from major changes in assessment instruments that have already or recently been made, such as the ICD–10–CM changes for IRFs;

•

To provide for additional reliability and validity testing;

•

To allow for more time to interact with stakeholders and convene Technical Expert Panels (TEPs).

In selecting data elements, CMS and RAND are evaluating them based on four factors: 1. Potential for Improving Quality: •

Improve care transitions, personcentered care and care planning;

•

Improve care practices and

Highlight: • •

CMS/RAND Explain Next Steps in IMPACT Act Implementation Data Items to Receive Additional Consideration patient safety;

•

Use for quality comparisons, including value based payment models;

•

Supports clinical decision making and care coordination.

2. Validity and Reliability •

Inter-rater reliability (consensus in ratings by two or more assessors);

•

Validity (captures the construct being assessed).

3. Feasibility for Use in PAC •

Potential to be standardized and made interoperable across settings;

•

Clinically appropriate;

•

Relevance to work flow.

4. Utility for Describing Case Mix •

Potential use for payment models;

•

Measures differences in severity levels related to resource needs.

Clearly, waiting on implementing the many data elements allows time for further necessary testing. To date, RAND has conducted Track 1, which was focused primarily on feasibility testing of AMRPA Magazine November 2017

Milestones Timeline

Beta Research Nurse Training Field trainings in 14 markets Beta data collection Stakeholder outreach (e.g. focus groups, updates webinars) Public Comment

TEP (est.)

Final Beta data delivery

2017

2017

Sep

Nov Today

Jan

•

Qualitative feedback from assessors was used to help evaluate and improve training instructions and data element

Jul

2018

Sep

Mar 15

Jul 13

Sep 14

Mar SODF (est.)

June SODF (est.)

Sept SODF (est.)

The majority of data elements were feasible to administer and showed adequate to excellent agreement between raters; Some data elements did not perform well in Alpha 1 and were modified and retested in Alpha 2 and most showed improvement;

May

Dec SODF (est.)

The results of the Track 2 studies (Alpha 1 and Alpha 2 conducted from August 2016 to July 2017) were that:

•

Mar

Dec 15

various data elements as represented by those that were in the FY 2018 proposed rule. Those data elements were drawn primarily from the Post-Acute Care Payment Reform Demonstration (PAC PRD). The researchers believed there was sufficient evidence for these elements to be used across all post-acute care providers. Track 2 focused on feasibility of data elements that filled gaps in certain categories but required more feasibility and performance testing. They included function, cognition (looking at executive function), behavioral signs and symptoms, mood (anxiety), care preferences, medication reconciliation and observational assessments.

•

Sep 19

2018

specifications; •

Both qualitative and quantitative information was used to identify data elements that may be problematic for use across PAC settings.

The next step is a nationwide field test referred to as Beta testing. This testing will occur in 14 markets across the country over six months starting this November. The test will seek to include 210 PAC providers: 28 IRFs, 28 LTCHs, 84 SNFs and 70 HHAs. It will include: •

Extensive outreach and consensus building activities, such as focus groups, in each setting;

•

Feedback sessions with provider staff and administrators to help understand the impact of collecting the data and how to mitigate the burden; and

•

Stakeholder webinars.

The assessments will focus on cognitive status, impairments, mental status, pain, special services and treatments and interventions. Other categories include care preferences, global health and a streamlined medication reconciliation set of data elements. A detailed list of the Beta data elements by category is

available in the handout from CMS for the September 28, 2017, Special OpenDoor Forum at: https://www.cms.gov/ Medicare/Quality-Initiatives-PatientAssessment-Instruments/Post-AcuteCare-Quality-Initiatives/Downloads/ S e p t - 2 0 1 7 - C M S - S O D F - I M PA C TAct-92917_v2.pdf CMS plans to hold additional Special Open-Door Forums on or around December 15, 2017, March 15, 2018, July 13, 2018, and September 14, 2018. It also expects to hold continued stakeholder outreach via focus groups, webinars, speaking at conferences, etc., from January to July 2018, according to a timeline for 2018. In addition, there will be a third RAND public comment period currently scheduled for some time between April 30 and June 29, 2018.

Curiously, these dates could overlap directly with the IRF PPS proposed rule for FY 2019.

The timeline for September 2017 to September 2018 activities presented by RAND is below.

17

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18

AMRPA Magazine November 2017

MEDPAC CONTINUES PAC PPS WORK, SUPPORTS REFORMING POST-ACUTE CARE REGULATIONS

By Mimi Zhang, Policy and Research Associate, AMRPA

T

he Medicare Payment Advisory Commission (MedPAC) recently convened in Washington, DC, and discussed its scope of work this year with regard to the unified post-acute care prospective payment system (PAC PPS). The Commission’s mandatory PAC PPS work at this stage, as required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, was completed with the Commission’s June 2016 Report to Congress on the feasibility of a PAC PPS. However, because the IMPACT Act does not require the actual implementation of a unified payment system, MedPAC states that it will continue to evaluate implementation issues and make the necessary recommendations to keep the PAC PPS “front and center” for Congress and the Centers for Medicare and Medicaid Services (CMS).

This year, the Commission will focus on issues related to developing accurate payment for sequential PAC stays and the alignment of regulatory requirements across settings. These topics were the focus of an October 5 a meeting session titled Paying for Sequential Stays and Aligning Regulatory Requirements in a Unified Payment System for Post-acute Care Providers, and are summarized in this article.

Aligning PAC Regulatory Requirements MedPAC has previously recommended that Congress should implement a PAC PPS beginning in 2021 with a threeyear transition period, and concurrently begin to align regulatory requirements.

Specifically, MedPAC recommended that PAC regulatory reform be carried out in a phased manner consisting of near-term and longer-term policy approaches:

•

•

In the near term, certain settingspecific requirements such as the LTCH 25 percent rule or the IRF 60 percent rule can be waived.

In the longer term, a common core set of requirements can be developed and applied to all PAC settings.

These would include staffing and services requirements, with additional requirements if a provider will furnish specialized care (such as treating ventilator-dependent patients).

The near-term options are intended to align provider costs across PAC settings and “level the playing field.” The longer-term approach would in essence redesign PAC settings and requirements so that provider/ facility characteristics will meet the needs of the patients they treat. In other words, a provider’s facility characteristics, like their PAC PPS payment, will be driven by the patients they treat.

MedPAC states that regulatory reform is necessary because PAC settings face different regulatory requirements that

Highlights: •

•

Under a unified post-acute care prospective payment system, Medicare payments across PAC settings would be based on patient characteristics, not the site of care.

Accordingly, MedPAC supports eliminating regulations that distinguish PAC settings such as the IRF 60 Percent rule and LTCH 25 Percent rule.

influence costs as well the complexity of patients that PAC providers are able to treat. MedPAC staff detailed how inpatient rehabilitation hospitals and units (IRFs) and long-term care hospitals (LTCHs) must meet more stringent service and staffing requirements than skilled nursing facilities (SNFs) and home health agencies (HHAs).

Further, IRFs and LTCHs must be certified as hospitals, have physicians integral to the provision of services, and require a richer mix of nursing staff. According to MedPAC,

MedPAC summarized the current regulatory environment as follows: Regulations that limit coverage

Regulations that distinguish levels of care •

•

• LTCH: Average length of stay > 25 days IRF: 60% rule

IRF: only if the beneficiary needs 2 or more types of therapy and can tolerate and benefit from 3 hours/ day of therapy

•

SNF: only after an acute care hospital stay of 3+ days

•

LTCH: only after ICU stay or 3+ days or if on ventilator

•

Regulations that ensure appropriate care •

Services and staffing

•

Patient assessment and care planning

•

Quality and safety

• HH: only if beneficiary is homebound •

Patients’ rights Administration 19

regulatory reform will afford higher-cost PAC settings the flexibility to lower costs and be more in line with those of lower-cost settings, and give all providers the flexibility to treat a broad mix of patients.

Near-term Policies In an environment where payment is driven by patient characteristics rather than the site of care, MedPAC states that there would be no need to categorize PAC providers by setting.

Accordingly, MedPAC suggest that the nearterm policies should eliminate regulations that distinguish between PAC levels of care, such as the IRF 60 percent rule and the LTCH 25 percent rule. MedPAC will also evaluate whether, in a unified PAC PPS, there need to be regulations that limit coverage (i.e., serve as gatekeepers), such as: •

IRF intensive therapy requirement;

•

SNF three-day ACH stay requirement;

•

LTCH three-day intensive care unit stay and ventilator requirement; and

•

HH home bound requirement.

Longer-term Policies In the longer term, there would be a common core set requirements that, like payment, track with the patients and their needs rather than be siloed to one particular setting. These include general requirements for staffing and services, as well as special provider requirements specific to the treatment of certain conditions such as prolonged ventilator dependence, intensive therapy, severe wounds, or brain and spinal cord injury.

For some settings, these requirements 20

would be more stringent than the current regulations.

MedPAC also discussed states’ PAC regulatory requirements. It plans to study further how state and federal regulations would interplay should federal regulations change, and whether states would adopt and be aligned with Medicare’s requirements.

MedPAC notes that some states have different setting definitions, Certificate of Need requirements, more stringent standards (especially with regard to SNF staffing), or specific requirements for facilities to furnish certain types of services. For instance, New York already has requirements for spinal cord and traumatic brain injuries.

Developing Accurate Payments for Sequential Stays According to MedPAC’s preliminary research, about half of PAC stays are sequential stays (i.e., the second or third site of PAC) and the vast majority are transitions from higher intensity to lower intensity settings. The average cost of care is likely to decline as a patient’s care needs decline over the course of sequential PAC stays. As such, MedPAC staff believe that payments for the second or third PAC site of care, i.e., sequential PAC stays, would require a downward adjustment.

For instance, a spinal cord injury patient may be first admitted to an IRF for acute medical rehabilitation and then discharged to a SNF for continued therapy. Because the patient has most likely gained function during their IRF stay, their subsequent SNF stay would be less intensive/costly and

therefore warrant a lower payment rate. It appears that MedPAC’s PAC PPS payment work would price the IRF and SNF episodes at the same rate due to the underlying patient characteristics remaining the same.

According to MedPAC, payment adjustments are necessary for sequential stays so as to 1) not underpay the initial site of PAC and create incentives for those providers to discharge patients prematurely to downstream settings, and 2) reduce unnecessary PAC utilization, thereby lowering Medicare costs and also minimizing beneficiaries’ exposure to care transitions.

In the coming year, MedPAC staff will examine the cost of initial PAC stays versus later stays and consider policies to adjust payments. They will develop rules for defining initial versus sequential stays, which will derive from existing payment policies or billing practices. They will also evaluate alternative ways to delineate “stays” when a beneficiary is treated in place and how to discourage unnecessary PAC use.

Next Steps The Commissioners supported the work’s direction and offered recommendations to guide the ongoing analysis. The Commission is expected to vote on its formal recommendations in spring 2018, and will include a chapter on these issues in MedPAC’s June 2018 Report to Congress.

For more information and access to the meeting materials, see www.medpac.gov.

AMRPA Magazine November 2017

HHS OIG FINDS IRFS FAILED TO PROPERLY BILL FOR SERVICES PROVIDED AT ACUTE-CARE HOSPITALS

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

A

recent study by the U.S. Department of Health and Human Services Inspector General (HHS OIG) found that Medicare inappropriately paid $56 million to acute-care hospitals for outpatient services while the patients receiving the services were inpatients at other types of facilities, such as inpatient rehabilitation facilities (IRFs) or longterm care hospitals. Further, OIG found that beneficiaries were held responsible for unnecessary deductibles and coinsurance totaling $14.4 million to the acute-care hospitals for the outpatient services.

To conduct this study, OIG collected inpatient Medicare claims from LTCHs, IRFs, Inpatient Psychiatric Facilities (IPFs), and Critical Access Hospitals (CAHs) from January, 2013 to August, 2016. OIG then looked for outpatient claims from acute-care hospitals for the

same beneficiary and same dates as the inpatient stays from the other facilities.

OIG did not include the admission and discharge dates in its examination of the outpatient services, providing the benefit of the doubt that the outpatient services could have been rendered prior or following the discharge from the facility on that day.

OIG concluded that all of the outpatient claims paid to acute care hospitals that it examined were paid in error. Under Medicare regulations, all items and non-physician services provided during a Medicare Part A inpatient stay must be provided directly by the inpatient hospital or under arrangements with the inpatient hospital and another provider.

According to OIG, the inpatient facilities should have included those outpatient services on their inpatient claims to Medicare, and the acute-care hospitals could then have looked to the inpatient facilities for payment for the outpatient

Highlights: •

•

Acute-care hospitals cannot bill for patients that are currently inpatients at other hospitals.

CMS says it will work to recover the improper payments.

services. The study broke down the $56 million in improper payments by type of inpatient facilities that failed to bill Medicare for the outpatient services, as shown in the chart below, which also shows the number of improperly billed claims attributed to each type of facility.

OIG put much of the blame on Medicare contractors for failing to identify the improper payments. They said that in 94 percent of these cases a “post-payment edit alert” was generated after the claims were entered into the Medicare Common Working File (CWF), but the contractors did not act to recover the

Source: U.S. Department Of Health and Human Services, Office of the Inspector General 21

overpayments. In the other 6 percent, OIG said that the system set up to create a “prepayment edit alert,” did not work properly. The study further broke down the types of outpatient services that were billed by acutecare hospitals, but that should have been billed by the other inpatient facilities.

In response to its findings, OIG made a number of recommendations to the Centers for Medicare and Medicaid Services (CMS). These included that CMS should direct the Medicare contractors to recover the $51,640,727 in identified improper payments, instruct the acute-care hospitals to refund beneficiaries up to $14,365,590 in out of pocket costs, and identify and recover any improper payments to acute-care hospitals after the audit period.

Source: U.S. Department Of Health and Human Services, Office of the Inspector General

The OIG also recommended that CMS edit the post and prepayment edit alerts so that these types of payments are identified in the future, and that CMS instruct the Medicare contractors to more effectively educate acutecare hospitals not to bill Medicare for outpatient services they provided to beneficiaries who were inpatients of other facilities. CMS concurred with all of the OIG’s recommendations and stated that it had or is planning to take action to correct all of the issues identified with the report. *Admitted Only in Illinois. Supervision by Carolyn C. Zollar, JD, a member of the DC Bar

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AMRPA Magazine November 2017

AMRPA SUBMITS COMMENTS TO CMS ON ITS PROPOSED RULE TO RESCIND THE EPISODE PAYMENT MODEL AND CARDIAC REHABILITATION INCENTIVE PAYMENT PROGRAM, AND REVISE THE CJR MODEL Editor’s Note: On October 16, the American Medical Rehabilitation Providers Association (AMRPA) submitted comments to the Centers for Medicare and Medicaid Services (CMS) in response to the proposed rule to cancel and rescind the regulations issued thereto for the Episode Payment Models (EPM) and the Cardiac Rehabilitation (CR) Incentive Payment Program and to revise the Comprehensive Care for Joint Replacement model. AMRPA’s general comments and recommendations are summarized below and the complete letter is available on the www.amrpa.org website.

October 16, 2017 The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244-1850 Dear Administrator Verma: This comment letter is submitted by the American Medical Rehabilitation Providers Association (AMRPA) in response to the Centers for Medicare and Medicaid Services’ (CMS’) proposed rule captioned above. AMRPA is the national trade association representing more than 500 freestanding inpatient rehabilitation hospitals, rehabilitation units of general hospitals (collectively referred to as inpatient rehabilitation facilities, or IRFs), and outpatient rehabilitation service providers. The majority of our members are Medicare participating providers. In 2015, IRFs served 381,000 Medicare beneficiaries. On average, Medicare Part A payments represent about 60 percent of IRFs’ revenues.

IRFs seek to maximize Medicare beneficiaries’ health, functional skills, and independence so they can return to their homes, professional work, and an otherwise active life through an intensive, coordinated program. Our members provide hospitallevel care, which is significantly different in physician, nursing, and rehabilitation intensity, capacity, and outcomes from care provided in non-hospital facilities.

General Comments AMRPA supports patient-centric and quality-driven Medicare

payment reforms. We provided comments on the proposed rules for the Episode Payment Models (EPMs), surgical hip and femur fracture treatments (SHFFT) model, Comprehensive Care for Joint Replacement (CJR) mandatory bundling proposals, and the Cardiac Rehabilitation (CR) Incentive payment model when they were initially proposed. While AMRPA commended CMS for seeking to demonstrate how a bundled payment approach to care payment can improve health outcomes while maintaining or reducing costs, we stated our fundamental concerns and cautioned the Agency against driving care delivery reform via financial incentives for providers without a concomitantly robust set of measures and protections for the care experience and outcomes achieved for patients. Given our prior and ongoing concerns with a mandatory approach to bundled payment models, AMRPA supports CMS’ proposal to cancel the EPMs and rescind the regulations issued thereto.

We continue to believe a more prudent first step to testing such payment and service redesign is a voluntary bundled payment pilot limited to post-acute care providers that would include crosssetting patient-centered quality measures. The Bundled Payment Care Improvement (BPCI) Initiative Model 3 is a voluntary program specific to post-acute care, and its initial results show positive outcomes that merit CMS’ further investment into innovative post-acute care and service delivery models. Under current law, CMS is required to pilot test a model known as the Continuing Care Hospital (CCH) in which the post-acute care bundle would be held by a consolidated provider with the capabilities of multiple post-acute care settings (IRFs, long-term care hospitals (LTCHs), and hospital-based skilled-nursing facilities (SNFs)). The CCH would allow predictable and reduced cost to the Medicare program yet keep the responsibility for serving the clinical needs of the beneficiary in the hands of providers who understand the patients’ medical rehabilitation needs and medical complexity.

Furthermore, a post-acute care-only bundle would enable CMS to explore condition-specific episode payment models that are not tethered to an acute care hospital index admission.

Previously, CMS indicated its interest in exploring potential future condition-specific episode payment models. For instance, many innovative care delivery models for joint replacement already avoid the acute care hospital stay altogether and are routinely performed in ambulatory surgical centers (ASCs) with generally 23

positive outcomes. Given that MS-DRG payments in CJR and the EPMs are essentially invariable, other than risk adjustment and outlier payments, most of the cost reduction in the CJR and EPMs would be realized in the post-operative period. Hence, a postacute care-only bundled payment model for certain conditions – irrespective of where a procedure was performed – would concentrate on reducing Medicare’s post-acute expenditures, yet also keep the responsibility for serving clinical needs in the hands of providers who understand patients’ need for post-acute care. AMRPA welcomes the opportunity to work with the Agency in developing a pilot program such as the CCH. AMRPA has considered many of the issues surrounding bundled payments and service redesign, which are discussed in our policy paper, American Medical Rehabilitation Providers Association Position Paper on a National Pilot Program on Payment Bundling.

We believe that as the Agency reconsiders approaches to payment and service delivery redesign through episode-based payment models and other approaches that any such program should adhere to a core set of guiding principles.

AMRPA’s Guiding Principles for Bundled Payment Initiatives •

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Nondiscrimination: Any program should assure that there is no discrimination in admission or treatment of vulnerable populations, particularly persons with disabilities.

Patients: The programs should be patient-centered with a focus on restoring health; enhancing function; returning patients to their communities, jobs and school; and maintaining access and quality. Any program must avoid incentives to withhold care or steer patients only to select providers and allow patients to exercise informed choice regarding their course of care.

Providers: Participating providers should be empowered to deliver clinically appropriate services based on clinical evidence and professional judgment.

Payers: Cost-effective and cost-efficient care should be promoted. Payment must be equitable and thoroughly account for all payment, costs and resources that reflect the characteristics of patients served, as well as costs not related to patient characteristics such as facility maintenance. The system should maximize administrative simplicity for providers and payers.

Quality: High-quality care should be enhanced, sought, delivered, fairly reimbursed and maximize patient/caregiver outcomes and satisfaction. Reimbursement and measures of success for providers should be risk adjusted to promote the care of those with the greatest need. The programs must assure that any bias against caring for the most medically complex cases is removed and that there are no incentives to withhold on care or game the payment. Quality measures selected should promote positive outcomes, avoid potential adverse events, and demonstrate effectiveness and efficiency of care.

Summary of Recommendations AMRPA appreciates the opportunity to comment on this proposed rule and CMS’s careful consideration of the issues 24

raised in this letter. A summary of our recommendations follow, and our complete recommendations and comments are included as Attachment A. We have also included in Appendices the summaries of our key recommendations on the EPM, CR and CJR programs when they were proposed initially.

I. Rescission of the Episode Payment Model Recommendation: AMRPA supports cancelling the mandatory EPM program and rescinding the regulations implementing it. AMRPA recommends that any future bundling programs be voluntary in nature.

A. Any New Payment or Service Delivery Programs or Demonstrations Must Include Payment Flexibility for IRFs and Regulatory Waivers.

Recommendations: 1. AMRPA recommends that for any future bundling proposals, episode-based models, or new initiatives that CMS afford IRFs the option of accepting reduced payment rates compared to what they would otherwise receive under the IRF PPS for treating EPM or other patients included in such a program. This framework could be comprised of two basic features: a. A reduced base payment rate relative to current base rate/weight applicable to affected cases; and b. A per diem payment rate derived from that reduced rate/weight.

2. For IRFs that elect to accept reduced payments for treating beneficiaries, AMRPA recommends that CMS waive several of the regulatory requirements imposed on IRFs for affected cases only. These waivers would: a. Allow specific modes of therapy to be delivered under the 3-Hour Rule; and b. Not count cases against IRFs’ compliance with the 60 Percent Rule.

3. AMRPA recommends that CMS grant IRFs regulatory relief from retroactive payment denials for patients treated under any such program.

B. Any Future Cardiac Care Bundling Program Must Include Valid Quality Metrics.

Recommendations: 1. AMRPA strongly recommends that CMS include a minimum of one functional outcome measure for each of the AMI, CABG, and SHFFT models.

2. AMRPA recommends that CMS use a patient satisfaction and experience measure that covers all potential post-acute care settings to which the patient may be discharged. Short of that, CMS should include patients discharged to nursing homes and SNFs in the HCAHPS Survey.

3. Regarding the AMI and CABG models, AMRPA recommends CMS work with organizations such as the American Association of Cardiovascular and Pulmonary Rehabilitation, AMRPA Magazine November 2017

4.

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the American College of Cardiology, and the American Heart Association to identify appropriate measures that address domains such as function and functional capacity, health care-related quality of life, use of preventative medication, and depressive symptoms.

AMRPA requests CMS provide information to stakeholders ensuring that the AMI Excess Days measure is valid and tested measure for the AMI patient population.

Regarding the SHFFT model, CMS should develop measures that are more clinically appropriate for hip and femur fracture patients. AMRPA does not recommend applying only the CJR measure set to the SHFFT patient population.

AMRPA recommends that CMS assess EPM participant hospitals’ performance on quality metrics within the postoperative period immediately following surgery as well as up to six months after the patients’ index admission.

AMRPA recommends that CMS impose a separate financial penalty on participant hospitals if they are found to withhold care through poor performance on the quality measures.

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II. Cancellation and Rescission of Cardiac Rehabilitation Incentive Payment Model Recommendations: AMRPA supports cancelling and rescinding this mandatory cardiac rehabilitation incentive program. We agree with the Agency’s rationale and believe the program should be reexamined.

At the same time, AMRPA urges CMS to utilize its existing waiver and demonstration authority coupled with the authority granted to it pursuant to the establishment of CMMI to expand awareness and provision of participation in cardiac rehabilitation programs.

We urge the Agency to quickly yet thoroughly consider instituting a voluntary cardiac rehabilitation incentive demonstration with the following characteristics: 1. Offer it on a voluntary basis, and encourage the most interested and ideally most competent providers to participate. Although a voluntary program may run the risk of selection bias, we believe a voluntary program would ensure that only those providers most capable of undertaking this demonstration do so and thereby does not jeopardize beneficiaries’ wellbeing.

2. Allow multiple types of providers familiar with various types of cardiac patients and such programs to participate.

Eligible providers should include acute care hospitals, inpatient rehabilitation hospitals and units, and their outpatient departments, as well as other clinics. It could be made available in selected MSAs and not be limited to acute care hospitals only as the provider to receive the incentive payments. It should not be linked to any kind of index hospital admission.

3. Assure it covers the type of conditions allowed by CMS under the current cardiac rehabilitation programs.

4. Increase the amount of current payment under the FFS Medicare program by the amount of the incentive payments.

5. Change the sequence of the incentive payments, change the amounts or both. Having a larger payment for the first 1-11 visits may be more enticing and financially feasible for hospitals wanting to participate. Then, if necessary, slightly

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decrease the incentive payments for the second set of visits (12-36). We recognize that CMS structured in the CR Incentive Payment program higher payments for visits 1236 to address and encourage beneficiaries’ adherence to the CR program beyond the first 11 visits. We agree that beneficiary behavior is a key element that is traditionally outside the control of hospitals. We recommend that the Agency consider additional approaches, beyond adjusting provider payments, that would incentivize beneficiaries to adhere to and complete their CR regimen.

Change the timing of incentive payments so that providers are paid for the furnished CR services at the time the associated claim is filed, instead of at an end-of-year reconciliation.

Institute robust quality measures. At a minimum, these measures must include an assessment of patient outcomes overall (such as mortality and readmissions) and a comprehensive set of functional measures such as cognitive ability, mobility, strength, endurance, and health related quality of life, among others. Additionally CMS should review the clinical performance and quality measures being developed by the American Heart Association/American College of Cardiology for cardiac rehabilitation to be published in 2018. Additional measures to consider are those used by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACPR) used in program certification. These include measures on depression, blood pressure control, tobacco use, etc. The quality reporting requirements must prioritize quality of care and patient centric outcomes over utilization management.

Provide for beneficiary engagement incentives as are included in the current program. They may include providing transportation, copayments, technology and other services (subject to various guidelines).

If there are any waivers regarding physician supervision, some physician oversight should be maintained even it if is only approving the protocols used by the non-physicians as originally proposed.

III. Revision to the Comprehensive Care for Joint Replacement (CJR) Program A. The Entire CJR Program Should Be Voluntary.

Recommendations: 1. AMRPA supports CMS’ proposal to make the CJR model voluntary for hospitals in the 33 lowest-cost Metropolitan Statistical Areas (MSAs) and for all rural and low-volume hospitals.

2. AMRPA recommends that CMS make CJR voluntary for participant hospitals in all program MSAs. B. Quality of Care Measures Must be More Robust and Patient Centric.

Recommendations: 1. AMRPA recommends that CMS stringently evaluate the CJR model and its performance on key measures such as patient experience of care, outcomes and quality, access, health care provider cost, market impact, and service utilization. These findings should be transparent and accessible to the public.

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2. AMRPA urges CMS to strengthen the quality reporting requirements so that they encourage all providers to prioritize quality of care and patient-centric outcomes, rather than utilization management. CMS should include an ambulation functional measure that assesses beneficiaries’ short-term and long-term functional capacity, and measures that assess for wound infection, cardiac events, DVT and UTIs, among others.

3. AMRPA recommends that CMS assess CJR participant hospitals’ performance on quality metrics within 90 days immediately following the patients’ joint replacement surgery as well as up to six months after the patients’ anchor hospitalization for a CJR episode.

C. CMS Should Make Changes to Incentivize Participation in CJR Model.

Recommendations: 1. AMRPA recommends that CMS allow IRFs to opt-in as participant hospitals, therefore bundle holders, under the CJR model.

2. AMRPA recommends that CMS afford IRFs the option of accepting reduced payment rates alternative to what they would otherwise receive under the IRF PPS for treating CJR patients. This framework would comprise of two basic features: a. A reduced base payment rate relative to current base rate/weight applicable to CJR cases; and b. A per-diem payment rate derived form that reduced rate/weight.

3. For IRFs that elect to accept reduced payments for treating CJR beneficiaries, AMRPA recommends that CMS waive several of the regulatory requirements imposed on IRFs for CJR cases only. These waivers would: a. Allow specific modes of therapy to be delivered under the 3-Hour Rule; and b. Not count CJR cases against IRFs’ compliance with the 60 Percent Rule.

which clinicians could be eligible as QP under the Advanced APM track of CJR. Conclusion AMRPA appreciates this opportunity to respond to the proposal to rescind and cancel the EPMs and CR Incentive Payment Model and modify the CJR mandatory bundling program. Throughout our examination of the proposed rule, our analytic premise is framed upon the principle that any such models could be designed to be more patient-centric and outcome-oriented in order to recognize the critical role medical rehabilitation providers play for these patients and thereby meet the primary needs of a patient who seeks care under these or any future initiatives, be they mandatory or voluntary.

Please refer any questions about our comments to AMRPA’s Executive Vice President for Government Relations and Policy Development, Carolyn Zollar, J.D. (czollar@amrpa.org | 202-2231920) and Mimi Zhang, Policy and Research Associate (mzhang@ amrpa.org | 202-223-1920).

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 Douglas M. Baer, CPA Chair, AMRPA Bundled Payments Work Group President and Chief Executive Officer, Brooks Rehabilitation Hospital Suzanne Snyder Kauserud Chair, AMRPA Quality Committee Vice President, Carolinas Rehab Mark J. Tarr Chair, AMRPA Legislative and Regulatory Committee CEO, HealthSouth Corporation

4. AMRPA recommends that CMS grant IRFs regulatory relief from retroactive payment denials for cases treated under the CJR model.

D. Proposed Adjustment to the Pricing Calculation for the CJR Telehealth HCPCS Codes To Include the Facility PE Values.

Recommendation: AMRPA recommends CMS finalize its proposal to revise the PE RVUs it is using for the telehealth E/M HCPCS codes by using PE RVUs that are analogous to the in-person services.

E. Proposed Clinician Engagement List for Eligibility in the Quality Payment Program Will Help Many Clinicians.

Recommendation: AMRPA recommends CMS finalize its proposal to develop a Clinician Engagement List which would broaden the scope by 26

AMRPA Magazine November 2017

NEW AHRQ TRAINING PROGRAM HELPS HOSPITALS AND PATIENTS PREVENT FALLS

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ach year, between 700,000 and 1,000,000 persons in the United States experience falls in the hospital, resulting in fractures, lacerations, or internal bleeding, leading to increased health care utilization.

Yet, research has shown that close to onethird of falls can be prevented by managing a patient’s underlying fall risk factors and optimizing the hospital’s physical design and environment. A new training program from the Agency for Healthcare Research and Quality (AHRQ) is now available to help acute care hospitals prevent patient falls, a leading cause of hospital acquired conditions (HACs).

Fall Prevention in Hospitals Training Program AHRQ’s Fall Prevention in Hospitals Training Program grew out of a three-year AHRQfunded pilot initiative to: 1.

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Develop training resources that provide guidance on how to use and implement into practice the tools and strategies outlined in AHRQ’s Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care released in 2013.

Provide training and ongoing technical assistance—using the newly developed training curriculum—to a cohort of hospitals selected to implement the Toolkit.

Evaluate the impact of implementing AHRQ’s Toolkit, combined with training and technical assistance, on participating hospitals’ fall-related outcomes.

AHRQ’s evidence-based Fall Prevention Program is designed for hospital quality improvement staff, patient safety officers and others staff who seek to reduce falls through a structured fall prevention initiative based on quality improvement principles.

The content was developed from an AHRQ project that ran from 2014 to 2017. It is based on the experiences of 10 hospitals that participated in a two-year pilot project of the Training Program. Data from 10 hospitals that used the program showed a 14 percent decrease in the average number of falls and a 20 percent decrease in falls-with-injury during the one-year period post implementation.

Reductions were significantly greater for rehabilitation hospitals and geriatric/ psychiatric units. Hospitals participating in the pilot implementation of the Training Program and Toolkit reduced their fall and fall with injury rates and sustained these reductions for a year (the period of time over which hospitals were followed as part of this project).

Implementation Guide The Implementation Guide offers strategies and resources to assist hospital team leaders, practice facilitators, and quality improvement specialists (QISs) in efforts related to fall prevention in hospital settings. It includes: •

A readiness assessment tool to help hospitals determine if they are ready to implement the change activities outlined in the Training Program and Toolkit.

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A Roadmap for how to roll out the Training Program modules and companion webinars in a systematic quality improvement effort focused on reducing falls and falls with injury.

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A collection of additional resources that can be used to support implementation of the Training Program.

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Examples of how hospitals have addressed common challenges encountered when doing quality improvement activities.

Training Curriculum The training curriculum is designed to help hospitals implement AHRQ’s Fall Prevention Toolkit. The Training Program consists of a five-module, in-person training curriculum and a series of companion webinars on specific topics related to fall prevention.

In-Person Training The in-person training purpose is to: •

Educate hospital leadership and Implementation Teams on the AHRQ Fall Prevention Toolkit to facilitate the change process in their hospitals.

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Develop hospital-specific action plans for implementing a Fall Prevention Program using the Toolkit.

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Identify some of the specific challenges for fall prevention in hospitals.

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Use and adapt the tools and resources contained in the Toolkit to implement the Fall Prevention Program.

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The six-hour interactive meeting provides an opportunity for hospitals to discuss their current needs, policies and procedures. The training supports adult learning and allows participants to immediately apply their new knowledge to their fall reduction efforts.

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Critical Thinking for Fall Injury Prevention (55 minutes)

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Sustainment (61 minutes)

AFYA, Inc., led the project team, with support from partners ECRI Institute and Stratis Health. During the first year of the initiative, AFYA and its partners designed • Evidence for Fall Prevention Strategies and developed a focused training curriculum (75 minutes) Training Webinars based on AHRQ’s Toolkit. They also recruited 10 varied and geographically • Staff Roles and Training diverse hospitals to participate in for Your Fall Prevention a two-year pilot implementation Program (42 minutes) (PDF program.

QISs supported of the slides, 1.79 MB) hospital implementation through Hospitals participating in the pilot • Using Fall Risk Assessment structured training and ongoing reduced their fall and fall with Tools in Care Planning (25 technical assistance. The project minutes) (PDF of the slides, injury rates and maintained team developed the Guide to 2.16 MB) share participating hospitals’ sustained reductions for a year. implementation strategies, • Measuring Fall and Fallexperiences, and lessons learned Related Injury Rates and from hospitals.

Prevention Practices (26 • Measurement: Using Data To Tell a minutes) (PDF of the slides, 1.39 MB) For more information about AHRQ’s Fall Story (65 minutes) • Sustaining Fall Prevention Practices at Prevention in Hospitals Training Program • Patient-Centered Fall Prevention Care Your Hospital (46 minutes) (PDF of the please see AHRQ’s website: http://www.

Planning (61 minutes) slides, 1.71 MB) ahrq.gov/professionals/systems/hospital/ • Post-Fall Huddles: Reducing fallpxtraining/implguide-overview.html Learning Network Webinars Preventable Falls and Fall-Related Injuries (61 minutes) • Creating Control Charts to Interpret Fall Data (62 minutes) •

Lean Six Sigma—A Deep Dive Into Reducing Patient Falls: AHRQ Toolkit for Preventing Falls (67 minutes)

JOIN TODAY!

EDUCATION , COMMUNICATION, PARTICIPATION & OPERATIONAL ASSISTANCE AMRPA: Working Together Together To Access To Medical Rehabilitation AMRPA: Working toPreserve Preserve Access to Medical Rehabilitation

Maggie Ramirez · VP of Membership Services · 347-573-3732 · mramirez@amrpa.org

Rachel Koresky, AMRPA Member Services Coordinator | 202-591-2469 | rkoresky@amrpa.org

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AMRPA Magazine November 2017

KAISER FOUNDATION EXAMINES MEDICARE ADVANTAGE PHYSICIAN NETWORKS

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he Kaiser Family Foundation released a new analysis that examined the size and composition of physician networks among Medicare Advantage (MA) private plans, which now cover 19 million persons, or onethird of the Medicare population. The report Medicare Advantage: How Robust Are Plans’ Physician Networks? was released in October.

The report stated that Medicare Advantage plans have a more limited network of doctors and other providers than traditional Medicare, but typically have lower cost-sharing, limits on out-of-pocket spending, and some extra benefits. In contrast, traditional Medicare allows enrollees to see the

overwhelming majority of providers without referrals or prior authorization but has no annual out-of-pocket spending limit. Provider networks are important for MA enrollees because seeing an out-of-network provider can result in significant out-of-pocket expenses.

Methods For the analysis, Kaiser examined physician networks of MA health maintenance organizations (HMOs) and local preferred provider organizations (PPOs) offered in 20 counties in 2015, which encompassed a sizeable share of the total MA population. The counties ranged in size, per capita Medicare spending, the number of plans (391) offered by 55 insurers to Medicare

Highlights: •

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Medicare Advantage networks included less 46 percent of all physicians in a county.

More than one in three MA enrollees were in a plan with a narrow network.

beneficiaries, and MA penetration rates.

On average MA plan networks included 46 percent of all physicians in a county and access to physicians varied by specialty as well.

The analysis adds to the Foundation’s prior work that documents variations across MA plans in premiums, cost29

than five plastic surgeons, and 16 percent of plans included fewer than five radiation oncologists.

sharing, extra benefits, quality, and in the composition and size of their hospital networks.

Key Findings: •

More than three in ten (35 percent) Medicare Advantage enrollees were in narrow-network plans while about 2 in 10 (22 percent) were in broad-network plans.

The relative narrowness of plan networks covered the total number of physicians that enrollees could access, particularly in larger counties.

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Medicare Advantage networks included less than half (46 percent) of all physicians in a county, on average.

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Network size varied greatly among Medicare Advantage plans, for example, while enrollees in Erie County, NY, had access to 60 percent of physicians in their county, on average, 16 percent of the plans in Erie had less than 10 percent of the physicians in the county while 36 percent of the plans had more than 80 percent of the physicians in the county.

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Access to psychiatrists was typically more restricted than for any other specialty.

Medicare Advantage plans had 23 percent of the psychiatrists in a county. Some plans provided relatively little choice for other specialties as well; 20 percent of plans included fewer than five cardiothoracic surgeons, 18 percent of plans included fewer than five neurosurgeons, 16 percent of plans included fewer

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Broad-network plans tended to have higher average premiums than narrow-network plans, and this was true for both HMOs ($54 versus $4 per month) and PPOs ($100 versus $28 per month).

More than one in three Medicare Advantage enrollees were in a plan with a narrow network. Enrollees may choose narrow network plans because they are comfortable with the way in which the plan delivers care, or based on other factors, such as low premiums.

In large counties, such as Los Angeles, some narrow network plans have many doctors, so for consumers the question is whether the network includes the specific doctors they want or need when someone gets sick.

The study states that insurers may create narrow networks for a variety of reasons, such as to have greater control over the costs and quality of care provided to enrollees in the plan. The size and composition of MA provider networks is likely to be particularly important to enrollees when they have an unforeseen medical event or serious illness. However, accessing the information may not be easy for users, and comparing networks could be especially challenging.

Beneficiaries could face significant costs if they accidentally go out-of-network.

Differences across plans, including provider networks, pose challenges for Medicare beneficiaries in choosing

among plans and in seeking care, and raise questions for policymakers about the potential for wide variations in the healthcare experience of MA enrollees across the country.

The report documents that MA plans’ networks vary across the country and within counties – to a degree and in a manner that has not been previously recognized. The extent of this variation raises important questions about the experiences of current and future enrollees who end up in narrow-network plans, as a result of their inability to evaluate plans’ provider networks. The report adds that these wide variations in provider networks are important for policymakers because they raise questions about the minimum standards for physician access and the lack of tools and resources to allow Medicare beneficiaries to compare the scope and composition of MA plans’ provider networks.

With Medicare’s open enrollment period beginning Oct. 15, the analysis documents one of the biggest tradeoffs for consumers choosing between Medicare Advantage plans and traditional Medicare.

See the Kaiser Foundation website to access the complete report, Medicare Advantage: How Robust Are Plans’ Physician Networks? https://www. kff.org/report-section/medicarea d v a n t a g e - h o w - ro b u s t - a re - p l a n s physician-networks-report/.

AMRPA Magazine November 2017

MEDICARE ADVANTAGE PREMIUMS TO DECREASE IN 2018, CMS SAYS

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he Centers for Medicare and Medicaid Services (CMS) recently released the annual 2018 premium averages for Medicare Advantage (MA), which covers about one-third of all Medicare beneficiaries, and the optional Medicare drug benefit, Part D, prior to the October 15 enrollment period.

The information provided below is for both programs.

Enrollment is projected to be 20.4 million for Medicare in 2018, a 1.7 million (nine percent) increase from 18.7 million in 2017.

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Average monthly premiums is estimated to decrease by $1.91 to $30 in 2018 from $31.19 in 2017.

The average monthly premium for a basic Medicare prescription drug plan is projected to decrease by $1.20 to an estimated $33.50 per month in 2018 from $34.70 in 2017.

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99 percent of Medicare beneficiaries will have access to at least one health plan in their area, with 85 percent having access to 10 or more MA plans in 2018.

All Medicare beneficiaries will have access to at least one standalone Medicare prescription drug plan.

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For more information on the premiums and costs of 2018 Medicare health and drug plans, see https:// www.cms.gov/Medicare/ Prescription-Drug-Coverage/ PrescriptionDrugCovGenIn/index. html

Approximately 77 percent of enrollees in 2017 will have the same or lower premium in 2018 if they continue in the same plan.

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Medicare Advantage is expected to increase 9 percent in 2018.

More plans to be available in each country.

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Changes in the “Medicare & You” handbook to better explain coverage options.

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Establishing a help wizard on Medicare.gov that will point to resources to help make informed healthcare decisions.

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Establishing a new email communication opportunity to improve the customer service experience through important messages and reminders.

Medicare Part D •

Plan choices per county are expected to increase by two plans – up to approximately 29 plan choices per county – and with continued growth in access to supplemental benefits, such as dental, vision, and hearing.

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CMS is also expected to make the following improvements to Medicare Open Enrollment to assist Medicare beneficiaries in making a decision between Original Medicare and Medicare Advantage. These include:

Medicare Advantage •

Highlights:

Medicare Open Enrollment for 2018 Medicare health and drug plans began on October 15, 2017, and will end on December 7, 2017.

For the CMS fact sheet on Medicare Advantage and Part D premiums and information for 2018, please visit: h t t p s : / / w w w. c m s . g o v / N e w s r o o m / MediaReleaseDatabase/Fact-sheets/2017Fact-Sheet-items/2017-09-29.html

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MEDICARE ADVANTAGE SHOULD INCREASE TRANSPARENCY AND REDUCE BURDEN, ACP SAYS

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ncreased transparency in and greater alignment across Medicare Advantage (MA) plans would help the program to reduce administrative burdens on physicians, the American College of Physicians (ACP) said in a new policy paper, Promoting Transparency and Alignment in Medicare Advantage.

The paper explores the quality of care, utilization and cost of services in the Medicare Advantage program in comparison to traditional Medicare.

Reducing administrative burdens on physicians is a goal of ACP’s Patients Before Paperwork initiative. ACP has long identified reducing administrative burdens as a priority and the initiative seeks to reinvigorate the patientphysician relationship by challenging unnecessary practice burdens. Requiring transparency in and alignment across the MA program is essential to reducing unnecessary burdens and also confusion for patients.

with physicians to further promote transparency and reduce excessive and burdensome administrative tasks.

3. ACP called for more research on how federal payments to the MA Program are utilized by MAOs. Specifically, ACP calls for further research on the types of payment models used and prices paid by MAOs to contracted physicians, hospitals, and other clinicians compared with the models used and prices paid by traditional Medicare and commercial health insurance plans.

The paper outlined three recommendations on addressing Under the Medicare Advantage concerns about the MA program: program, Medicare beneficiaries can receive their benefits through a private “As Medicare moves away insurance plan, rather than the from its traditional fee-fortypical fee-for-service (FFS) service and toward the Quality Medicare program. Medicare Payment Program linking Advantage plans are designed physician payment to highIncreased transparency in and to enhance care coordination value care, it is a critical time and quality of care as well greater alignment across Medicare for the MA program to make as provide supplementary Advantage (MA) plans would help improvements,” concluded benefits, including dental Dr. Ende.

“The relief from the program to reduce administrative coverage, vision coverage and administrative burdens that wellness plans. However, the burdens on physicians. our recommendations would MA program has long been provide to clinicians is an a subject of debate among important component of policymakers and the health promoting high-value care for insurance industry over the balance 1. ACP supports current policies to all Medicare beneficiaries.” between promoting beneficiary choice, ensure that MA plans are funded at maintaining quality of care, providing the level of the traditional Medicare For the announcement, please see access to MA plans, and setting the cost program and that at least 85 percent h t t p s : / / w w w. a c p o n l i n e . o r g / a c p of these private plans. of that funding goes to actual newsroom/american-college-ofbeneficiary care. physicians-says-medicare-advantage“As enrollment in Medicare Advantage should-increase-transparency-align-and2. ACP urged Medicare Advantage plans increases, there is a growing interest reduce Organizations (MAOs) to be in understanding the differences in care transparent in their processes, delivery, quality, resource utilization policies and procedures for how and cost between MA and traditional they develop and administer Medicare,” said Jack Ende, MD, MACP, their MA plans and portfolios for president, ACP. “If MA plans were to all key stakeholders to ensure increase transparency that would give program integrity. Furthermore, the Centers for Medicare and Medicaid MAOs administering MA plans Services the opportunity to examine them must collaborate with all relevant more closely and promote alignment, stakeholders to streamline and thus lessening the administrative burden align varying policies, procedures, associated with clinician participation in and contracting arrangements these plans.”

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AMRPA Magazine November 2017

MEDSTAR HEALTH SIGNIFICANTLY REDUCES PATIENT HARM USING CANDOR TOOLKIT

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he Agency for Healthcare Research and Quality (AHRQ) recently announced that MedStar Health, a large health system in the Baltimore, MD/ Washington, DC, metropolitan area, reduced serious patient safety events by 65 percent and reduced the cost of care associated with serious safety events (including medical liability payments) by more than $70 million since 2012. These successes were achieved by implementing a comprehensive patient safety program that included objectives such as high reliability, human factors, patient and family partnerships, as well as principles and strategies from its Communication and Optimal Resolution (CANDOR) toolkit.

AHRQ selected MedStar to develop and pilot the toolkit for the CANDOR program because of its system-wide commitment to achieving zero preventable harm.

Despite the best efforts of hospitals, doctors, nurses and other health care professionals, about 1 in 10 patients experience harm by the care they receive. Harms such as hospital-acquired infections (HAIs) or medication errors can occur during any stage of care.

Based on expert input and lessons learned from AHRQ’s $23 million Patient Safety and Medical Liability grant initiative launched in 2009, the CANDOR toolkit was tested and applied in 14 hospitals across three U.S. health systems.

The toolkit was built using processes already working at hospitals and health systems around the country, such as the University of Michigan Health System’s “Michigan Model” and the University of Illinois, Chicago’s “Seven Pillars” of patient safety: 1.

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Occurrence reporting Assessment and investigation Communication Disclosure and apology Process or performance improvement Data analysis Education

The CANDOR toolkit provides methods and tools for hospitals and health systems to respond immediately when patients are unintentionally harmed by the medical care they receive. Despite the best efforts of doctors, nurses, and other health care

Highlights: •

MedStar Health reduced serious patient safety events by 65 percent.

professionals, research shows about 1 in 10 patients is harmed by medical care. The CANDOR toolkit contains eight different modules, each containing PowerPoint slides with facilitator notes. Some modules also contain tools, resources, or videos.

The key learnings for hospitals implementing the CANDOR process in their institutions include how to: •

Engage patients and families in disclosure communication following adverse events.

•

Implement a Care for the Caregiver program for providers involved in adverse events.

•

Investigate and analyze an adverse event to learn from it and prevent future adverse events.

•

Review and revise the organization’s

CANDOR Toolkit The Communication and Optimal Resolution (CANDOR) process is a process that health care institutions and practitioners can use to respond when unexpected events cause patient harm.

The CANDOR process emphasizes the importance of reporting unanticipated patient harm events as soon as they occur. By learning from those events and engaging in communication with patients and families, hospitals can provide a timely resolution for patients and families and make sustainable changes in care models to prevent similar events from reoccurring, AHRQ states.

33

current processes to align with the CANDOR process.

•

Establish a resolution process for the organization.

Hospitals involved in the 2010 AHRQ demonstration grants experienced: •

40 percent reduction in preventable medical harm events

•

40 percent decline in the number of malpractice claims

•

80 percent decrease in self-insured funds set-aside ($40 million to $8 million)

•

80 percent reduction in time to settle cases

•

20 percent reduction in services associated with defensive medicine

David Mayer, MD, MedStar Health’s vice president of quality and safety, said the CANDOR program has been a significant component helping to contribute to reductions in serious safety events and malpractice claims.

“The CANDOR process has raised the bar in terms of doing what’s best to help 34

the patient,” Mayer said. “With increased reporting and learning from these events when they occur, we can improve our systems and processes, without blaming people when unintentional mistakes do happen.” “We’ve also found that the implementation of the ‘Care for the Caregiver’ component of the CANDOR process contributes to improved employee morale and greater joy and meaning in the workplace.”

MedStar Health, with 10 hospitals and 300 outpatient clinics, promotes CANDOR process workshops and continuous training for its 31,000-member workforce and 4,700 affiliated physicians. “We’ve trained our entire workforce on highreliability tools and techniques, including board members,” Mayer said.

In addition to MedStar, the CANDOR process was implemented and tested at Christiana Care in Delaware and Dignity Health in California. According to the Patient Safety Movement Foundation (PSMF), hospitals that have implemented CANDOR have seen improved patient safety outcomes, improved patient satisfaction scores and a reduction in medical liability claims and recommends

that healthcare organizations around the world implement the CANDOR toolkit on its website.

Tim McDonald, MD, JD, director of MedStar Health’s Center for Open and Honest Communication, said the CANDOR process enables healthcare organizations to successfully resolve patient safety errors without patients and families having to endure a burdensome, drawn-out legal process. He explained, “With the CANDOR process, we’re in the position to hold ourselves accountable and ‘own’ the patient safety issue. We hope to resolve the situation completely, using the legal system only as a last resort.”

The toolkit is available to hospitals and health leaders at no charge.

For more information, see https:// www.ahrq.gov/professionals/qualitypatient-safety/patient-safety-resources/ resources/candor/introduction.html

AMRPA Magazine November 2017

NEW SURVEY FINDS 20 PERCENT OF U.S. ADULTS EXPERIENCED MEDICAL ERRORS; DIAGNOSTIC AND COMMUNICATION ERRORS MOST COMMON

A

ccording to a new national survey released by the Institute for Healthcare I m p ro v e m e n t / N a t i o n a l Patient Safety Foundation (IHI/NPSF) Lucian Leape Institute and the National Opinion Research Center (NORC) at the University of Chicago the vast majority of Americans are having positive experiences with the health care system, yet 21 percent of adults report having personally experienced a medical error.

The survey found that, when errors do occur, they often have a lasting impact on patients’ physical health, emotional health, financial well-being or family relationships.

The survey expands on a 1997 survey conducted by the National Patient Safety Foundation (NPSF) and featured a nationally representative sample of 2,536 adults using the AmeriSpeak Panel, the probability-based panel of NORC at the University of Chicago from May 12-June 26, 2017.

Major Findings •

Ambulatory settings are a frequent site of medical errors.

•

Errors related to diagnosis and patient-provider communications are

the most commonly reported in the survey.

Other Findings •

Nearly half of those who perceived that an error had occurred brought it to the attention of medical personnel or other staff at the health care facility.

•

Most respondents (8 in10) believe that, while health care providers are chiefly responsible for patient safety, patients and their families also have a role to play.

•

When asked what caused the medical error they experienced, people identified, on average, at least seven different factors.

•

Beyond personally experiencing errors, 31 percent of Americans report that someone else whose care they were closely involved with experienced an error.

“The survey results show that Americans recognize that patient safety is a critically important, but complex, issue,” says Tejal K. Gandhi, MD, MPH, CPPS, chief clinical and safety officer, IHI, and president of the IHI/NPSF Lucian Leape Institute.

“The focus on diagnostic errors and

Highlights: •

Errors related to diagnosis and patient-provider communications were the most common.

the outpatient settings closely parallels other research in this area and confirms that health care improvers need to take a systems approach to safety that encompasses all settings of care, not just hospitals.”

The survey was conducted with support from Medtronic, funder of the IHI/ NPSF Lucian Leape Institute. The study design, analysis and report are solely the responsibility of the authors and were in no way influenced or shaped by Medtronic, the survey states.

Citation To view the full report, Americans’ Experiences with Medical Errors and Views on Patient Safety, go to http://www.ihi. org/about/news/Documents/IHI_NPSF_ Patient_Safety_Survey_2017_Final_Report. pdf

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RISING OBESITY LEVELS UNDERSCORE NEED FOR ENHANCED TRANSITIONAL CARE MODELS

E

lderly, chronically ill people experience frequent changes in health status that require transitions among health care providers and settings.

Significant attention has been focused on coordinated transitional care models that assure continuity of care, prevention of hospital readmission, avoidance of complications, and close clinical treatment and management.

Ninety-seven (response rate 39.8 percent) discharge planners returned surveys addressing the frequency of, and issues encountered when, arranging placements.

Community and hospital characteristics were also collected.

Findings 1.

One-third of the respondents from Pennsylvania and Arkansas reported inability to transfer patients and these barriers included reimbursement, staffing and equipment.

extended hospital stays. These include an elevated risk for hospital adverse events and increased cost.

“Given increasing obesity rates, health care delivery systems must be prepared to provide necessary resources and all levels of care, including transitions for hospitalized patients who are severely obese needing nursing home care post-discharge,” explains lead-author Christine K. Bradway, PhD, RN, CRNP, FAAN, associate professor of gerontological nursing.

A recent study, “Barriers in Transitioning Patients with Severe Obesity from Hospital to Nursing Homes,” published in The study was supported by the Western Journal of Nursing the Translational Research Research from the University of Institute grants UL1TR000039 Pennsylvania School of Nursing and KL2TR000063 through the (Penn Nursing) discusses the National Institute of Health’s Failure to move severely obese challenges of transitioning National Center for Research patients out of hospitals into persons who are severely obese Resources, the National Center post-acute care can to lead to to a nursing home after an for Advancing Translational acute care stay and, specifically, Sciences, and the Research poor outcomes associated with the experiences of hospital Committee of the University of extended hospital stays. discharge planners. It is not clear Pennsylvania’s School of Nursing. if inpatient rehabilitation facilities (IRFs) face similar problems in Co-authors of the study include transferring their patients.

Holly C. Felix, PhD, MPA and Xiaocong Li, 2. Patient size and perceived availability of PhD(c), both of the University of Arkansas for bariatric equipment can act as barriers The cross-sectional, descriptive study Medical Sciences, Fay W. Boozman College to discharging obese patients to nursing explored perspectives of discharge planners of Public Health; and Tonya Whitfield of homes. Respondents perceiving nursing regarding transitions of hospitalized patients Hornby Zeller Associates. homes to have equipment concerns who are severely obese seeking discharge to were nearly seven times more likely to a nursing home. Attention has been focused For the abstract, see: http://journals. report patient size as a barrier (p = .001). on care transitions regarding high hospital sagepub.com/doi/abs/10.1177/019394 readmission rates, yet the specific needs of 5916683682?url_ver=Z39.88-2003&rfr_ 3. Failure to move patients who are patients who are severely obese who need id=ori%3Arid%3Acrossref.org&rfr_dat=cr_ severely obese out of hospitals into to be transferred to nursing homes for postpub%3Dpubmed& post-acute care has the potential to acute care have been largely overlooked. lead to poor outcomes associated with 36

AMRPA Magazine November 2017

TRANSITION TO VALUE-BASED PAYMENT TAKES TIME TO BE ADOPTED, ACCEPTED, SURVEY FINDS

A

ccording to, “Health Plan Survey: Industry Perspectives on ValueBased Payment Survey Results & Key Insights,” published by HealthScape Advisors, the shift to value-based care is on the list as one of the biggest challenges managed care executives face in their organizations.

HealthScape Advisors partnered with the Health Plan Alliance (a national organization that brings health plans together with their health system and provider group leaders for collaboration) and health plan clients to survey plans about their experiences, approaches and performance under value-based payment (VBP) models.

HealthScape surveyed more than 30 health plans through a standardized questionnaire and follow-up interviews to understand each organization’s journey toward value-based care and supporting fee-forvalue payment models.

challenges in driving affordability and quality outcomes through value-based payment models.

The major findings and recommendations are provided below: Findings 1. The shift to value-based payment is a slow one, with most plans not yet making the transition to risk.

The majority (60 percent) of the plans surveyed indicated that pay-forperformance (P4P) or upside-only shared savings arrangements were the most prevalent value-based payment models (VBPM) in their portfolio.

An increase in provider commitment and engagement occurred once 25 percent to 30 percent of a provider’s panel is involved and/or assuming risk in value-based payment arrangements.

Of the health plans that report over 25 percent “wallet share” with their network providers, the majority (53 percent) of these plans report positive outcomes in quality and cost. However, for the plans representing less than 25 percent wallet share, only 36 percent report positive quality and cost outcomes. Most PSPs surveyed report that they represent less than 25 percent of their providers’ panels.

Care transformation and data/ analytics are core capabilities for value-based payment success.

The survey focused on:

•

Common themes and distinctions across market segments and products.

•

Effectiveness of health plan operating models in supporting execution.

•

Differences in performance between provider-sponsored health plans (PSPs) and traditional health plans (non-PSPs).

Provider-sponsored plans (PSPs) may be a bit further along in shifting financial risk to providers. Between 20 percent to 40 percent of PSPs surveyed indicated that a VBPM with downside risk is the most prevalent model for a particular line of business, compared to 5 percent to 30 percent of non-PSPs. There were also noted differences among lines of business and risk assumption was highest in the fully insured group line of business via upside and downside shared savings/ risk and in Medicare Advantage (MA) through a mixture of shared risk and capitation.

The survey states that the insights collected reflect an industry in transition and its results demonstrate a wide variety of approaches, reported successes and

2. Scale and health plan market share are critical to drive provider engagement.

For a provider practice to justify the capital investment (both human and

•

financial), a sufficient portion of its patient panel must be involved in the VBPM.

Perspectives on value-based payment models and drivers of success.

3. While provider integration or alignment is a prerequisite, it does not guarantee improved performance in VBPMs (and differences are noted between PSPs/nonPSPs).

Just over half of the plans that reported they are “wellintegrated with their provider partners” did not report success in both quality and cost of care outcomes.

Despite reporting tighter integration with providers, PSPs do not necessarily report greater success in quality and cost outcomes than non-PSPs. Generally, PSPs reported lower rates of achievement in quality and cost of care outcomes.

For example, only 30 percent of PSPs surveyed reported success in both quality and cost of care outcomes, as compared to 60 percent of non-PSPs reporting improvements on both measures.

4. Transformation capabilities within care management, data management and analytics are viewed as critical drivers of success under VBPM. For the plans reporting success and 37

effectiveness in the care transformation function, it noted a wide variation in approaches. They also observed that many PSPs leverage their unique and strategic relationship with their provider owners in the deployment of their care management tactics and interventions.

5. Product alignment and member engagement are missing enablers across the industry.

Nearly all health plans report low effectiveness of product and member engagement compared to the other core capabilities that are critical toward successful execution under VBPM. Only 44 percent and 33 percent of surveyed health plans reported that product/benefit design and member engagement, respectively, are effective in supporting VBPM. Recommendations 1. Care transformation and data/ analytics are core capabilities for valuebased payment success.

PSPs may have an inherent structural advantage for these capabilities, which can help to overcome the wallet share challenges noted previously. However, recent partnership ventures between providers and non-PSPs are seeking to replicate this structural advantage and use scale to drive interest in these 38

VBPMs. Continued focus must be on collaboration with providers for bidirectional information sharing and delineation of roles and responsibilities between the provider and health plan to help advance VBPM success.

2. Improve consumer engagement through enhanced product benefit design and consumer navigation support.

Both product/benefit design and member engagement are critical levers; yet, up to this point, they have been under-utilized by health plans to support value-based payment models. Valuebased benefit design without adequate member engagement through both clinical and financial navigation has not led to significant savings. Accordingly, enhancements in product design can help support VBPMs in achieving desired cost and quality outcomes by lowering financial barriers that could prevent patient adherence or management of their conditions (e.g., free primary care visits, no copays for maintenance drugs/ supplies).

3. Accelerate the roadmap to risk by aligning with government models, such as MACRA.

VBPMs with the parameters outlined by MACRA. While timing may be delayed, it is recognized that the FFS model is fiscally unsustainable and MACRA may also help accelerate providers’ willingness to accept risk. Accordingly, health plans should look for opportunities to migrate existing models to include risk assumption or create new models that meet required risk thresholds.

“It is widely recognized that the fee-forservice model is unsustainable given the rapidly escalating healthcare costs in our country,” says Alexis Levy, director at HealthScape Advisors. “CMS has also signaled its commitment to shift to value-based payment. Given these industry demands, this study provides executives with context and benchmarks on other organizations’ shift to valuebased payment, along with insights and recommendations to help guide health plans to achieve greater success during their continued evolution to value-based payment models.”

For the Health Plan Survey: Industry Perspectives on Value-Based Payment Survey Results & Key Insights please see https://healthscape.com/sites/ default/files/uploads/VBP%20Survey_ Executive%20Summary_FINAL.pdf.

Health plans can capitalize on the disruption created by this legislation and should work to align the structure of AMRPA Magazine November 2017

CMS TRANSMITTALS OF INTEREST FOR MEDICAL REHABILITATION PROVIDERS

November 2017

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

Issue Date

Subject

Implementation Date

R1928OTN

2017-10-04

Multi-Carrier System (MCS), Fiscal Intermediary Shared System (FISS) and VIPS Medicare Shared System (VMS) Automation of Prior Authorization (PA) Requests/Pre-Claim Reviews (PCR) and their Responses with Multiple Services (for programs like Home Health (HH)) via the Electronic Submission of Medical Documentation (esMD) System

2018-01-02

R3869CP

2017-09-29

Quarterly Update to the National Correct Coding Initiative (NCCI) Procedureto-Procedure (PTP) Edits, Version 24.0, Effective January 1, 2018

2018-01-02

R3871CP

2017-09-29

Revisions to Medicare Claims Processing Manual for Foreign, Emergency and Shipboard Claims

2017-10-30

R11p240

2017-09-29

Medicare Provider Reimbursement Manual Part 2, Provider Cost Reporting Forms and Instructions, Chapter 40, Form CMS-2552-10

N/A

R1925OTN

2017-09-28

Guidance on Implementing System Edits for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

2017-10-02

R3865CP

2017-09-22

Instructions for Retrieving the 2018 Pricing and HCPCS Data Files through CMS' Mainframe Telecommunications Systems

2018-01-02

R1923OTN

2017-09-22

Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals

2017-10-23

R1922OTN

2017-09-22

Shared System Enhancement 2014: Implementation of Fiscal Intermediary Shared System (FISS) Obsolete Financial and Expert Claims Processing System (ECPS) Reports

N/A

R475PR1

2017-09-22

Medicare Payment Rates for routine SNF-type services by swing-bed hospitals during calendar year 2018

N/A

R39COM

2017-09-22

Updates to Pub. 100-09, Chapter 6 Beneficiary and Provider Communications Manual, Chapter 6, Provider Customer Service Program

2017-10-23

R13SS

2017-09-22

IOM 100-17 Update

N/A

R3861CP

2017-09-15

Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2018

2018-01-02

R3863CP

2017-09-15

Updated Editing of Always Therapy Services - MCS

2018-01-02

R3864CP

2017-09-15

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

2017-10-02

R293FM

2017-09-14

Revision to Publication 100-06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment

2018-04-02

Updated as of October 10, 2017

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AMRPA Magazine November 2017